Citation Nr: 21073415
Decision Date: 12/08/21	Archive Date: 12/08/21

DOCKET NO. 17-43 654
DATE: December 8, 2021

ORDER

Entitlement to an initial increased disability rating in excess of 10 percent for right knee osteoarthritis and patellofemoral pain syndrome (PFS) status post meniscectomy (to include gout), prior to December 20, 2019, is denied.

Entitlement to an increased disability rating of 30 percent, but no greater, for right knee osteoarthritis and PFS status post meniscectomy from December 20, 2019, is granted.

Entitlement to an initial increased disability rating in excess of 10 percent for left knee osteoarthritis and PFS status post meniscectomy, prior to December 20, 2019, is denied.

Entitlement to an increased disability rating of 30 percent, but no greater, for left knee osteoarthritis and PFS status post meniscectomy from December 20, 2019, is granted.

Entitlement to a separate compensable evaluation for right knee limitation of extension associated with right knee osteoarthritis and PFS status post meniscectomy before December 20, 2019, is denied.

Entitlement to an increased disability rating of 30 percent, but no greater, for right knee limitation of extension associated with right knee osteoarthritis and PFS status post meniscectomy from December 20, 2019, is granted.

Entitlement to a separate compensable evaluation for left knee limitation of extension associated with left knee osteoarthritis and PFS status post meniscectomy before December 20, 2019, is denied.

Entitlement to an increased disability rating of 30 percent, but no greater, for left knee limitation of extension associated with left knee osteoarthritis and PFS status post meniscectomy from December 20, 2019, is granted.

Entitlement to an initial compensable disability rating for sinusitis is denied.

Entitlement to an initial compensable disability rating for gastroesophageal reflux disease (GERD) prior to December 20, 2019, is denied.

Entitlement to an increased disability rating in excess of 30 percent for GERD from December 20, 2019, is denied.

Entitlement to an initial compensable rating for onychomycosis (claimed as chronic toenail infection) is denied.

FINDINGS OF FACT

1. Before December 20, 2019, the Veteran's service-connected right knee osteoarthritis and PFS status post meniscectomy (to include gout) manifested in flexion to 90 degrees. 

2. On an after December 20, 2019, the Veteran's service-connected right knee osteoarthritis and PFS status post meniscectomy has been manifested by flexion that more nearly approximated 15 degrees or less. 

3. Before December 20, 2019, the Veteran's service-connected left knee osteoarthritis and PFS status post meniscectomy manifested in flexion to 90 degrees. 

4. On an after December 20, 2019, the Veteran's service-connected left knee osteoarthritis and PFS status post meniscectomy has been manifested by flexion that more nearly approximated 15 degrees or less. 

5. The Veteran's right knee osteoarthritis disability manifested full (0 degrees) extension before December 20, 2019.

6. On and after December 20, 2019, the Veteran's service connected right knee osteoarthritis disability manifested with limitation of extension that more nearly approximated 20 degrees. 

7. The Veteran's left knee osteoarthritis disability manifested full (0 degrees) extension before December 20, 2019.

8. On and after December 20, 2019, the Veteran's service connected left knee osteoarthritis disability manifested with limitation of extension that more nearly approximated 20 degrees. 

9. The Veteran's sinusitis has been manifested by congestions, pain, and tenderness of the sinuses; however, it did not manifest one or two incapacitating episodes per year characterized by headaches, pain, and purulent discharge or crusting; there were no incapacitating episodes requiring prolonged antibiotic treatment. 

10. Before December 20, 2019, the Veteran's GERD was manifested by regurgitation (reflux); however, it was not manifested by dysphagia, pyrosis, or substernal or arm or shoulder pain.

11. On and after December 20, 2019, the Veteran's GERD has manifested with persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation that is accompanied by substernal pain, productive of considerable impairment of health; but not vomiting, material weight loss and hematemesis or melena with moderate anemia or other symptom combinations productive of severe impairment of health. 

12. The Veteran's onychomycosis of the toes has manifested with less than five percent of the total body areas affected and none of the exposed areas affected; the Veteran has not undergone systemic therapy.

CONCLUSIONS OF LAW

1. The criteria for a disability rating in excess of 10 percent for right knee osteoarthritis and PFS status post meniscectomy (to include gout) prior to December 20, 2019, are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71A, Diagnostic Code (DC) 5260.

2. On and after December 20, 2019, the criteria for a disability rating of 30 percent, but no greater, for right knee osteoarthritis and PFS status post meniscectomy are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71A, DC 5260.

3. The criteria for a disability rating in excess of 10 percent for left knee osteoarthritis and PFS status post meniscectomy prior to December 20, 2019, are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71A, DC 5260.

4. On and after December 20, 2019, the criteria for a disability rating of 30 percent, but no greater, for left knee osteoarthritis and PFS status post meniscectomy are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71A, DC 5260.

5. The criteria for a separate evaluation for right knee limitation of extension associated with right knee osteoarthritis and PFS status post meniscectomy prior to December 10, 2020, are not met.  38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, DC 5261.

6. On and after December 20, 2019 the criteria for a rating of 30 percent, but no greater, for right knee limitation of extension associated with right knee osteoarthritis and PFS status post meniscectomy are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, DC 5261.

7. The criteria for a separate evaluation for left knee limitation of extension associated with left knee osteoarthritis and PFS status post meniscectomy prior to December 10, 2020, are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, DC 5261.

8. On and after December 20, 2019 the criteria for a rating of 30 percent, but no greater, for left knee limitation of extension associated with left knee osteoarthritis and PFS status post meniscectomy are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, DC 5261.

9. The criteria for entitlement to an initial compensable rating for sinusitis are not met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.3, 4.7, 4.97, DC 6513.

10. The criteria for an initial compensable disability rating for service-connected GERD before December 20, 2019, are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1-4.7, 4.21, 4.114, DC 7399-7346.

11. The criteria for a disability rating in excess of 30 percent for GERD from December 20, 2019, are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1-4.7, 4.21, 4.114, DC 7399-7346.

12. The criteria for an initial compensable rating for service-connected onychomycosis are not met. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.321, 4.1-4.7, 4.118, DC 7813-7806.

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran served in the Army Reserves from July 1984 with active duty service from July to November 1984 and September 1985 to June 2008.

These matters come to the Board of Veterans' Appeals (Board) from a July 2013 and March 2017 rating decision issued by the Agency of Original Jurisdiction (AOJ). In May 2019, the Board remanded the appeals for sinusitis and left and right knee osteoarthritis disabilities so the AOJ could obtain new VA disability examinations. The new examinations were obtained in December 2019. The Board finds that there has been substantial compliance with its directives and may now proceed with a decision. Stegall v. West, 11 Vet. App. 268, 271 (1998). 

The Board notes the Veteran's claims for onychomycosis and GERD were filed with the claims noted above but took separate routes for appellate review. Given that the separate appeal streams for entitlement to increased ratings were certified to the Board around the same, the Board will address all of the Veteran's appeals in a single decision.  

1. Entitlement to an initial disability rating in excess of 10 percent for right knee osteoarthritis and PFS status post meniscectomy prior to December 20, 2019, and a rating no greater than 30 percent from that date.  

The Veteran contends the severity of his right knee osteoarthritis and PFS status post meniscectomy (right knee osteoarthritis disability) warrants a greater than 10 percent rating before December 20, 2019, and highest rating available on and after that date. See August 2017, April 2020 VA Forms 9.

The questions for the Board are whether the Veteran has established entitlement to a greater than 10 percent disability rating for his service-connected right knee osteoarthritis disability before December 20, 2019, and a greater than 20 percent rating on and after that date. For the reasons discussed below, the Board concludes the evidence does not support the assignment of an increased disability rating before December 20, 2019. However, the Board concludes the evidence supports the assignment of a 30 percent disability rating on and after December 30, 2019.

Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities found in 38 U.S.C. § 1155; 38 C.F.R., Part 4. If there is a question as to which evaluation to apply to the Veteran's disability, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7.

In considering the severity of a disability, it is essential to trace the medical history

of the Veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41. Consideration of the whole-recorded

history is necessary so that a rating may accurately reflect the elements of any

disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991).

Although the regulations do not give past medical reports precedence over current

findings, the Board is to consider the veteran's medical history in determining the

applicability of a higher rating for the entire period in which the appeal has been

pending. Powell v. West, 13 Vet. App. 31, 34 (1999).

If later evidence indicates that the degree of disability increased or decreased

following the assignment of the initial rating, "staged" ratings may be assigned for

separate periods of time. Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007).

When assessing the severity of a musculoskeletal disability that is rated on the

basis of limitation of motion, VA must, in addition to applying scheduler criteria,

also consider evidence of pain, weakened movement, excess fatigability, or

incoordination. 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202,

204-207 (1995). Given the nature of the present claim for a higher initial evaluation, the Board has considered all evidence of severity since the effective date for the award of service connection in September 2011.Fenderson v. West, 12 Vet. App. 119 (1999).

Although pain may cause a functional loss, pain itself does not constitute

functional loss. Pain must affect some aspect of "the normal working movements

of the body" such as "excursion, strength, speed, coordination, and endurance," in

order to constitute functional loss. Mitchell v. Shinseki, 25 Vet. App. 32, 36-

39 (2011).

The Veteran's service-connected left and right knee osteoarthritis and PFS status post meniscectomy (to include gout) are rated under DC 5260, Under 5260, rates are based on limitation of flexion (bending) of the leg. That code provides when flexion is limited to 60 degrees, a noncompensable (0 percent) disability rating is warranted. When it is limited to 45 degrees, a 10 percent disability rating is warranted. When limitation is at 30 degrees, a 20 percent disability rating is warranted. When it is limited to 15 degrees, a 30 percent disability rating is warranted. A 30 percent rating is the maximum schedular rating under 5260. 38 C.F.R. § 4.71a.

Any reasonable doubt regarding a degree of disability is resolved in favor of the Veteran. 38 C.F.R. § 4.3. Reasonable doubt exists when there is an approximate balance of positive and negative evidence for and against the claim. 38 C.F.R.§ 3.102.

Beginning with the evidence of record, the Veteran visited an orthopedic specialist with complaints of right knee pain in January 2011. He reported the pain was aggravated when he twisted the knee picking something up. See January 28, 2011, Tricare Record at 1. The medical provider conducted range of motion testing on the Veteran's right knee with flexion at 110 degrees; for extension, five degrees. Id. at 3, 4. Later that year, in September 2011, the VA received the Veteran's entitlement claims for left and right knee osteoarthritis, sinusitis, GERD, and onychomycosis. 

In April 2012, the VA received a statement from the Veteran wherein he provided lay observations of his sinusitis, onychomycosis, and knee disabilities. Beginning with his knee disabilities, he asserted knee pain (he did not specify whether his pain was in one knee or both knees) limited his ability to engage in physical activity. He added he can no longer run. Also, he could not walk up and down stairs without having to use handrails. He referenced the use of a cane but did not indicate he used it more than occasionally. With regards to his sinusitis disorder, he reported he constantly used sinus medication, but they did not alleviate his sinus symptoms. He did not describe the symptoms his medication controlled. As to onychomycosis, he reported he has used prescription medication and a topical medication, but the infection did not seem to go away. See April 2012 Statement. 

Also, the Veteran underwent an April 2012 VA disability examination for his knee disabilities. This is the first VA examination for his knees during the appeal period. During the examination, he associated his current knee problems with a diagnosis of gout. But he also stated he observed knee pain during service which led to arthroscopic (meniscal) surgery on his knees. He added that he occasionally uses a brace and cane. See April 2012 VA Disability Benefits Questionnaire (DBQ) at 1, 5.

The examiner did not find limited movement at either knee. Neither did he find ankylosis, recurrent subluxation or lateral instability. Joint stability and muscle strength testing of the knees was normal. Id. at 2, 3. The examiner noted that diagnostic imaging showed moderate osteoarthritic changes and diagnosed left and right knee osteoarthritis and PFS status post meniscectomy. Id. at 1, 6.

Tricare medical records from April 2012 to July 2016 note visits to medical providers for symptoms the Veteran believes are related to GERD and his knee osteoarthritis disabilities. Throughout that period of time, he maintained he observed left and right knee pain, difficulty with running, and walking up and down stairs. See February 6, 2013, Tricare Record by P.P., MD (noting range of motion measurements with flexion at 90 degrees and full extension); November 26, 2014, Tricare Record by S.S., MD (noting complaints of instability and good range of motion at the knees). 

During the same period (April 2012 to July 2016), he reported abdominal pain, and observed vomiting, diarrhea that was attributed to an allergic reaction. He denied bladder and bowel dysfunction. See January 4, 2013, Tricare Record (noting persistent abdominal pain at multiple sites and diagnosis of GERD); November 26, 2014, Record by S.S.,MD (noting the Veteran denied observing bladder, bowel dysfunction, paresthesias); March 25, 2016, Tricare Record by K.S., MD (noting complaints of an allergic reaction after eating, with symptoms that included swelling lips). Then, during a July 2016 conversation with a VA representative, the Veteran reported his sinus and knee disabilities had worsened. See Report of General Information. He did not report specific symptoms nor provide a description of his worsened disability picture.

In January 2017 the Veteran underwent VA disability examinations for his service-connected knee osteoarthritis disabilities, GERD, sinusitis, and onychomycosis. Beginning with his examination for left and right knee osteoarthritis, he reported his knee pain was so severe he could no longer run. He also observed difficulty with lateral movements and occasionally used a cane. He reported flare-ups at both knees that were brought on by walking up and down stairs. See VA DBQ at 2, 10.

The examiner found limited movement without objective evidence of pain at both knees. Initial range of motion measurement for flexion at the right knee was 0 to 100; for extension, it was 100 to 0 degrees.  Id. at 2. With regards to the left knee, initial range of motion measurements were 0 to 120 degrees; for extension, it was 120 to 0 degrees. Id at 3.  The examiner noted the Veteran could not perform repetitive use testing. The examiner added that he could not provide an opinion on any additional function loss due to flare-ups because he did not observe the Veteran during a flare-up. Id. at 5. The Board notes the range of motion findings noted in the examination were found to be unreliable due to the lack of consideration of functional loss during flare-ups. See May 2019 Board Remand at 2. 

The examiner did not find the Veteran's left or right knee was ankylosed, nor recurrent subluxation or lateral instability. Joint stability testing for both knees was normal. Id. at 6, 7. Also, muscle strength testing was normal. The examiner endorsed the diagnosis of left and right knee osteoarthritis and PFS status post meniscectomy (to include gout). Id. at 1. He also noted the Veteran's left and right knee disabilities make it difficult for the Veteran to perform a job that includes a lot of going up and down stairs as well as prolonged walking, standing, running. Id. at 11. 

With regards to the Veteran's January 2017 GERD examination, he reported he observed indigestion and regurgitation (reflux), but used Nexium to control it. He added that he still observed regurgitation. The examiner found the Veteran's GERD is manifested with regurgitation and did not find any other symptoms or complications associated with GERD. See VA DBQ at 2. 

As to the Veteran's January 2017 sinusitis examination, he reported he had not been prescribed antibiotics for several years but used antihistamines and nasal saline spray to keep his disorder under control. See VA DBQ at 1. The examiner found the Veteran has rhinitis. The examiner acknowledged that he emphasized rhinitis because he believes sinusitis is a misdiagnosis and the Veteran no longer has that disorder. See January 26, 2017, VA Medical Opinion. The examiner explained that a 2002 diagnostic test showed the Veteran did not have a sinus disease. He added that the test result, combined with the long period of time without prescribed antibiotics indicates the Veteran's sinusitis has been stable. Id.  The Board notes the Veteran is not service-connected for rhinitis.

With regards to the Veteran's January 2017 onychomycosis examination, he reported he soaked his toes in a mixture of bleach and Epsom salts as needed. See VA DBQ at 2. The examiner noted the diagnosis of onychomycosis of the left big toe. The examiner also noted the Veteran has not been treated with oral or topical medications in the past 12 months for any skin disorder. Id. at 2. Also, physical examination did not show the Veteran had any visible skin disorder on the face, neck, or hands. The examiner did not find any other symptoms, complications, or condition(s) due to onychomycosis. Id. at 2, 3.

Later that year, in April and May 2017, the Veteran visited a medical provider with complaints of sinusitis and knee disabilities. He visited the provider in April 2017 with complaints of congestion, cough, postnasal drip, lasting for three days; the provider diagnosed acute sinusitis. See Tricare Record by G.B., MD. In May 2017 the Veteran reported to another medical provider that he heard his left knee pop and lock up while walking downstairs. He added that he has observed consistent pain at the back of the left knee since the event. See May 18, 2017, Tricare Record by D.A., MD. The provider referred the Veteran to an orthopedic specialist who conducted range of motion testing on the left knee: flexion was 0 to 140 degrees; for extension, it was 140 to 0 degrees. The orthopedist did not find instability at either knee. See May 23, 2017, Tricare Record by D.M., MD. 

In August 2017, the Veteran reported to the VA his left and right knee disabilities had worsened. See VA Form 9 at 1. He reported he needed to use a cane more often and his knee disabilities have caused him to miss work. Id. at 2. The Veteran's claim was then sent to the Board with affording him another VA examination. After a May 2019 Board remand, the VA obtained new VA examinations for the Veteran's knee osteoarthritis disabilities, GERD, sinusitis, and onychomycosis in December 2019. Beginning with the Veteran's December 2019 examination for left and right knee osteoarthritis, he reported he received steroid injections in the left knee in 2019. Now, he observes persistent knee pain (at both knees) that varies throughout the day. He reported the pain is so severe he is limited to walking, standing for short periods of time. When he does stand and walk, he observes a sense of looseness at the knee joints and uses constantly uses a cane for stability. He added that he observed difficulties with activities that involve bending the knees. Also, his ability to walk up and down stairs has diminished to the point that he now sleeps on the first floor of his home. He also observes pain when he bends his knees while sitting and now must sit with his legs extended for comfort. See December 2019 VA DBQ at 2, 10.

The examiner found limited movement with pain at both knees. Initial range of motion testing for flexion at both knees was 10 to 20 degrees; for extension, 20 to 10 degrees. The examiner did not provide an opinion on any additional functional loss due to flare-ups because the Veteran did not report observing flare-ups. Id. at 2, 3. Repetitive use testing did not reveal any additional loss of motion due to pain or fatigue. Id. at 4, 5. The examiner endorsed the diagnosis of left and right knee osteoarthritis and PFS and noted the Veteran's knee osteoarthritis disabilities are so severe that the Veteran's ability to perform daily activities are impacted, but he remains independent. Id. at 1, 11. 

The examiner also found recurrent left and right knee effusion and noted it contributes to the Veteran's disabilities. Id. at 5, 11. Effusion is defined as the escape of fluid into a part or tissue (in this case, the knees). DORLAND'S ILLUSTRATED MEDICAL DICTIONARY 589 (33rd ed. 2020). The examiner did not find ankylosis at the left or right knee, nor recurrent subluxation or lateral instability. Joint stability testing for both knees was normal. Id. at 5, 6, 7.

With regards to the Veteran's December 2019 GERD examination, he reported he observed continuous difficulty swallowing (dysphagia), heartburn (pyrosis), regurgitation (reflux), and substernal pain. See VA DBQ at 1, 2. He also reported difficulty sleeping due to reflux, nausea, and vomiting that that occur at a frequency of four or more times a year and last less than a day. Also, he takes continuous medications for his disorder, to include omeprazole and tums. The examiner found the Veteran's symptoms were productive of considerable impairment of health. Id. at 1, 2.

With regards to the Veteran's December 2019 sinusitis examination, he reported he has been using antihistamines and nasal saline to try to control his symptoms but has developed nasal symptoms over the last few years, to include runny nose and mild congestion. See VA DBQ at 1, 2. The congestion is observed every day. He added that he observes increased sinus congestion, pain, and drainage around three to four times a month that improves with increased use of medications. He reported he has been prescribed antibiotic treatment (lasting 10 days) once over the last 12 months, which was in the summer of 2019. Id. The examiner noted the Veteran's history of prescribed medications shows antibiotics were prescribed in August 2019not the summer of 2019. The examiner also noted two infections were treated more than 12 months ago, in June and July 2018. See VA DBQ at 1, 2. The Board notes the record shows a prescription in June 2018 for antibiotic treatment lasting six days. See June 1, 2018, Tricare Record by G.B., MD (noting prescription of azithromycin with instructions to take one pill for six days). There is no record of prescribed antibiotics on July 3, 2018; however, the record shows he was treated for cough, postnasal drip, fever, and chest congestion. See June 28, 2019, Tricare Record by G.B., MD (reporting symptoms treated in June 2018 have returned). 

The examiner found the Veteran has maxillary sinusitis. Id. at 1, 2. The examiner explained that when the Veteran was diagnosed with sinusitis in service (in March 2005) his symptoms were consistent with the disorder. Also, no other sinus disorder (to include rhinitis) was diagnosed at that time. Regarding the Veteran's current sinusitis disability picture, the examiner found episodes of sinusitis consisting of pain and tenderness without noticeable drainage. The examiner did not find non-incapacitating or incapacitating episodes of sinusitis over the last 12 months. Also, there are no other complications or condition(s) associated with the Veteran's chronic sinusitis. Id. at 2, 3.

With regards to the Veteran's December 2019 onychomycosis examination, he reported his disorder began at his big toes and has spread to other toes. His symptoms include discoloration and increased thickness of the toenails, which cause discomfort and difficulty wearing certain shoes, like dress shoes for work. See VA DBQ at 1. The examiner noted all of the Veteran's toes showed fungal changes with seven of the 10 toenails noticeably thickened. Id. at 2. Also, he has been treated with constant or near-constant anti-fungal topical medication in the past 12 months. Id. at 2.

The examiner noted less than five percent of the Veteran's total body is affected by his onychomycosis skin disorder. None of the Veteran's visible exposed body is affected by the disorder. Id. at 2. The examiner clarified that the Veteran's skin disorder does not include acne, chloracne, vitiligo, scarring alopecia, hyperhidrosis, chronic urticaria, vasculitis, erythroderma, or erythema multiform. Id. at 3.

A.	Entitlement to a greater than 10 percent rating for right knee osteoarthritis before December 20, 2019. 

After reviewing the record, the Board concludes the evidence does not support the assignment of a greater than 10 percent disability rating for the Veteran's right knee osteoarthritis disability before December 20, 2019. 

The Board recognizes the Veteran's lay statements describing pain and functional loss before December 20, 2019. He has personal knowledge of symptoms like pain and greater difficulty going up and down stairs. So, he is competent to report it. Layno v. Brown, 6 Vet. App. 465, 469 (1994). The record shows he consistently reported to medical providers that his right knee pain was so severe he could it interfered with physical activities, like running and walking up and down stairs. Because reports to medical providers are generally found reliable, the Board finds his statements credible. See January 28, 2011, Tricare Record at 1 (noting reports of right knee pain); February 6, 2013, Tricare Record by P.P., MD (noting reports of knee pain that limit his ability to walk up and down stairs); November 26, 2014, Tricare Record by S.S., MD (noting reports of knee pain); August 2017 VA Form 9 at 1 (reporting left and right knee pain have started to cause him to miss work).

Although the Board finds the Veteran observations of pain crediblethey are not sufficient to assign an increased disability rating under DC 5260. Under 5260, disability ratings are assigned based on evidence of limited flexion (bending the leg). A Veteran's descriptions of symptoms may be helpful in making that determination, but the statements of record here do not provide enough information to help the Board approximate his described knee problems into degrees of limited flexion. Given that his statements indicate some observed functional loss at the right knee, his statements were assigned some, but not significant, probative weight. 

While the Veteran's statements may not be informative enough to approximate the degree of limited flexion, medical records generated during the relevant period provide the type of findings needed to decide the claim. Those records show his right knee osteoarthritis disability manifested in flexion no less than 90 degrees before December 20, 2019. See January 28, 2011, Tricare Record at 1(noting flexion was 110 degrees with pain); April 2012 VA DBQ (noting flexion at 140 degrees); February 6, 2013, Tricare Record by P.P., MD (noting flexion was 90 degrees). Given that the next higher rating (20 percent) under DC 5260 requires limited flexion at 45 degrees or less, his medical records weigh strongly against finding the assignment of a greater than 10 percent rating is warranted at any time before December 20, 2019. 

Based on the range of motion limitations noted during the relevant period (September 2011 to December 20, 2019), the Veteran is entitled to a 10 percent disability rating under DC 5260, which is the rating currently assigned. As noted, the Veteran's limited flexion did not meet the criteria DC 5260 requires for a 20 percent rating (45 degrees or less). Given that the next higher rating (30 percent) requires limited flexion that is 30 degrees or less, the medical evidence weighs strongly against finding the assignment of any rating greater than 10 percent is warranted. 38 C.F.R. § 4.71a.

Also, when the range of motion findings from September 2011 to December 20, 2019, are viewed as a whole, they do not show progressive loss of flexion; therefore, the Board cannot approximate when his right knee osteoarthritis disability may have manifested with limited flexion at the degree noted in the December 20, 2019 VA DBQ. That means the Board could not identify a point in time the assignment of staged ratings is warranted. Hart, 21 Vet. App. at 509-10.

In this case, the evidence is not approximately balanced in favor of finding the assignment of a greater than 10 percent disability rating is warranted before December 20, 2019. Although the Veteran believes the limited motion he observed during the relevant period warrants a higher rating, the Board finds the medical evidence showing range of motion estimates more probative. The range of motion estimates show flexion was limited to 90 degrees before December 20, 2019. Because 90 degrees flexion does not meet the criteria DC 5260 requires for the assigment of a greater than 10 percent disability rating, doubt is not resolved in the Veteran's favor. 38 C.F.R. § 4.3. Accordingly, the Board finds that a disability rating in excess of 10 percent for right knee osteoarthritis is not warranted at this time. DC 4.71a.

B.	Entitlement to a 30 percent rating, but no greater, for right knee osteoarthritis from December 20, 2019. 

Although the December 20, 2019, VA DBQ noted the Veteran has limited motion in a range that falls between the criteria DC 5260 requires for 20 and 30 percent ratings, the Board finds it more nearly approximates the criteria for a 30 percent rating. The examiner who prepared the VA DBQ found flexion limited to 10 to 20 degrees at the right knee, which is a range that falls between the criteria 5260 requires for a 20 percent rating (30 degrees) and a 30 percent rating (15 degrees or less). 38 C.F.R. § 4.71a. Also, the examiner noted the Veteran's difficulty bending his knees he resorted to sleeping on the first floor rather than walking up stairs to where he normally slept. Given that the range of motion findings for flexion are closer to the 30 percent criteria than 20 percent criteria and the examiner described a disability picture manifested with severe difficulties bending the knees, the Board resolves doubt in the Veteran's favor. 38 C.F.R. § 4.3. Accordingly, the Board finds his disability picture more nearly approximates limited motion at 15 degrees and, therefore, the assignment of a 30 percent rating is warranted from December 20, 2019. 

The Board notes a greater than 30 percent rating is not available under DC 5260; therefore, consideration of a disability rating greater than 30 percent is not warranted. Also, the Veteran has not alleged, nor does the record reflect, he has observed symptoms that exceed the severity contemplated by 5260; therefore, consideration of an extraschedular Total Disability Rating Based Upon Individual Unemployability (TDIU) is not warranted at this time. Holmes, 33 Vet. App. at 76. 

C.	Entitlement to a greater than 30 percent disability rating under other applicable diagnostic codes.

Because the Board must consider all other potentially applicable DCs, the next question is whether a higher rating under other applicable DCs is available. Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). Even though the record reflects the Veteran had meniscal surgery, the residual effects are contemplated by his currently assigned right knee osteoarthritis disability. So, the assignment of separate ratings under DC 5258, 5259 would result in compensation for the same symptomatology, which is not allowed under VA regulations. 38 C.F.R. § 4.14. Also, ratings under that code would not provide a greater than 30 percent rating. 

Even though the record reflects reports of locking at the knees, the evidence does not support finding ankylosis. See April 2012 VA DBQ (noting frequent episodes of locking at the knees). Ankylosis is defined as "immobility and consolidation of a joint due to disease, injury, surgical procedure." DORLANDS at 92. Here, three VA examiners assessed the Veteran's knees for ankylosis. See April 2012, January 2017, and December 20, 2019 VA DBQs at 2, 6. Also, a medical provider evaluated the Veteran's reports of locking of the knees while walking down stairs and did not note any finding of ankylosis. See May 18, 2017, Tricare Record by D.A., MD (noting reports of hearing a pop and knee locking up). Given that the findings were provided by medical professionals who are qualified to identify ankylosis, there is sufficient medical evidence to find that the Veteran's right knee osteoarthritis disability has not manifested with ankylosis; therefore, a separate rating under DC 5256 is not warranted. 

Given that the Veteran has been diagnosed with a form of degenerative arthritis, the next issue is whether rating under DC 5003 (degenerative arthritis) would provide a greater than 30 percent disability rating. Under 5003, limited motion is rated under the appropriate DC for the specific joint, which in this case, is 5260. So, rating the Veteran's service-connected right knee osteoarthritis under 5003 would not result in a greater than 30 percent rating. 

In sum, the evidence of record does not show that the severity of the Veteran's service-connected right knee osteoarthritis disability manifested with limited flexion that warrants a greater than 10 percent rating under DC 5260 at any time before December 20, 2019. However, the evidence does show the Veteran's disability picture manifested with limited flexion that more nearly approximates the criteria for a 30 percent rating from December 20, 2019. 38 C.F.R. § 4.3. Accordingly, the assignment of a 30 percent disability rating, but no greater, is granted on and after December 20, 2019. Hart, 21 Vet. App. at 505.

2. Entitlement to an initial disability rating in excess of 10 percent for left knee osteoarthritis and PFS status post meniscectomy (to include gout) prior to December 20, 2019, and a rating no greater than 30 percent from that date.  

The Veteran contends the severity of his left knee osteoarthritis disability warrants a greater than 10 percent rating before December 20, 2019, and highest rating available on and after that date. See August 2017, April 2020 VA Forms 9.

The questions for the Board are whether the Veteran has established entitlement to a greater than 10 percent disability rating for his service-connected left knee disability before December 20, 2019, and a greater than 20 percent rating on and after that date. For the reasons discussed below, the Board concludes the evidence does not support an increased disability rating before December 20, 2019. However, the Board concludes the evidence supports the assignment of a 30 percent disability rating on and after December 30, 2019.

A.	Entitlement to a greater than 10 percent rating for left knee osteoarthritis before December 20, 2019. 

After reviewing the record, the Board concludes the evidence does not support the assignment of a greater than 10 percent disability rating for the Veteran's left knee osteoarthritis disability before December 20, 2019. 

Similar to the Veteran's right knee disability claim, his reports of left knee pain and functional loss are too general to approximate whether he met the criteria DC 5260 requires for a greater than 10 percent rating. Here, he has provided general reports of pain that interfere with physical activity, like walking down stairs. But his statements do not provide enough information to help the Board approximate his described knee problems into degrees of limited flexion. Because his statements provide evidence of some unspecified degree of function loss, they were  assigned some, but not significant, probative weight in favor of an increased rating. See April 2012 Statement at 2 (reporting left and right knee pain interferes with his ability to go up and down stairs); February 6, 2013, Tricare Record by P.P., MD noting reports of left and right knee pain that limit his ability to go up and down stairs); November 26, 2014, Tricare Record by S.S., MD (noting reports of left and right knee pain); May 18, 2017, Tricare Record by D.A., MD (noting report of left knee popping, locking while walking down stairs); August 2017 VA Form 9 at 1 (reporting left and right knee pain have started to cause him to miss work).

Any question the Veteran's observed functional loss met the criteria for the next higher (20 percent) rating was resolved by the by the range of motion findings in the record. They show the Veteran's left knee osteoarthritis disability manifested in flexion no less than 90 degrees. See January 28, 2011, Tricare Record at 1 (noting flexion was 110 degrees with pain); April 2012 VA DBQ (noting flexion was 140 degrees); February 6, 2013, Tricare Record by P.P., MD (noting flexion was limited to 90 degrees); May 23, 2017, Tricare Record by D.M., MD (noting flexion was 140 degrees). Given that the next higher rating (20 percent) under DC 5260 requires limited flexion at 30 degrees or less, the available medical evidence weigh strongly against finding the assignment of a greater than 10 percent rating is warranted before December 20, 2019. 

Also, when the range of motion findings from September 2011 to December 20, 2019, are viewed as a whole, they do not show progressive loss of flexion; therefore, the Board cannot approximate when his left knee osteoarthritis disability may have manifested with limited flexion at the degree noted in the December 20, 2019 VA DBQ. That means the Board could not identify a point in time the assignment of staged ratings is warranted. Hart, 21 Vet. App. at 509-10.

In this case, the weight of the evidence against finding a greater than 10 percent disability rating for left knee osteoarthritis is warranted before December 20, 2019. Although the Veteran believes the limited motion he observed during the relevant period warrants a higher rating, the Board finds the medical evidence showing range of motion estimates more probative. Because 90 degrees flexion does not meet the criteria DC 5260 requires for the assigment of a greater than 10 percent disability rating, doubt is not resolved in the Veteran's favor. 38 C.F.R. § 4.3. Accordingly, the Board finds that a disability rating in excess of 10 percent for left knee osteoarthritis is not warranted at this time. DC 4.71a.

B.	Entitlement to a 30 percent rating, but no greater, for left knee osteoarthritis from December 20, 2019. 

Although the December 20, 2019, VA DBQ noted the Veteran has limited motion in a range that falls between the criteria DC 5260 requires for 20 and 30 percent ratings, the Board finds it more nearly approximates the criteria for a 30 percent rating. The examiner who prepared the VA DBQ found flexion limited to 10 to 20 degrees at the left knee, which is a range that falls between the criteria for a 20 percent rating (30 degrees) and a 30 percent rating (15 degrees or less). 38 C.F.R. § 4.71a. As noted, because the range of motion findings for flexion are closer to the 30 percent criteria than 20 percent criteria and the examiner described a disability picture manifested with severe difficulties bending the knees, the Board resolves doubt in the Veteran's favor. 38 C.F.R. § 4.3. Accordingly, the Board finds his disability picture more nearly approximates limited motion at 15 degrees and, therefore, the assignment of a 30 percent rating is warranted from December 20, 2019. 

Because a greater than 30 percent rating is not available under DC 5260, consideration of a disability rating greater than 30 percent under 5260 is not warranted. As noted, the Veteran has not alleged, nor does the record reflect, he has observed symptoms that exceed the severity contemplated by 5260; therefore, consideration of an extraschedular TDIU is not warranted at this time. Holmes, 33 Vet. App. at 76. 

C.	Entitlement to a greater than 30 percent disability rating under other applicable diagnostic codes.

The evidence of record does not show other DCs applicable to the Veteran's left knee osteoarthritis claim provide a greater than 30 percent rating. The applicable code is 5003 which rates degenerative arthritis. As noted above, 5003 does not provide a greater than 30 percent rating. 

In sum, the evidence of record does not show that the severity of the Veteran's service-connected left knee osteoarthritis disability manifested with limited flexion that warrants a greater than 10 percent rating under DC 5260 before December 20, 2019. However, the evidence does show the Veteran's disability picture manifested with limited flexion that more nearly approximates the criteria for a 30 percent rating, but no greater, from December 20, 2019. 38 C.F.R. § 4.3. Accordingly, the assignment of a 30 percent disability rating, but no greater, is granted on and after December 20, 2019. Hart, 21 Vet. App. at 505.

3. Entitlement to separate evaluation for right knee limitation of extension associated with right knee osteoarthritis disability prior to December 20, 2019, and a rating no greater than 30 percent from that date.

Although the Veteran has not sought an increased rating for his service-connected right knee limitation of extension associated with right knee osteoarthritis, he is presumed to be seeking the maximum possible rating. A.B. v. Brown, 6 Vet. App. 35, 38 (1993). 

The questions for the Board are whether the evidence of record supports finding a separate compensable evaluation is warranted for right knee limitation of extension before December 20, 2019. Also, whether a greater than 10 percent rating is warranted on and after that date. For the reasons discussed below, the Board concludes the evidence does not support a separate compensable evaluation before December 20, 2019. However, the evidence supports the assignment of a 30 percent disability rating under DC 5261 for right knee limitation of extension on and after December 30, 2019.

The Veteran's service-connected left and right knee osteoarthritis disability is rated as 10 percent disabling under DC 5261, Under 5261, rates are based on limitation of extension (straightening) of the leg. That code provides when extension is limited to five degrees, a noncompensable (0 percent) disability rating is warranted. When it is limited to 10 degrees, a 10 percent disability rating is warranted. When limitation is at 15 degrees, a 20 percent disability rating is warranted. When it is limited to 20 degrees, a 30 percent disability rating is warranted. When it is limited to 30 degrees, a 40 percent disability rating is warranted. Finally, when it is limited to 45 degrees, a 50 percent disability rating is warranted. A 50 percent disability rating is the maximum schedular rating under 5261. 38 C.F.R. § 4.71a.

A.	Entitlement to a separate evaluation for right knee limitation of extension before December 20, 2019.

After reviewing the record, the Board concludes the evidence does not support the assignment of a separate evaluation for greater for right knee limitation of extension is warranted for any part of the appeal period before December 20, 2019.  

The Board recognizes the Veteran's reports of pain and functional loss before December 20, 2019; however, they are not sufficient to decide whether a separate evaluation for limited extension (straightening the leg) is warranted. Although he is competent to report pain and difficulty performing physical activities, to include running, going up and down stairs, his reports are too general to determine whether pain and his observed difficulties are due to limited extension rather than his already service-connected limited flexion (bending the leg). So, his statements were assigned little probative weight towards evaluating whether a separate evaluation is warranted before December 20, 2019. See April 2012 Statement at 2 (reporting left, right knee pain interferes with his ability to go up and down stairs); February 6, 2013, Tricare Record by P.P., MD (noting reports of left and right knee pain that limit his ability to go up and down stairs); November 26, 2014, Tricare Record by S.S., MD (noting reports of left and right knee pain); August 2017 VA Form 9 at 1 (reporting left and right knee pain have started to cause him to miss work).

Any question that the Veteran's right knee osteoarthritis disability manifested with limited extension before December 20, 2019, was resolved by the medical evidence in the record. Certain records provide range of motion findings for the right knee showing he had full (0 degrees) extension up to December 20, 2019. See April 2012 VA DBQ at 2, 3 (noting full extension at the right knee); February 6, 2013, Tricare Record by P.P., MD (noting full extension at the knees); January 2017 VA DBQ at 2, 3 (noting full extension at the knees when not experiencing a flare up). The Board acknowledges a January 2011 record found right knee extension at five degrees; however, there are many more findings from other medical providers showing full extension. The Board finds the range of motion findings showing full extension to be more probative. This is because they consistently show full extension and, therefore, are more reliable than one finding of extension at 5 degrees. So, the Board assigned the medical records showing full extension great probative weight. 

Because the range of motion findings from September 2011 to December 20, 2019, show full extension at the right knee, the Board cannot approximate when his right knee osteoarthritis disability manifested with limited extension near the degree noted in the December 20, 2019 VA DBQ. That means the Board could not identify a point in time the assignment of staged ratings is warranted. Hart, 21 Vet. App. at 509-10.

In this case, the weight of the evidence is against finding a separate disability rating for limited knee extension is warranted before December 20, 2019. Although the Veteran has not expressly alleged he observed loss of extension before that date, medical evidence generated through the period shows he had full extension. So, doubt on that matter is not resolved in the Veteran's favor. 38 C.F.R. § 4.3. Accordingly, assignment of a separate evaluation under DC 5261 is not warranted before December 20, 2019. DC 4.71a.

B.	Entitlement to a 30 percent disability rating, but no greater, for right knee limitation of extension from December 20, 2019. 

Although the December 20, 2019, VA DBQ noted the Veteran has limited motion in a range that falls between the criteria DC 5261 requires for 10, 20, and 30 percent ratings, the Board finds it more nearly approximates the criteria for a 30 percent rating. The examiner who prepared the VA DBQ found extension limited to 20 to 10 degrees at the right knee, which is a range that falls between the criteria for a 10 percent rating (10 degrees), 20 percent rating (15 degrees), and 30 percent rating (10 degrees or less). 38 C.F.R. § 4.71a. Also, the examiner noted the Veteran's knee disabilities interfere with his ability to move without the need of assistance (ambulate). Given that the range of motion findings for right knee extension are closer to the 30 percent criteria than the 10 or 20 percent criteria, the Board resolves doubt in the Veteran's favor. 38 C.F.R. § 4.3. Accordingly, the Board finds his disability picture more nearly approximates limited motion at 10 degrees and, therefore, the assignment of a 30 percent rating is warranted. 

A search of the record did not find evidence that indicates a greater than 30 percent rating is warranted from December 20, 2019. The next higher rating, a 40 percent rating, requires limited extension to 30 degrees or less, which was not found in the record. So, the evidence does not support finding the assignment of a greater than 30 percent rating is warranted at this time.

C.	Entitlement to a greater than 30 percent disability rating under other applicable diagnostic codes.

The evidence of record does not show other DCs applicable to the Veteran's right knee osteoarthritis disability would provide a greater than 30 percent rating. The applicable code is DC 5003 (degenerative arthritis). As noted above, 5003 does not provide a greater than 30 percent rating. 

In sum, the evidence of record does not show that the severity of the Veteran's service-connected right knee osteoarthritis disability manifested with limited extension before December 20, 2019; therefore, the assignment of a separate evaluation for limitation of extension under 5261 before that date is not warranted. However, the evidence does show the Veteran's disability picture manifested with limited extension that more nearly approximates the criteria for a 30 percent rating from December 20, 2019. Accordingly, an increased rating of 30 percent, but no greater, is granted on and after December 20, 2019. Hart, 21 Vet. App. at 505.

4. Entitlement to separate evaluation for left knee limitation of extension associated with left knee osteoarthritis disability prior to December 20, 2019, and a rating no greater than 30 percent from that date.

Although the Veteran has not sought an increased rating for his service-connected left knee limitation of extension associated with left knee osteoarthritis disability, he is presumed to be seeking the maximum possible rating. A.B. v. Brown, 6 Vet. App. 35, 38 (1993). 

The questions for the Board are whether the evidence of record supports finding a separate compensable evaluation is warranted for left knee limitation of extension before December 20, 2019. Also, whether a greater than 10 percent rating is warranted on and after that date. For the reasons discussed below, the Board concludes the evidence does not support a separate compensable evaluation before December 20, 2019. However, the evidence supports the assignment of a 30 percent disability rating under DC 5261 for left knee limitation of extension on and after December 30, 2019.

A.	Entitlement to a separate evaluation for left knee limitation of extension before December 20, 2019.

After reviewing the record, the Board concludes the evidence does not support the assignment of a separate evaluation for greater for left knee limitation of extension is warranted for any part of the appeal period before December 20, 2019.  

The Board recognizes the Veteran's reports of pain and functional loss before December 20, 2019. He has provided general reports of pain that interfere with physical activity, like walking down stairs. But his reports are too general to determine whether pain and difficulties are due to limited extension rather than limited flexion. So, his statements were assigned little probative weight towards evaluating whether a separate evaluation is warranted before December 20, 2019.. See April 2012 Statement at 2 (reporting left and right knee pain interferes with his ability to go up and down stairs); February 6, 2013, Tricare Record by P.P., MD noting reports of left and right knee pain that limit his ability to go up and down stairs); November 26, 2014, Tricare Record by S.S., MD (noting reports of left and right knee pain); May 18, 2017, Tricare Record by D.A., MD (noting report of left knee popping, locking while walking down stairs); August 2017 VA Form 9 at 1 (reporting left and right knee pain have started to cause him to miss work).

Any question that the Veteran's right knee osteoarthritis disability manifested with limited extension before December 20, 2019, was resolved by the medical evidence in the record. Certain records provide range of motion findings that show the Veteran's left knee osteoarthritis disability manifested with full extension. See January 28, 2011, Tricare Record by T.J.M., MD at 1 (noting full extension at the left knee); April 2012 VA DBQ at 2, 3 (noting full extension at the left knee); February 6, 2013, Tricare Record by P.P., MD (noting full extension at the knees); January 2017 VA DBQ at 2, 3 (noting full extension at the left knee when not experiencing a flare-up); May 23, 2017, Tricare Record by D.M., MD (noting full extension at the left knee). Given that several different medical professionals assessed for limited left knee extension and consistently found he had full extension, the medical evidence weighs strongly against finding the assignment of a separate evaluation is warranted before December 20, 2019. 

Because the range of motion findings from September 2011 to December 20, 2019, show full extension at the left knee, the Board cannot approximate when his right knee osteoarthritis disability manifested with limited extension near the degree noted in the December 20, 2019 VA DBQ. That means the Board could not identify a point in time the assignment of staged ratings is warranted. Hart, 21 Vet. App. at 509-10.

In this case, the weight of the evidence is against finding the assignment of a separate disability rating for left knee limitation of extension is warranted before December 20, 2019. Although the Veteran has not expressly alleged he observed limited extension before that date, the more probative medical evidence generated through the relevant period show he had full extension. So, doubt on that matter is not resolved in the Veteran's favor. 38 C.F.R. § 4.3. Accordingly, assignment of a separate evaluation under DC 5261 is not warranted prior to December 20, 2019. DC 4.71a.

B.	Entitlement to a 30 percent disability rating, but no greater, for left knee limitation of extension on and after December 20, 2019. 

Although the December 20, 2019, VA DBQ noted the Veteran has limited motion in a range that falls between the criteria DC 5261 requires for 10, 20, and 30 percent ratings, the Board finds it more nearly approximates the criteria for a 30 percent rating. The examiner who prepared the VA DBQ found extension limited to 20 to 10 degrees at the left knee, which is a range that falls between the criteria for 10 percent rating (10 degrees), 20 percent rating (15 degrees), and 30 percent ratings (10 degrees or less). 38 C.F.R. § 4.71a. As noted, because the range of motion findings for extension are closer to the 30 percent criteria than 10 or 20 percent criteria and the examiner described a disability picture manifested with severe difficulties straightening the knees, the Board resolves doubt in the Veteran's favor. 38 C.F.R. § 4.3. Accordingly, the Board finds his disability picture more nearly approximates limited motion at 10 degrees and, therefore, the assignment of a 30 percent rating is warranted from December 20, 2019.

Similar to the Veteran's right knee limitation of extension claim, a search of the record did not reveal evidence that indicates a greater than 30 percent rating is warranted from December 20, 2019. A finding of limited extension at 30 degrees or less was not found in the record. So, the evidence does not support finding the assignment of a greater than 30 percent rating is warranted at this time.

C.	Entitlement to a greater than 30 percent disability rating under other applicable diagnostic codes.

The evidence of record does not show other DCs applicable to the Veteran's left knee osteoarthritis disability would provide a greater than 30 percent rating. The applicable code is DC 5003, which rates degenerative arthritis. As noted above, 5003 does not provide a greater than 30 percent rating. 

In sum, the evidence of record does not show that the severity of the Veteran's service-connected left knee osteoarthritis disability manifested with limited extension before December 20, 2019; therefore, the assignment of a separate evaluation for limitation of extension under 5261 before that date is not warranted. However, the evidence does show the Veteran's disability picture manifested with limited extension that more nearly approximates the criteria for a 30 percent rating from December 20, 2019. Accordingly, an increased rating of 30 percent, but no greater, is granted on and after December 20, 2019. Hart, 21 Vet. App. at 505.

5. Entitlement to an initial compensable disability rating for sinusitis. 

The Veteran contends the severity of his service-connected sinusitis disability warrants a compensable rating. See August 2017 VA Form 9 at 2. 

The question for the Board is whether the Veteran has established entitlement to a compensable disability rating for his service-connected sinusitis at any time across the appeal period. For the reasons discussed below, the Board concludes the evidence does not support the assignment of a compensable disability rating. 

The Veteran's service-connected sinusitis is rated under DC 6513, maxillary sinusitis. That code instructs the rating official to rate the disorder under the General Rating Formula for Sinusitis. Under the general rating formula (located under DC 6514), a noncompensable (0 percent) disability rating is warranted when sinusitis is detected by X-ray only. A 10 percent rating is warranted for sinusitis manifested by one or two incapacitating episodes per year of sinusitis requiring prolonged (lasting four to six weeks) antibiotic treatment. An incapacitating episode of sinusitis is specifically defined in the regulations as one requiring bed rest and treatment by a physician. 38 C.F.R. § 4.97. A 10 percent rating is also warranted for sinusitis manifested by three to six non-incapacitating episodes per year of sinusitis characterized by headaches, pain, and purulent discharge or crusting. "Purulent" is defined as pertaining to or consisting of pus; containing pus. DORLAND'S at 1534. 

The next higher rating, a 30 percent rating, is warranted for sinusitis manifested by three or more incapacitating episodes per year of sinusitis requiring prolonged (lasting four to six weeks) antibiotic treatment. A 30 percent rating is also warranted for sinusitis manifested by more than six non-incapacitating episodes per year of sinusitis characterized by headaches, pain, and purulent discharge or crusting. The next higher rating, a 50 percent rating, is warranted if the Veteran has received radical surgery with chronic osteomyelitis; or near constant sinusitis characterized by headaches, pain, and purulent discharge or crusting. A 50 percent rating is the highest rating available under DC 6513.

A.	Entitlement to a compensable disability rating for sinusitis at any time across the appeal period. 

After a review of the record, the Board concludes the evidence does not support finding the Veteran's sinusitis was manifested by incapacitating episodes during a 12-month period. An incapacitating sinusitis episode is defined as one requiring bed rest and treatment by a physician. 38 C.F.R. § 4.97. Although the record reflects lay statements reporting on the severity of his sinusitis symptomatology, none of them indicate he had required bed rest. See April 2012 Statement at 1 (asserting his symptoms persist even though he uses sinus medications); July 2016 Report of General Information (provided general assertion that sinus symptoms have worsened); January 2017 VA DBQ at 1 (reported he uses antihistamines and nasal spray to keep his disorder under control); December 2019 VA DBQ at 1, 2 (reported persistent symptoms, to include runny nose, congestion, and flares of increased congestion, pain, drainage). 

His statements to the VA as well as medical providers give an account of his symptoms but do not indicate episodes that were so severe he required bed rest. For example, in June 2018 he contacted his provider and reported sinus congestion lasting six days but would have difficulty showing for an appointment due to work activities. See June 25, 2018, Tricare Record by B.B. Statements like the one provided suggest he remained active while observing symptoms. 

Even if the Veteran's statements indicated he observed sinusitis episodes that limited him to bed rest, the available evidence does not show he received antibiotic treatment lasting four to six weeks. There is no record of antibiotic treatment from the beginning of the appeal period through January 2017. Based on his reports to the VA examiner during the January 2017 disability examination, there is no reason to believe such records would be found. See VA DBQ at 1 (noting the Veteran's report that he had not been prescribed antibiotics for several years). 

Even if the Veteran contends his recollection had not been accurate, there is other credible evidence showing he had not been received antibiotic treatment lasting four to six weeks. The examiner who prepared the December 2019 VA DBQ did not find records of prescribed antibiotics before August 2019, which the Veteran reported was for a treatment period lasting 10 days. See VA DBQ (noting infections were treated in June and July 2018, and antibiotics were prescribed in August 2019). The Board notes the record shows antibiotics were prescribed in 2018, but those were for a course of treatment lasting six days. See June 1, 2018, Tricare Record by G.B., MD (noting prescription of azithromycin with instructions to take one pill for six days).

Given that the record does not support finding the Veteran's sinusitis was manifested by one or two episodes of sinusitis per year requiring bed rest and prolonged antibiotic treatment, he has not established entitlement to a compensable rating under DC 6513 based on incapacitating episodes. For a 10 percent rating under 6513 the Veteran's sinusitis must have been manifested with one to two incapacitating episodes that require prolonged antibiotic treatment. Because he has not met the criteria for a 10 percent rating, he is unable to meet the requirements for the next higher (30 percent) rating under 6513. Diagnostic Code 6513 requires three or more incapacitating episodes per year. 38 C.F.R. § 4.97.

With regards to the assignment of a compensable rating based on non-incapacitating episodes, the medical or lay evidence does not show episodes characterized by headaches, pain, and purulent discharge or crusting. See April 3, 2017, Tricare Record by G.B., MD (noting reports of congestion, cough, postnasal drip, lasting three days); June 25, 2018, Tricare Record by B.B. (noting reports of congestion, cough, lasting six days); June 28, 2018, Tricare Record by B.G., MD (noting reports of cough, congestion, postnasal drip, fever); December 2019 VA DBQ at 1, 2 (noting running nose, congestion, flares that include severe congestion, nasal pain, drainage). Neither does the record support finding that symptomatology occurred at a frequency of three to six episodes per year. See December 2019 VA DBQ (noting one treatment for sinusitis between December 2018 and December 2019, and two episodes in 2018).

Given that the Veteran has not alleged he observed episodes that meet the criteria DC 6513 requires for a 10 percent rating based on non-incapacitating episodes, the Board finds the medical evidence weighs strongly against finding the assignment of a compensable rating based on non-incapacitating episodes is warranted. Diagnostic code 6513 requires three to six episodes of non-incapacitating episodes in a 12-month period. Because he has not met the criteria for a 10 percent rating under 6513 based on non-incapacitating episodes, he is unable to meet the requirements for the next higher (30 percent) rating under 6513. Diagnostic Code 6513 requires more than six non-incapacitating episodes per year characterized by headaches, pain, and purulent discharge or crusting. 38 C.F.R. § 4.97. DCs 6513.

The Board recognizes the Veteran has, at times, reported he manages some of his sinusitis symptoms through the use of over the counter medication; however, the available evidence does not indicate a compensable rating under DC 6513 would have been warranted if he had not enjoyed the relief provided by his medication. Jones v. Shinseki, 26 Vet. App. 56, 63 (2012). First, when the Veteran's statements are considered as a whole, he has provided contrary statements on the effectiveness of his medications. See April 2012 Statement at 1 (asserting his sinusitis symptoms persist even though he uses medication); January 2017 VA DBQ at 1 (reported he uses antihistamines and nasal saline spray to control his symptoms); December 2019 VA DBQ at 2, 3 (reported he use antihistamines and nasal saline spray, but symptoms persist).

The Board recognizes disorders can progress through time and the Veteran reported worsening symptoms in July 2016, but the report of worse symptoms predates a statement indicating he has his symptoms under control. See January 2017 VA DBQ at 1. Due to the inconsistency between the Veteran's statements, the Board cannot decide the extent of the relief provided by over-the-counter medications based on his statements alone.

Given that the record shows the Veteran contacted his medical provider several times throughout the appeal period for sinusitis symptoms that include cough, congestion, postnasal drip, pain, while using over-the-counter medicationthe Board finds the extent of relief he enjoyed from their use did not reduce his disability picture in a way that prevented the assignment of a compensable rating. Based on the frequency of his medical complaints, over-the-counter medication did not provide complete relief from his sinusitis symptoms. 

Also, he has not indicated he obtained relief from the symptoms listed in the criteria for a compensable rating under DC 6513, to include headaches, pain, and purulent discharge or crusting. Given that he described the extent of relief he obtained through over-the-counter medication to medical providers, the Board finds it is likely he would have reported obtaining relief from the symptoms listed in the criteria for a 30 percent rating under 6513, if observed. See June 28, 2019, Tricare Record by G.B., MD (reporting possible relief from fever or chills through over-the-counter medications); January 2017 VA DBQ at 1 (reporting he uses antihistamines and nasal saline spray to control his symptoms); December 2019 VA DBQ at 2, 3 (reporting he use antihistamines and nasal saline spray, but symptoms persist). 

In this case, the evidence weighs against finding the Veteran's service-connected sinusitis disability manifested with symptomatology that meets the criteria DC 6513 requires for a compensable rating. He has not described sinusitis episodes that are incapacitating and require prolonged antibiotic treatment. Neither does the record show three to six non-incapacitating sinusitis episodes characterized by headaches, pain, and purulent discharge or crusting. Because the frequency, duration, severity, of the Veteran's sinusitis disability does not meet the criteria for a 10 percent rating, consideration of a greater than 10 percent rating is not warranted. Accordingly, the Board finds the assignment of a compensable rating is not warranted at any time across the appeal period. 38 C.F.R. § 4.97, DCs 6513, 6514. 

B.	Entitlement to a compensable disability rating under other applicable diagnostic codes.

The evidence of record does not show other DCs are applicable to this increased rating claim. The Veteran has not been diagnosed with any other forms of sinusitis, to include ethmoid, sphenoid, frontal, and pansinusitis; therefore, DCs 6510, 6511, 6512 do not apply to the Veteran's claim. The Board also finds consideration of other applicable DCs for the Veteran's individual symptoms is not warranted. The symptoms described, like congestion, postnasal drip, and cough are noted with findings of sinusitis, which indicates sinusitis is the predominant disability. A single rating will be assigned under the DC which reflects the predominant disability. 38 C.F.R. § 4.96(a). 

In sum, the available evidence shows that the severity of the Veteran's service-connected sinusitis does not warrant a compensable rating under DC 8100, throughout the entire period on appeal. Accordingly, the Veteran's increased rating claim must be denied. 

6. Entitlement to an initial compensable disability rating for GERD prior to December 20, 2019, and a greater than 30 percent rating on and after that date.

The Veteran contends the severity of his service-connected GERD warrants a compensable rating before December 20, 2019. See March 2018 Notice of Disagreement (NOD). 

The questions for the Board are whether the Veteran has established entitlement to a compensable disability rating for his service-connected GERD before December 20, 2019, and a greater than 30 percent rating on and after that date. For the reasons discussed below, the Board concludes the evidence does not support the assignment of a compensable rating before December 20, 2019. Neither does the evidence support the assignment of a greater than 30 percent disability rating on and after that date.

The Veteran's service-connected GERD is rated as 30 percent disabling under DC 7399-7346, from December 20, 2019. Hyphenated diagnostic codes are used when a rating under one DC (7399, which rates disabilities of the digestive system) requires the use of an additional DC to identify the basis for the evaluation assigned. The additional code is shown after the hyphen. The hyphenated code for the Veteran's disability is 7346, which rates hiatal hernia. In this case, GERD is not listed in the rating schedule and the hyphenated codes reflect that the Veteran's disorder is more closely captured by the symptoms listed under hiatal hernia. 

A.	Entitlement to a compensable disability rating for GERD before December 20, 2019. 

Turning to the Veteran's claim for disability compensation, the first question is whether there is sufficient evidence to find a compensable disability rating GERD before December 20, 2019. 

To answer that question, the first issue is whether the Veteran's GERD medication had any ameliorative (alleviating) effects on the Veteran's disability picture. It is significant because a higher rating may not be denied on the basis of relief provided by medication when those effects are not specifically contemplated by the rating criteria. Jones, 26 Vet. App. at 63. Diagnostic code 7346 does not contemplate relief through the use of medication. So, the Board must determine whether the relief the Veteran enjoyed from medication included relief from symptoms listed in 7346.

Based on a search of the Veteran's statements throughout the relevant period, he used prescribed medication to manage indigestion and regurgitation (reflux). The Veteran has personal knowledge of symptoms observed when they are not relieved by medication that works at keeping them under control, like regurgitation. So, he is competent to report it. Layno, 6 Vet. App. at 469. A review of his Tricare records shows medical complaints of bloating and regurgitation when he stopped taking medication that effectively controlled his symptoms. Because reports to medical providers are generally found reliable, the Board finds his statements probative towards evaluating the extent of relief he obtained through the use of medication. See January 6, 2010, Tricare Record by G.B. (noting the Veteran reported that Nexium helped control bloating, lower rib soreness); May 11, 2010, Record by G.B. (noting the Veteran ran out of Nexium and started observing regurgitation); January 4, 2013, Record by G.B. (noting the Veteran reported Nexium provided relief from burning sensation in the throat); February 11, 2020, Record by R.P., MD (noting the Veteran reported abdominal bloating and regurgitation when using medication that was less effective than Nexium).

Given that he was seeking medical attention for GERD and reported some symptoms, like regurgitation, the Board finds it is likely he would have reported other symptoms observed when medication was not helping control his symptoms. Because the available record does not show reports of difficulty swallowing (dysphagia), heartburn (pyrosis), and substernal (chest) or arm or shoulder pain when not using Nexium, the Board assigned his statements significant weight against finding the use of medication provided relief from the symptoms listed in the criteria for a 30 percent rating under DC 7346 (dysphagia, pyrosis, or substernal or arm or shoulder pain).

If there are doubts about the Board's assessment of the record, the January 2017 VA disability examination supports the Board's finding. First, the Veteran reported Nexium has been effective at controlling his symptoms of bloating and regurgitation. See VA DBQ at 2. That statement indicates to the Board, the effects of his GERD medication did not provide relief from dysphagia, pyrosis, or substernal or arm or shoulder pain. 38 C.F.R. § 4.114.

Second, the VA examiner who conducted the January 2017 VA disability examination did not find any symptoms associated with GERD. See VA DBQ at 2. The examiner based his findings on the record, his personal examination, and Veteran's lay observations. So, the Board finds the examiner was aware of the relevant details of the Veteran's past medical history when he found the Veteran's GERD was manifested by one symptomregurgitation(reflux). Nievez-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2006). Given that the examiner is qualified to evaluate the record as well as the Veteran's lay observations and opine on the symptoms associated with the Veteran's GERD, the Board finds the VA DBQ is probative towards evaluating the range of symptoms associated with Veteran's GERD. Based on the examiner's findings, the Veteran's GERD was manifested one symptom listed in the criteria for a 30 percent rating under DC 7346 (regurgitation).  

In this case, the weight of the evidence is against finding GERD medication provided relief from any symptoms other than indigestion and regurgitation. The Veteran has expressly stated it controlled those symptoms and the record shows when he took medication that was less effective at providing relief he observed bloating and regurgitation. Also, the VA examiner who conducted the January 2017 VA DBQ found the symptoms associated with GERD were limited to regurgitation. 

Now that the Board has determined the Veteran's GERD medication effected the severity of his regurgitation, the next issue is whether the evidence supports the assignment of a compensable disability rating. As noted above, the Veteran expressed his GERD is manifested by bloating and regurgitation. See January 2017 VA DBQ at 2. Considering the medical evidence through December 20, 2019, show medical complaints limited to bloating, abdominal pain associated with bloating, and regurgitation, the Board finds the Veteran's reports to medical providers highly probative towards finding a compensable rating is not warranted during the relevant period. 

Based on the Veteran's lay reports and statements to medical providers, he is not entitled to a compensable disability rating. Under DC 7346 a 10 percent rating is warranted when the Veteran's GERD is manifested by two or more of the following: dysphagia, pyrosis, and regurgitation, substernal or arm or shoulder pain. 38 C.F.R. § 4114. Given that the Veteran has indicated his GERD was manifested by one symptom (regurgitation) that is listed in the criteria for a 30 percent rating under DC 7346. His statements do not support the assignment of a compensable disability rating. 

Also, the January 2017 VA DBQ provides medical evidence that weighs against finding a compensable rating is warranted before December 20, 2019. The examiner found the Veteran's GERD was manifested by one of the symptoms listed in the criteria for a 30 percent rating (regurgitation). Given that the examiner is a medical professional, and therefore, likely to accurately identify whether the Veteran's GERD was manifested by dysphagia, pyrosis, and regurgitation, substernal or arm or shoulder pain, it is assigned significant weight against finding a compensable rating was warranted during the relevant period. 

The Board recognizes there is a period of two years between the January 2017 and December 2019 VA DBQs; however, there is insufficient evidence to approximate a point in time that the Veteran's GERD manifested with symptoms that meet the criteria DC 7346 contemplates for a compensable rating. He has not provided lay assertions indicating when his GERD symptoms manifested with symptomatology that meets the criteria for a compensable rating before December 20, 2019. Neither does the available record show medical complaints of more symptoms listed in DC 7346, like dysphagia, pyrosis. So, the Board could not ascertain an approximate point in time that the assignment of a compensable rating was warranted before December 20, 2019. Hart, 21 Vet. App. at 509-10.

In this case, the weight of the evidence is against finding a compensable disability rating for GERD was warranted before December 20, 2019. The Veteran has not asserted he observed two or more symptoms listed in the criteria for a 30 percent rating under DC 7346. A search of the record does not support finding his GERD manifested with two or more of the relevant symptoms. Also, the examiner who prepared the January 2017 VA DBQ found the Veteran's symptomatology included one of the relevant symptoms (regurgitation). So, doubt on that matter is not resolved in the Veteran's favor. 38 C.F.R. § 4.3. Accordingly, assignment of a compensable rating under DC 736 is not warranted prior to December 20, 2019. 38 C.F.R. § 4.114.

B.	Entitlement to a greater than 30 percent disability rating on and after December 20, 2019. 

The December 20, 2019, VA DBQ weighs strongly against finding the current severity of the Veteran's GERD warrants a greater than 30 percent rating at this time. The examiner considered his personal examination and evidence of record, to include the Veteran's lay observations, when he made his findings. So, the Board finds the examiner was aware of the relevant details of the Veteran's medical history when he found the Veteran's GERD is manifested by dysphagia, pyrosis, and regurgitation, accompanied by substernal pain productive of considerable impairment of health. Nievez-Rodriguez, 22 Vet. App. at 301. 

Based on the examiner's description of the Veteran's disability picture, the Veteran is entitled to a disability rating of 30 percent, which is the rating currently assigned. The examiner did not find vomiting, material weight loss and hematemesis (vomiting of blood) or melena (dark colored feces stained with blood pigments or with altered blood) with moderate anemia; or other symptom combinations productive of severe impairment of health as required for the assignment of the next higher (60 percent) rating under DC 7346. See December 2019 VA DBQ at 2.

The Board notes the medical records that postdate the December 2019 VA DBQ support the VA examiner's findings. From December 2019, the Veteran had visited his medical provider for complaints of abdominal pain, bloating, diarrhea, reflux. See February 11, 2020, Tricare Record by R.P., MD (noting the Veteran reported bloating and regurgitation when using medication that is less effective than Nexium); April 6, 2020, Tricare Record by R.P., MD (noting reports of regurgitation, abdominal pain). Given that he was seeking medical attention for GERD and reported some symptoms, like regurgitation, the Board finds it is likely he would have reported other symptoms, to include vomiting, material weight loss and hematemesis or melena with moderate anemia; therefore, the Board assigned his statements probative weight against finding his GERD was manifested with symptom combinations productive of severe impairment of health. 

In this case, the evidence weighs against finding the Veteran's service-connected GERD is manifested by symptomatology that meets the criteria DC 7346 requires for a greater than 30 percent rating. He has not asserted he observes symptoms listed in the criteria for a 60 percent rating under 7346. A search of the record does not show medical complaints referencing symptoms like hematemesis, melena. Also, the VA examiner who examined the Veteran in December 2019 did not find symptom combinations productive of severe impairment of health. Accordingly, the Board finds the assignment of a disability rating greater than the currently assigned rating (30 percent) is not warranted. See 38 C.F.R. § 4.114.

C.	Entitlement to a greater than 30 percent disability under other applicable diagnostic codes.

The available evidence does not show other DCs are applicable to this increased rating claim. The Board also finds consideration of other applicable DCs for the Veteran's individual symptoms is not warranted. The symptoms described, like bloating, difficulty sleeping occur while observing reflux, occur while observing GERD indicating it is the predominant disability. See December 2019 VA DBQ at 1, 2. A single rating will be assigned under the DC which reflects the predominant disability. 38 C.F.R. §§ 4.113, 4.114. 

In sum, the available evidence shows that the severity of the Veteran's service-connected GERD does not warrant a greater than 30 percent rating under DC 7346 or any other code, on and after December 20, 2019. Accordingly, the Veteran's increased rating claim must be denied. 

7. Entitlement to an initial compensable rating for onychomycosis.

The Veteran contends the severity of his service-connected onychomycosis warrants a compensable rating. See March 2018 NOD. 

The question for the Board is whether the Veteran has established entitlement to a compensable disability rating for his service-connected onychomycosis at any time across the appeal period. For the reasons discussed below, the Board concludes the evidence does not support the assignment of a compensable disability rating. 

The Veteran's service-connected onychomycosis is rated under DC 7813-7806. As noted above, hyphenated diagnostic codes are used when a rating under one DC requires the use of an additional DC to identify the basis for the evaluation assigned. Diagnostic code 7813 rates certain fungal infections. The additional code shown after the hyphen (7806) rates eczema and dermatitis. The hyphenated codes reflect that the Veteran's skin disorder is more closely captured by the symptoms listed under the rating criteria for eczema or dermatitis. 

There are two versions of DC 7806 that have been in effect since the filing of the Veteran's claim. One that was in effect before August 13, 2018, and one that became effective on and after that date. Under the version of DC 7806 that was in effect before August 13, 2018, a noncompensable rating is warranted where less than five percent of the entire body or less than five percent of exposed areas are affected, and no more than topical therapy was required during the past 12-month period. A 10 percent rating is warranted under at least one of the following: (i) when at least five percent, but less than 20 percent, of the entire body are affected; (ii) when at least five percent, but less than 20 percent of exposed areas are affected; or (iii) when systemic therapy such as corticosteroids or other immunosuppressive drugs were required for a total duration of less than six weeks during the past 12-month period. 38 C.F.R. § 4.118.

The next higher rating, a 30 percent rating is warranted under at least one of the following: (i) when 20 to 40 percent of the entire body is affected; (ii) when 20 to 40 percent of exposed areas are affected; or (iii)  when systemic therapy such as corticosteroids or other immunosuppressive drugs was required for a total duration of six weeks or more, but not constantly, during the past 12-month period. 

The next higher rating, a 60 percent rating, is warranted under one of the following: (i) when more than 40 percent of the entire body or more than 40 percent of exposed areas are affected; (ii) when constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs was required during the past 12-month period. A 60 percent rating is the highest rating available under the version of DC 7806 in effect before August 13, 2018. Id. 

Under the version of DC 7806 that became effective on and after August 13, 2018, dermatitis or eczema is evaluated under the General Rating Formula for the Skin. Under that rating formula, a noncompensable rating is warranted when no more than topical therapy was required over the past 12-month period and at least one of the following: (i) characteristic lesions involving less than five percent of the entire body affected; or (ii) characteristic lesions involving less than five percent of exposed areas affected.

A 10 percent rating is warranted for at least one of the following: (i) characteristic lesions involving at least five percent, but less than 20 percent, of the entire body affected; (ii) at least five percent, but less than 20 percent, of exposed areas affected; or (iii) intermittent systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, PUVA (photochemotherapy, psoralen with long-wave ultraviolet-A light) or other immunosuppressive drugs required for a total duration of less than six weeks over the past 12-month period. 

A 30 percent rating is warranted for at least one of the following: (i) characteristic lesions involving 20 to 40 percent of the entire body; (ii) 20 to 40 percent of exposed areas affected; or (ii) systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, PUVA, or other immunosuppressive drugs required for a total duration of six weeks or more, but not constantly, during the past 12-month period. 

The next higher rating, a 60 percent rating, is warranted when at least one of the following: (i) characteristic lesions involving more than 40 percent of the entire body or more than 40 percent of exposed areas affected; or (ii) constant or near-constant systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, PUVA or other immunosuppressive drugs required over the past 12-month period. A 60 percent rating is the highest rating available under DC 7806.

Although the VA regulations for DC 5271 have been changed during the appeal period, the Board can apply whichever set of criteria is more favorable to periods after August 13, 2018, if the claim was pending prior to that date. Kuzma v. Principi, 341 F.3d 1327, 1328 (Fed. Cir. 2003).

A.	Entitlement to a compensable disability rating for onychomycosis at any time across the appeal period. 

After a review of the record, the Board concludes the evidence does not support finding the Veteran's onychomycosis affected at least five percent of the total body or exposed areas of the body, like face, neck, and hands. The Veteran has not asserted his skin disorder affected any portion of his body other than his toenails. See April 2012 Statement (describing his disorder as a nail infection); January 2017 VA DBQ at 1 (describing skin disorder as a toenail problem); December 2019 VA DBQ at 1 (reported his skin disorder affects his toenails). Because he can generally see how much of his body is affected by the disorder, he is competent to report it. Layno, 6 Vet. App. at 469. Given that he has consistently maintained the affected area is limited to his toenails, the Board finds his statements probative towards evaluating whether onychomycosis affected more than five percent of his total body area. 

Because a person's toenails amount to a small percentage of the total body area, the Board finds the Veteran's statements weigh strongly against finding a compensable rating. The versions of DC 7806 in effect before August 13, 2018, and the version in effect after that date require at least five percent of the of the entire body affected. 38 C.F.R. § 4.118. Based on the Veteran's descriptions of the extent of the areas affected, the Veteran is entitled to a noncompensable rating. A noncompensable rating is the rating currently assigned. 

If there is any question about the Veteran's ability to accurately detect signs of his specific form of skin disorder, the January 2017 and December 2019 VA DBQs provide medical evidence that support the Veteran's lay observations. The examiners who prepared those VA DBQs conducted personal examinations of the Veteran and found his skin disorder does not affect any other portion of his body than his toes. See VA DBQs at 1, 2. Although the examiner who prepared the December 2019 VA DBQ noted the Veteran's skin disorder had spread, the extent of the spreading was limited to the rest of his toes. See VA DBQ at 1. Given that the examiners are qualified to detect signs of a skin disorder on the Veteran's body, the Board finds the January 2017 and December 2019 VA DBQs highly probative towards evaluating whether the Veteran met the criteria DC 7806 requires for a compensable rating. 

With regards to a compensable rating based on percentage of exposed areas of the body, the evidence does not indicate exposed areas, like face, neck, and hands have been affected by onychomycosis. As noted above, the Veteran has not indicated any portion of his exposed areas have been affected by onychomycosis. His observations are supported by the findings of the VA examiners who conducted their own examinations of the Veteran in January 2017 and December 2019; the VA examiners did not find any exposed areas have been affected. See VA DBQs at 2. Based on the Veteran's lay descriptions and the medical findings in the VA DBQs, the Veteran is not entitled to a compensable disability rating based on percentage of exposed areas of the body affected. The versions of DC 7806 in effect before August 13, 2018, and the version in effect after that date require at least five percent of the exposed areas to be affected for the assignment of a 10 percent rating. 38 C.F.R. § 4.118. Based on the evidence available, the Veteran is entitled to a noncompensable rating. A noncompensable rating is the rating currently assigned. 

With regards to the assignment of a compensable disability rating based on intermittent systemic therapy or immunosuppressive drugs, the available record does not show the Veteran was the recipient of either form of treatment during the appeal period. Systemic therapy means "treatment pertaining to or affecting the body as a whole." Johnson v. Shulkin, 862 F.3d 1351, 1354-56 (Fed. Cir. 2017). In contrast, topical therapy means "treatment pertaining to a particular surface area, as a topical anti-infective applied to a certain area of the skin and affecting only the area to which it is applied." Id. 

Based on a review of the January 2017, December 2019 VA DBQs, and available evidence, the Veteran did not use any form of prescribed medications or therapy until around the time he underwent his December 2019 disability examination. See VA DBQ at 2. The medication he reported using at that time was topical antifungal medication. The versions of DC 7806 in effect before August 13, 2018, and the version in effect after that date require intermittent systemic therapy including, but not limited to, corticosteroids, and other immunosuppressive drugs for the assignment of a 10 percent rating. 38 C.F.R. § 4.118. Because the record reflects the Veteran's treatment was limited to topical therapy, he has not met the criteria 7806 requires for the assignment of a compensable rating based on medical treatment. Johnson, 862 F. 3d. at 1354-56. 

In this case, the weight of the evidence is against finding the Veteran met the criteria for a compensable rating based on the version of DC 7806 that was in effect before August 18, 2018, or the version that applied on and after that date. As noted above, the Veteran has described a skin disorder that only affects his toenails. Also, he has not received systemic therapy to treat his skin disorder during the appeal period. Given that he has not met the criteria 7806 requires for a 10 percent rating, consideration of greater than 10 percent rating is not warranted at this time. A greater than 10 percent rating under 7806 require larger areas of the body to be affected than the criteria for a 10 percent rating. 38 C.F.R. § 4.118. Accordingly, the evidence does not support finding a compensable rating under 7806 is warranted at this time.

B.	Entitlement to a compensable disability rating for onychomycosis under other applicable diagnostic codes.

The evidence of record does not show other DCs are applicable to this increased rating claim. Given that there is no indication of disfigurement of the head, face, or neck, consideration of a rating under DC 7800 is not warranted. Neither does the record reflect he has scars associated with his skin disability; therefore, consideration of disability ratings under DCs 7801-7805 are not warranted. 

In this case, the evidence weighs against finding the Veteran's service-connected onychomycosis of the toes is manifested by symptomatology that meets the criteria DC 7806 requires for a compensable rating. So, the Board finds the assignment of a compensable rating is not warranted at any time across the appeal period. See 38 C.F.R. § 4.118, DC 7806. Accordingly, the Veteran's increased rating claim must be denied. 

Also, the Board notes that none of the Veteran's claims raise the issue of entitlement for a TDIU. Although the Veteran has claimed his knee disabilities affect his ability to run, go up and down stairs, he has not asserted it prevents him from working. Similarly, even though he has indicated his service-connected sinusitis, GERD, cause respiratory and abdominal problems, he has not asserted they prevent him from working. Likewise, even though the Veteran has reported his onychomycosis of the toes restricts him from wearing certain shoes, he has not asserted the disorder prevents him from working. 

Further, the record reflects he has been employed throughout the appeal period. See November 26, 2014, Tricare Record by S.S., MD (Veteran indicated he has a sedentary job); June 25, 2018, Tricare Record by B.B. (the Veteran referenced a job that interferes with his ability to make an appointment); December 2019 VA Skin Diseases DBQ at 1(Veteran reported he is working). Thus, there is no indication that he is unable to secure or follow a substantially gainful occupation as a result of one or more of his service-connected disabilities. 38 C.F.R. § 4.16(a); Rice v. Shinseki, 22 Vet. App. 447, 454 (2009). The Board regrets a more favorable decision could not be reached in the Veteran's case. 

 

DAVID L. WIGHT

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	Dean, Michael S.

The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.