Citation Nr: 21075108 Decision Date: 12/17/21 Archive Date: 12/17/21 DOCKET NO. 17-65 908 DATE: December 17, 2021 ORDER 1. Entitlement to service connection for headaches, to include as secondary to a service-connected disability, is denied. 2. Entitlement to a 20 percent rating for the Veteran's duodenal ulcer with reflux esophagitis and chronic constipation is granted prior to August 19, 2021; entitlement to a rating in excess of 60 percent for duodenal ulcer with reflux esophagitis from that date is denied. 3. Entitlement to a rating in excess of 10 percent for a left knee disability is denied. REMANDED 4. Entitlement to a total disability rating based on individual unemployability due to service-connected disability (TDIU) prior to August 19, 2021 is remanded. FINDINGS OF FACT 1. A chronic headache disability was not manifested in service, and the preponderance of the evidence is against a finding that such disability is etiologically related to the Veteran's service or was caused or aggravated by his service-connected gastrointestinal (GI) disabilities. 2. Prior to August 19, 2021, the Veteran's duodenal ulcer with reflux esophagitis and chronic constipation is shown to have been manifested by mild duodenal ulcer with recurring symptoms once or twice yearly, with the overall disability picture (including consideration of reflux esophagitis symptoms, such as persistently recurrent epigastric distress with dysphagia, pyrosis, regurgitation, and substernal/arm/shoulder pain) reasonably shown to warrant elevation to the next higher rating; from August 19, 2021, the 60 percent rating assigned is the maximum schedular rating provided for either hiatal hernia or duodenal ulcer, and separately ratable complications, or gastroesophageal or duodenal symptoms or impairment not encompassed by the schedular criteria are not shown or alleged. 3. The Veteran's left knee disability is not shown to have been manifested by flexion limited to 30 degrees, extension limited at 15 degrees, or flexion limited to 45 degrees and extension limited at 10 degrees; additional limitations due to pain, weakened movement, excessive fatigability with use, or incoordination; recurrent subluxation or instability; or from February 7, 2021, sprain, incomplete ligament tear, or complete ligament tear (repaired, unrepaired, or failed repair) causing persistent instability; or a diagnosed condition involving the patellofemoral complex with recurrent instability (with or without history of surgical repair). CONCLUSIONS OF LAW 1. Service connection for headaches is not warranted. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.303, 3.304, 3.310. 2. The Veteran's duodenal ulcer with reflux esophagitis and chronic constipation warrants "staged" ratings of 20 percent prior to August 19, 2021, and 60 percent from that date. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.1, 4.20, 4.21, 4.114, Diagnostic Codes (Codes) 7305, 7346. 3. A rating in excess of 10 percent for a left knee disability is not warranted. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1-4.7, 4.10, 4.40, 4.45, 4.71a, Codes 5003, 5257, 5260, 5261. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The appellant is a Veteran who served on active duty from September 1984 to July 1994. These matters are before the Board on appeal from April 2015 and August 2015 Department of Veterans Affairs (VA) rating decisions. In April 2021, a hearing was held before the undersigned; a transcript is in the record. In July 2021, the matters were remanded for additional development. An August 2021 rating decision increased (to 60 percent) the rating for duodenal bulb ulcer with reflux esophagitis, effective August 19, 2021. The Veteran has established service connection for two separately rated GI disabilities. Prior to the August 2021 rating decision, he was assigned ratings under Code 7319 for duodenal bulb ulcer with reflux esophagitis and chronic constipation, and under Code 7332 for impairment of rectal sphincter control. The August 2021 rating decision recharacterized the disabilities according to their respective symptoms, and he is now rated 60 percent under Codes 7346-7305 for duodenal bulb ulcer with reflux esophagitis, and 30 percent under Codes 7319-7332 for impairment of rectal sphincter control with irritable bowel syndrome (IBS) constipation. The matter on appeal before the Board is the rating for duodenal bulb ulcer with reflux esophagitis; the separate rating 30 percent rating for impairment of rectal sphincter control is not before the Board. 1. Entitlement to service connection for headaches is denied. Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated in line of duty during active service. See 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). To substantiate a claim of service connection, there must be evidence of (1) a current disability (for which service connection is sought); (2) incurrence or aggravation of a disease or injury in service; and (3) a causal connection between the disease or injury in service and the current disability. See Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). A disease first diagnosed after service may be service connected if all the evidence, including pertinent service records, establishes that it was incurred in service. 38 C.F.R. § 3.303(d); Combee v. Brown, 34 F.3d 1039, 1043 (Fed. Cir. 1994). Lay evidence may be competent evidence to establish incurrence. See Davidson v. Shinseki, 581 F. 3d 1313 (Fed. Cir. 2009). Competent medical evidence is necessary where the determinative question is one requiring medical knowledge. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. 38 C.F.R. § 3.310(a). Any increase in severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease, will be service connected. VA will not concede that a non-service-connected disease or injury was aggravated by a service-connected disease or injury unless the baseline level of severity of the nonservice-connected disease or injury is established by medical evidence created before the onset of aggravation or by the earliest medical evidence created at any time between the onset of aggravation and the receipt of medical evidence establishing the current level of severity of the nonservice-connected disease or injury. The rating activity will determine the baseline and current levels of severity under the Schedule for Rating Disabilities and determine the extent of aggravation by deducting the baseline level of severity, and any increase in severity due to the natural progress, from the current level. 38 C.F.R. § 3.310(b). The Veteran contends that when he has increased severity of his service-connected GI issues, that can lead to onset of a headache or aggravates headaches. His STRs are silent for complaints, findings, treatment, or diagnosis of a chronic headache disability. On July 1994 service separation examination, neurologic clinical evaluation was normal; in a contemporaneous report of medical history, he denied any history of frequent or severe headaches. The postservice medical evidence in the claims file is silent regarding headaches until an October 2001 VA treatment record, which notes that the Veteran reported having occasional headaches. On December 2014 VA treatment, he reported that he had stopped taking atorvastatin for hyperlipidemia and Viagra for erectile dysfunction (ED) because both caused headaches. The VA treatment records otherwise include consistent reports of no headaches (in November 2004, May 2010, November 2010, March 2012, November 2012, April 2013, October 2014, March 2015, October 2015, January 2016, July 2016, December 2016, May 2017, November 2017, May 2018, September 2018). At the April 2021 Board hearing, the Veteran testified that most of the time when he has digestive symptoms he cannot sleep, and the lack of sleep causes a morning headache. He testified that he has headaches, two or three times a week, and has had them for years. On August 2021 VA examination, the Veteran reported that his headaches started during service in the 1980s as severe headaches. He reported current symptoms of daily morning headaches and mood swings, treated with Tylenol and ibuprofen. Following physical examination, the diagnosis was migraine including migraine variants. The examiner opined that the Veteran's claimed condition of headache disorder was less likely than not incurred in or caused by service, and less likely than not proximately due to, the result of, or aggravated beyond its natural progression by his service-connected GI disabilities. The examiner noted that there were no complaints of headaches or migraines during service and that a treatment record mentions headaches from glaucoma, and also noted that the Veteran has a diagnosis of severe primary open angle glaucoma uncontrolled on maximal medical therapy, and opined that this can contribute to changes in vision and eye/forehead pain. The examiner opined that therefore, the claimed condition of headache disorder is less likely than not incurred in or caused by service, or proximately due to, the result of, or aggravated beyond its natural progression by the service-connected GI disabilities. The Veteran has established service connection for duodenal bulb ulcer with reflux esophagitis and impairment of rectal sphincter control with irritable bowel syndrome (IBS) with constipation. A chronic headache disability is not shown to have been manifested in service and is not noted in postservice clinical records in the claims file prior to 2001. Accordingly, service connection for such disability on the basis that it became manifest in service and persisted is not warranted. It is not shown by the record that the Veteran's current headaches are etiologically related directly to his active duty service. The earliest documented postservice clinical notation of complaints pertaining to headaches is in 2001, approximately 7 years after the Veteran's discharge from active duty. A VA examiner has opined that it is less likely than not that the claimed headaches were incurred during, or caused by, his military service, explaining in essence that the factual record provides no basis for relating the current headaches to a disease, injury, or event in service (as there was none). It was also explained that medical literature does not identify any pathophysiological basis for finding that the Veteran's service-connected GI disabilities either caused or aggravated his headaches. The provider cited to factual data and medical principles, explaining that the more likely etiology for the headaches was his nonservice-connected glaucoma. The opinion is probative evidence in the matter, and the Board finds it persuasive. Whether the Veteran's service-connected GI disabilities caused or aggravated his headache disability is a medical question that is beyond the scope of common knowledge and incapable of resolution by lay observation; it requires medical expertise. The Veteran is a layperson; consequently, his own opinion is not competent evidence in this matter. See Jandreau, supra. He has not submitted a medical opinion (with rationale) in support of this claim (or identified any medical provider who has offered such opinion). The August 2021 VA examiner's opinion is the only medical opinion evidence in the record that addresses that question. The opinion cites to clinical data in the record and to medical principles, including that there is no mention of headaches in STRs (no disease or injury in service to which the headaches could be related) and no basis by which a GI disorder would impact on (cause or aggravate headaches), and that the Veteran's nonservice-connected glaucoma is a disease known to have manifestations of headaches. The Board notes the Veteran's hearing testimony indicates he had onset of severe headaches in service, but also notes that he denied having headaches, or a history of headaches, on service separation. Regardless, continuity of a chronic headache disability postservice (which could potentially warrant a chronic disease presumption of service connection -as an organic disease of the nervous system under 38 U.S.C. § 1112) is not shown; the earliest postservice mention of headaches was in 2001. The opinion is probative evidence in the matter. The Veteran has not presented competent evidence to the contrary (and has not alleged any specific deficiency in the opinion). Therefore, the preponderance of the evidence is against this claim, and the appeal in the matter must be denied. Increased Rating Revisions were made to certain regulations governing ratings for musculoskeletal disabilities, effective February 7, 2021. As the Veteran's appeal was pending at the time of this revision, from that date, he is entitled to a rating under the old or the new criteria, whichever are more favorable. Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. With the initial rating assigned upon a grant of service connection, separate (staged) ratings may be assigned for separate periods of time, based on the facts found. Fenderson v. West, 12 Vet. App. 119, 126 (1999). Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary importance. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). In claims for increase, as here, the relevant temporal focus for adjudicating an increased rating claim is on the evidence concerning the state of the disability for a period beginning one year before the claim was filed until VA makes a final decision on the claim. However, separate ratings may be assigned for separate periods of time based on facts found. This practice is known as "staged" ratings." Hart v. Mansfield, 21 Vet. App. 505 (2007). In evaluating the severity of a particular disability, it is essential to consider its history. 38 C.F.R. § 4.1; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Where there is a question as to which of two ratings shall be applied, the higher rating 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. Reasonable doubt as to the degree of disability will be resolved in the veteran's favor. 38 C.F.R. § 4.3. 2. Entitlement to a 20 percent (but not higher) rating for duodenal ulcer with reflux esophagitis is granted prior to August 19, 2021; entitlement to a rating in excess of 60 percent from that date is denied. At the outset, it is noteworthy that instructions under 38 C.F.R. § 4.114 provide that ratings under Codes 7305 (for duodenal ulcer) and 7346 (for hiatal hernia, under which GERD is rated) may not be combined. Instead, a single rating is to be assigned under the code for the predominant disability with elevation to the next higher rating where the severity of the overall disability warrants such elevation. Duodenal ulcer is rated under Code 7305, which provides for a 60 percent (maximum) rating for severe disability; pain only partially relieved by standard ulcer therapy, periodic vomiting, recurrent hematemesis or melena, with manifestations of anemia and weight loss productive of definite impairment of health. A 40 percent rating is assigned for moderately severe disability; less than severe but with impairment of health manifested by anemia and weight loss; or recurrent incapacitating episodes averaging 10 days or more in duration at least four or more times a year. A 20 percent rating is assigned for moderate disability; recurring episodes of severe symptoms two or three times a year averaging 10 days in duration; or with continuous moderate manifestations. A 10 percent rating is assigned for mild disability, with recurring symptoms once or twice yearly. The rating schedule does not provide a specific code for GERD; the disability is rated by analogy to the criteria for rating hiatal hernia. 38 C.F.R. § 4.20. On review of those criteria, the Board finds such analogy appropriate, as symptoms of GERD most approximately resemble the symptoms and impairment in the criteria for rating hiatal hernia (under Code 7346). Under Code 7346 for hiatal hernia/GERD, a 60 percent (maximum) rating is assigned for symptoms of pain, vomiting, material weight loss, and hematemesis or melena with moderate anemia; or other symptom combinations productive of severe impairment of health; a 30 percent rating is warranted when there is persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health. With two or more of the symptoms for the 30 percent evaluation of lesser severity, a 10 percent rating is warranted. 38 C.F.R. § 4.114. On April 2015 VA esophageal, stomach, and duodenum examinations, the diagnoses included gastroesophageal reflux disease (GERD) and duodenal ulcer. The Veteran was noted to have been seen and treated for a stomach ulcer during service and was placed on an acid blocker at that time, and he has been on medication to reduce stomach acid since then. He reported taking esomeprazole twice a day. His GERD symptoms included persistently recurrent epigastric distress, dysphagia, reflux, regurgitation, and substernal/shoulder/arm pain. He reported having sleep disturbances caused by esophageal reflux, nausea, and vomiting, each occurring 4 or more times per year and lasting less than 1 day. He did not have esophageal stricture, spasm of esophagus, or an acquired diverticulum of the esophagus. He was noted to be obese. He reported that in 2014 he had to go to the ER due to black tarry stool and nausea which lasted a few weeks. His duodenal ulcer symptoms included recurring episodes of severe symptoms occurring once a year with a duration of 10 days or more; he also reported periodic abdominal pain only partially relieved by standard ulcer therapy, and recurrent nausea occurring 4 or more times per year and lasting less than a day. There were no incapacitating episodes due to signs or symptoms of a stomach or duodenum condition. A March EGD was normal, without recurrence of duodenal ulcer. A December 2014 upper endoscopy was normal, and a solid gastric emptying study showed no evidence of gastroparesis, with normal gastric emptying using standardized solid meal. The examiner opined that the esophageal condition impacted the Veteran's ability to work, noting his report that his combined GI symptoms from GERD, history of GI ulcer, and chronic constipation all made it difficult for him to work. On April 2015 VA intestinal conditions examination, the Veteran was noted to have chronic constipation; he was started on a stool softener during service, and since then had tried Miralax and Linzess which had helped somewhat. Continuous medication was required for control of the condition. Symptoms included abdominal distension daily, and daily nausea, although medication kept him from vomiting. He reported episodes of bowel disturbance with more or less constant abdominal distress. There was no weight loss, malnutrition, or other serious complications or general health effects attributable to the intestinal condition. Based on this evidence, an August 2015 rating decision granted service connection for chronic constipation effective February 6, 2015, and noted that the disability would be evaluated in conjunction with the Veteran's service-connected duodenal bulb ulcer with reflux esophagitis, then rated 10 percent, and together they would remain rated 10 percent. January 2016 anal manometry revealed high baseline anal sphincter pressures, pelvic floor dyssynergia with incomplete relaxation during bear down, and failed balloon expulsion. The Veteran was referred for pelvic floor therapy. On February 2017 VA treatment, he reported that his GI issues were improving. In July 2018, the Veteran submitted a Stomach and Duodenal Conditions Disability Benefits Questionnaire (DBQ), which noted his conditions as duodenal ulcer and Helicobacter (H.) Pylori. It was noted that the H. Pylori was treated with medication; he underwent EGD every several years to monitor the duodenal ulcer condition and modified his diet as needed. He reported ongoing symptoms, treated by taking Nexium continuously. His reported symptoms included recurring episodes of symptoms that are not severe, occurring 4 or more times per year and 10 days or more in duration; recurring episodes of severe symptoms 4 or more times per year; continuous abdominal pain unrelieved by standard ulcer therapy; anemia in 1993 due to blood loss; and mild nausea occurring 3 times per year with duration of 1 to 9 days. He reported one incapacitating episode when he "fell down one day due to sharp stomach pain" which lasted 1 to 9 days. He reported having hypertrophic gastritis, chronic, with small nodular lesions, and symptoms, per EGD, and that he had internal scar tissue that was not painful or unstable; difficulty eating food if it is irritating or burning to the stomach; and having nausea at times. He reported that a May 2018 upper endoscopy showed inflammation of healing ulcer, a May 2018 ultrasound showed that his gallbladder was normal, and that May 2018 laboratory studies were negative for H. Pylori. The provider opined that the disability impacts the Veteran's ability to work, noting his report that he is unable to work with his current conditions due to pain, and he is unable to eat food and digest quickly with needing the restroom. In July 2018, the Veteran also submitted an Intestinal Conditions DBQ, which noted his condition as irritable bowel syndrome (IBS) with constipation. He reported using several medications to control the pain and condition as well as diets and procedures; continuous medication was required to control the disability. His reported symptoms included diarrhea due to medication; alternating diarrhea and constipation due to medication; occasional abdominal distension with stomach flare-ups; anemia; and frequent nausea with abdominal issues. He reported having frequent episodes of bowel disturbance with abdominal distress occurring 7 or more times during the previous 12 months. He did not have weight loss attributable to an intestinal condition. He was noted to have serious complication such as a liver abscess attributable to his IBS, specifically hemangioma and fatty liver; a May 2018 ultrasound showed fatty liver and hemangioma of the right hepatic lobe, and bowel gas limited evaluation. The provider of the DBQ opined that the intestinal disability impacts the Veteran's ability to work, noting his report that he is unable to get from one place to another due to unexpected bowel movements, abdominal pain, and worsened diarrhea due to treating medications; it was noted that he drove a truck and faced constant daily obstacles due to his disability. On September 2018 VA treatment, the Veteran reported having bloating, gas, cramping, and change in his bowel habits with chronic constipation. He reported having occasional firm stools and occasional diarrhea, and having a bowel movement at least every other day and a sense of incomplete evacuation. He had no GI bleeding. He reported weight gain which he attributed to no longer working. He complained of some issues with dysphagia to solids and less so with liquids, typically in the morning. He was compliant in taking Nexium twice a day with good control of GERD symptoms. The impressions were GERD currently well-controlled, with unremarkable recent upper endoscopy; dysphagia not assisted with heartburn and possible underlying dysmotility; chronic constipation, bloating, incomplete evacuation, urgency due to IBS; and stable chronic liver hemangioma. On October 2018 VA examination, the Veteran's reported symptoms included reflux, intermittent epigastric pain, intermittent dysphagia despite medical treatment, and intermittent vomiting. Continuous treatment with medication was required. His symptoms due to GERD included persistently recurrent epigastric distress, dysphagia, pyrosis, reflux, regurgitation, substernal pain, sleep disturbance 4 or more times per year with duration of less than 1 day, and vomiting 4 or more times per year lasting less than 1 day. He reported recurring episodes of symptoms that are not as severe occurring 4 or more times per year with duration of less than 1 day; periodic abdominal pain occurring at least monthly and only partially relieved by standard ulcer therapy; and recurrent vomiting occurring 4 or more times per year with duration of less than 1 day. There were no incapacitating episodes due to signs or symptoms of any stomach or duodenum condition. His IBS symptoms included marked constipation with bowel movement every 2 to 3 days despite treatment; severe cramping prior to bowel movement; marked bloating; multiple bowel movements with urgency following constipation; occasional incontinence; and all symptoms were worse with stressful situations. He reported episodes of bowel disturbance with more or less constant abdominal distress, and episodes of exacerbations and/or attacks of IBS 7 or more times in the previous 12 months. There were no weight loss, malnutrition, serious complications, or other general health effects attributable to IBS. The examiner opined that the esophageal, stomach, or duodenum conditions do not impact on the Veteran's ability to work. The examiner further opined that the intestinal condition impacts on ability to work, noting historically severe reoccurring abdominal pain and cramping followed by erratic multiple urgent stooling requiring immediate bathroom access. In a December 2020 medical opinion statement, the Veteran's VA treating gastroenterologist noted that he has had longstanding chronic abdominal symptoms for over 10 years, and stated that she has treated the Veteran since 2012 and has attempted to optimize his symptoms since then. She stated that he suffers from chronic GERD, and irritable bowel constipation predominantly with constipation and fecal leakage, and has been on acid suppression, medication such as Linzess, and has undergone pelvic floor therapy. The provider opined that overall, the Veteran's chronic refractory GI symptoms have been challenging for him and contributed to a poor quality of life. At the April 2021 Board hearing, the Veteran testified that his symptoms prior to January 2020 included vomiting, inability to swallow due to food getting stuck in his throat, and inability to use the bathroom. He testified that every two years he has to go to the VA [for a procedure] to stretch his esophagus to enable him to swallow food. He testified that he has had to wear Depends undergarments due to his IBS and has excruciating pain when the urge to use the bathroom occurs. On August 19, 2021 VA esophageal conditions examination, the Veteran's current symptoms due to GERD included inability to sleep, severe nausea, vomiting, dysphagia, choking, reflux, regurgitation, restricted airway, and chest burning; he felt like he always had something stuck in his throat. He reported that he had to retire from working in food services at a prison because he was always sick, and required continuous medication. His GERD symptoms included a combination productive of severe impairment of health; persistently recurrent epigastric distress; dysphagia; reflux; regurgitation; substernal pain; sleep disturbance caused by esophageal reflux 4 or more times per year with a duration of 1 to 9 days; nausea 4 or more times per year with duration of 1 to 9 days; and vomiting 4 or more times per year with duration of less than 1 day. He had difficulty with esophageal spasms at times even after the esophageal dilation, of moderate severity. The examiner opined that the Veteran's GERD impacted his ability to work, noting that the symptoms caused multiple missed days at work, and he was unable to focus due to the pain and other symptoms. On August 19, 2021 VA stomach and duodenal conditions examination, the Veteran's current symptoms due to his duodenal ulcer condition included sharp abdominal pain, bloating, constipation, sweating, sudden urge to go to the bathroom, and gas. His symptoms included recurring episodes of severe symptoms occurring 4 or more times a year with average duration of 1 to 9 days; abdominal pain at least monthly, continuous, and only partially relieved by standard ulcer therapy; anemia; recurrent nausea and vomiting 4 or more times a year with average duration of 1 to 9 days; mild hematemesis 4 or more times a year with average duration of less than 1 day; and recurrent melena 4 or more times a year with average duration of 1 to 9 days. He reported having 4 or more incapacitating episodes a year with average duration of 1 to 9 days, when he gets weak and cannot do anything. The examiner opined that the Veteran's stomach or duodenum condition impacted his ability to work, noting that the symptoms caused multiple missed days at work, and he was unable to focus due to pain and other symptoms. The examiner noted that the diagnosis of duodenal bulb ulcer with chronic constipation was corrected to duodenal ulcer. On August 19, 2021 VA intestinal conditions examination, the Veteran's current symptoms due to IBS included 5 to 9 days without a bowel movement, severe constipation, and abdominal pain. Continuous medication is required, along with a special diet. He reported he wore Depends due to IBS. His symptoms due to IBS included alternating diarrhea and constipation, abdominal distension with gas and bloating, and nausea when he has gone days without a bowel movement. He reported having episodes of bowel disturbance with more or less constant abdominal distress. There were no weight loss, malnutrition, serious complications, or other general health effects attributable to IBS. The examiner opined that the Veteran's IBS impacted his ability to work, in that symptoms caused multiple missed days at work and inability to focus due to pain and other symptoms. The Veteran reported working as a bus driver with incontinent episodes of stool, and working at a prison with needing multiple trips to the bathroom and occasions of incontinent episodes of stool. The examiner noted that the diagnosis of chronic constipation was corrected to IBS-constipation. The examiner opined that the Veteran's hard stool results in fecal impaction that produces constant inhibition of internal anal sphincter tone, permitting leakage of liquid stool around the impaction, and thus the current symptomatology is consistent with the manifestation of his service-connected impairment of rectal sphincter control [rather than a manifestation of his service-connected ulcer disability]. Based on this evidence, an August 2021 rating decision increased the rating for duodenal bulb ulcer with reflux esophagitis to 60 percent effective August 19, 2021, noting that the duodenal bulb ulcer is the dominant (more disabling) disability and was considered and evaluated with the GERD as one condition for disability rating purposes under Code 7346-7305. The rating decision also noted that the impairment of rectal sphincter control, which is the more dominant (more disabling) disability, and residuals of IBS constipation, are considered and evaluated as one condition for disability rating purposes under Code 7319-7332, and the IBS constipation would no longer be rated with the evaluation of duodenal bulb ulcer with reflux esophagitis. Additional VA and private treatment records show symptoms that are largely similar to those found on the VA examinations described above. As noted in the Introduction above, the Veteran is service connected with two separate ratings for gastrointestinal disabilities: prior to August 19, 2021, under Code 7319 for duodenal bulb ulcer with reflux esophagitis and chronic constipation, and Code 7332 for impairment of rectal sphincter control; and from August 19, 2021 under Codes 7346-7305 for duodenal bulb ulcer with reflux esophagitis, and Codes 7319-7332 for impairment of rectal sphincter control with IBS constipation. The matter on appeal is the Veteran's rating for duodenal bulb ulcer with reflux esophagitis. The Board finds that, prior to August 19, 2021, symptoms found on VA examinations and treatment records exceeded what is needed for a 10 percent rating under Code 7305 (noting that duodenal ulcer has been determined as the predominant disability picture, based on the symptoms shown to be the most prevalent manifestations of the disability). While the examiners did not find more than mild duodenal ulcer, with recurring episodes of severe symptoms two or three times a year averaging 10 days in duration, or with continuous moderate manifestations (so as to meet the criteria for a 20 percent rating under that Code), the Board finds that with consideration of the GERD symptoms consistently shown throughout that period (persistently recurrent epigastric distress with dysphagia, pyrosis, regurgitation, and substernal/arm/shoulder pain, although not productive of considerable impairment of health), the overall disability picture may reasonably (see 38 C.F.R. § 4.3) be found to warrant elevation to the next higher (20 percent) rating throughout prior to August 19, 2021. Moderate, moderately severe, or severe duodenal ulcer, with pain only partially relieved by standard ulcer therapy, periodic vomiting, recurrent hematemesis or melena, with manifestations of anemia and weight loss productive of definite impairment of health is not shown, and a still higher (20 percent + bump up to 40 percent, or higher than 40 percent) rating for that period is not warranted. Continuing the analysis, while the assignment of the maximum schedular rating for the Veteran's duodenal ulcer with reflux esophagitis from August 19, 2021 raises a question of whether referral of the claim for increase to the Director of Compensation for consideration of an extraschedular rating is warranted, the Board's review of the evidence of record in the matter found that referral is not necessary. There is no evidence showing (or allegation of) symptoms or functional impairment not encompassed by the schedular criteria. While VA examiners have opined that the GI disability impacts on the Veteran's ability to work, they have not opined that he is unable to work due to his service-connected duodenal ulcer with reflux esophagitis, or found that symptoms he has reported are not all encompassed by the schedular criteria. Consequently, referral for extraschedular consideration is not warranted. The Board notes the lay statements submitted by the Veteran in support of this claim. They describe the types of problems that result from the duodenal ulcer with reflux esophagitis. The symptoms and impairment described are consistent with the criteria for the 20 percent and 60 percent ratings now assigned, and do not support that a further increase in the staged ratings for this disability is warranted. 3. Entitlement to a rating in excess of 10 percent for a left knee disability is denied. On April 2015 VA examination, the Veteran reported that during flare-ups, both knees wake him up with aching, throbbing pain. He reported functional impairment consisting of decreased range of motion. On physical examination, left knee flexion was to 130 degrees and extension was to 0 degrees; the range of motion itself did not contribute to functional loss. Pain was not noted on examination. There was evidence of pain with weight-bearing. There was no objective evidence of localized tenderness or pain on palpation of the left knee, and no objective evidence of crepitus. There was no additional functional loss or range of motion after repetitive use testing. There were no additional contributing factors of disability. Muscle strength testing was normal with no reduction in muscle strength. Left lower extremity muscle atrophy was noted, with circumference of the right side at 10 centimeters above the knee measuring noted to be 54 centimeters and circumference on the left at the same level measuring 50 centimeters. The knee was not ankylosed. There was no history of recurrent subluxation, lateral instability, or recurrent effusion. Joint stability testing was normal. Left knee X-rays showed degenerative arthritis. The examiner opined that the knee disability impacts the Veteran's ability to perform occupational tasks, noting his report that he cannot stand, walk, bend, or squat, all movements that were required by his last employment working in a kitchen. Based on this evidence, an August 2015 rating decision granted service connection for left knee degenerative arthritis, rated 10 percent effective February 6, 2015. At the April 2021 Board hearing, the Veteran testified that he wears a brace on the left knee all the time. On August 2021 VA examination, the Veteran reported radiating knee pain, pain with movements, limited range of motion, weakness, and instability; treatment consisted of knee braces, ice/heat packs, rest, Voltaren gel, steroid injections, and over-the-counter pain treatments. He reported being unable to stand up for more than 30 minutes and falling often. He reported daily severe left knee flare-ups precipitated by normal daily activities. On physical examination, the decreased range of motion reduced his ability to pick things up off the floor or don his shoes and socks. Left knee flexion was to 85 degrees with pain and extension was to 0 degrees. On passive range of motion, flexion was to 90 degrees with pain and extension was to 0 degrees. There was evidence of pain in active and passive motion and in weight-bearing, that did not result in or cause functional loss. There was no objective evidence of crepitus or localized tenderness or pain on palpation. On repetitive use testing, there was no additional loss of function or range of motion. The evidence suggested pain, fatigability, weakness, and lack of endurance significantly limited functional ability with repeated use over time and during flare-ups; estimated range of motion after repeated use over time or during a flare-up was from 0 to 80 degrees. Additional factors contributing to disability included interference with standing, disturbance of locomotion, less movement than normal, weakened movement, and swelling throughout the day; he had increased pain with sitting, standing, or walking. There was no muscle atrophy or ankylosis of the knee. There was no recurrent subluxation or persistent instability. Left knee anterior instability, posterior instability, medial instability, and lateral instability test results were each 1+ (0 to 5 millimeters). There was no ligament tear (sprain), and the Veteran did not require a prescription for any device to assist ambulation. There was no recurrent patellar instability. There was a diagnosis of shin splints with treatment for less than 12 consecutive months; the shin splints have no symptoms and do not affect the left knee range of motion. There was no history of a meniscal condition. The Veteran did not use assistive devices. The examiner opined that the Veteran's left knee disability impacts his ability to perform occupational tasks, noting that knee pain slows his walk, he has increased falls from joint instability, and he is unable to stand for prolonged periods (more than 10 to 15 minutes) without pain. Additional VA and other treatment records show symptoms similar to those reported on the VA examinations described above. The Veteran has also submitted lay statements attesting to the severity of his knee problems. When evaluating a service-connected disability based on limitation of motion, the Board must take into consideration functional loss due to pain under 38 C.F.R. § 4.40 and functional loss due to weakness, fatigability, incoordination, or pain on movement of a joint under 38 C.F.R. § 4.45. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see Johnson v. Brown, 9 Vet. App. 7 (1996). In DeLuca, the Court held that a diagnostic code based on limitation of motion does not subsume 38 C.F.R. §§ 4.40 and 4.45 and that the 38 C.F.R. § 4.14 rule against pyramiding does not forbid consideration of a higher rating based on a greater limitation of motion due to pain on use, including use during flare-ups). Id. A finding of functional loss due to pain must be supported by adequate pathology and evidenced by the visible behavior of the veteran. 38 C.F.R. § 4.40; Johnston v. Brown, 10 Vet. App. 80, 85 (1997). As noted above, some revisions to musculoskeletal Codes have been made effective February 7, 2021. However, the record does not reflect that a higher rating is warranted under either the old or new version of the Codes for rating knee disability. Knee disabilities are rated under Codes 5256 to 5263. Under Code 5260, limitation of knee flexion warrants a 30 percent rating when limited to 15 degrees, a 20 percent rating when limited to 30 degrees, a 10 percent rating when limited to 45 degrees, and a 0 percent rating when limited to 60 degrees (or lesser limitation). Under Code 5261, limitation of knee extension warrants a 40 percent rating when limited at 30 degrees; a 30 percent rating when limited at 20 degrees; a 20 percent rating when limited at 15 degrees; a 10 percent rating when limited at 10 degrees; and a 0 percent rating when limited at 5 degrees (or for lesser limitation). Under the old criteria for Code 5257, a 30 percent rating is warranted for severe recurrent subluxation or lateral instability; a 20 percent rating is warranted for moderate recurrent subluxation or lateral instability; and a 10 percent rating is warranted for slight recurrent subluxation or lateral instability. Under the new criteria for Code 5257, for recurrent subluxation or instability, a 30 percent 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. A 20 percent rating is warranted for sprain, incomplete ligament, or repaired complete ligament tear causing persistent instability, and a medical provider prescribes a brace and/or assistive device for ambulation; or unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribes either an assistive device or bracing for ambulation. A 10 percent 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 or bracing for ambulation. Also under the new criteria for Code 5257, for patellar instability, a 30 percent 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 walker. A 20 percent 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 10 percent 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. Rating the knee disabilities under Codes 5256, 5258, 5259, 5262, 5263 is inappropriate in this case as the Veteran's left knee disability does not include the pathology required for rating under those Codes (ankylosis, dislocated semilunar cartilage, symptomatic removal of semilunar cartilage, malunion or nonunion of tibia or fibula, or genu recurvatum). 38 C.F.R. § 4.71a. While the Veteran has reported chronic left knee pain and stiffness, at no time has there been objective evidence of limitation of knee flexion limited to 30 degrees, so as to warrant a 20 percent rating under Code 5260 for the left knee. Likewise, at no time is there objective evidence of knee extension limited at 15 degrees, to warrant a 20 percent rating under Code 5261. Furthermore, at no time is it shown that flexion was limited to 45 degrees and extension was limited at 10 degrees, to warrant a 20 percent rating based on a combination of ratings under Codes 5260 and 5261, even with factors such as pain and use (repetitive motion), as well as the degree of severity of the disability during flare-ups. The 10 percent rating assigned accounts for all left knee pathology and functional limitations shown. On the examinations and treatment reports of record, tests for left knee instability were predominantly normal, and subluxation was not found. On April 2021 VA examination, tests for left knee instability found mild instability that does not rise to the level of sprain, incomplete ligament tear, or complete ligament tear (repaired, unrepaired, or failed repair) causing persistent instability, and patellar instability has not been shown at any time. Therefore, a separate rating under Code 5257 is not warranted. The Board notes the lay statements submitted by the Veteran in support of this claim. They describe the types of problems that result from the left knee disability. The symptoms and impairment described are consistent with the criteria for the rating assigned, and do not support that any higher rating is warranted. The Board finds that an increased rating for left knee disability is not warranted at any time during the appeal period under consideration. The preponderance of the evidence is against this claim, and the appeal in the matter must be denied. REASONS FOR REMAND Entitlement to a TDIU rating prior to August 19, 2021 is remanded. In Rice v. Shinseki, 22 Vet. App. 447 (2009), the U.S. Court of Appeals for Veterans Claims held, in essence, that when the matter of entitlement to a TDIU rating is raised by the record in a claim for increase, such matter becomes part of the increased rating claim. Here, the Veteran submitted a September 2021 statement (among others) raising entitlement to TDIU as part and parcel of the claims for increased ratings; he contends that he has been unemployable throughout the appeal period due to his service-connected disabilities. A claim seeking a TDIU rating has not been developed or adjudicated by the agency of original jurisdiction. Therefore, remand for such action is necessary. [The combined schedular rating for the Veteran's service-connected disabilities is 100 percent effective August 19, 2021, therefore the matter remaining for consideration is entitlement to a TDIU rating prior to that date.] The matter is REMANDED for the following action: 1. Obtain for the record complete, updated to the present, records of the Veteran's VA treatment for his service-connected disabilities. 2. Thereafter, review the record and, following completion of all further development indicated (with the Veteran's co-operation), adjudicate the matter of entitlement to a TDIU rating prior to August 19, 2021. If TDIU is denied, so advise the Veteran (and advise him of his appellate rights). GEORGE R. SENYK Veterans Law Judge Board of Veterans' Appeals Attorney for the Board D. Schechner, Counsel 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.