Citation Nr: 21073471 Decision Date: 12/08/21 Archive Date: 12/08/21 DOCKET NO. 15-36 357 DATE: December 8, 2021 ORDER Entitlement to service connection for a neurological disability of the left arm, claimed as numbness, is denied. Entitlement to service connection for a neurological disability of the right arm, claimed as numbness, is denied. Entitlement to service connection for a neurological disability of the left leg, claimed as nerve damage, is denied. Entitlement to service connection for a neurological disability of the right leg, claimed as nerve damage, is denied. Entitlement to a disability rating in excess of 20 percent for a disability of the right shoulder is denied. Entitlement to a disability rating in excess of 10 percent rating for a disability of the right elbow is denied. Entitlement to a disability rating in excess of 10 percent for degenerative joint disease of the cervical spine (neck condition) is denied. Entitlement to a disability rating in excess of 10 percent for lumbosacral strain (back condition) with degenerative disease is denied. Entitlement to a disability rating in excess of 10 percent for degenerative joint disease of the right knee is denied. Entitlement to a disability rating in excess of 10 percent for degenerative joint disease of the left knee, prior to June 27, 2012, is denied. Entitlement to a disability rating in excess of 30 percent for left knee replacement, since August 1, 2013, is denied. Entitlement to a separate 20 percent rating for a torn, symptomatic meniscus of the left knee is granted from December 4, 2008 to June 27, 2012. FINDINGS OF FACT 1. The probative evidence of record does not demonstrate that the Veteran's neurological disabilities of the bilateral upper extremities and bilateral lower extremities are etiologically related to his military service, to include as secondary to a service-connected condition. 2. The probative evidence of record demonstrates that the Veteran's right shoulder disability manifests in symptomology of limitation of motion to the shoulder level, but not limited to midway between the side and shoulder level. 3. The probative evidence of record demonstrates that the Veteran's elbow manifested in painful motion, but with no flail joint, false flail joint, malunion or nonunion of the radius or ulna. 4. The probative evidence of record demonstrates that the Veteran's cervical spine manifested in slightly limited flexion and 193 degrees combined range of motion, but without forward flexion of the cervical spine greater than 15 degrees but not greater than 30 degrees. There was no muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour, or ankylosis. 5. The probative evidence of record demonstrates that the Veteran's lumbar spine manifested in flexion limited to 80 degrees and his total range of motion was limited to 195 degrees, but without forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis; or ankylosis of the lumbar spine or the functional equivalent thereof. 6. The probative evidence of record demonstrates that the Veteran's right knee manifested in painful flexion and extension, but is not limited to 30 degrees flexion or 15 degrees extension. 7. The probative evidence of record demonstrates that the Veteran's left knee manifested in painful flexion and extension, but is not limited to 30 degrees flexion or 15 degrees extension. 8. The Veteran had a left knee replacement June 27, 2012. Since the applicable presumptive recovery period of one year ended on August 1, 2013, the probative evidence regarding the Veteran's postoperative residuals does not demonstrate severe painful motion or weakness. 9. The probative evidence of record demonstrates that the Veteran had a torn meniscus of his left knee prior to his knee replacement, from December 4, 2008 to June 27, 2012. CONCLUSIONS OF LAW 1. The criteria for service connection for a neurological disability of the left arm are not met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 2. The criteria for service connection for a neurological disability of the right arm are not met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 3. The criteria for service connection for a neurological disability of the left leg are not met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 4. The criteria for service connection for a neurological disability of the right leg are not met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 5. The criteria for a rating in excess of 20 percent for a right shoulder disability have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.6, 4.7, 4.118, 4.71a, Diagnostic Code 5201, 5010. 6. The criteria for a rating in excess of 10 percent for a right elbow disability are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.7, 4.10, 4.20, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5299-5206 & 5205 to 5213 7. The criteria for a rating greater than 10 percent for a neck condition have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5242. 8. The criteria for a rating in excess of 10 percent for a back condition have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5242. 9. The criteria for a rating in excess of 10 percent for a right knee condition have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Codes 5003, 5260. 10. The criteria for a rating in excess of 10 percent for a left knee condition, prior to June 27, 2012, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Codes 5003, 5260 11. The criteria for a rating in excess of 30 percent for residuals of a left knee replacement, effective August 1, 2013, are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5055, 5256, 5261, 5262. 12. The criteria for a separate 20 percent rating for a torn left meniscus have been met from December 4, 2008 to June 27, 2012. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5258. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from August 1970 to August 1994. This case comes before the Board of Veterans' Appeals (Board) from an August 2010 rating decision from a Department of Veterans Affairs (VA) Regional office (RO). The Veteran's claims were most recently before the Board in March 2019 wherein they were remanded to the agency of original jurisdiction (AOJ) for additional development. This development included obtaining VA and private treatment records, Social Security Administration (SSA) records, and VA examinations. The agency of original jurisdiction (AOJ) complied with the remand instructions because they requested and obtained the records and attempted to obtain VA examinations. However, the record indicates that once contacted about the examinations, the Veteran declined the examinations. "[T]he duty to assist in the development and adjudication of a claim is not a one-way street." Wamhoff v. Brown, 8 Vet. App. 517, 522 (1996). "If a veteran wishes help, he cannot passively wait for it in those circumstances where he may or should have information that is essential in obtaining the putative evidence." Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). It is the responsibility of appellants to cooperate with VA. See Olson v. Principi, 3 Vet. App. 480, 483 (1992). As the Veteran declined examinations (rather than missing them and asking to reschedule), the Board will not remand the Veteran's claim to allow for another opportunity to schedule the exams. Further, the Board notes that the last time the Veteran, as opposed to his representative, had any contact with VA about any current or new claim for benefits, was in October 2015, over six years ago. Nevertheless, the Board will adjudicate the Veteran's claims considering the evidence of record. Service Connection 1. Entitlement to service connection for a neurological disability of the left arm, claimed as numbness, is denied. 2. Entitlement to service connection for a neurological disability of the right arm, claimed as numbness, is denied. 3. Entitlement to service connection for a neurological disability of the left leg, claimed as nerve damage, is denied. 4. Entitlement to service connection for a neurological disability of the right leg, claimed as nerve damage, is denied. On his September 2009 application for service connection, the Veteran claimed that he had numbness of the bilateral upper extremities numbness and nerve damage of the bilateral lower extremities. He contended that these conditions were secondary to his service-connected cervical and lumbar spine conditions, respectively. He echoed these contentions on his March 2011 notice of disagreement. Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). Service connection may be granted for a disability that is proximately due to, or aggravated by, service-connected disease or injury. 38 C.F.R. § 3.310. However, VA will not concede that a nonservice-connected disease or injury was aggravated by a service-connected disease or injury unless the baseline level of severity of the nonservice-connected disease or injury is established by medical evidence created before the onset of aggravation or by the earliest medical evidence created at any time between the onset of aggravation and the receipt of medical evidence establishing the current level of severity of the nonservice-connected disease or injury. Lay witnesses are competent to provide testimony or statements relating to symptoms or facts of events that the lay witness observed and is within the realm of his or her personal knowledge, but not competent to establish that which would require specialized knowledge or training, such as medical expertise. Layno v. Brown, 6 Vet. App. 465, 470 (1994). Lay evidence may also be competent to establish medical etiology or nexus. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). However, "VA must consider lay evidence but may give it whatever weight it concludes the evidence is entitled to." Waters v. Shinseki, 601 F.3d 1274, 1278 (2010). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the Veteran. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Analysis The Board finds that the Veteran has a current disability of "neurological impairment" of the bilateral upper extremities and bilateral lower extremities. In the instant case, the Board finds that the Veteran is competent to report that he experiences neurological symptoms. See Jandreau v. Nicholson, 492 F.3D. 1372, 1377 (Fed. Cir. 2007). However, the Board finds the exact diagnosis and relationship to service, to include as second to his service-connected disabilities, to be complex in nature. Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007). No medical opinion relates the Veteran's neurological impairments to his service-connected cervical or lumbar disabilities. In December 2009, while the Veteran complained of symptoms, the examiner did not link the neurological manifestations to the Veteran's neck and back disabilities. While there are medical records discussing the conditions, that alone is not sufficient as the records do not relate the Veteran's neurological disabilities to his service-connected back and neck disabilities. The Veteran's service treatment records (STRs) do not document these neurological impairments. Thus, the weight of the evidence is against the claims for service connection for neurological impairments of the bilateral upper extremities and bilateral lower extremities. Accordingly, the claims are denied. Absent a relative balance of the evidence for and against the claim, the evidence is not in equipoise and the benefit of the doubt doctrine does not apply. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Increased Ratings Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. The percentage ratings are based on the average impairment of earning capacity as a result of a service-connected disability, and separate diagnostic codes identify the various disabilities and the criteria for specific ratings. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. If two disability evaluations are potentially applicable, 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. Pertinent regulations do not require that all cases show all findings specified by the Rating Schedule, but that findings sufficiently characteristic to identify the disease and the resulting disability and above all, coordination of rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21. Therefore, the Board has considered the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the Veteran, as well as the entire history of the Veteran's disability in reaching its decision. Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). Staged ratings must be considered, which are appropriate when the evidence establishes that the claimed disability manifested symptoms that would warrant different ratings for distinct time periods during the appeal. Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007). See also Fenderson v. West, 12 Vet. App. 119, 126 (1999) (applying this concept to initial ratings). The Board has considered the record and has found that staged ratings are not warranted (except as previously granted) because the degree of disability has remained approximately the same during the period on appeal given the probative evidence of record. Diagnostic Code 5003 provides that degenerative arthritis that is established by X-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. When there is limitation of motion of the specific joint or joints that is compensable (10 percent or higher) under the appropriate diagnostic codes, the compensable limitation of motion should be rated under the appropriate diagnostic codes for the specific joint or joints involved. 38 C.F.R. § 4.71a. When evaluating musculoskeletal disabilities based on limitation of motion such as the Veteran's left ankle and back, when assessing the severity of musculoskeletal disabilities that are at least partly rated on the basis of limitation of motion, VA must also consider the extent that the Veteran may have additional functional impairment above and beyond the limitation of motion objectively demonstrated, such as during times when her symptoms are most prevalent ("flare-ups") due to the extent of her pain (and painful motion), weakness, premature or excess fatigability, and incoordination-assuming these factors are not already contemplated by the governing rating criteria. DeLuca v. Brown, 8 Vet. App. 202, 204-7 (1995); see also 38 C.F.R. §§ 4.40, 4.45, 4.59. Further, the final sentence of 38 C.F.R. § 4.59 requires that VA examinations include joint testing for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint. Correia v. McDonald, 28 Vet. App. 158 (2016). In Sharp v. Shulkin, 29 Vet. App. 26 (2017), the Court held that VA examiners must obtain information about the severity, frequency, duration, precipitating and alleviating factors, and extent of functional impairment of flares from the veterans themselves, when a flare-up is not observable at the time of examination. All reasonable doubt as to the degree of disability will be resolved in favor of the claimant. 38 U.S.C. § 5107 (b); 38 C.F.R. § 4.3. It is the Board's responsibility to determine whether a preponderance of the evidence supports the claim or whether the evidence is in relative equipoise, with the veteran prevailing in either event, or whether there is a preponderance of evidence against the claim, in which case the claim must be denied. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 5. Entitlement to a disability rating in excess of 20 percent for a disability of the right shoulder At the time of his September 2009 application, the Veteran was in receipt of a 10 percent rating for his right shoulder. Through a May 2020 rating decision, the Veteran was awarded a temporary total rating from June 1, 2009 to August 1, 2009. Thereafter, the Veteran was awarded a 20 percent rating from August 1, 2009. The Veteran contends that a higher rating is warranted because of pain, weakness, loss of flexibility, fatigue, and pain with repeated use. See VBMS, document labeled NOD, receipt date March 25, 2011. The Veteran's right shoulder disability is rated under 38 C.F.R. § 4.71a, Diagnostic Code 5201. Under Diagnostic Code 5201, limitation of motion of the arm at shoulder level warrants a 20 percent rating for both the major and minor extremity. Limitation of motion of the arm midway between side and shoulder warrants a 20 percent rating for the minor extremity and a 30 percent rating for the major extremity. Limitation of motion of the arm to 25 degrees from side warrants a maximum 30 percent rating for the minor joint and a maximum 40 percent rating for the major joint. 38 C.F.R. § 4.71a, Diagnostic Code 5201. Diagnostic Code 5201 "does not provide separate ratings for limitation of motion in the flexion and abduction planes, but rather is addressed generically to limitation of motion of the arm." Yonek v. Shinseki, 722 F.3d 1355, 1358 (Fed. Cir. 2013). The Veteran's right upper extremity is his dominant arm. During the pendency of this appeal, VA amended the Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 76453, 76463 (Nov. 30, 2020) (to be codified at 38 C.F.R. § 4.71a), effective from February 7, 2021. The descriptions of limitation of motion were clarified in this amendment. Limitation of motion of the arm at "the shoulder level" means flexion and/or abduction limited to 90 degrees. Limitation of motion of the arm "midway between the side and shoulder" is flexion and/or abduction limited to 45 degrees. Limitation of motion of the arm to 25 degrees from side is based on flexion and/or abduction. Evidence and analysis There is little in the file regarding objective findings related to the Veteran's right shoulder. The Veteran had a VA examination in December 2009. He reported daily pain, worse since a workplace injury February 2009. He reported that he took pain medications. The Veteran stated that during flare-ups of pain, he could not lift or reach past 90 degrees. Upon range of motion tested, the examiner found the Veteran's abduction was painful at 90 degrees (shoulder level). The examiner did not find additional limitation in range of motion after repetitions and did not provide an opinion during flare-ups. (The Board notes that while the examiner did not state "0 degrees lost" but rather "0 degrees", the Board finds that the examiner used the language "0 degrees lost" in the section before and after). The Veteran provided physical therapy records from January to September 2009 after his shoulder surgery. In September 2009, after physical therapy was completed, the Veteran's active range of motion was 125 degrees flexion and 75 degrees abduction. As the Veteran's range of motion improved by December 2009, the Board finds that improvement continued to occur after physical therapy ended. Given the above, the Board finds that the preponderance of the evidence is for a rating of 20 percent for his right shoulder disability, but no higher. The Veteran's shoulder pain limited his motion to 90 degrees at shoulder level, which warrants a 20 percent rating for both the major and minor extremity. This is consistent with the Veteran's reports at the VA examination and in his notice of disagreement. To the extent that the Veteran asserts a higher rating is warranted, the Board acknowledges the Veteran's lay reports of symptoms and that there was functional loss due to pain. However, even considering the Veteran's lay reports of symptoms and noted functional loss, the degree of additional limitation reflected by the statements that any sort of lifting would cause pain would not result in symptoms more nearly approximating limitation of motion of the arm midway between side and shoulder level (45 degrees). At most, during flare-ups and repetitive use, the Veteran would have 90 degrees abduction. The Board has considered whether any other Diagnostic Codes related to disabilities of the shoulder would provide for a higher disability rating. However, the evidence does not reflect that the symptoms would warrant a higher rating under a different Diagnostic Code. See 38 C.F.R. § 4.71a. The Board acknowledges that the Veteran believes that the disability on appeal has been more severe than the assigned disability rating reflects. Moreover, the Veteran is competent to report observable symptoms. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). However, the probative medical record does not substantiate greater limitations for the period on appeal and the Board finds the medical record more probative than the Veteran's lay statements. In conclusion, the Board finds that the preponderance of the evidence is against a rating in excess of 20 percent for a right shoulder disability. In granting such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. 6. Entitlement to a disability rating in excess of 10 percent rating for a disability of the right elbow is denied. At the time of his September 2009 application, the Veteran was in receipt of a non-compensable (0 percent) rating for his right elbow. Through a May 2020 rating decision, the Veteran was awarded a 10 percent rating effective September 30, 2009. The 10 percent rating was warranted based on painful limitation of motion. The Veteran reported in his notice of disagreement that he experienced great pain in his right elbow. See VBMS, document labeled NOD, receipt date March 25, 2011. Under Diagnostic Code 5206, the disability is rated based on limitation of flexion of the forearm. Limitation to 100 degrees is assigned a 10 percent rating. Limitation from 90 to 45 degrees warrants higher ratings from 20 to 40 percent for the minor arm. 38 C.F.R. § 4.71a. Under Diagnostic Code 5207, limitation of extension of the forearm requires limitation to 45 degrees or 60 degrees to be assigned a 10 percent rating. Limitation from 75 to 110 degrees warrants higher ratings from 20 to 40 percent for the minor arm. Id. Under Diagnostic Code 5208, a 20 percent rating is assigned for either side if forearm flexion is limited to 100 degrees and extension is also limited to 45 degrees. Id. Under Diagnostic Code 5213, impairment of supination or pronation may be rated based on loss of motion (bone fusion), limitation of pronation, or limitation of supination. Limitation of pronation of the minor side will be assigned a 20 percent rating for motion lost beyond last quarter of the arc so that the hand does not approach full pronation, or where there is pronation lost beyond the middle of the arc. Limitation of supination will be assigned a 10 percent rating for limitation to 30 degrees or less. Ratings of 20 or 30 percent are available for the minor arm for loss of supination or pronation due to bone fusion, with fixation of the hand. Id. In rating all forearm and wrist injuries, multiple impaired finger movements due to tendon tie-up, muscle or neve injury, are to be separately rated and combined, not to exceed the rating for loss of use of the hand. Id. at Note after Diagnostic Code 5213. Evidence and analysis There is little in the file regarding objective findings related to the Veteran's right elbow. The Veteran attended a VA examination in December 2009. The Veteran reported he experienced pain when writing and leaning on his elbow. Also, he may hit his elbow which would be painful. He reported symptoms of weakness, stiffness, fatigability, and lack of endurance. He took pain medications as needed. Upon examination, the examiner observed tenderness and guarding of movement, but he had virtually full range of motion without pain. The clinician did not find additional range of motion lost during flare-ups or repeated use. In consideration of the above, the Board does not find a rating in excess of 10 percent nor a separate rating for the Veteran's right elbow to be warranted. There is insufficient flexion, extension, supination, and/or pronation lost to warrant a higher or separate rating. The December 2009 VA examiner did not find additional range of motion lost during flare-ups or repeated use and the Veteran did not assert that to be the case. In this case, the Veteran's statements do not show that flareups or repeated use over time additionally limited function in a quantifiable way, or that they are of such length or duration that a higher or staged rating would not violate the rule regarding stabilization of ratings. The Board finds the VA examinations to be the most probative evidence of record related to the Veteran's elbow disability. While there are treatment records noting elbow pain, there are no VA or private treatment records that provide a numerical equivalent to range of motion lost. In summary, the evidence supports a 10 percent rating for the right elbow with pain and painful or limited motion that does not meet the compensable criteria under the applicable diagnostic codes for limitation of motion, to include Diagnostic Codes 5206, 5207, and 5208, based on competent and credible reports of pain and painful motion at times. There is no evidence of flail joint, false flail joint, malunion or nonunion of the radius or ulna, or effects on the fingers due to the left elbow disability to warrant a rating under Diagnostic Codes 5209 to 5213 or the note to the forearm and wrist injuries. In conclusion, the Board finds that the criteria for a rating in excess of 10 percent for a right elbow disability have not been met. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. 7. Entitlement to a disability rating in excess of 10 percent for degenerative joint disease of the cervical spine is denied. The Veteran is currently in receipt of a 10 percent rating for his neck disability. The Veteran contends that a higher rating is warranted because of pain, weakness, and stiffness all the time. See VBMS, document labeled NOD, receipt date March 25, 2011. The Veteran's neck condition is rated under 38 C.F.R. § 4.71a, Diagnostic Code 5242. Under the General Rating Formula for Diseases and Injuries of the Spine, a 10 percent rating is warranted for forward flexion of the cervical spine greater than 30 degrees but not greater than 40 degrees; or, combined range of motion of the cervical spine greater than 170 degrees but not greater than 335 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height. A 20 percent rating is warranted for forward flexion of the cervical spine greater than 15 degrees but not greater than 30 degrees; or, the combined range of motion of the cervical spine not greater than 170 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 30 percent rating is warranted for forward flexion of the cervical spine to 15 degrees or less; or favorable ankylosis of the entire cervical spine. A 40 percent rating is warranted for unfavorable ankylosis of the entire cervical spine. A 100 percent rating is warranted for unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine. Ankylosis is defined as "immobility and consolidation of a joint due to disease, injury, or surgical procedure." Dorland's Illustrated Medical Dictionary, 94 (32nd ed. 2012). Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. Id. at Note 5. Ankylosis can also mean the "functional equivalent" of ankylosis. Chavis v. McDonough, 34 Vet. App. 1 (2021). In addition to the neck rating, the schedule directs that any associated objective neurological abnormalities are to be evaluated separately under an appropriate diagnostic code. See "General Rating for Diseases and Injuries of the Spine, at Note 1. To the extent that radiculopathy is indicated, this is addressed in the service connection discussion above. Evidence and analysis Again, there is little objective evidence regarding the Veteran's neck disability. At the Veteran's December 2009 VA examination, the Veteran reported neck pain, radiation, stiffness, and weakness. The pain was aching and constant and he took pain medications as needed. He reported daily flare-ups of pain, without limited range of motionjust more pain. Upon range of motion testing, the Veteran had essentially full flexion, but his total range of motion was 193 degrees. The Board finds the VA examination to be the most probative evidence of record related to the Veteran's neck disability. The examiner has the medical expertise to assess objective limitations from the Veteran's service-connected disability. Thus, the Board gives the VA examination great probative weight. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). The Veteran's lay statements are mostly consistent with the findings of the VA examination. While there are treatment records noting neck pain, there are no VA or private treatment records that provide a numerical equivalent to range of motion lost. Given the above, the record does not substantiate that ratings in excess of those currently assigned are warranted. In order to warrant a higher initial rating, the Veteran's neck would have to meet one of the following: forward flexion of the cervical spine greater than 15 degrees but not greater than 30 degrees; or, the combined range of motion of the cervical spine not greater than 170 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. The Veteran's neck range of motion had only slightly limited flexion and his 193 combined range of motion is less than the requirement for a 20 percent rating. There is no indication of ankylosis or the "functional equivalent" of ankylosis. Chavis v. McDonough, 34 Vet. App. 1 (2021). In Sharp v. Shulkin, 29 Vet. App. 26 (2017), the Court held that VA examiners must obtain information about the severity, frequency, duration, precipitating and alleviating factors, and extent of functional impairment of flares from the veterans themselves, when a flare-up is not observable at the time of examination. The Veteran only pain during flare-ups, without range of motion lost. While the Veteran reported pain, flareups must be quantifiable and must result in limitation of motion of function beyond that contemplated by the already provided evaluation. Additionally, because there is a regulation addressing the stabilization of ratings, flareups must be of such length as to establish that the overall impairment is more severe than currently evaluated. In this instance, the Veteran's statements made in this case do not show that any flareups or repeated use over time have additionally limited function in a quantifiable way, nor do they show that they are of such length or duration that a higher rating would be warranted The specific clinical measures of ranges of motion, including examiners' findings and opinions regarding additional limitations of motion due to such factors, have been weighed and considered by the Board. Such specific measures and findings are of more probative value in determining specific ranges of motion than are general histories or general descriptions of symptoms of pain or limitations, such as this Veteran's report of pain and limitation of function. Despite the Veteran's contention of a greater degree of limitation on his neck condition, the disability rating assigned herein indicates a significant impact on his functional ability. Such disability evaluations assigned by VA recognizes his painful motion. The critical question in this case, however, is whether the problems he has cited meet an even higher level under the rating criteria. For reasons cited above, the Board finds they do not. For the foregoing reasons, the preponderance of the evidence is against the Veteran's claim for an increased rating for his neck disability. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7 8. Entitlement to a disability rating in excess of 10 percent for lumbosacral strain with degenerative disease is denied The Veteran is currently in receipt of a 10 percent rating for his back disability. The Veteran reported on his notice of disagreement that he has pain on use, weakness, stiffness in the morning and after sitting, pain when standing, that he has to shift weight, and he is unable to bend without pain. See VBMS, document labeled NOD, receipt date March 25, 2011. The Veteran's back condition is rated under 38 C.F.R. § 4.71a, Diagnostic Code 5242. Under the General Rating Formula for Diseases and Injuries of the Spine, a 10 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height. A 20 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent rating is warranted for forward flexion of the thoracolumbar spine to 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is warranted for unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent evaluation is warranted for unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine. Ankylosis is defined as "immobility and consolidation of a joint due to disease, injury, or surgical procedure." Dorland's Illustrated Medical Dictionary, 94 (32nd ed. 2012). Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. Id. at Note 5. Ankylosis can also mean the "functional equivalent" of ankylosis. Chavis v. McDonough, 34 Vet. App. 1 (2021). In addition to the back rating, the schedule directs that any associated objective neurological abnormalities are to be evaluated separately under an appropriate diagnostic code. See "General Rating for Diseases and Injuries of the Spine, at Note 1. To the extent that radiculopathy is indicated, this is addressed in the service connection discussion above. Evidence and analysis Again, there is limited objective evidence in the Veteran's file. The Veteran attended a VA examination in December 2009. He reported sharp low back pain that was constant. He took pain medications as needed and he experienced daily flare-ups of pain, especially when walking. Upon examination, his flexion was limited to 80 degrees and his total range of motion was limited to 195 degrees. The examiner did not find additional range of motion would be lost during flare-ups or after repeated use. The Board finds the most probative evidence of record to be the VA examination of record. The examiner has the medical expertise to assess objective limitations from the Veteran's service-connected disability. Thus, the Board gives the VA examination great probative weight. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). The Veteran's lay statements are mostly consistent with the findings of the VA examination. The examiner has the medical expertise to assess objective limitations from the Veteran's service-connected disability. While there are treatment records noting back pain, there are no VA or private treatment records that provide a numerical equivalent to range of motion lost. Given the above, the record does not substantiate that a rating in excess of the currently assigned rating is warranted. In order to warrant a higher rating (in excess of 10 percent), the Veteran's back would need to manifest in one of the following: (1) forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; (2) or the combined range of motion of the thoracolumbar spine not greater than 120 degrees; (3) muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis; or (4) ankylosis of the functional equivalent thereof. Here, the Board does not so find. At most, the Veteran had painful range of motion, but not limited as required above. The Veteran reported flare-ups during the period at issue. The clinician gave an estimated range of motion lost during flare-ups or with repeated use. The Board does not find that the Veteran's range of motion would be additionally limited, even considering the Veteran's pain on weightbearing and non-weightbearing, during passive range of motion, or considering functional loss. To approximate an initial 20 percent rating, the Veteran's range of motion would need to be substantially more limited. The Board does not find these limitations to be approximated. While the Veteran reported pain, flareups must be quantifiable and must result in limitation of motion of function beyond that contemplated by the already provided evaluation. Additionally, because there is a regulation addressing the stabilization of ratings, flareups must be of such length as to establish that the overall impairment is more severe than currently evaluated. In this instance, the Veteran's statements made in this case do not show that any flareups or repeated use over time have additionally limited function in a quantifiable way, nor do they show that they are of such length or duration that a higher rating would be warranted. The specific clinical measures of ranges of motion, including examiners' findings and opinions regarding additional limitations of motion due to such factors, have been weighed and considered by the Board. Such specific measures and findings are of more probative value in determining specific ranges of motion than are general histories or general descriptions of symptoms of pain or limitations, such. For the foregoing reasons, the preponderance of the evidence is against the Veteran's claim for increased rating for his back disability. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. 9. Entitlement to a disability rating in excess of 10 percent for degenerative joint disease of the right knee 10. Entitlement to a disability rating in excess of 10 percent for degenerative joint disease of the left knee, for the period between September 30, 2009 to June 27, 2012 11. Entitlement to a disability rating in excess of 30 percent for left knee replacement, since August 1, 2013 12. Entitlement to a separate 20 percent rating for a torn, symptomatic meniscus of the left knee is granted for the period between December 4, 2008 to June 27, 2012 The Veteran applied for an increased rating for his bilateral knees on September 30, 2009. While the Veteran's claims were pending, the Veteran filed a claim for a temporary total rating due to left knee replacement. Through a February 2013 rating decision, the Veteran was awarded the temporary, 100 percent rating from June 27, 2012 to August 1, 2013. After August 1, 2013, the Veteran was awarded the minimum 30 percent rating for his post-prosthetic knee replacement. In his notice of disagreement, the Veteran relayed identical symptoms for his knees: that he experienced pain on use; his knees would lock, give way, and bend in the wrong direction; his knees were easily fatigued, weak, and would swell; and he had difficulty with sitting, standing, walking, and getting out of a chair. He reported that he had "no material between the bones." See VBMS, document labeled NOD, receipt date March 25, 2011. Knee disabilities are unique in the rating code, as they are one of a few orthopedic disabilities in which a Veteran may receive multiple ratings based on separate symptoms in the same joint. While the law generally prevents considering the same symptoms under various diagnoses to support separate ratings, some of the relevant Diagnostic Codes for the knee have been interpreted to apply to different functions of the knee, therefore warranting separate consideration. Specifically, the evidence may warrant separate ratings for limitation of flexion of the knee, limitation of extension of the knee, lateral instability and recurrent subluxation of the knee, and meniscal disabilities. The Board will explore all possibilities in this case. Diagnostic Code 5055 applies to a prosthetic replacement of the knee joint and provides for a 100 percent rating for one year following implantation of the prosthesis, followed by ratings from 30 to 60 percent. 38 C.F.R. § 4.71a. Additionally, for claims that were pending prior to July 16, 2015, this prior version of Diagnostic Code 5055 has been interpreted to apply to both total and partial knee replacements. See Hudgens v. McDonald, 823 F.3d 630 (Fed. Cir. 2016); 80 Fed. Reg. 42040 (July 16, 2015) (VA regulatory change, effective July 16, 2015, which clarified only total knee replacements may be evaluated under DC 5055). The temporary total rating through August 1, 2013, and the minimum 30 percent rating (or higher, as discussed below) after that date under Diagnostic Code 5055, would replace any currently assigned separate ratings for that period based on limited motion and meniscal impairment. Prior to June 27, 2012, the Veteran's left knee must be evaluated under the general knee rating codes (Diagnostic Codes 5003 for arthritis and 5256 to 5263 for the leg or knee). After August 1, 2013, it must be evaluated as directed in Diagnostic Code 5055. The Veteran's right knee does not need separate periods of evaluations because there is no evidence of a surgical replacement. Standard range of knee motion is from zero degrees (on extension) to 140 degrees (on flexion). See 38 C.F.R. § 4.71, Plate II. When the limitation of motion is non-compensable under the appropriate diagnostic codes, a rating of 10 percent may be applied to each such major joint (such as the knee) or group of minor joints affected by limitation of motion. The limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. 38 C.F.R. § 4.71a. Under Diagnostic Code 5260, a 0 percent (noncompensable) disability rating is assigned for flexion limited to 60 degrees, a 10 percent disability rating is assigned for flexion limited to 45 degrees, a 20 percent disability rating is assigned for flexion limited to 30 degrees, and a 30 percent disability rating is assigned for flexion limited to 15 degrees. 38 C.F.R. § 4.71a. Under Diagnostic Code 5261, a 0 percent (noncompensable) disability rating is assigned for extension limited to 5 degrees, a 10 percent disability rating is assigned for extension limited to 10 degrees, a 20 percent disability rating is assigned for extension limited to 15 degrees, a 30 percent disability rating is assigned for extension limited to 20 degrees; a 40 percent disability rating is assigned for extension limited to 30 degrees; a 50 percent disability rating is assigned for extension limited to 45 degrees. 38 C.F.R. § 4.71a. Under Diagnostic Code 5259, a 10 percent rating is available for removal of the semilunar cartilage (meniscus) that is symptomatic. Under Diagnostic Code 5258, a symptomatic meniscus is described as "locking," pain, and effusion into the joint. Significantly, § 4.71a does not expressly prohibit separate evaluation under DC 5261 and 5259. See Lyles v. Shulkin, 29 Vet. App. 107 (2017); see also Esteban v. Brown, 6 Vet. App. 259 (1994). During the pendency of this appeal, VA amended the Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 76453, 76463 (Nov. 30, 2020) (to be codified at 38 C.F.R. § 4.71a, Diagnostic Codes 5257, 5262), effective from February 7, 2021. However, no amendments are implicated in the Veteran's knee ratings. Evidence Unlike the other service-connected conditions above, there are considerably more records related to the Veteran's knees. The Veteran had a VA examination in December 2009. The Veteran reported that he had right knee pain, with stiffness, fatigability, lack of endurance, and occasional locking. As for his left knee, the examiner noted that he had a torn left meniscus. He reported weakness, stiffness, locking, fatigability, and lack of endurance. The Veteran took pain medications as needed. He reported flare-ups of pain twice a week and when he walked or stood too long. Upon examination, the Veteran had painful range of motion, edema that was worse on the left, and noted instability, weakness, abnormal movement, and guarding of movement. The Veteran's right knee motion was 0 degrees of extension (normal) to 100 degrees of flexion, with no additional range of motion lost after repeated use or during flare-ups. As for the left, the Veteran's range of motion was 0 degrees to 105 degrees. Instability was reported, but stability testing was within normal limits. The Veteran submitted a letter from Dr. T.H., dated January 22, 2010. The doctor reported bilateral range of motion from 0 to 80 degrees, with a consistent antalgic gait. The Veteran received injections in his knees, but without improvement. The doctor believed that the Veteran would need bilateral knee replacement in the future. See VBMS, document labeled Third Party Correspondence, receipt date March 25, 2011. The Veteran had a consultation for his knees in July 2011. His subjective symptoms were similar to those at the December 2009 VA examination. He reported left pain worse than right. His bilateral range of motion was 0 to 125 degrees. Tenderness was noted. Knee replacement surgery was discussed. See VBMS, document labeled Medical Treatment Records-Furnished by SSA, receipt date October 21, 2019, page 90 of 174. In May 2012, the Veteran's range of motion was 5 degrees of extension to 130 degrees of flexion on the right and 5 degrees to 115 degrees on the left. The Veteran elected to proceed with surgery. See VBMS, document labeled Medical Treatment Records-Furnished by SSA, receipt date October 21, 2019, page 88 of 136. The Veteran had his left total knee arthroplasty on June 27, 2012. See VBMS, document labeled Medical Treatment Record-Non-Government Facility, receipt date July 9, 2012. In May 2012, the Veteran sustained a work injury when his left knee twisted and went out on him. Through a worker's compensation claim, an examiner found that the Veteran had a preexisting injury from 2008 and that due to his history of arthrosis in his left knee, the injury "aggravated the arthritis and may have torn his medial meniscus." It is unclear to what injury the examiner is referencing: the 2008 or 2012 injury. The proposition that the Veteran's meniscus was torn in 2008 is supported by an October 13, 2008 MRI that showing a meniscus tear. See VBMS, document labeled Medical Treatment Records-Furnished by SSA, receipt date October 21, 2019, pages 88-92 of 160. In resolving the benefit of the doubt to the Veteran, the Board finds the examiner's opinion to be as follows: "the 2008 injury aggravated the left knee arthritis and may have torn his medial meniscus." This opinion is speculative because the examiner notes the injury "may have" torn his meniscus. See Obert v. Brown, 5 Vet. App. 30, 33 (1995); Tirpak v. Derwinski, 2 Vet. App. 509, 611 (1992). Speculative opinions are ordinarily entitled to little probative weight. However, the Board finds the Veteran's descriptions of symptoms to be consistent with a torn meniscus and gives the examiner's opinion great probative weight. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). Analysis In order to warrant a higher initial rating based on limitation of motion (either flexion or extension), the Veteran's knee conditions would need to manifest in symptomology approximating a limitation of 30 degrees flexion or 15 degrees extension. Here, the Board finds that the evidence does not support this finding, even considering pain during both motions, and pain on weight bearing, and considering repeated use and during flare-ups. At most the Veteran's flexion was limited to 80 degrees and extension was limited to five degrees. In Sharp v. Shulkin, 29 Vet. App. 26 (2017), the Court held that VA examiners must obtain information about the severity, frequency, duration, precipitating and alleviating factors, and extent of functional impairment of flares from the veterans themselves, when a flare-up is not observable at the time of examination. The December 2009 examiner considered additional range of motion lost during flare-ups. Thus, the evidence does not show that even during flare-ups, the Veteran's range of motion or symptomology would approximate a greater degree of range of motion lost. While the Veteran reported pain and some functional loss, flareups must be quantifiable and must result in limitation of motion of function beyond that contemplated by the already provided evaluation. Additionally, because there is a regulation addressing the stabilization of ratings, flareups must be of such length as to establish that the overall impairment is more severe than currently evaluated. In this instance, the Veteran's statements made in this case do not show that any flareups or repeated use over time have additionally limited function in a quantifiable way, nor do they show that they are of such length or duration that a higher rating would be warranted. The specific clinical measures of ranges of motion, including examiners' findings and opinions regarding additional limitations of motion due to such factors, have been weighed and considered by the Board. Such specific measures and findings are of more probative value in determining specific ranges of motion than are general histories or general descriptions of symptoms of pain or limitations, such as this Veteran's report of pain and limitation of function. As for the Veteran's meniscus injury, the Board finds that the Veteran had a torn meniscus that was symptomatic prior to his knee replacement. Further, that the Veteran's last final rating decision regarding his left knee was December 3, 2008. Finally, the Veteran's meniscus injury occurred because of his left knee arthritis. Thus, a 20 percent rating is warranted for the Veteran's torn left meniscus from December 4, 2008 to June 27, 2012. Effective June 27, 2012, the Veteran had his left knee surgically replaced. He was under a period of convalescence until August 1, 2013. Therefore, effective August 1, 2013, his left knee must be evaluated as directed in Diagnostic Code 5055. Under Diagnostic Code 5055, a 30 percent rating is the minimum rating after a replacement. There is no medical evidence related to the functioning of the Veteran's knee after August 1, 2013. Thus, a rating in excess of 30 percent is not warranted. Despite the Veteran's contention of a greater degree of limitation on the conditions of his knees, the disability ratings assigned herein indicate a significant impact on his functional ability. Such disability evaluations assigned by VA recognizes his painful motion. The critical question in this case, however, is whether the problems he has cited meet an even higher level under the rating criteria. For reasons cited above, the Board finds they do not. For the foregoing reasons, the preponderance of the evidence is against the Veteran's claim for increased ratings for his knee conditions, except that a separate 20 percent rating for his torn left meniscus is warranted from December 4, 2008 to June 27, 2012. The benefit of the doubt doctrine is applicable as explained above. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. Bethany L. Buck Veterans Law Judge Board of Veterans' Appeals Attorney for the Board I. M. Hitchcock 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.