Citation Nr: 21076324 Decision Date: 12/23/21 Archive Date: 12/23/21 DOCKET NO. 18-31 469 DATE: December 23, 2021 ORDER Entitlement to service connection for left wrist disability is granted. Entitlement to service connection for rectocele is granted. Entitlement to service connection for right knee disability, secondary to service-connected s/p left knee surgery, claimed as left knee pain, cartilage thinning on causation basis is granted. Entitlement to service connection for bilateral pes planus is granted. Entitlement to an initial rating of 20 percent, but no higher, for s/p left knee surgery, claimed as left knee pain, cartilage thinning is granted, subject to controlling regulations governing the payment of monetary awards.. Entitlement to a separate initial 10 percent rating, but no higher, for left knee instability is granted, subject to controlling regulations governing the payment of monetary awards. Entitlement to a compensable rating for recurrent corneal erosion, claimed as left eye condition is denied. REMANDED Entitlement to service connection for misaligned pelvis is remanded. Entitlement to service connection for arthritis of multiple joints is remanded. FINDINGS OF FACT 1. The evidence is at least evenly balanced as to whether the Veteran's current left wrist disability is related to service. 2. The evidence is at least evenly balanced as to whether the Veteran's current rectocele disability is related to service. 3. The Veteran's right knee disability is caused by service-connected left knee disability. 4. The evidence is at least evenly balanced as to whether the Veteran's current bilateral pes planus is related to service. 5. The Veteran's s/p left knee surgery, claimed as left knee pain, cartilage thinning symptoms, more nearly approximated limitation of flexion to 30 degrees, to include consideration of functional loss. Symptoms did not more nearly approximate flexion limited to 15 degrees or limitation of extension to 15 degrees. 6. The Veteran's left knee instability more nearly approximated slight symptoms throughout the appeal period, but at no time did left knee instability more nearly approximate moderate instability. 7. The Veteran's service-connected left eye disability has been productive of visual acuity of 20/40 or better in both eyes without visual defect, contraction of visual field, loss of visual field, scotoma, muscle dysfunction, or incapacitating episodes. CONCLUSIONS OF LAW 1. The criteria for service connection for left wrist disability have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for service connection for rectocele have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. 3. The criteria for service connection for right knee disability, secondary to service-connected s/p left knee surgery, claimed as left knee pain, cartilage thinning on a causation basis have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.310. 4. The criteria for service connection for bilateral pes planus have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. 5. The criteria for an initial rating of 20 percent, but no higher, for s/p left knee surgery claimed as left knee pain, cartilage have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.159, 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5260. 6. The criteria for a separate rating of 10 percent, but no higher, for left knee instability have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1-4.7, 4.71a, Diagnostic Code 5257. 7. The criteria for an initial compensable rating for recurrent corneal erosion, claimed as left eye condition have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.75 - 4.79, Diagnostic Code 6066. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from August 2007 to August 2013. This case comes before the Board of Veterans' Appeals (Board) on appeal from an April 2015 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) which, inter alia, granted service connection for s/p left knee surgery, claimed as left knee pain, cartilage thinning, and recurrent corneal erosion, claimed as left eye condition, and assigned noncompensable ratings effective August 28, 2013. The RO also denied entitlement to service connection for misaligned pelvis, tendonitis, rectocele, right knee, pes planus, and arthritis disabilities. In January 2016, the Veteran submitted a notice of disagreement (NOD), and a statement of the case (SOC) was issued in April 2018 addressing the matter. The Veteran timely appealed. In an April 2018 rating decision, the RO increased the rating for s/p left knee surgery, claimed as left knee pain, cartilage thinning to 10 percent, effective August 28, 2013, date of claim. Although a higher rating has been granted for s/p left knee surgery, claimed as left knee pain, cartilage thinning, this issue remains in appellate status, as the maximum available benefit has not been assigned. AB v. Brown, 6 Vet. App. 35, 38 (1993). In August 2021, the Veteran testified at a virtual hearing before the undersigned Veterans Law Judge (VLJ). A transcript of the hearing is associated with the record. Given the symptoms in this case, the claim for service connection for misaligned pelvis has been more broadly characterized as entitlement to service connection for pelvic disability, to include bilateral hip pain, and back pain. Additionally, in the January 2016 NOD, the Veteran clarified that he was claiming tendonitis in wrist. Therefore, the claim of service connection for tendonitis has been recharacterized as entitlement to service connection of the wrist disability, to include tendonitis and pain. See Clemons v. Shinseki, 23 Vet. App. 1, 4-5 (2009). These issues have been recharacterized accordingly on the title page. As a final preliminary matter, on November 17, 2021 the Board received a motion to advance the case on the docket. As the decision is being issued, the motion is moot. Service Connection Service connection will be granted if the evidence demonstrates that current disability resulted from an injury or disease incurred in the active military, naval, air, or space service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Establishing service connection generally requires competent evidence of three things: (1) current disability; (2) in-service disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Saunders v. Wilkie, 886 F.3d 1356, 1361 (Fed. Cir. 2018). Consistent with this framework, service connection is including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection may be established on a secondary basis for a disability that is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). A diagnosis is not required to meet the current disability requirement and pain alone can constitute disability if it causes impairment in earning capacity. Saunders v. Wilkie, 886 F.3d 1356, 1364-65 (Fed. Cir. 2018). 1. Left Wrist In this case, the evidence of record indicates a current disability. Specifically, an April 2015 VA examination report shows a complaint of left wrist pain. At her August 2021 Board hearing, the Veteran reported functional impairment due to wrist pain. In Saunders, 886 F.3d at 1364-65, the Federal Circuit held that pain alone could constitute disability under 38 U.S.C. § 1110 if it causes impairment. The Veteran's lay statements reflect that there is impairment of the wrist that causes impairment in earning capacity. Consequently, the first element of service connection has been met. The Veteran's service treatment records (STRs) show complaints and treatment for left wrist joint pain, noted as consistent with tendonitis in March 2013. At the Veteran's August 2021 Board hearing, she testified that she experienced wrist symptoms in service, and her symptoms has continued since service. Based on the evidence contained in the Veteran's STRs and her competent and credible statements, the Board finds that the second element of service connection has been met. In addition, the Veteran's testimony indicating wrist symptoms in and since service, combined with current diagnosis, is sufficient to establish that the left wrist disability had its onset in service. Buchanan, 451 F.3d at 1335 ("[N]othing in the regulatory or statutory provisions [relating to evidence to be considered] require both medical and competent lay evidence; rather, they make clear that competent lay evidence can be sufficient in and of itself ); 38 C.F.R. § 3.303(a) (service connection connotes many factors but basically it means that the facts, shown by evidence, establish that a particular injury or disease resulting in disability was incurred coincident with service in the Armed Forces). There is no evidence to the contrary. For the reasons set forth above, the Board finds that the evidence is at least in equipoise as to whether the Veteran's wrist disability had its onset in service. Thus, resolving reasonable doubt in the Veteran's favor, the Board finds that service connection is warranted for left wrist disability. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 2. Rectocele In this case, the evidence of record indicates a current disability. Specifically, March 2018 and April 2018 private treatment records shows a diagnosis of rectocele. Consequently, the first element of service connection has been met. The Veteran's STRs shows a diagnosis of rectocele in May 2011. At the Veteran's August 2011 Board hearing, she reported that the wall of her pelvis is weakened and collapsing due to trauma from her deliveries in service. The Veteran noted being told that it is a permanent condition, and they would like for her to get a hysterectomy eventually. She reported experiencing rectocele symptoms in service, and the continuation of symptoms since service. Based on the evidence contained in the Veteran's STRs and her competent and credible statements, the Board finds that the second element of service connection has been met. In April 2015, the Veteran underwent a VA examination. She reported having to press rectal sphincter for bowel movement in 2008. The Veteran reported that she was diagnosed with rectocele during her pregnancy in 2011. Her current symptom was having trouble with bowel movement. The examiner indicated no current rectocele diagnosis and did not provide an opinion. The Veteran's testimony indicating rectocele symptoms in and since service, combined with current diagnosis, is sufficient to establish that the rectocele disability had its onset in service. Buchanan, 451 F.3d at 1335 ("[N]othing in the regulatory or statutory provisions [relating to evidence to be considered] require both medical and competent lay evidence; rather, they make clear that competent lay evidence can be sufficient in and of itself ); 38 C.F.R. § 3.303(a) (service connection connotes many factors but basically it means that the facts, shown by evidence, establish that a particular injury or disease resulting in disability was incurred coincident with service in the Armed Forces). There is no evidence to the contrary. For the reasons set forth above, the Board finds that the evidence is at least in equipoise as to whether the Veteran's rectocele disability had its onset in service. Thus, resolving reasonable doubt in the Veteran's favor, the Board finds that service connection is warranted for rectocele disability. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 3. Right Knee The Veteran contends that her right knee disability is related to active service. In an alternative theory, she contends that right knee disability is secondary to service-connected left knee disability. For the following reasons, service connection for right knee disability, secondary to left knee disability is warranted. In this case, the evidence of record demonstrates that the requirement for a current disability has been met. Specifically, private treatment records dated in April 2015, July 2016, November 2017, and March 2018 shows diagnoses of knee pain and osteoarthritis. In an October 2016 private Disability Benefits Questionnaire (DBQ), the physician opined that the Veteran has continued to have left knee pin since the surgery, and since then developed right knee pain, and this is likely secondary to the left knee surgery. Although the private physician did not provide a detailed rationale for his opinion, he nonetheless concluded based upon an examination of the Veteran and a review of her reported history that the Veteran's right knee disability is related to her left knee disability. This opinion is thus entitled to some probative weight. See Monzingo v. Shinseki, 26 Vet. App. 97, 106 (2012) (the fact that the rationale provided by an examiner did not explicitly lay out the examiner's journey from the facts to a conclusion, did not render the examination inadequate); Acevedo v. Shinseki, 25 Vet. App. 286, 294 (2012) (medical reports must be read as a whole and in the context of the evidence of record). There is no contrary medical opinion in the evidence of record. For the foregoing reasons, the private opinion indicating that right knee disability is caused by her service-connected left knee disability, provide a sufficient basis to grant service connection for right knee disability. Thus, service connection for right knee disability, secondary to service-connected s/p left knee surgery, claimed as left knee pain, cartilage thinning is warranted on a causation basis. 4. Bilateral Pes Planus In this case, the evidence of record indicates a current disability. Specifically, an October 2016 private DBQ shows a diagnoses of bilateral pes planus. Thus, the first element of service connection has been met. The evidence of record indicates that the in-service disease requirement has been met. At the Veteran's June 2007 enlistment examination, her feet were examined and determined to be normal. She is thus presumed to have been in sound condition as to her feet. 38 U.S.C. § 1111. The Veteran's STRs shows complaints and treatment for right foot pain in January 2009. In August 2009, she reported that at the same time she had low back pain, she was told that she has flat feet. She was currently profiled for running. In March 2013, the Veteran exhibited foot pronation. At her August 2021 Board hearing, the Veteran testified that her feet were fine prior to service, she began experiencing foot problems in service, and has continued to experience symptoms since service. Based on the evidence contained in the Veteran's STRs and her competent and credible statements, the Board finds that the second element of service connection has been met. The Veteran's testimony indicating pes planus symptoms in and since service, combined with current diagnosis, is sufficient to establish that the pes planus had its onset in service. Buchanan, 451 F.3d at 1335 ("[N]othing in the regulatory or statutory provisions [relating to evidence to be considered] require both medical and competent lay evidence; rather, they make clear that competent lay evidence can be sufficient in and of itself ); 38 C.F.R. § 3.303(a) (service connection connotes many factors but basically it means that the facts, shown by evidence, establish that a particular injury or disease resulting in disability was incurred coincident with service in the Armed Forces). There is no evidence to the contrary. For the reasons set forth above, the Board finds that the evidence is at least in equipoise as to whether the Veteran's pes planus had its onset in service. Thus, resolving reasonable doubt in the Veteran's favor, the Board finds that service connection is warranted for bilateral pes planus. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. Higher Ratings Disability ratings are determined by the application of a schedule of ratings which is based on average impairment of earning capacity. 38 U.S.C. § § 1155; 38 C.F.R. § Part 4. Separate diagnostic codes identify the various disabilities. The basis of disability evaluations is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. Evaluations are based upon lack of usefulness of the part or system affected, especially in self-support. 38 C.F.R. § § 4.10. Where there is a question as to which of two disability ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § § 4.7. Any reasonable doubt regarding the degree of disability is resolved in favor of the veteran. 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 disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Where the Veteran is appealing the initial assignment of a disability rating, the severity of the disability is to be considered during the entire period from the initial assignment of the disability rating to the present time. Fenderson v. West, 12 Vet. App. 119 (1999). disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Where a claimant appeals the denial of a claim for an increased disability rating for a disability for which service connection was in effect before, he filed the claim for increase, the present level of disability is the primary concern, and past medical reports should not be given precedence over current medical findings. Francisco v. Brown, 7 Vet. App. 55, 57-58 (1994). Where VA's adjudication of the claim for increase is lengthy and factual findings show distinct time periods where the service-connected disability exhibits symptoms which would warrant different ratings, different or staged ratings may be assigned for such different periods of time. Hart v. Mansfield, 21 Vet. App. 505, 509-510 (2007). Disability of the musculoskeletal system is primarily the inability, due to damage or infection in the parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. It is essential that the examination on which ratings are based adequately portray the anatomical damage, and the functional loss, with respect to all these elements. The functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part which becomes painful on use must be regarded as seriously disabled. 38 C.F.R. § §§ 4.10, 4.40, 4.45. VA must analyze the evidence of pain, weakened movement, excess fatigability, or incoordination and determine the level of associated functional loss in light of 38 C.F.R. § 4.40, which requires the VA to regard as seriously disabled any part of the musculoskeletal system that becomes painful on use. DeLuca v. Brown, 8 Vet. App. 202 (1995). 5. Left Knee The Veteran left knee exhibits painful and limited motion and is being rated under the criteria pertaining to limitation of motion. 38 C.F.R. § 4.71a, Diagnostic Code 5260. Although the RO assigned a 10 percent rating under DC 5260, it appears to the Board that the Veteran has different, non-overlapping symptoms, including instability, such that she is entitled to separate ratings under Lyles v. Shulkin, 29 Vet. App. 107 (2017) (there is no prohibition of separate evaluation under 38 C.F.R. § 4.71a, Diagnostic Code 5257 or 5261 and a meniscal Diagnostic Code, i.e., Diagnostic Codes 5258 or 5259). The selection of a particular diagnostic code "is a determination that is completely dependent upon the facts of a particular case," and the Board has discretion in determining the appropriate diagnostic code. Butts v. Brown, 5 Vet. App. 532, 538 (1993) (en banc) (applying the more deferential "arbitrary, capricious" standard, rather than de novo review, to the Board's determination of the appropriate diagnostic code). Thus, consideration of separate ratings under DC's 5257, 5260, and 5261 are appropriate in this case. The Board recognizes that the criteria for Rating Musculoskeletal System was amended effective February 7, 2021. However, with regard for the criteria for rating limitation of motion of the knees (Diagnostic Codes 5260 and 5261), the criteria were not changed. See Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 76453, 76463 (Nov. 30, 2020). Evaluations for limitation of flexion of a knee are assigned as follows: flexion limited to 60 degrees is noncompensable; flexion limited to 45 degrees is 10 percent; flexion limited to 30 degrees is 20 percent; and flexion limited to 15 degrees is 30 percent. 38 C.F.R. § 4.71a, Diagnostic Code 5260. Evaluations for limitation of knee extension are assigned as follows: extension limited to 10 degrees is 10 percent; extension limited to 15 degrees is 20 percent; extension limited to 20 degrees is 30 percent; extension limited to 30 degrees is 40 percent; and extension limited to 45 degrees is 50 percent. 38 C.F.R. § 4.71a, Diagnostic Code 5261. Normal range of motion of a knee is from zero degrees of extension to 140 degrees of flexion. 38 C.F.R. § 4.71, Plate II.0. As noted above, the regulations pertaining to the musculoskeletal system were amended effective February 7, 2021. The amendments provide that the Board should apply the criteria which are more favorable to the Veteran. The amended rating criteria, if favorable to the claim, can be applied only for periods from the effective date of the regulatory change; however, the old regulations will be considered for the periods both before and after the change was made. See VAOPGCPREC 3-2000, 65 Fed. Reg. 33,422 (2000); Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). Under the prior version of DC 5257, a 10 percent rating is available for slight recurrent subluxation or lateral instability. A 20 percent rating is assigned for moderate recurrent subluxation or lateral instability. A 30 percent rating is assigned for severe recurrent subluxation or lateral instability. 38 C.F.R. § 4.71a, DC 5257. Under the revised version of DC 5257, for recurrent subluxation or lateral instability, a 30 percent rating is assigned 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 assigned 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; (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 10 percent rating is assigned 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. 38 C.F.R. § 4.71a, DC 5257 (2021). In cases of patellar instability, a 30 percent rating is warranted for 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. 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 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. Under Note (1): For patellar instability, the patellofemoral complex consists of the quadriceps tendon, the patella, and the patellar tendon. Per Note (2): A surgical procedure that does not involve repair of one or more patellofemoral components that contribute to the underlying instability shall not qualify as surgical repair for patellar instability (including, but not limited to, arthroscopy to remove loose bodies and joint aspiration). 38 C.F.R. § 4.71a, Diagnostic Code 5257 (2021). a) Limitation of Motion The Veteran contends that a rating higher than 10 percent for s/p left knee surgery, claimed as left knee pain, cartilage thinning is warranted. For the following reasons, the Board finds that the preponderance of evidence is against the assignment of an increased rating higher than 10 percent for the Veteran's left knee disability based on limitation of flexion and extension. In this case, repeated examinations have shown that the Veteran's left knee motion is not limited to the extent necessary to meet the criteria for a rating in excess of 10 percent under Diagnostic Code 5260, the code setting forth the criteria for limitation of flexion. Specifically, an April 2015 VA examination report shows flexion was to 140 degrees, and extension was normal at 0 degrees, without pain. An October 2016 private DBQ report shows flexion was to 140 degrees, and extension was normal at 0 degrees. A June 2019 VA examination report shows flexion was to 37 degrees with pain, and extension was at 0 degrees. The Board must also consider whether symptoms including pain produced additional functional loss or limitation of motion to support the assignment of higher ratings. At the April 2015 VA examination, the Veteran reported left knee flare-ups where she cannot bend knees and stand for long periods. An October 2016 private DBQ shows the Veteran reported flareups of left knee causing difficulty with all exercises and pain with jogging. At the June 2019 VA examination, the Veteran reported flareups of left knee pain causing difficulty with climbing stairs, walking, standing for long periods, and swelling. The June 2019 VA examiner found that during a flare-up the additional limitation of flexion would be to 32 degrees, and extension normal. Significantly, the June 2019 VA examiner, consistent with Sharp v. Shulkin, 29 Vet. App. 26, 33 (2017), estimated that flexion would be limited to 32 degrees. That more nearly approximates the flexion limited to 30 degrees warranting a 20 percent rating. Accordingly, a rating of 20 percent is warranted. A higher or separate rating is not warranted because neither flexion nor extension to 15 degrees was more nearly approximated during flare-ups. b) Subluxation or Instability The record on appeal, however, does show that the Veteran's service-connected left knee disability exhibits additional symptomatology associated with instability. For the following reasons, the Board finds that a separate 10 percent initial rating is warranted for left knee instability. The evidence regarding left knee instability is conflicting. The April 2015 VA examination report and October 2016 private DBQ have shown normal joints stability tests. In a June 2018 statement, the Veteran reported that she has learned to always walk near a railing and never use the stairs without holding on, because her left knee buckles more times each day than she can begin to count. At her August 2021 Board hearing, the Veteran testified that her left knee gives out and buckles underneath her. She noted that she fell at work the other day and landed on her face due to her left knee buckling. buckles, and caused her to fall at work the other day and land on her face. The June 2019 VA examination report notes a history of lateral instability, however, the Veteran's joint instability tests were normal. Based on the Veteran's reports, the Board resolves reasonable doubt in her favor to award a separate 10 percent rating for slight left knee instability. The Veteran is competent to report left knee stability symptoms and her reports are credible. English v. Wilkie, 30 Vet. App. 347, 349 (2018) (objective evidence is not required to establish knee instability under DC 5257 and the Board cannot categorially find objective medical evidence more probative than lay evidence). The evidence does not, however, more nearly approximate moderate left knee instability under DC 5257. Id. The Veteran's left knee instability reports have been considered. English, 30 Vet. App. at 355. However, the consistent normal stability tests on examination reflect that the instability was not so significant as to more nearly approximate moderate or severe subluxation or lateral instability. The Board has considered whether higher ratings could be assigned under an alternative diagnostic code, however, the Board finds that no other diagnostic codes are applicable. Repeated examinations indicate no evidence of ankylosis of the left knee. Thus, a rating under Diagnostic Code 5256 is not warranted. Furthermore, a rating under Diagnostic Codes 5258 and 5259 is not applicable. Specifically, the March 2015 VA examination report shows the Veteran had a meniscus condition with frequent episodes of pain, but without frequent episodes of joint locking and joint effusion. The October 2016 private DBQ and June 2019 VA examination report indicates that the Veteran did not have a meniscal disability. Thus, a rating under Diagnostic Codes 5258 and 5259 is not warranted. For the reasons set forth above, the Board finds that an increased rating higher than 10 percent for s/p left knee surgery, claimed as left knee pain, cartilage thinning is not warranted. The Board also finds that a separate 10 percent rating for left knee instability under Diagnostic Code 5257 is warranted. The preponderance of the evidence is against the assignment of ratings higher than those currently assigned, thus the benefit of the doubt doctrine is not for application. See 38 U.S.C. § 5107 (b); 38 C.F.R. § 4.3 6. Left Eye The Veteran asserts that her service-connected left eye disability is more severe than the current noncompensable evaluation. At her August 2021 Board hearing, she reported symptoms of decreased vision, blurriness, and pain. The Veteran's left eye recurrent corneal erosion is evaluated as noncompensable pursuant to 38 C.F.R. § 4.79, Diagnostic Code 6066 pursuant to Impairment of Visual Acuity. The Veteran's representative asserts that the disorder should be evaluated under the paired organs provision of 38 C.F.R. § 3.383. Hearing Transcript at 17. The March 2015 VA examination report demonstrates that there is no evidence of impairment in each eye rated at a visual acuity of 20/200 or less, or peripheral field of vision of each eye is 20 degrees or less. 38 C.F.R. § 3.383; see also 38 C.F.R. § 4.75. During the pendency of the appeal, VA issued a final rule revising the portion of the VA Schedule for Rating Disabilities that addresses the organs of special sense and schedule of ratings-eye. 89 Fed. Reg. 15316 (Apr. 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. General Rating Formula for Diseases of the Eye: The Board notes that the General Rating Formula for Diseases of the Eye instructs to evaluate a condition based on visual impairment or for incapacitating episodes, whichever results in a higher evaluation. Thus, the primary difference between the former and revised criteria is consideration of incapacitating episodes. With regard to visual impairment, the amendments made no substantive changes to how visual acuity is rated. With regard to visual field and muscle function examinations, the use of a Goldman chart is no longer required. There are otherwise no substantive changes to how those types of visual impairment are rated. Incapacitating Episodes: Where there are documented incapacitating episodes requiring at least 1 but less than 3 treatment visits for an eye condition during the past 12 months, a 10 percent rating is warranted. Where there are documented incapacitating episodes requiring at least 3 but less than 5 treatment visits for an eye condition during the past 12 months, a 20 percent rating is warranted. Where there are documented incapacitating episodes requiring at least 5 but less than 7 treatment visits for an eye condition during the past 12 months, a 40 percent rating is warranted. Where there are documented incapacitating episodes requiring 7 or more treatment visits for an eye condition during the past 12 months, a 60 percent rating is warranted. Note (1) indicates that, for the purposes of evaluations 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) indicates that 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) indicates that, for the purposes of evaluating visual impairment due to a particular condition, refer to 38 C.F.R. § 4.75-4.78 and to § 4.79, DCs 6061-6091. Here, the Veteran does not contend, and the evidence does not suggest that her service-connected left eye disability has been productive of incapacitating episodes as defined by the rating criteria. Specifically, the March 2015 VA examination report indicates that her service-connected eye disorder has not been productive of incapacitating episodes. Accordingly, a higher rating is not warranted on the basis of incapacitating episodes. Visual Impairment: Generally The evaluation of visual impairment is based on impairment of visual acuity (excluding developmental errors of refraction), visual field, and muscle function. 38 C.F.R. § 4.75 (a). Examinations of visual impairment must be conducted by a licensed optometrist or ophthalmologist, and the examiner must identify the disease, injury, or other pathologic process for any visual impairment found. Id. at (b). Examinations of visual field or muscle function will be conducted only when medically indicated. Id. a) Visual Impairment: Muscle Function As to muscle function, the Veteran does not contend, and the evidence does not suggest that her eye disorder has been productive of muscle dysfunction. Specifically, the March 2015 VA examination export indicates that her service-connected eye disorder has not been productive of muscle dysfunction, to include diplopia. Accordingly, a higher rating is not warranted on the basis of muscle function. b) Visual Impairment: Visual Acuity As to visual acuity, evaluations are based on corrected distance vision with central fixation. 38 C.F.R. § 4.76 (b)(1). The measurements for each eye are applied to the table for Impairment of Central Visual Acuity. Generally, the table is divided into steps corresponding to different levels of visual acuity for one eye, and each step is further divided into subsections of visual acuity for the other eye, with corresponding ratings. The rater will first locate the step that matches the visual acuity of the poorer eye. Within that step, the rater will then locate the subsection that matches the visual acuity of the better eye, which will produce the corresponding rating. Where a reported visual acuity is between two sequentially listed visual acuities, the visual acuity which permits the higher evaluation will be used. 38 C.F.R. § 4.76 (c). Here, the March 2015 VA examination report shows that the Veteran's visual acuity is 20/40 or better in both eyes. Applying these measurements to the table for Impairment of Central Visual Acuity, visual acuity is consistent with a noncompensable rating. The Board acknowledges the Veteran's report of blurry vision; indeed, however, the March 2015 VA examination report shows bilateral uncorrected distance and near vision are 20/40 or better. Accordingly, a higher rating on the basis of visual acuity is not warranted. c) Visual Impairment: Vision Field Evaluation of visual field is based on the remaining field of vision in each eye. The examiner must record the remaining visual field of at least 16 meridians 2212 degrees apart for each eye, even though only the visual field at eight principal meridians 45 degrees apart will be used for rating purposes. Id. The table of Ratings for Impairment of Visual Fields provides ratings for visual field loss. The first half of the table provides ratings based on loss of an entire half of field of vision in an eye. The second half of the table provides ratings based on the average concentric contraction of the visual field of each eye. To calculate average concentric contraction, the rater should add the remaining visual field (in degrees) at each of eight principal meridians 45 degrees apart and divide the sum by eight. 38 C.F.R. § 4.77 (b). To determine the evaluation for visual impairment when both decreased visual acuity and visual field defect are present in one or both eyes and are service connected, separately evaluate the visual acuity and visual field defect (expressed as a level of visual acuity) and combine them under the provisions of § 4.25. 38 C.F.R. § 4.77 (c). Here, the March 2015 VA examiner indicated that the Veteran does not have a visual defect. As such, the criteria for a compensable rating of visual field impairment are not applicable. See 38 C.F.R. § 4.79, Diagnostic Code 6080. As set forth above, the evidence of record does not support an initial compensable rating for service-connected left eye disability on the bases of visual impairment or incapacitating episodes. Accordingly, an initial compensable rating for the service-connected left eye disability is not warranted. REMAND 6. Pelvic Disability The Veteran contends that service connection for pelvic disability, to include bilateral hip pain, and back pain is warranted. The Veteran's STRs indicates her pelvis showed abnormalities unleveling on the right, high crest left, and torsion clockwise in August 2009. In April 2013, the Veteran reported that she sees a chiropractor for misaligned pelvis and back pain. In a January 2016 statement, the Veteran reported that her misaligned pelvis occurred during active duty and causes pain in lower back and hips when standing or sitting for extended periods of time. A July 2016 private treatment shows complaints of low back pain and bilateral hip pan. The physician noted hip pain could be caused by mal-alignment and will need repeat films and possibly MRI. The record indicates that the Veteran has a current disability that may be associated with service. As the Veteran has not been afforded a VA examination in connection with this claim a remand for such an examination is warranted. McLendon v. Nicholson, 20 Vet. App. 79 (2006). The Board notes that, in Saunders v. Wilkie, 886 F.3d 1356, 1361 (Fed. Cir. 2018), the Federal Circuit held that pain could constitute disability under 38 U.S.C. § 1110 if it causes impairment in earning capacity and a diagnosis is not required to meet the current disability requirement. 7. Arthritis of Multiple Joints The Veteran contends that arthritis of multiple joints is related to her military service. In an alternative theory, she contends that arthritis of multiple joints is secondary to her pelvic disability, to include hip pain and back pain. The Veteran's STRs shows complaints and treatment for joint pain of the hips, knees, back, and wrist. In April 2015, the Veteran was afforded a VA examination. The examiner indicated that the Veteran did not have a current arthritis diagnosis. The Veteran's March 2018 private treatment records reflects diagnoses of arthritis and osteoarthritis of both knees. At the Veteran's August 2021 Board hearing, she testified that she experiences arthritis symptoms of swelling in her back, knees, hips, hands, ankles, and fingers. She reported that she suffered in silence and did not seek treatment to avoid being kicked out of the service. The Veteran also asserted that the arthritis in all the joints is secondary to her pelvic disability, to include hip pain and back pain. As the evidence is unclear as to whether the Veteran has arthritis of multiple joints, a new VA examination is warranted with a medical opinion on this question. Additionally, the arthritis of multiple joints claim may be significantly impacted by the pending pelvic disability, to include bilateral hip pain, and back pain claim referenced above and is therefore inextricably intertwined. See e.g., Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (holding that when a determination on one issue could have a significant impact on the outcome of another issue, and that impact in turn could render any appellate review meaningless and a waste of judicial resources, the two claims are inextricably intertwined). The matters are REMANDED for the following action: 1. Schedule the Veteran for an examination with an appropriate VA clinician to determine the nature of her pelvic disability, to include via telehealth if warranted. The claims file must be reviewed by the clinician. The examiner is to provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that any pelvic disability had its onset during service or is otherwise related to military service. In this regard, disability does not require a diagnosis, as symptoms causing impairment in earning capacity can constitute disability. A complete rationale should accompany any opinion provided. The examiner is advised that the Veteran is competent to report symptoms and treatment, and that her reports must be considered in formulating the requested opinion. 2. Schedule the Veteran for an examination with an appropriate VA clinician to determine the nature of her arthritis, to include via telehealth if warranted. The claims file must be reviewed by the clinician. (a.) The examiner should provide an opinion as to whether it is at least as likely as not (at least a 50 percent probability) that any arthritis had its onset in service or is otherwise related to military service. (b.) If not, is it at least as likely as not (50 percent probability or more) that any arthritis was caused or aggravated by the pelvic disability, to include bilateral hip pain, and back pain? If aggravation is found, please identify the baseline level of disability prior to aggravation to the extent possible. A complete rationale should be provided for all opinions given. The examiner is advised that the Veteran is competent to report symptoms and treatment, and that her reports must be considered in formulating the requested opinion. Jonathan Hager Veterans Law Judge Board of Veterans' Appeals Attorney for the Board R. Walker, 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.