Citation Nr: 21075034 Decision Date: 12/17/21 Archive Date: 12/17/21 DOCKET NO. 17-38 994 DATE: December 17, 2021 ORDER Entitlement to an initial disability rating in excess of 100 percent for somatoform pain syndrome disorder with recurrent major depression and posttraumatic stress disorder (PTSD) is denied. Entitlement to an initial disability rating in excess of 10 percent for tinnitus is denied. Entitlement to an automobile allowance or adaptive equipment is denied. Entitlement to an initial compensable disability rating for bilateral eye vitreous is denied. Entitlement to an initial disability rating in excess of 10 percent for right knee instability is denied. Entitlement to an initial disability rating in excess of 20 percent for status post meniscectomy of the left knee with instability is denied. Entitlement to an initial disability rating in excess of 10 percent for right knee painful motion associated with right knee instability is denied. Entitlement to an initial disability rating in excess of 60 percent for status post right shoulder arthroplasty and degenerative arthritis, is denied. Entitlement to an initial disability rating in excess of 20 percent for left shoulder tendonitis with dislocation (nondominant), impairment of humerus, is denied. Entitlement to an initial disability rating in excess of 20 percent for left shoulder tendonitis, limitation of motion, is denied. Entitlement to an initial disability rating in excess of 10 percent for painful scars (2) of the right shoulder associated with right shoulder arthroplasty and degenerative arthritis, is denied. Entitlement to an initial compensable disability rating for right shoulder scars (2) associated with right shoulder arthroplasty and degenerative arthritis is denied. Entitlement to an initial compensable disability rating for hemorrhoids is denied. Entitlement to an initial compensable disability rating for bilateral hand dermatitis (also claimed as skin condition from hazardous chemicals) is denied. Entitlement to service connection for pigmented villonodular synovitis (PVNS) is denied. Entitlement to service connection for bilateral hearing loss is denied. Entitlement to service connection for migraine headaches is denied. Entitlement to service connection for traumatic brain damage, claimed as head injury causing eye issues is denied. Entitlement to service connection for nerve damage to neck is denied. Entitlement to service connection for back problems (claimed as upper back condition) is denied. Entitlement to service connection for back problems (claimed as lower back condition) is denied. Entitlement to service connection for residuals of right foot fracture, claimed as broken bones in right foot is denied. Entitlement to service connection for bilateral index finger disability is denied. Entitlement to service connection for degenerative arthritis of the right hip, also claimed as broken right hip disability, is denied. Entitlement to service connection for residuals of left ankle fracture is denied. FINDINGS OF FACT 1. Throughout the period on appeal, the Veteran's somatoform pain syndrome disorder with recurrent major depression and PTSD has been rated at 100 percent disabling (the maximum schedular rating for psychiatric disabilities). 2. Throughout the period on appeal, the Veteran's tinnitus has been rated at 10 percent disabling (the maximum schedular rating for tinnitus); factors warranting extraschedular rating are not shown. 3. The Veteran does not have loss or permanent loss of use of one or both feet; or loss or permanent loss of use of one or both hands; permanent impairment of vision of both eyes to the required specified degree; a severe burn injury to the required specified degree; amyotrophic lateral sclerosis; or, for adaptive equipment eligibility only, ankylosis of one or both knees or one or both hips, by reason of a service-connected disability. 4. The Veteran's bilateral eye vitreous manifests as impaired visual acuity to no worse than 20/40 or better bilaterally; without impaired visual fields, diplopia, nor incapacitating episodes in a twelve-month period. 5. Throughout the period on appeal, the Veteran's right knee instability is manifest by 0-5 millimeters (+1) of instability. 6. The Veteran's status post meniscectomy of the left knee with instability is manifest by 5-10 millimeters (+2) of instability prior to March 27, 2017 and no instability from March 27, 2017. 7. Throughout the period on appeal, the Veteran's right knee painful motion is manifest by limitation of flexion range of motion to no worse than 110 degrees. 8. Throughout the period on appeal, the Veteran's status post right shoulder arthroplasty and degenerative arthritis is already at the schedular maximum for the dominant extremity. 9. Prior to July 20, 2021, the Veteran's left shoulder tendonitis with dislocation (nondominant) produced no worse than limited range of motion to 45 degrees and guarding at the shoulder level. 10. From July 20, 2021, the Veteran's left shoulder tendonitis produced no worse than limited range of motion 10 145 degrees and no longer produced guarding. 11. Throughout the period on appeal, the Veteran has had two scars on his right shoulder measuring less than 144 square inches (929 square cm) that are painful, but stable. 12. The preponderance of the evidence of record is against finding that the Veteran's hemorrhoids manifested with large or thrombotic hemorrhoids that were irreducible, with excessive redundant tissue evidencing frequent recurrences nor with persistent bleeding and with secondary anemia, or with fissures. 13. The preponderance of the evidence of record is against finding that the Veteran's bilateral hand dermatitis resulted in characteristic lesions involving at least 5 percent, but less than 20 percent of the entire body affected; nor at least 5 percent of the exposed areas affected nor systemic therapy. 14. The preponderance of the evidence of record is against finding that the Veteran has had PVNS at any time during or approximate to the pendency of the claim. 15. The preponderance of the evidence of record is against finding that the Veteran has had bilateral hearing loss at any time during or approximate to the pendency of the claim. 16. The preponderance of the evidence is against finding that migraine headaches began during active service, or is otherwise related to an in-service injury or disease. 17. The preponderance of the evidence of record is against finding that the Veteran has had residuals of a traumatic brain injury at any time during or approximate to the pendency of the claim. 18. The preponderance of the evidence is against finding that nerve damage to the neck began during active service, or is otherwise related to an in-service injury or disease. 19. The preponderance of the evidence is against finding that back problems (claimed as upper back condition) began during active service, or is otherwise related to an in-service injury or disease. 20. The preponderance of the evidence is against finding that back problems (claimed as lower back condition) began during active service, or is otherwise related to an in-service injury or disease. 21. The preponderance of the evidence is against finding that for residuals of right foot fracture, claimed as broken bones in right foot began during active service, or is otherwise related to an in-service injury or disease. 22. The preponderance of the evidence is against finding that any disability of the bilateral index fingers began during active service, or is otherwise related to an in-service injury or disease. 23. The preponderance of the evidence is against finding that degenerative arthritis of the right hip, also claimed as broken right hip disability began during active service, or is otherwise related to an in-service injury or disease. 24. The preponderance of the evidence is against finding that residuals of left ankle fracture began during active service, or is otherwise related to an in-service injury or disease. CONCLUSIONS OF LAW 1. The criteria for a disability rating in excess of 100 percent for somatoform pain syndrome disorder with recurrent major depression and PTSD have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.126, 4.130, Diagnostic Code 9411, Diagnostic Code 9423, and Diagnostic Code 9434. 2. The criteria for a disability rating in excess of 10 percent for tinnitus have not been met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 3.321(b), 4.1, 4.87, Diagnostic Code 6260. 3. The eligibility criteria for financial assistance in acquiring an automobile or other conveyance or special adaptive equipment have not been met. 38 U.S.C. §§ 3901, 3902(b)(1), 5107; 38 C.F.R. §§ 3.808, 17.156. 4. The criteria for a compensable disability rating percent for bilateral eye vitreous (also claimed as floaters) have not been met. 38 U.S.C. § 1155, 5107; 38 C.F.R. §§ 3.321, 4.1, 4.75-4.79, Diagnostic Codes 6099, Diagnostic Code 6009. 5. The criteria for a disability rating in excess of 10 percent for right knee instability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5257. 6. The criteria for a disability rating in excess of 20 percent for status post medial meniscectomy of the left knee have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5257. 7. The criteria for an initial disability rating in excess of 10 percent for right knee painful motion have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5003, Diagnostic Code 5010, Diagnostic Code 5260. 8. The criteria for an initial disability rating in excess of 60 percent for right shoulder arthroplasty and degenerative arthritis have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71A, Diagnostic Code 5003, Diagnostic Code 5051, Diagnostic Code 5200, Diagnostic Code 5203. 9. The criteria for a rating in excess of 20 percent for left shoulder tendonitis with dislocation and limitation of motion have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5201. 10. The criteria for a rating in excess of 20 percent for left shoulder tendonitis, impairment of the humerus, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5202. 11. The criteria for a disability rating in excess of 10 percent for painful scars (2) of the right shoulder have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.118, Diagnostic Code 7804. 12. The criteria for a compensable disability rating for right shoulder scars (2) have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.118, Diagnostic Code 7802. 13. The criteria for entitlement to an initial compensable disability rating for hemorrhoids have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.3, 4.7, 4.21, 4.114, Diagnostic Code 7336. 14. The criteria for a compensable disability rating for bilateral hand dermatitis have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.118, Diagnostic Code 7806. 15. The criteria for entitlement to service connection for PVNS are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 16. The criteria for entitlement to service connection for bilateral hearing loss are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 17. The criteria for entitlement to service connection for migraine headaches are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 18. The criteria for entitlement to service connection for residuals of a traumatic brain injury are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 19. The criteria for entitlement to service connection for nerve damage to neck are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 20. The criteria for entitlement to service connection for back problems (claimed as upper back condition) are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 21. The criteria for service connection for back problems (claimed as lower back condition) are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 22. The criteria for service connection for residuals of right foot fracture are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 23. The criteria for service connection for bilateral index finger disability are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 24. The criteria for service connection for degenerative arthritis of the right hip, also claimed as broken right hip disability, are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 25. The criteria for service connection for residuals of left ankle fracture are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Navy from December 1988 until his General Discharge (under honorable conditions) in November 1992. These matters come before the Board of Veterans' Appeals (Board) on appeal from the June 2013, May 2017, February 2020, March 2020, and August 2021 rating decision(s) by the Regional Office(s) (RO) of the United States Department of Veterans Affairs (VA). In October 2019, the Veteran testified at a Board hearing before the undersigned Veterans Law Judge (VLJ), sitting in Washington, District of Columbia. A transcript of the hearing has been associated with the record on appeal. During the October 2019 Board hearing, the Veteran withdrew his claims for increased evaluation for somatoform disorder with recurrent major depression and PTSD, tinnitus, and entitlement to automobile or adaptive equipment. However, in a May 2020 correspondence, subsequent to the October 2019 Board hearing, the Veteran indicated that he wished to pursue all of the issues on appeal and requested a Video Conference on those issues in a June 2020 correspondence. The Veteran was subsequently scheduled for a Board hearing on September 28, 2021. However, the September 28, 2021 Board hearing was subsequently cancelled and the issues that were previously separated for a Board hearing were once again included with the original claims for consideration. In March 2021, the Board remanded the case to the RO for further development. Specifically, the Board directed the RO to obtain appropriate VA examination(s), and pertinent medical treatment records. As a preliminary matter, the Veteran's inconsistent statements included within the Veteran's Board hearing testimony, Service Treatment Records, VA treatment records, and VA examination(s) compel the Board to find that the Veteran's more recent statement as to in-service onset of the claimed disabilities are not credible. See Caluza v. Brown, 7 Vet. App. 498, 510-11 (1995) (Board must evaluate credibility of all evidence; lay statements may be evaluated based on, inter alia, inconsistent statements, facial plausibility, and consistency with other evidence of record); see also Buchanan v. Nicholson, 451 F.3d 1331, 1336-37 (Fed. Cir. 2006). To be clear, the Board is not questioning the Veteran's honesty. The Veteran is attempting to recollect events that transpired a long time ago, and the passage of time, along with the inconsistencies noted above, compels a conclusion that the Veteran is not an accurate historian as to these particular statements. See Caluza, 7 Vet. App. at 510-11. Therefore, the Board cannot assign them probative weight. Id. Increased Rating Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Schedule), found in 38 C.F.R. Part 4. The Schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations shall be applied, 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. When reasonable doubt arises as to the degree of disability, such doubt will be resolved in the Veteran's favor. 38 C.F.R. § 4.3. 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). Where entitlement to compensation has been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Where an appeal is based on an initial rating for a disability, however, evidence contemporaneous with the claim and the initial rating decision are most probative of the degree of disability existing when the initial rating was assigned and should be the evidence "used to decide whether an original rating on appeal was erroneous." Fenderson v. West, 12 Vet. App. 119, 126 (1999). In either case, 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. Fenderson, 12 Vet. App. at 126; Hart v. Mansfield, 21 Vet. App. 505 (2007) (noting that staged ratings are appropriate whenever the factual findings show distinct time periods in which a disability exhibits symptoms that warrant different ratings). In Correia v. McDonald, 28 Vet. App. 158 (2016), the Court held that the final sentence of 38 C.F.R. § 4.59 requires that the examiner record the results of range of motion testing "for pain on both active and passive motion [and] in weight-bearing and non-weight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint." The spine has no opposite joint. 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. 1. Entitlement to an initial disability rating in excess of 100 percent for somatoform pain syndrome disorder with recurrent major depression and PTSD The Veteran asserts that he is entitled to a higher disability rating for his somatoform pain syndrome disorder with recurrent major depression and PTSD. Under the General Formula for Mental Disorders (General Formula), the Board must conduct a "holistic analysis" that considers all associated symptoms, regardless of whether they are listed as criteria. Bankhead v. Shulkin, 29 Vet. App. 10, 22 (2017); 38 C.F.R. § 4.130. The Board must determine whether unlisted symptoms are similar in severity, frequency, and duration to the listed symptoms associated with specific disability percentages. Then, the Board must determine whether the associated symptoms, both listed and unlisted, caused the level of impairment required for a higher disability rating. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 114-118 (Fed. Cir. 2013). A noncompensable disability rating is assigned when a mental condition has been formally diagnosed, but symptoms are not severe enough to either require continuous medication, or to interfere with occupational and social functioning. A 10 percent disability rating is assigned when mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of occasional stress, or symptoms controlled by medication cause occupational and social impairment. A 30 percent disability rating is assigned when symptoms such as depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, or mild memory loss (such as forgetting names, directions, or recent events), cause occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and normal conversation). A 50 percent disability rating is assigned when symptoms such as flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; or difficulty in establishing and maintaining effective work and social relationships cause occupational and social impairment with reduced reliability and productivity. A 70 percent disability rating is assigned when symptoms such as suicidal ideation; obsessional rituals which interfere with routine activities; intermittently illogical, obscure, or irrelevant speech; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); or inability to establish and maintain effective relationships cause occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. A 100 percent disability rating is assigned for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; or memory loss for names of close relatives, own occupation or own name. The Board notes that the Veteran was afforded a VA examination in February 2011. The February 2011 VA examiner utilized an evaluation form for mental disorders except PTSD and Eating Disorders. See February 2011 Compensation and Pension Examination, p. 1. However, the February 2011 VA examiner diagnosed the Veteran with PTSD. See February 2011 Compensation and Pension Examination, p. 4. Therefore, the February 2011 VA examination is inadequate because it did not provide the correct analysis for a diagnosis of PTSD. However, since the Veteran is currently rated at a 100 percent disability rating for his acquired psychiatric disabilities, and has maintained the100 percent disability rating throughout the period on appeal, the Board shall not remand the issue for a retrospective reevaluation. As for the Veteran's assertion that he is entitled to a separate and compensable disability rating for his PTSD, the February 2011 VA examiner clearly noted that "[h]is somatic complaints, depression, anxiety, social avoidance, nightmares, sleep problems, and lack of relationships are all due to PTSD. His past diagnosis of undifferentiated somatoform disorder with recurrent depression are part-and-parcel to his PTSD..." Therefore, a single disability rating for the Veteran's acquired psychiatric disabilities is appropriate and a separate compensable disability rating is not warranted. The Veteran's somatoform pain disorder with recurrent major depression and PTSD has already been assigned the maximum schedular disability rating available for psychiatric disabilities under 38 C.F.R. § 4.130, Diagnostic Code 9411, Diagnostic Code 9423, and Diagnostic Code 9434; and a higher schedular rating is not warranted. 2. Entitlement to an initial disability rating in excess of 10 percent for tinnitus The Veteran asserts that he is entitled to a higher disability rating for his service-connected tinnitus. Recurrent tinnitus is evaluated under Diagnostic Code 6260, which provides for a maximum disability rating of 10 percent. Diagnostic Code 6260, which was revised effective June 13, 2013 to clarify existing VA practice, also provides that only a single 10 percent evaluation is assigned for tinnitus, whether the sound is perceived as being in one ear, both ears, or in the head. 38 C.F.R. § 4.87, Diagnostic Code 6260, Note 2. In Smith v. Nicholson, 451 F.3d 1344 (Fed. Cir. 2006), the United States Court of Appeals for the Federal Circuit (Federal Circuit) affirmed VA's longstanding interpretation of Diagnostic Code 6260 as authorizing only a single 10 percent disability rating for tinnitus, whether perceived as unilateral or bilateral. Citing United States Supreme Court precedent, the Federal Circuit explained that an agency's interpretation of its own regulations was entitled to substantial deference by the courts as long as the interpretation was not plainly erroneous or inconsistent with the regulations. Smith, 451 F.3d at 1350-51. Finding that there was a lack of evidence in the record suggesting that VA's interpretation of Diagnostic Code 6260 was plainly erroneous or inconsistent with the regulations, the Federal Circuit concluded that VA's interpretation of a single 10 percent disability rating being the maximum available for tinnitus was reasonable. The Veteran's tinnitus has been assigned the maximum schedular disability rating available for tinnitus under 38 C.F.R. § 4.87, Diagnostic Code 6260, and a higher schedular rating or separate 10 percent disability rating for tinnitus of each ear are not warranted. The Veteran was afforded VA examinations in May 2013 and May 2021. During the May 2013 VA examination, the Veteran reported intermittent tinnitus that occurs at least daily. During the May 2021 VA examination, the Veteran reported constant ringing in both ears and believes it causes a minor earache. The Board has considered whether referral of the Veteran's claim for consideration of an extraschedular disability rating is warranted. See 38 C.F.R. § 3.321(b)(1); see Fanning v. Brown, 4 Vet. App. 225, 229 (1993). Under Thun v. Peake, 22 Vet. App. 111 (2008), there is a three-step inquiry for determining whether a Veteran is entitled to an extraschedular disability rating. First, the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Second, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is, thus, found inadequate, the Board must determine whether the disability picture exhibits other related factors such as those provided by the regulation as "governing norms." Third, if the disability rating schedule is inadequate to evaluate a Veteran's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, the case must be referred to [the Director of the Compensation Service] to determine whether an extraschedular disability rating is warranted. The Board finds that the first prong of the Thun analysis is not satisfied. The Veteran's tinnitus is not shown (or alleged) to have manifestations or to cause impairment not encompassed by the schedular criteria. His reports of ringing in the ears are the basis for a 10 percent disability rating for tinnitus. He has not identified factors warranting referral for extraschedular consideration, such as marked interference with employment. Furthermore, there is nothing exceptional or unusual about his tinnitus (masking is a commonly known ameliorative measure). See Long v. Wilkie, No. 16-1537 (Vet. App. December 30, 2020). Therefore, the schedular criteria are not inadequate, and referral for extraschedular consideration is not necessary. 3. Entitlement to an automobile allowance or adaptive equipment The Veteran asserts that he is entitled to an automobile allowance or adaptive equipment. In order to establish entitlement to an automobile and adaptive equipment under 38 U.S.C. § 3901, the evidence must demonstrate service-connected disability (or disabilities) resulting in the loss, or permanent loss of use, of at least one foot or a hand; permanent impairment of vision in both eyes, resulting in (1) vision of 20/200 or less in the better eye with corrective glasses, or, (2) vision of 20/200 or better, if there is a field defect in which the peripheral field has contracted to such an extent that the widest diameter of the visual field subtends an angular distance no greater than twenty degrees in the better eye; a severe burn injury, where deep partial thickness or full thickness burns result in scar formation that causes contractures and limits motion of one or more extremities or the trunk and precludes effective operation of an automobile; or amyotrophic lateral sclerosis (ALS). 38 C.F.R. § 3.808 (a), (b). A veteran is also entitled to adaptive equipment if he has ankylosis of at least one knee or one hip due to service-connected disability. 38 U.S.C. § 3902 (b)(2); 38 C.F.R. § 3.808 (b)(6). The Veteran requests an automobile conveyance, presumably due to the service-connected anatomical loss of the right eye disability. See September 2017 Application for Automobile or Other Conveyance and Adaptive Equipment. After review of all the evidence of record, the criteria for financial assistance in acquiring an automobile or other conveyance or special adaptive equipment are not met. The Veteran is service-connected for somatoform pain disorder with recurrent major depression and PTSD, right shoulder arthroplasty and degenerative arthritis, left shoulder tendonitis with dislocation (nondominant), status post medial meniscectomy of the left knee with instability, left shoulder tendonitis (nondominant), status post medical meniscectomy of the left knee, tinnitus, right knee instability, right knee painful motion, painful scars (2) of the right shoulder, hemorrhoids, bilateral eye vitreous with corrected distance visual impairment of no worse than 20/20 or better bilaterally and no visual field defects, bilateral hand dermatitis, left knee scars (2), right shoulder scars (2), right knee scar (1). None of the service-connected disabilities results in or are manifested by the loss, or permanent loss of use, of at least one foot or a hand; permanent impairment of vision in both eyes, resulting in (1) vision of 20/200 or less in the better eye with corrective glasses, or, (2) vision of 20/200 or better, if there is a field defect in which the peripheral field has contracted to such an extent that the widest diameter of the visual field subtends an angular distance no greater than twenty degrees in the better eye; a severe burn injury, where deep partial thickness or full thickness burns result in scar formation that causes contractures and limits motion of one or more extremities or the trunk and precludes effective operation of an automobile; or amyotrophic lateral sclerosis (ALS). For these reasons, automobile allowance or specially adapted equipment is not warranted in this case. In reaching this decision the Board considered the doctrine of reasonable doubt, however, as the preponderance of the evidence is against the Veteran's claim, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 4. Entitlement to an initial compensable disability rating for bilateral eye vitreous The Veteran asserts that he is entitled to a higher disability rating for his bilateral eye vitreous. However, the Veteran also reported that he no longer believes that he has floaters and that he now believes that he sees flashes of light that streak across his eyes, float up or down, appear like a blob of light [and] then dissipates, or just a sudden flash. See July 8, 2021 VA Treatment Records. As a preliminary matter, the Board notes that the record reflects additional eye disabilities (including claimed and undiagnosed eye disabilities) that the Veteran is not service connected for. However, as will be addressed in greater detail below, because the Veteran's eye examinations reveal that the results of the Veteran's total eye disabilities combined would not warrant a compensable disability rating, the Board will not remand for a more detailed opinion. However, the Board notes that although this opinion has reviewed the evidence that includes the effects of the Veterans nonservice-connected disabilities, this opinion does not grant service connection for the Veteran's additional eye disabilities. The Veteran remains service-connected for only his bilateral eye vitreous (floaters). Evaluations of defective vision from noncompensable to 100 percent based on organic impairment of visual acuity (excluding developmental errors of refraction), visual field, and muscle function. 38 C.F.R. §§ 4.76(a), 4.79. The examination for visual impairment must be conducted by a licensed optometrist or by a licensed ophthalmologist and the examiner must identify the disease, injury, or any other pathologic process found. 38 C.F.R. § 4.76(b). Examination of visual fields or muscle function will be conducted only when there is a medical indication of disease or injury that may be associated with visual field defect or impaired muscle function. Id. Unless medically contraindicated, the fundus must be examined with the Veteran's pupils dilated. Id. Unless otherwise directed, evaluate diseases of the eye under the General Rating Formula for Diseases of the Eye. 38 C.F.R. § 4.79, Diagnostic Codes 6000 through 6009. Impairment of Visual Acuity is rated under Diagnostic Codes 6061 through 6066. Impairment of Visual Fields is rated under Diagnostic Codes 6080 through 6081. Impairment of Muscle Function is rated under Diagnostic Codes 6090 through 6091. The Veteran is rated under Diagnostic Code 6099-6009. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the specific basis for the evaluation assigned; the additional code is shown as a hyphen. 38 C.F.R. § 4.27. Unlisted disabilities requiring rating by analogy are coded with the first two numbers of the schedule provisions most closely related body part and 99. Here, the hyphenated diagnostic code indicates that the Veteran's bilateral eye vitreous disability is currently rated as analogous to diseases of the eye (Diagnostic Code 6099) under the criteria for an unhealed eye injury (Diagnostic Code 6009). 38 C.F.R. § 4.79, Diagnostic Code 6009, Diagnostic Code 6099. During the pendency of the Veteran's appeal, VA issued a final rule revising the portion of the VA Schedule for Rating Disabilities that address the organs of special sense and schedule of ratings-eye. 83 Fed. Reg. 15316 (April 10, 2018). The final rule went into effect May 13, 2018. Where there is a change in the rating criteria during the appeal period, the Board will consider the claim in light of both the former and revised schedular rating criteria, although an increased evaluation based on the revised criteria cannot predate the effective date of the amendments. Under both the former and revised criteria, a 10 percent disability rating is warranted for localized scars, atrophy, or irregularities of the retina, unilateral or bilateral, that are centrally located and that result in an irregular, duplicated, enlarged, or diminished image. Both versions of the criteria also provide for an alternative basis for the evaluation if it results in a higher disability rating. Under the former criteria, the alternative evaluation is based on the General Rating Formula for Diseases of the Eye. The General Rating Formula for Diseases of the Eye instructs to evaluate the disability based on visual impairment or its rating criteria for incapacitating episodes. Thus, the primary difference between the former and revised criteria is consideration of incapacitating episodes. Prior to the May 13, 2018 changes, the criteria under the General Rating Formula for Diseases of the Eye instructs to evaluate on the basis of either visual impairment due to the particular condition or on incapacitating episodes, whichever results in a higher evaluation. 38 C.F.R. § 4.79. Where incapacitating episodes have a total duration of at least 1 week, but less than 2 weeks, during the past 12 months, a 10 percent disability rating is warranted. Where incapacitating episodes have a total duration of at least 2 weeks, but less than 4 weeks, during the past 12 months, a 20 percent disability rating is warranted. Where incapacitating episodes have a total duration of at least 4 weeks, but less than 6 weeks, during the past 12 months, a 40 percent disability rating is warranted. Where incapacitating episodes have a total duration of at least 6 weeks during the past 12 months, a 60 percent disability rating is warranted. A Note following the General Rating Formula indicates that, for VA purposes, an incapacitating episode is a period of acute symptoms severe enough to require prescribed bed rest and treatment by a physician or other healthcare provider. Id. From May 13, 2018; the criteria under the General Rating Formula for Diseases of the Eye instructs to evaluate on the basis of either visual impairment due to the particular condition or on incapacitating episodes, whichever results in a higher evaluation. 38 C.F.R. § 4.79. Where documented incapacitating episodes requiring at least 1 but less than 3 treatment visits for an eye condition in the past 12 months, a 10 percent disability rating is warranted. Where documented incapacitating episodes requiring at least 3 but less than 5 treatment visits for an eye condition in the past 12 months, during the past 12 months, a 20 percent disability rating is warranted. Where documented incapacitating episodes requiring at least 5 but less than 7 treatment visits for an eye condition in the past 12 months, during the past 12 months, a 40 percent disability rating is warranted. Where documented incapacitating episodes requiring 7 or more treatment visits for an eye condition in the past 12 months, during the past 12 months, a 60 percent disability rating is warranted. The Board also notes that the May 2018 changes also included a change to the Note(s) under General Rating Formula for Diagnostic Codes 6000 through 6009. Specifically, prior to the May 2018 changes, the Note provided "For VA purposes, an incapacitating episode is a period of acute symptoms severe enough to require prescribed bed rest and treatment by a physician or other healthcare provider." However, subsequent to the May 2018 changes, there are now three notes under General Rating Formula for Diagnostic Codes 6000 through 6009. Note: (1) provides "For the purposes of evaluation under 38 C.F.R. § 4.79, an incapacitating episode is an eye condition severe enough to require a clinic visit to a provider specifically for treatment purposes. Note: (2) provides "examples of treatment may include but are not limited to: systemic immunosuppressants or biologic agents; intravitreal or periocular injections; laser treatments; or other surgical interventions." Note: (3) provides for the purposes of evaluating visual impairment due to the particular condition, refer to 38 C.F.R. §§ 4.75 through 4.78 and 4.79, Diagnostic Codes 6061-6091. Finally, the Board notes that the record does not reflect any incapacitating episodes, nor does the Veteran assert that he has had any incapacitating episodes throughout the period on appeal under either the former or current regulation(s). Examinations of visual acuity must include the central uncorrected and corrected visual acuity for distance and near vision using Snellen's test type or its equivalent. 38 C.F.R. § 4.76(a). Evaluation of central visual acuity is on the basis of corrected distance vision with central fixation, even if a central scotoma is present. 38 C.F.R. § 4.76(b). However, when the lens required to correct distance vision in the poorer eye differs by more than three diopters from the lens required to correct distance vision in the better eye (and the difference is not due to congenital or developmental refractive error), and either the poorer eye or both eyes are service connected, evaluate the visual acuity of the poorer eye using either its uncorrected or corrected visual acuity, whichever results in better combined visual acuity. Id. A February 2011 VA examination reveals that the Veteran had subjective complaints of bilateral floaters. 02.11.2011 Uncorrected Distance Corrected Distance Uncorrected Near Corrected Near RIGHT 20/50 20/20 20/80 20/20 LEFT 20/40 20/20 20/80 20/20 The September 2011 VA examination also revealed that the Veteran did not have a documented visual field defect. Based on the evidence above, a compensable disability rating for the Veteran's loss of visual acuity is not warranted. The Veteran's visual acuity of 20/20 corrected distance bilaterally warrants a noncompensable disability rating. A March 2017 VA examination reveals that the Veteran had bilateral hyperopia, bilateral presbyopia (neither of which are service connected), and bilateral vitreal floaters. 03.28.2017 Uncorrected Distance Corrected Distance Uncorrected Near Corrected Near RIGHT 20/70 20/40 or better 20/200 20/40 or better LEFT 20/70 20/40 or better 20/200 20/40 or better The March 2017 VA examination also revealed that the Veteran did not have a documented visual field defect. Based on the evidence above, a compensable disability rating for the Veteran's loss of visual acuity is not warranted. The Veteran's visual acuity of 20/40 or better corrected distance bilaterally warrants a noncompensable disability rating. A May 2021 VA examination reveals that the Veteran had bilateral cupping of the optic nerves (not service connected) and bilateral vitreous floaters. 05.21.2021 Uncorrected Distance Corrected Distance Uncorrected Near Corrected Near RIGHT 20/70 20/20 or better 20/200 20/20 or better LEFT 20/40 20/20 or better 20/200 20/20 or better The May 2021 VA examination also revealed that the Veteran did not have a documented visual field defect. Based on the evidence above, a compensable disability rating for the Veteran's loss of visual acuity is not warranted. The Veteran's visual acuity of 20/20 or better corrected distance bilaterally warrants a noncompensable disability rating. Accordingly, the preponderance of the most probative evidence is against the claim of entitlement to a compensable disability rating for a loss of visual acuity. In reaching the conclusion above, the Board considered the doctrine of reasonable doubt, however, as the preponderance of the evidence is against the Veteran's claim, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 5. Entitlement to an initial disability rating in excess of 10 percent for right knee instability 6. Entitlement to an initial disability rating in excess of 20 percent for status post meniscectomy of the left knee with instability Due to the similar dispositions for the above claims on appeal, the Board will address them in a common discussion below. The Veteran asserts that he is entitled to a disability higher rating for his bilateral knee instability disabilities. The Veteran's bilateral knee instability is each separately rated under 38 C.F.R. § 4.71a, Diagnostic Code 5257, for other impairment of the knee. Under Diagnostic Code 5257, a 10 percent disability rating is warranted for slight recurrent subluxation or lateral instability. A 20 percent disability rating is warranted for moderate recurrent subluxation or lateral instability. A 30 percent disability rating is warranted for severe recurrent subluxation or lateral instability. 38 C.F.R. § 4.71a, Diagnostic Code 5257. According to MERRIAM WEBSTER'S COLLEGIATE DICTIONARY 999 (11th Ed. 2007), "slight" means small in amount. "Moderate" means limited in scope or effect. "Severe" means very painful or harmful or of a great degree. Objective medical evidence is not required to establish lateral knee instability under Diagnostic Code 5257, so objective medical evidence cannot be categorically found more probative than lay evidence with respect to this Diagnostic Code. See English v. Wilkie, 30 Vet. App. 347, 352-53 (2018). Effective February 7, 2021, VA amended the rating criteria for disabilities of the knee and leg. The amended Diagnostic Code 5257 provides ratings for other impairment of the knee based on recurrent subluxation or instability, and patellar instability. For recurrent subluxation or instability, a 10 percent disability rating is warranted for sprain, incomplete ligament tear, or complete ligament tear (repaired, unrepaired, or failed repair) causing persistent instability, without a prescription from a medical provider for an assistive device (e.g., cane(s), crutch(es), walker) or bracing for ambulation. A 20 percent disability rating is warranted for one of the following: (a) Sprain, incomplete ligament tear, or repaired complete ligament tear causing persistent instability, and a medical provider prescribes a brace and/or assistive device (e.g., cane(s), crutch(es), walker) for ambulation; or (b) Unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribes either an assistive device (e.g., cane(s), crutch(es), walker) or bracing for ambulation. A maximum 30 percent disability rating is warranted for unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribes both an assistive device (e.g., cane(s), crutch(es), walker) and bracing for ambulation. For patellar instability, a 10 percent disability rating is warranted for a diagnosed condition involving the patellofemoral complex with recurrent instability (with or without history of surgical repair) that does not require a prescription from a medical provider for a brace, cane, or walker. A 20 percent disability rating is warranted for a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for one of the following: A brace, cane, or walker. A maximum 30 percent disability rating is warranted for a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for a brace and either a cane or a walker. Note (1) provides that, for patellar instability, the patellofemoral complex consists of the quadriceps tendon, the patella, and the patellar tendon. Note (2) provides that a surgical procedure that does not involve repair of one or more patellofemoral components that contribute to the underlying instability shall not qualify as a surgical repair for patellar instability (including, but not limited to, arthroscopy to remove loose bodies and joint aspiration). The Board finds that the preponderance of the evidence is against a disability rating in excess of 10 percent for right knee instability and against a disability rating in excess of 20 percent for status post medial meniscectomy of the left knee with instability (under the criteria prior to February 7, 2021). The Board has carefully considered the Veteran's reports about instability. English, 30 Vet. App. 347, 352-53. However, overall, the lay and medical evidence indicates that the instability symptoms have consistently produced 0-5 millimeters (+1) of instability in the right knee and do not suggest the presence of symptoms more nearly approximating moderate severity. See May 2013, April 2017, and July 2021 VA examinations. During the May 2013 VA examination, the examiner found that the Veteran's left knee instability was 5-10 millimeters (+2). See May 2013 VA examination, p. 6. However, since the May 2013 VA examination, the VA examiners have no longer found instability in his left knee. See April 2017 VA examination, p. 21; see also July 2021 VA examination, p. 13. The Board finds that the preponderance of the evidence is against a disability rating in excess of 10 percent for right knee instability and against a disability rating in excess of 20 percent for status post medial meniscectomy of the left knee with instability (under the criteria from February 7, 2021). The Board has carefully considered the Veteran's reports about instability. English, 30 Vet. App. 347, 352-53. However, overall, the lay and medical evidence indicates that the Veteran has persistent instability, without a prescription from a medical provider for an assistive device (e.g., cane(s), crutch(es), walker) or bracing for ambulation. See July 2021 VA examination. The Board has also considered the other Diagnostic Codes pertaining to the knee and leg. Other disability ratings may be assigned only if the symptomatology for a disability is not duplicative or overlapping with the symptomatology of any other disability. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994); Lyles v. Shulkin, 29 Vet. App. 107 (2017) (holding that 38 C.F.R. § 4.14 prohibits paying compensation twice for the same symptoms or functional impairment). The record reflects that the Veteran is also service connected for right knee painful motion, which is also on appeal for an increased disability rating and will be addressed below. In conclusion, the Board finds that the preponderance of the evidence is against the Veteran's claim for a disability rating in excess of 10 percent for right knee instability and against the Veteran's claim for a disability rating in excess of 20 percent for status post medial meniscectomy of the left knee with instability. 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. In reaching this decision the Board considered the doctrine of reasonable doubt, however, as the preponderance of the evidence is against the Veteran's claim, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 7. Entitlement to an initial disability rating in excess of 10 percent for right knee painful motion associated with right knee instability As a preliminary matter, the Board notes that the February 7, 2021 changes to the criteria for disabilities of the knee did not change Diagnostic Code 5260. The Veteran asserts that he is entitled to a higher disability rating for his right knee disability. The Veteran's right knee painful motion is currently rated under Diagnostic Code 5260. The assigned Diagnostic Code 5260 suggests that the Veteran's right knee painful motion is rated based on compensable limitation of flexion. 38 C.F.R. § 4.71a. A review of the evidence reflects that the right knee painful motion has manifested as osteoarthritis and been rated based on painful noncompensable limitation of motion, and that the right knee painful motion has not had compensable limitation of motion (i.e. limitation of flexion or extension) at any time during the relevant rating period. Diagnostic Code 5260 provides that a noncompensable disability rating is warranted for flexion limited to 60 degrees. A 10 percent disability rating is warranted for flexion limited to 45 degrees. A 20 percent disability rating is warranted for flexion limited to 30 degrees. A 30 percent disability rating is warranted for flexion limited to 15 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5260. Diagnostic Code 5010 provides that arthritis, due to trauma, substantiated by x-ray findings is rated as degenerative arthritis under Diagnostic Code 5003. Degenerative arthritis is rated under Diagnostic Code 5003, which provides disability ratings for degenerative arthritis. Degenerative arthritis (osteoarthritis or hypertrophic) 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, however, the limitation of motion of the specific joint or joints involved is noncompensably disabling under the appropriate diagnostic codes, a disability rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under Diagnostic Code 5003. 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. The Veteran was afforded a VA examination in July 2021. The July 2021 VA examiner found that the Veteran's right knee had an initial range of motion of 125 degrees with pain in both flexion and extension (during both active and passive movement) and evidence of pain in weight-bearing, active motion, passive motion, but does not result in or cause functional loss. The July 2021 VA examiner also found that the Veteran did not have additional loss of function or range of motion after three repetitions but did find that the Veteran lost 5 degrees of range of motion after repeated use over time (to 120 degrees) and the Veteran reported further reduction of an additional 10 degrees (to 110 degrees) during flare-ups. As noted above, a compensable disability rating (of 10 percent disabling) for limitation of range of motion under Diagnostic Code 5260 would require flexion of the Veteran's right knee to be limited to 45 degrees, which the Veteran does not have. Additionally, the Board notes that for a compensable disability rating limitation of range of motion in excess of 10 percent disabling (the Veteran's current disability rating) under Diagnostic Code 5260, the Veteran's right knee limitation of flexion would need to be limited to 30 degrees for a 20 percent disability rating. Therefore, the Board finds that the preponderance of the evidence demonstrates that a disability rating in excess of 10 percent for the Veteran's right knee painful motion is not warranted. 8. Entitlement to an initial disability rating in excess of 60 percent for status post right shoulder arthroplasty and degenerative arthritis The Veteran asserts that he is entitled to a higher disability rating for his right shoulder arthroplasty and degenerative arthritis. 38 C.F.R. § 4.71A, Diagnostic Code 5051 provides that a 100 percent disability rating shall be provided for prosthetic replacement of the shoulder joint for 1 year following implantation of prosthesis. With chronic residuals consisting of severe, painful motion or weakness in the affected extremity, a 60 percent disability rating is warranted for the major extremity and a 50 percent disability rating is warranted for the minor extremity. With intermediate degrees of residual weakness, pain or limitation of motion, the disability is rated by analogy under Diagnostic Codes 5200 and 5203 with a minimum disability rating of 30 percent for the major extremity and 20 percent for the minor extremity. The Board notes that the maximum disability rating under Diagnostic Codes 5200 and 5203 for a major extremity is 50 percent disabling. Because the Veteran is already rated at a disability rating in excess of the maximum disability rating under Diagnostic Codes 5200 and 5203, an analysis under those Diagnostic Codes would not be applicable. Furthermore, the Board notes that the evidence of record shows that the Veteran is right-handed. See May 2013 VA examination, p. 13. The Veteran was afforded a VA examination in May 2013. The May 2013 VA examiner found that the Veteran had chronic residuals consisting of severe painful motion and/or weakness. See May 2013 VA examination, pp. 18-19. Initial range of motion testing demonstrated that the Veteran had limited range of motion of the right shoulder flexion and abduction to 45 degrees with less movement than normal, weakened movement, excess fatigability, incoordination and impaired ability to execute skilled movements smoothly, pain on movement, deformity, and atrophy of disuse. See May 2013 VA examination, p. 16. The May 2013 VA examiner noted localized tenderness, infrequent episodes of recurrent dislocation and guarding of the right shoulder. See May 2013 VA examination, pp. 16 and 18. The Veteran was afforded a second VA examination in July 2021. The July 2021 VA examiner found that the Veteran no longer had chronic residuals consisting of severe painful motion and/or weakness. See July 2021 VA examination, p. 18. Initial range of motion testing demonstrated that the Veteran had limited range of motion of the right shoulder flexion and abduction to 145 degrees and both internal and external rotation endpoints of 70 degrees with less movement than normal and weakened movement due to pain. See July 2021 VA examination, pp. 11-12. The May 2013 noted that the Veteran reported that he has flare-ups 4 or 5 days per week, with each flare-up lasting for 2 days causing constant aching and sharp pain that the Veteran rated as a 10/10 and causes his inability to reach over his head. See July 2021 VA examination, p. 4. The Veteran's right shoulder arthroplasty and degenerative arthritis has been assigned the maximum schedular disability rating available for prosthetic implants under 38 C.F.R. § 4.71A, Diagnostic Code 5051, and a higher schedular rating is not warranted. 9. Entitlement to an initial disability rating in excess of 20 percent for left shoulder tendonitis The Veteran asserts that he is entitled to a higher disability rating for his left shoulder disability. The Veteran's left shoulder tendonitis with dislocation is rated under 38 C.F.R. § 4.71a, Diagnostic Code 5201, for limitation of motion of the arm. 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). Effective February 7, 2021, VA amended Diagnostic Code 5201 to reflect that limitation of motion may be shown by flexion and/or abduction and clarified the degrees of limitation of motion that correspond to each rating. Now, limitation of motion at the shoulder level (flexion and/or abduction limited to 90 degrees) warrants a 20 percent rating for both the major and minor extremity. Limitation of motion of the arm midway between side and shoulder level (flexion and/or abduction limited to 45 degrees) warrants a 20 percent rating for the minor extremity and a 30 percent rating for the major extremity. Flexion and/or abduction limited to 25 degrees from the side warrants a maximum 30 percent rating for the minor joint and a maximum 40 percent rating for the major joint. Therefore, the question for the Board is if the Veteran's left shoulder disability produces a limitation of range of motion of flexion and/or abduction limited to at least 25 degrees from the side. When evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use and therefore, not be reflected on range-of-motion testing. 38 C.F.R. § 4.45 requires consideration also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Nonetheless, even when the background factors listed in § 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a; a separate or higher rating under § 4.40 or 4.45 itself is not appropriate. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016) ("[I]t is clear that the guidance of § 4.40 is intended to be used in understanding the nature of the veteran's disability, after which a rating is determined based on the § 4.71a criteria."). Under 38 C.F.R. § 4.59, painful motion is a factor to be considered with any form of arthritis; however, 38 C.F.R. § 4.59 is not limited to disabilities involving arthritis. See Burton v. Shinseki, 25 Vet. App. 1 (2011). The Board finds that the preponderance of the evidence is against a rating in excess of 20 percent for left shoulder tendonitis with dislocation. The evidence of record shows that the Veteran is right-handed. See May 2013 VA examination, p. 13. The Board acknowledges the Veteran's lay reports of symptoms and that there was functional loss due to pain, weakened movement, excess fatigability, incoordination, repetitive use, pain during flare-ups, and pain during repetitive use over time, etc. However, even considering the Veteran's lay reports of symptoms and noted functional loss, the degree of additional limitation reflected by the statements that his left shoulder pain is always severe with marked increase with any motion above 45 degrees, would not result in symptoms more nearly approximating limitation of motion of the arm to 25 degrees from the side of the minor extremity. As noted above, the Veteran was afforded VA examinations in May 2013 and July 2021. In both VA examinations, the Veteran's range of motion of his left shoulder was no worse than 45 degrees. 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 that is not already service-connected. See 38 C.F.R. § 4.71a. However, as will be discussed in greater detail below, the Board notes that the Veteran is service connected under Diagnostic Code 5202 for this disability as well. In conclusion, the Board finds that the preponderance of the evidence is against the Veteran's appeal for a rating in excess of 20 percent for left shoulder tendonitis with dislocation. 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. 10. Entitlement to an initial disability rating in excess of 20 percent for left shoulder tendonitis with dislocation The Veteran asserts that he is entitled to a higher disability rating for his left shoulder disability. The Veteran's left shoulder tendonitis is also rated under 38 C.F.R. § 4.71a, Diagnostic Code 5202, for other impairment of the humerus. Under Diagnostic Code 5202, malunion of the humerus with moderate deformity warrants a 20 percent rating for both the major and minor extremity. Malunion of the humerus with marked deformity warrants a 20 percent rating for the minor extremity and a 30 percent rating for the major extremity. Recurrent dislocation of the humerus at scapulohumeral joint with infrequent episodes and guarding of movement only at shoulder level warrants a 20 percent rating for both the major and minor extremity. Recurrent dislocation of the humerus at scapulohumeral joint with frequent episodes and guarding of all arm movements warrants a 20 percent rating in the minor extremity and a 30 percent rating in the major extremity. Fibrous union of the humerus warrants a 40 percent rating in the minor extremity and a 50 percent rating in the major extremity. Nonunion of the humerus (false fail joint) warrants a 50 percent rating in the minor extremity and a 60 percent rating in the major extremity. Loss of head of the humerus (flail shoulder) warrants a maximum 70 percent rating for the minor extremity and a maximum 80 percent rating for the major extremity. 38 C.F.R. § 4.71a, Diagnostic Code 5202. Effective February 7, 2021, VA amended Diagnostic Code 5202 to reflect that limitation of motion may be shown by flexion and/or abduction and to clarify the degrees of range of motion that relate to movement at the shoulder level. Now, recurrent dislocation of humerus at scapulohumeral joint with infrequent episodes and guarding of movement only at shoulder level (flexion and/or abduction at 90 degrees) warrants a 20 percent rating for both the major and minor extremity. According to MERRIAM WEBSTER, "moderate" means "tending toward the mean or average amount or dimension". See www.merriam-webster.com/dictionary/moderate. "Marked" means "having a distinctive or emphasized character". See www.merriam-webster.com/dictionary/marked. When evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use and therefore, not be reflected on range-of-motion testing. 38 C.F.R. § 4.45 requires consideration also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Nonetheless, even when the background factors listed in § 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a; a separate or higher rating under § 4.40 or 4.45 itself is not appropriate. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016) ("[I]t is clear that the guidance of § 4.40 is intended to be used in understanding the nature of the veteran's disability, after which a rating is determined based on the § 4.71a criteria."). Under 38 C.F.R. § 4.59, painful motion is a factor to be considered with any form of arthritis; however, 38 C.F.R. § 4.59 is not limited to disabilities involving arthritis. See Burton v. Shinseki, 25 Vet. App. 1 (2011). The Board finds that the preponderance of the evidence is against a rating in excess of 20 percent for left shoulder tendonitis. The evidence of record shows that the Veteran is right-handed. See May 2013 VA examination, p. 13. The Board acknowledges the Veteran's lay reports of symptoms and that there was functional loss due to pain, weakened movement, excess fatigability, incoordination, repetitive use, pain during flare-ups, and pain during repetitive use over time, etc. However, even considering the Veteran's lay reports of symptoms and noted functional loss, the degree of additional limitation reflected by the statements that guarding of movement at shoulder level would not result in symptoms more nearly approximating malunion of the humerus with marked deformity of the major joint, recurrent dislocation of the humerus at scapulohumeral joint with frequent episodes and guarding of all movements of the major joint, fibrous union of the humerus, nonunion of the humerus, or loss of head of the humerus. The Board notes that although he May 2013 VA examination noted guarding of the shoulders, the July 2021 VA examination showed considerable improvement of the Veteran's left shoulder disability which no longer produced guarding, nor was there a malunion producing either marked or moderate deformity. See July 2021 VA examination, pp. 12 and 16. In conclusion, the Board finds that the preponderance of the evidence is against the Veteran's appeal for a rating in excess of 20 percent for left shoulder tendonitis. 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. 11. Entitlement to an initial disability rating in excess of 10 percent for painful scars (2) of the right shoulder associated with right shoulder arthroplasty and degenerative arthritis 12. Entitlement to an initial compensable disability rating for right shoulder scars (2) associated with right shoulder arthroplasty and degenerative arthritis Due to the similar dispositions for the above claims on appeal, the Board will address them in a common discussion below. The Veteran asserts that he is entitled to a higher disability rating for his right shoulder scars. The Veteran's right shoulder scars are rated under Diagnostic Code 7802 scars not of the head, face, or neck that are not associated with underlying soft tissue damage and under Diagnostic Code 7804 for unstable or painful scars. The Board notes that VA amended the criteria for rating skin disabilities effective from August 13, 2018. However, although Diagnostic Code 7802 was changed, Diagnostic Code 7804 was not changed by the August 13, 2018, amendments. These new regulations apply to all applications for benefits received by VA or that are pending before the agency of original jurisdiction on or after August 13, 2018. Claims pending prior to the effective date will be considered under both old and new rating criteria, and whatever criteria is more favorable to the veteran will be applied. The Board may not apply a current regulation prior to its effective date unless the regulation explicitly provides otherwise. Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). However, the Board is not precluded from applying prior versions of the applicable regulation to the period on or after the effective dates of the new regulation if the prior version was in effect during the pendency of the appeal. Prior to August 13, 2018, Diagnostic Code 7802, was for burn scar(s) or scar(s) due to other causes, not of the head, face, or neck, that were superficial and nonlinear. Under these criteria, a scar with an area or areas of 144 square inches (929 sq. cm.) or greater warrants a 10 percent disability rating. 38 C.F.R. § 4.118. Note 1 to Diagnostic Code 7802 instructed that a superficial scar was one not associated with underlying soft tissue damage. Id. Since August 13, 2018, Diagnostic Code 7802 is for burn scar(s) or scar(s) due to other causes, not of the head, face, or neck, that are not associated with underlying soft tissue damage. 38 C.F.R. § 4.118. Diagnostic Code 7802 was otherwise unchanged by the August 13, 2018, amendments. Under Diagnostic Code 7804, one or two scars that are unstable or painful scars warrants a 10 percent disability rating. Three or four scars that are unstable or painful scars warrants a 20 percent disability rating. Five or more scars that are unstable or painful warrants a 30 percent disability rating. 38 C.F.R. § 4.118. Note 1 to Diagnostic Code 7804 instructs that an unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. Id. Note (3) under Diagnostic Code 7804 provides that scars evaluated under Diagnostic Codes 7800, 7801, 7802, or 7805 may also receive an evaluation under this Diagnostic Code, when applicable. The Board finds that the preponderance of the evidence is against the assignment of a compensable evaluation under Diagnostic Code 7802 because the Veteran's right shoulder scars are not manifest by an area or areas of 144 square inches (929 sq. cm.) or greater. The Veteran was afforded a VA examination on July 20, 2021. The July 2021 VA examiner found that the Veteran had two scars of the right shoulder. The first scar is located on the right anterior shoulder extending to his right upper arm and measures 29 centimeters (cm) long and 3 cm wide. The second scar is located on the Veteran's right posterior AC joint and measures 6.5 cm long and 1.8 cm wide. See July 2021 VA examination, p. 4. The July 2021 VA examiner noted that the Veteran's right upper extremity scars measured an approximate total area of 98.7 square cm. See July 2021 VA examination, p. 7. Furthermore, the July 2021 VA examiner noted that the Veteran reported that his two right shoulder scars (noted above) are tender on palpation and painful, but the scars were not unstable. See July 2021 VA examination, p. 3. Therefore, the Board finds that the preponderance of the evidence is against the assignment of a rating in excess of 10 percent under Diagnostic Code 7804 because the Veteran's scars are not manifested by three or four scars that are unstable or painful. Finally, the evidence of record shows there are no other disabling effect(s) not considered in a rating provided under Diagnostic Codes 7800-04 as contemplated under both pre- and post-August 13, 2018, Diagnostic Code 7805. Pertaining to the claim for a compensable disability rating, the Veteran's right shoulder scars is not of the head, face, or neck, is not deep and nonlinear, and is not associated with underlying soft tissue damage. Although it is superficial and not associated with underlying soft tissue damage, it does not cover an area or areas of 144 square inches or greater. Therefore, Diagnostic Codes 7800 through 7802, both prior to and from August 13, 2018, are inapplicable. Finally, the evidence of record shows there are no other disabling effect(s) not considered in a rating provided under Diagnostic Codes 7800-04 (that is not already service-connected) as contemplated under both pre- and post-August 13, 2018, Diagnostic Code 7805. 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, to include pain, and his reports are credible. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). However, he does not assert, and medical treatment records do not show, that the Veteran's right shoulder scars are manifested by an area or areas of 144 square inches (929 square cm) or greater; nor by three or more scars that are unstable or painful. In conclusion, the Board finds that the preponderance of the evidence is against the Veteran's claim for a compensable rating for right shoulder scars and a separate compensable disability rating in excess of 10 percent for right shoulder scars. 13. Entitlement to an initial compensable disability rating for hemorrhoids The Veteran asserts that he is entitled to an initial compensable disability rating for hemorrhoids because he has constipation and diarrhea that exacerbates his hemorrhoids. As a preliminary matter, the Board notes that although a large portion of the Veteran's testimony relates to his negative experience during his initial hemorrhoid surgery, those complaints do not relate to the severity of the Veteran's hemorrhoid disability. The Veteran's hemorrhoids have been rated at a noncompensable disability rating pursuant to 38 C.F.R. § 4.114, Diagnostic Code 7336 for external or internal hemorrhoids. Under Diagnostic Code 7336, a noncompensable disability rating is warranted for mild or moderate external or internal hemorrhoids. A 10 percent disability rating is warranted for large or thrombotic hemorrhoids, irreducible, with excessive redundant tissue, evidencing frequent recurrences. A 20 percent disability rating is warranted for when there are hemorrhoids with persistent bleeding and secondary anemia, or with fissures. See 38 C.F.R. § 4.114, Diagnostic Code 7336. The Veteran has been afforded VA examinations in February 2011, March 2017, and July 2021. Throughout the period on appeal, the VA examiners have found that the Veteran has had mild or moderate internal and/or external hemorrhoids without large or thrombotic, irreducible, with excessive redundant tissue evidencing frequent recurrences, nor persistent bleeding with secondary anemia or with fissures. The February 2011 VA examiner noted that the Veteran underwent hemorrhoidectomy in December 2010 but still complained of mild residual bleeding that occurred weekly, pain, and swelling. The examiner found that the Veteran had external hemorrhoids at 2-6-7-10 o'clock position(s) and the anus was tender to palpation without evidence of bleeding. The March 2017 VA examiner found that the Veteran had small external hemorrhoids with skin tags. Finally, the July 2021 VA examiner found that the Veteran had mild or moderate internal or external hemorrhoids. Therefore, the Board finds that an initial compensable disability rating is not warranted under Diagnostic Code 7336 for the Veteran's hemorrhoids because the disability was not manifested by large or thrombotic, irreducible, with excessive redundant tissue evidencing frequent recurrences, nor persistent bleeding and with secondary anemia or with fissures. While the Veteran reports diarrhea with bleeding (not associated with the hemorrhoids but rather exacerbating the hemorrhoids), the evidence in this case does not show anemia nor anal fissures associated with hemorrhoids during the period on appeal. For the above reasons, the weight of the evidence is against finding that the criteria for a compensable disability rating is not warranted. 38 C.F.R. §§ 4.3, 4.7. 14. Entitlement to an initial compensable disability rating for bilateral hand dermatitis (also claimed as skin condition from hazardous chemicals) The Veteran asserts that he is entitled to a higher disability rating for his bilateral hand dermatitis because it covers more than 5 percent of his body. The Veteran's bilateral hand dermatitis is rated under Diagnostic Code 7806, for dermatitis or eczema. VA amended the criteria for rating skin disabilities effective from August 13, 2018. These new regulations apply to all applications for benefits received by VA or that are pending before the agency of original jurisdiction on or after August 13, 2018. Claims pending prior to the effective date will be considered under both old and new rating criteria, and whatever criteria is more favorable to the veteran will be applied. The Board may not apply a current regulation prior to its effective date unless the regulation explicitly provides otherwise. Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). However, the Board is not precluded from applying prior versions of the applicable regulation to the period on or after the effective dates of the new regulation if the prior version was in effect during the pendency of the appeal. Prior to August 13, 2018, under Diagnostic Code 7806, a noncompensable disability rating is assigned for less than 5 percent of the entire body or less than 5 percent of exposed areas affected, and; no more than topical therapy required during the past 12 months. A 10 percent disability rating is assigned for at least 5 percent, but less than 20 percent, of the entire body, or; at least 5 percent, but less than 20 percent, of exposed areas affected, or; intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of less than six weeks during the past 12-month period. A 30 percent disability rating is assigned for 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected, or; systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of six weeks or more, but not constantly during the past 12-month period. A 60 percent disability rating is assigned for more than 40 percent of the entire body or more than 40 percent of exposed areas affected, or; constant or near- constant systemic therapy such as corticosteroids or other immunosuppressive drugs required during the past 12- month period. Or rate as disfigurement of the head, face, or neck (Diagnostic Code 7800) or scars (Diagnostic Codes 7801, 7802, 7803, 7804, or 7805), depending on the predominant disability. 38 C.F.R. § 4.118, Diagnostic Code 7806. For claims filed prior to August 13, 2018, the Court held that a systematic therapy is one that that affects the entire body in its treatment of the condition at issue, and that the Board must determine (1) whether a topical treatment affects the body as a whole in treating a veteran's skin condition; and (2) whether the given treatment is "like" a corticosteroid or other immunosuppressive drug." Burton v. Wilkie, 30 Vet. App. 286 (2018). Only the second question need be addressed if the treatment is clearly systemic. Id. Effective August 13, 2018, VA regulations explicitly state that systemic therapy is treatment that is administered through any route other than the skin, and topical therapy is treatment that is administered through the skin. 38 C.F.R. § 4.118(a). Additionally, effective August 13, 2018, a new General Rating Formula for the Skin applies to Diagnostic Codes 7806, 7809, 7813 to 7816, 7820 to 7822, and 7824. See 38 C.F.R. § 4.118. Under this formula, a noncompensable disability rating is assigned for no more than topical therapy required over the past 12-month period and at least one of the following: characteristic lesions involving less than 5 percent of the entire body affected; or characteristic lesions involving less than 5 percent of exposed areas affected. A 10 percent disability rating is assigned for at least one of the following: characteristic lesions involving at least 5 percent, but less than 20 percent, of the entire body affected; or at least 5 percent, but less than 20 percent, of exposed areas affected; or intermittent systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, PUVA, or other immunosuppressive drugs required for a total duration of less than 6 weeks over the past 12- month period. A 30 percent disability rating is assigned at least one of the following: characteristic lesions involving more than 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected; or systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, PUVA, or other immunosuppressive drugs required for a total duration of 6 weeks or more, but not constantly, over the past 12-month period. A 60 percent disability rating is assigned for at least one of the following: characteristic lesions involving more than 40 percent of the entire body or more than 40 percent of exposed areas affected; or constant or near-constant systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, psoralen with long-wave ultraviolet-A light (PUVA), or other immunosuppressive drugs required over the past 12-month period. Or rate as disfigurement of the head, face, or neck (Diagnostic Code 7800) or scars (Diagnostic Code's 7801, 7802, 7803, 7804, or 7805), depending on the predominant disability. 38 C.F.R. § 4.118, General Rating for the Skin for DCs 7806, 7809, 7813-7816, 7820-7822, and 7824. Here, the Veteran was afforded VA examinations in February 2011, March 2017, and July 2021. The evidence of record demonstrates that the predominant disability is bilateral hand dermatitis that covers less than 5 percent of the Veteran's total body, less than 5 percent of the Veteran's exposed area, and has not required systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, PUVA, or other immunosuppressive drugs. The Board finds that the preponderance of the evidence is against the assignment of a compensable evaluation under the pre-August 13, 2018, regulations because the Veteran's bilateral hand dermatitis does not more nearly approximate at least 5 percent, but less than 20 percent, of the entire body, or at least 5 percent, but less than 20 percent, of exposed areas affected, or; required intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of less than six weeks during the past 12-month period. Furthermore, the Board finds that the preponderance of the evidence is against the assignment of a compensable evaluation under the August 13, 2018, regulations because the Veteran's bilateral hand dermatitis does not more nearly approximate characteristic lesions involving at least 5 percent, but less than 20 percent, of the entire body affected; or at least 5 percent, but less than 20 percent, of exposed areas affected; or intermittent systemic therapy required for a total duration of less than 6 weeks over the past 12- month period. 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, to include his reports of flare-ups, and his reports are credible. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). However, he does not assert, and medical treatment records do not show, that the Veteran's disability more nearly approximates the criteria in the next higher rating. The Board has considered whether any other Diagnostic Codes related to disabilities of the skin would provide for a higher disability evaluation. However, the evidence does not reflect that he would warrant a higher rating under a different diagnostic code. See 38 C.F.R. § 4.118. In conclusion, the Board finds that the preponderance of the evidence is against the Veteran's claim for a compensable disability rating for his bilateral hand dermatitis. Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). To establish a right to compensation for a present disability, a Veteran must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service - the so-called "nexus" requirement. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Service connection may be granted for any disease initially diagnosed after discharge when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). In addition, service connection for certain chronic diseases, including arthritis, may be established on a presumptive basis by showing that the condition manifested to a degree of 10 percent or more within one year from the date of separation from service. 38 U.S.C. §§ 1101, 1112, 1113, 1131, 1137; 38 C.F.R. §§ 3.307, 3.309(a); Fountain v. McDonald, 27 Vet. App. 258, 271-72 (2015). Although the disease need not be diagnosed within the presumptive period, it must be shown, by acceptable lay or medical evidence, that there were characteristic manifestations of the disease to the required degree during that time. 38 U.S.C. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309(a). Additionally, for certain chronic diseases with potential onset during service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. If chronicity in service is not established, a showing of continuity of symptoms after discharge may support the claim. 38 C.F.R. §§ 3.303(b), 3.309; Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). 15. Entitlement to service connection for PVNS The Veteran asserts that his PVNS is related to an in-service fall on the U.S.S. Ranger. The Board finds that there is no evidence of a current disability of PVNS. See Wallin v. West, 11 Vet. App. 509, 512 (1998); see also Allen v. Brown, 8 Vet. App. 374 (1995). The Veteran was afforded a VA examination in July 2021. The July 2021 VA examiner found that the Veteran does not have a diagnosis of PVNS. See July 2021 VA examination, p. 21. The Board notes that diagnostic testing found PVNS in 2001, over a decade prior to the Veteran's application for service connection, but not a disability during the pendency of the claim. In the absence of a disability during the pendency of the claim, service connection cannot be established. See Brammer v. Derwinski, 2 Vet. App. 223 (1992). There is also insufficient evidence of a disability at any point during the claim period or shortly before. See McClain v. Nicholson, 21 Vet. App. 219 (2007); Romanowsky v. Shinseki, 26 Vet. App. 289 (2013). Accordingly, entitlement to service connection is denied. At the core of service connection is functional impairment, which can be a disability even if there is no underlying diagnosis. Consideration should be given to the impact of functional limitation. See Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir., 2018). Here there is no assertion of functional limitation due to PVNS. In reaching this decision the Board considered the doctrine of reasonable doubt, however, as the preponderance of the evidence is against the Veteran's claim, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 16. Entitlement to service connection for bilateral hearing loss The Veteran asserts that he is entitled to service connection for bilateral hearing loss. As a preliminary matter, for VA purposes, impaired hearing will be considered a disability when the auditory threshold for any of the frequencies of 500, 1000, 2000, 3000 and 4000 Hertz is 40 decibels or greater; the auditory thresholds for at least three of these frequencies are 26 decibels or greater; or speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385. The Board finds that there is no evidence of a current disability of bilateral hearing loss. See Wallin v. West, 11 Vet. App. 509, 512 (1998); see also Allen v. Brown, 8 Vet. App. 374 (1995). The Veteran was afforded two VA Hearing Loss examinations. The first VA Hearing Loss examination was in May 2013, and the second in May 2021. The May 2013 VA examiner found auditory thresholds in the right ear of 0 decibels at 500 Hz and 1000 Hz, 5 Db at 2000 Hz, 10 Db at 3000 Hz and 4000 Hz with 100 percent speech recognition; and in the left ear of 5 Db at 500 Hz, 0 Db at 1000 Hz, 5 Db at 2000 Hz, 10 Db at 3000 Hz, and 15 Db at 4000 Hz with 100 percent speech recognition. See May 2013 VA examination, p. 2. The May 2021 VA examiner found auditory thresholds in the right ear of 20 decibels at 500 Hz, 15 Db at 1000 Hz, 10 Db at 2000 Hz, 25 Db at 3000 Hz, 20 Db at 4000 Hz with 100 percent speech recognition; and in the left ear of 10 Db at 500 Hz, 5 Db at 1000 Hz, 10 Db at 2000 Hz, 5 Db at 3000 Hz, and 25 Db at 4000 Hz with 100 percent speech recognition. See May 2021 VA examination, pp. 1-2. In the absence of a disability during the pendency of the claim, service connection cannot be established. See Brammer v. Derwinski, 2 Vet. App. 223 (1992). There is also insufficient evidence of a disability at any point during the claim period or shortly before. See McClain v. Nicholson, 21 Vet. App. 219 (2007); Romanowsky v. Shinseki, 26 Vet. App. 289 (2013). Accordingly, entitlement to service connection is denied. The Board notes that during the October 2019 Board Hearing, the Veteran's representative asserted that the Veteran does have hearing loss for VA purposes. See October 2019 Board Hearing, p. 25. However, the Veteran's representative is incorrect. In reaching this decision the Board considered the doctrine of reasonable doubt, however, as the preponderance of the evidence is against the Veteran's claim, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 17. Entitlement to service connection for migraine headaches The Veteran asserts that his headaches are related to an in-service fall. First, the Board finds that there is a current disability. See Holton, 557 F.3d at 1366; 38 C.F.R. § 3.303(d). The Veteran was afforded a VA examination in July 2021. The July 2021 VA examiner diagnosed the Veteran with common headaches. See July 2021 VA examination, p. 2. Notably, however, the Board finds that there was not an in-service event, injury, or disease, to which current disability may be reasonably related. The Board notes that the Veteran reported a history of frequent or severe headaches in January 1992 (medical surveillance for respirator certification) where the reported basis for the headache was due to a lack of sleep, specifically 3 to 4 hours per night without any mention of when the headaches occurred. See January 1992 (Phase I)/February 1992 (Phase II) Medical Surveillance for Respirator Certification. However, the Veteran's service treatment records do not reflect reports of treatment for headaches. The Board further notes that the limit of any reports of any head disability are in October 1991, in which the Veteran's service treatment records reflect head congestion, with a 3-day history of nasal congestion, cough that produces brown sputum, fever, and diarrhea and an inability to hold fluids down. See October 1991 Service Treatment Records. Similarly, the Veteran's separation evaluation noted a normal clinical evaluation without mention of headaches. See September 1992 Separation Evaluation. Subsequent to his discharge from service, VA treatment records reflect that the Veteran first reported that he had headaches, which were associated with nitroglycerin administration, in February 2002, approximately 10 years after his discharge from service. See February 2002 VA treatment records. Other records also show the Veteran reporting severe headaches many years after his discharge; specifically in December 2017, which was approximately 25 years after his discharge from service, without any link with service indicated. See December 2017 VA treatment records. In both cases, there were many times within the Veteran's VA treatment records that he denied headaches both before and after the above incidents. Thus, without more, the preponderance of the evidence is against a finding of an in-service incurrence of headaches. The second element of service connection has not been met, and an award of service connection is not warranted. See Holton, supra. Accordingly, service connection is denied. The Board has considered the Veteran's reports attributing his headaches to service, but the evidence of record does not demonstrate that the Veteran has the requisite medical training, expertise, or credentials needed to render a diagnosis or a competent opinion as to medical causation. Therefore, the Veteran is not competent to provide an opinion on the etiology of his migraine headache disability. See Jandreau v. Nicholson, 492 F. 3d 1372, 1377 (2007). In reaching this decision the Board considered the doctrine of reasonable doubt, however, as the preponderance of the evidence is against the Veteran's claim, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 18. Entitlement to service connection for traumatic brain damage, claimed as head injury causing eye issues The Veteran asserts that his traumatic brain injury is related to an in-service fall. The Board finds that there is not a current disability. See Holton, 557 F.3d at 1366; 38 C.F.R. § 3.303(d). The Veteran was afforded a VA examination in July 2021. The July 2021 VA examiner opined that the Veteran does not currently, nor has he ever had a traumatic brain injury. See July 2021 VA examination, p. 2. Although the Veteran had complaints of headaches, the Veteran had no complaints of memory, attention, concentration, not executive functions. The July 2021 VA examiner found that the Veteran's judgment was normal, social interaction is routinely appropriate, the Veteran is oriented to person, time, place, and situation; had normal motor activity and visual spatial orientation without any subjective symptoms nor neurobehavioral effects and was able to communicate by spoken and written language (expressive communication) and to comprehend spoken and written language with normal consciousness. In the absence of a disability during the pendency of the claim, service connection cannot be established. See Brammer v. Derwinski, 2 Vet. App. 223 (1992). There is also insufficient evidence of a disability at any point during the claim period or shortly before. See McClain v. Nicholson, 21 Vet. App. 219 (2007); Romanowsky v. Shinseki, 26 Vet. App. 289 (2013). Accordingly, entitlement to service connection is denied. In reaching this decision the Board considered the doctrine of reasonable doubt, however, as the preponderance of the evidence is against the Veteran's claim, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 19. Entitlement to service connection for nerve damage to neck 20. Entitlement to service connection for back problems (claimed as upper back condition) 21. Entitlement to service connection for back problems (claimed as lower back condition) 22. Entitlement to service connection for residuals of right foot fracture, claimed as broken bones in right foot 23. Entitlement to service connection for bilateral index finger disability 24. Entitlement to service connection for degenerative arthritis of the right hip, also claimed as broken right hip disability 25. Entitlement to service connection for residuals of left ankle fracture Due to the similar dispositions for the above claims on appeal, the Board will address them in a common discussion below. The Veteran asserts that the above disabilities all began during service and has existed since that time and/or it is related to an in-service fall. First, the Board finds that there are current disabilities. See Holton, 557 F.3d at 1366; 38 C.F.R. § 3.303(d). The Veteran is diagnosed with degenerative disc disease other than intervertebral disc syndrome (IVDS) and compression and irritation of the right upper radicular group, specifically C5/C6 nerve roots. See July 2021 Neck (Cervical Spine) VA examination, p. 11. The Veteran is also diagnosed with lumbosacral strain. See Back (Thoracolumbar Spine Conditions), p. 2. The Veteran is diagnosed with right foot strain. See July 2021 Foot Conditions, Including Flatfoot (Pes Planus) VA examination, p. 3. The Veteran is diagnosed with bilateral index finger strain. See July 2021 Hand and Fingers VA examination, p. 3. The Veteran is diagnosed with right hip strain. See July 2021 Hip and Thigh VA examination, p. 3. Finally, the Veteran is also diagnosed with residual loss of range of motion and pain status post left ankle fracture and surgery. See July 2021 Ankle VA examination, p. 3. Second, affording the Veteran the benefit of the doubt, the Board finds that there was an in-service event, injury, or disease. See Holton, 557 F.3d at 1366; 38 C.F.R. § 3.303(d). Although the Veteran's service treatment records do not reflect that the Veteran had a 60-foot fall during service, the Veteran does report a 60-foot fall during service. Nerve Damage to the Neck The Board notes that the evidence does not reflect that the Veteran had a cervical spine injury due to the fall and the Veteran's service treatment records are silent for nerve damage to his cervical spine. Furthermore, the Veteran's separation examination is silent for a neck disability. Back Problems (claimed as upper back condition) [Cervical Spine Disability] The Board notes that the evidence does not reflect that the Veteran had a cervical spine injury due to the fall and the Veteran's service treatment records are silent for degenerative disc disease of the cervical spine. Furthermore, the Veteran's separation examination is silent for a neck disability. Back Problems (claimed as lower back condition) The Board notes that the evidence does not reflect that the Veteran had a lumbar spine injury due to the fall and the Veteran's service treatment records are silent for a lumbar spine injury. Furthermore, the Veteran's separation examination is silent for a lumbar spine disability. Residuals of Right Foot Fracture The Board notes that the evidence does not reflect that the Veteran had a right foot injury due to the fall and the Veteran's service treatment records are silent for a right foot injury. Furthermore, the Veteran's separation examination is silent for a right foot disability. Bilateral Index Fingers The Board notes that the evidence does not reflect that the Veteran had an injury to his bilateral index fingers due to the fall and the Veteran's service treatment records are silent for an injury to his index finger(s). Furthermore, the Veteran's separation examination is silent for an index finger disability. Degenerative Arthritis of the Right Hip The Board notes that the evidence does not reflect that the Veteran had a right hip injury due to the fall and the Veteran's service treatment records are silent for a right hip injury. Furthermore, the Veteran's separation examination is silent for a right hip disability. Residuals of Left Ankle Fracture The Board notes that the evidence does not reflect that the Veteran had a left ankle injury due to the fall and the Veteran's service treatment records are silent for a left ankle injury. Furthermore, the Veteran's separation examination is silent for a left ankle disability. Finally, the Board finds that the evidence of record does not support a finding that the Veteran's disabilities (nerve damage to neck, back problems (claimed as upper and lower back conditions), residuals of right foot fracture, bilateral index fingers, degenerative arthritis of the right hip (claimed as broken right hip disability), and residuals of left ankle fracture) are related to the Veteran's active service. The Veteran was afforded VA examination(s) in July 2021. The July 2021 VA examiner opined that the Veteran's disabilities (nerve damage to neck, back problems (claimed as upper and lower back conditions), residuals of right foot fracture, bilateral index fingers, degenerative arthritis of the right hip (claimed as broken right hip disability), and residuals of left ankle fracture) are all less likely than not (less than 50 percent probability) incurred in or caused by service, including the in-service fall down a shaft during service that the Veteran asserts because the Veteran's service treatment records did not disclose the above disabilities as a result of the 60-foot fall, there is insufficient objective evidence to support the above disabilities during service, and there are post-service treatment records (significantly) after his discharge from active duty. Addressing post-service treatment and onset of the disabilities, the Board notes that for all of the above disabilities, the Veteran's treatment records do not reflect a diagnosis nor complaints of pain for many years after his discharge. Additionally, there is evidence of intervening events (including a nexus opinion) pertaining to his neck disabilities. Specifically, the Veteran's post-service June 2013 VA treatment records reflect that the Veteran's presented with complaints of pain and muscle spasm of the neck status post-surgery for degenerative disc disease secondary to roll over motor vehicle accident the prior year (2012) with an initial provisional diagnosis made in February 2012 of degenerative disc disease with radicular symptom. See February 2012 and June 2013 VA treatment records. The Board notes that the motor vehicle accident and preliminary cervical spine disability diagnosis were both approximately 2 decades after the Veteran was discharged from service. Accordingly, entitlement to service connection for nerve damage to the neck and back problems (claimed as upper back condition) are both denied. Furthermore, the Board notes that in the November 1992 Statement in Support of Claim (VA Form 21-4138), the Veteran's only assertion concerned his right shoulder disability due to his in-service fall. Finally, in April 1994, the Veteran completed a Counseling Record Personal Information which he listed his only disabilities as (1) degenerative joint disease in the right shoulder and an acquired psychiatric disability. Despite the Veteran's assertions that the above disabilities began during service and have continued since service, the Veteran did not indicate any of the above disabilities as a current disability. See April 1994 Counseling Record Personal Information, p. 2, Section F. In reaching this decision the Board considered the doctrine of reasonable doubt, however, as the preponderance of the evidence is against the Veteran's claim, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). M. E. KILCOYNE Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Deemer, Gregory T. 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.