Citation Nr: 21006123 Decision Date: 02/03/21 Archive Date: 02/03/21 DOCKET NO. 08-33 915A DATE: February 3, 2021 ORDER An initial rating in excess of 10 percent, from January 10, 2006 to the present, for left knee patellofemoral pain syndrome with healed tibia stress fracture, is denied. An initial rating in excess of 10 percent, from January 10, 2006 to the present, for right knee patellofemoral pain syndrome with healed tibia stress fracture, is denied. An initial rating in excess of 10 percent, from September 30, 2014 to the present, for left knee subluxation, is denied. An initial rating in excess of 10 percent, from September 30, 2014 to the present, for right knee subluxation, is denied. FINDINGS OF FACT 1. From January 10, 2006 to the present, the Veteran’s left knee patellofemoral pain syndrome with healed tibia stress fracture has been manifested by painful noncompensable range of motion (ROM). 2. From January 10, 2006 to the present, the Veteran’s right knee patellofemoral pain syndrome with healed tibia stress fracture has been manifested by painful noncompensable ROM. 3. From September 30, 2014 to the present, the Veteran’s left knee disability has been manifested by slight recurrent subluxation. 4. From September 30, 2014 to the present, the Veteran’s right knee disability has been manifested by slight recurrent subluxation. CONCLUSIONS OF LAW 1. From January 10, 2006 to the present, the criteria for an initial rating in excess of 10 percent for left knee patellofemoral pain syndrome with healed tibia stress fracture, have not been met. 38 U.S.C. §§ 1155, 5102, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 4.7, 4.14, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code (DC) 5024. 2. From January 10, 2006 to the present, the criteria for an initial rating in excess of 10 percent for right knee patellofemoral pain syndrome with healed tibia stress fracture, have not been met. 38 U.S.C. §§ 1155, 5102, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 4.7, 4.14, 4.40, 4.45, 4.59, 4.71a, DC 5024. 3. From September 30, 2014 to the present, the criteria for an initial rating in excess of 10 percent for left knee subluxation, have not been met. 38 U.S.C. §§ 1155, 5102, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 4.7, 4.14, 4.40, 4.45, 4.59, 4.71a, DC 5003-5257. 4. From September 30, 2014 to the present, the criteria for an initial rating in excess of 10 percent for right knee subluxation, have not been met. 38 U.S.C. §§ 1155, 5102, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 4.7, 4.14, 4.40, 4.45, 4.59, 4.71a, DC 5003-5257. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from September 1989 to September 1993; October 2001 to September 2002; and August 2004 to January 2006. Effective February 2012, the Veteran is in receipt of a 100 percent combined schedular evaluation of service-connected disorders. This matter was previously before the Board of Veterans’ Appeals (Board) in August 2014 when the matter was remanded for further development. Further development having been completed; the matter is once again before the Board. Increased Ratings Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule), found in 38 C.F.R. Part 4. The Board attempts to determine the extent to which the Veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, and the assigned rating is based, as far as practicable, upon the average impairment of earning capacity in civil occupations. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.10. 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 concern. 38 C.F.R. §§ 4.1, 4.2; see also Francisco v. Brown, 7 Vet. App. 55 (1994). In Hart v. Mansfield, 21 Vet. App. 505 (2007), however, the Court held that "staged ratings" are appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. When evaluating disabilities of the musculoskeletal system, 38 C.F.R. § 4.40 allows for consideration of functional loss due to pain and weakness causing additional disability beyond that reflected on range of motion measurements. See DeLuca v. Brown, 8 Vet. App. 202 (1995). This includes the analysis of additional functional impairment above and beyond the limitation of motion objectively demonstrated involving such factors as painful motion, weakness, incoordination, and fatigability, etc., particularly during times when these symptoms "flare up," such as during prolonged use, and assuming these factors are not already contemplated in the governing rating criteria. Id. See also 38 C.F.R. §§ 4.40, 4.45 and 4.59. In this regard, manifestation of pain alone does not equate with functional loss under 38 C.F.R. §§ 4.40 and 4.45 but may cause functional loss if affecting some aspect of the normal working movements of the body such as excursion, strength, speed, coordination, and endurance. Mitchell v. Shinseki, 25 Vet. App. 32 (2011). Pyramiding, that is the evaluation of the same disability, or the same manifestation of a disability, under different DCs, is to be avoided when evaluating a veteran's service-connected disability. 38 C.F.R. § 4.14. Separate disability ratings may be assigned for distinct disabilities resulting from the same injury so long as the symptomatology for one condition was not "duplicative of or overlapping with the symptomatology" of the other condition. See Esteban v. Brown, 6 Vet. App. 259, 262 (1994). 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 required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. 1. An initial rating in excess of 10 percent, from January 10, 2006 to the present, for left knee patellofemoral pain syndrome with healed tibia stress fracture, is denied. 2. An initial rating in excess of 10 percent, from January 10, 2006 to the present, for right knee patellofemoral pain syndrome with healed tibia stress fracture, is denied. The Veteran’s current 10 percent ratings, from January 10, 2006 to the present, for left and right knee patellofemoral pain syndrome with healed tibia stress fracture was assigned under DC 5024. DC 5024 states that this disability is to be rated based on limitation of motion of the affected parts. The Veteran also has current 10 percent ratings, from September 30, 2014 to the present, for left and right knee subluxation under DCs 5003-5257. This issue of increased ratings for bilateral knee subluxation is addressed separately below. Pursuant to DC 5260, when flexion of the leg is limited to 60 degrees, a noncompensable rating is warranted. When flexion is limited to 60 degrees, a noncompensable rating is warranted, and 45 degrees, a 10 percent rating is warranted. Flexion limited to 30 degrees warrants a 20 percent rating, while flexion limited to 15 degrees warrants the maximum 30 percent rating. DC 5261 rates based on limitation of extension. That code provides that when extension is limited to 5 degrees, a noncompensable rating is assigned. Extension limited to 10 degrees warrants a 10 percent rating. When limitation of extension is at 15 degrees, a 20 percent rating is warranted. Extension limited to 20 degrees warrants a 30 percent rating. Extension limited to 30 degrees warrants a 40 percent rating. Lastly, extension limited to 45 degrees warrants the maximum, 50 percent rating. Under DC 5258, a 20 percent rating is warranted for cartilage, semilunar, dislocated, with frequent episodes of "locking," pain, and effusion into the joint. VA and private treatment records reveal the Veteran's consistent complaints of bilateral knee pain that has been characterized as stabbing pain, sharp pain, aching pain, and throbbing pain. In an August 2006 QTC evaluation, the examiner noted the following symptoms of the bilateral knee: weakness, stiffness, swelling, and fatigability. Pain was noted to occur three times per day and last up to three hours. Pain was noted to travel to the back of the knee and was caused by physical activity and walking. The condition was noted not to cause incapacitation. Treatment with the use of Ibuprofen was noted. Functional impairment was noted as pain and discomfort. ROM bilaterally was recorded as flexion to 140 degrees and extension to 0 degrees. It was noted that bilateral joint function is not additionally limited by pain, fatigue, weakness, lack of endurance or incoordination after repetitive use. Stability testing was within normal limits bilaterally, on all tests performed. The medial and lateral meniscus test was within normal limits bilaterally. The Veteran was afforded a VA examination in August 2008. The examiner indicated that an in-person examination was conducted, and that the Veteran’s claims file was reviewed in conjunction with the examination. The examiner indicated a diagnosis of bilateral patellofemoral pain syndrome. The examiner noted that the Veteran denied episodes of dislocation, recurrent subluxation, inflammatory arthritis or constitutional symptomatology. The Veteran also denied additional limitation of motion or functional impairment during flare-ups; however, he endorsed increased pain during flare-ups. ROM testing using a goniometer was performed. Extension was recorded bilaterally as having no limitation. Flexion was recorded as ending at 125 degrees on the left knee and ending at 128 degrees on the right knee. No complaints of painful motion were indicated. A positive patellofemoral compression test bilaterally for pain, crepitus, and tenderness was noted. Medial and lateral collateral ligaments were noted as intact bilaterally. Instability testing revealed normal results. No effusion, edema, deformity, skin, or vascular changes were noted bilaterally. Muscle strength was noted as five out of five. Reflexes were noted as normal. No significant bone or joint abnormality was noted of either knee. No joint effusion was noted. The examiner noted no objective clinical evidence of function that was additionally limited by pain, fatigue, weakness, incoordination or lack of endurance. Subjective pain was noted to appear to have the greatest functional impact. A May 2014 private medical letter from M.A.B., M.D., an orthopedic surgeon, stated that the Veteran has been under his care since December 2011 for back and related radiculopathy conditions. The letter also stated that the Veteran is being treated for chronic severe bilateral knee pain, bilateral patella subluxation, bilateral patella chondromalacia, and bilateral degenerative joint disease (DJD). Dr. M.A.B. stated that he has not personally reviewed the Veteran’s medical treatment records. However, he stated that he personally examined the Veteran and based his opinion on his examination and the available imaging studies. The physician reported that the Veteran had bilateral knee pain over the patellofemoral joint and medial compartment. However, full ROM was noted bilaterally. Positive crepitus was also noted bilaterally. He stated that the x-rays show bilateral osteoarthritic changes in the medial and patellofemoral compartments with mild lateral patellar subluxation and tilting on the left knee. The right knee was noted to show mild lateral patellar subluxation and tilting as well as chondromalacia. He noted that a February 2012 MRI shows right knee mild lateral patellar subluxation with tilting and patellar chondromalacia. An MRI of the left knee taken at the same time was noted to show osteoarthritic changes in the medial and patellofemoral compartments with mild lateral subluxation and tilting in the left knee. After a clinical evaluation of the Veteran and review of available imaging, Dr. M.A.B. diagnosed the Veteran with bilateral knee pain resulting from patellar subluxation, worsening patellofemoral chondromalacia, and DJD. In a May 2014 Disability Benefits Questionnaire (DBQ), conducted by Dr. M.A.B. diagnoses of bilateral knee DJD, chondromalacia, patella subluxation, and chronic pain were noted. Flare-ups were reported as bilateral knee pain and difficulty squatting, descending stairs, and sitting and standing for long periods of time. Initial ROM testing was performed. Right knee flexion was recorded as 0 to 110 degrees with objective evidence of pain at 95 degrees. Extension was noted as not limited and without objective evidence of painful motion. Left knee flexion was recorded as 0 to 105 degrees with painful motion at 100 degrees. Extension was noted as not limited and without objective evidence of painful motion. Repetitive use testing with three repetitions was conducted. Right knee post-test flexion ended at 105 degrees and post-test extension was not limited. Left knee post-test flexion ended at 100 degrees and post-test extension was not limited. No additional limitation following repetitive-use testing was noted. Functional loss or impairment was indicated. Specifically, the Veteran was noted to have less movement than normal, weakened movement, excess fatigability, pain on movement, disturbance of locomotion, and interference with sitting, standing, and weight-bearing, all bilaterally. Objective evidence of localized tenderness to palpation bilaterally was noted. Muscle strength testing was performed and revealed right knee muscle strength of three out of five on flexion and extension and left knee muscle strength of four out of five on flexion and extension. Joint stability testing was performed. Anterior, posterior, and medial-lateral instability testing bilaterally revealed normal results. However, evidence of slight recurrent patellar subluxation/dislocation was noted bilaterally. Bilateral shin splints were noted. Stress fracture of the bilateral ankle were also noted. It was noted that the Veteran has not had any meniscal conditions or surgical procedures for any meniscal condition. Joint replacement and other surgical procedures were denied. No scars related to the Veteran’s condition were noted. It was noted that the Veteran experiences increased pain and stiffness when sitting for long periods of time. The regular use of soft knee braces to treat lateral patellar subluxation was noted. Dr. M.A.B., M.D., noted that available imaging studies show degenerative arthritis and patellar subluxation. In terms of impact on his ability to work, it was noted that the Veteran needs to get up every 15 to 20 minutes due to an inability to sit for long periods of time. In a January 2018 DBQ, the examiner noted that an in-person examination was conducted and that a review of the Veteran’s VA e-folder and CPRS file was conducted in conjunction with the examination. The examiner noted a diagnosis of bilateral patellofemoral pain syndrome with healed tibia stress fracture. The Veteran reported pain underneath the kneecap bilaterally and reported occasional giving out bilaterally. He reported that he has had a past injection in his right knee and that he uses Ibuprofen for pain. Flare-ups were reported bilaterally after walking and standing for long periods of time, which cause aching and throbbing pain. The Veteran reported using ice, rest, and Ibuprofen to treat his flare-ups. The Veteran reported functional loss or impairment that cause difficulty walking long distances, difficulty kneeling and squatting, and difficulty descending stairs. Initial ROM measurements were recorded. Right knee flexion was recorded as 0 to 90 degrees and extension from 90 to 0 degrees. Left knee flexion was recorded as 0 to 110 degrees and extension from 110 to 0 degrees. Pain was noted on flexion bilaterally that does not cause functional loss. Objective evidence of localized tenderness to palpation of the anterior knee bilaterally was noted. Evidence of pain with weight bearing on the right knee was denied but was endorsed on the left knee. Objective evidence of crepitus was endorsed bilaterally. However, no additional loss of function or ROM was noted with observed repetitive use testing. Repetitive use over time testing was not performed. The examination was not conducted during a flare-up. No additional contributing factors were indicated. Muscle strength testing was performed and revealed normal muscle strength, five out of five on all testing on each knee. Muscle atrophy was denied. Ankylosis was denied. The examiner noted no history of recurrent subluxation or lateral instability of either knee. Recurrent effusion was denied. Joint stability testing was performed and yielded normal results one all testing. No joint instability was indicated bilaterally. The Veteran specifically denied then having or ever having had recurrent patellar dislocation, shin splints, stress fractures, chronic exertional compartment syndrome or any other tibial and/or fibular impairment. The Veteran specifically denied having then had or ever having had a meniscus condition of either knee. No other pertinent findings were noted. No scars were noted. The regular use of right knee brace was noted. Imaging studies from September 2016 and November 2015 were noted to be of record. The examiner noted the September 2016 x-ray of the bilateral knee was negative. The November 2015 MRI of the right knee showed grade 2 chondral fissuring along the medial patellar facet and patellar right. No frank chondral denudation or full-thickness chondral defects were noted. A borderline discoid variant of the lateral meniscus was shown, but no degeneration or tearing of the meniscal variant was indicated. The indicated chondral fissuring was noted as related to patellofemoral syndrome of the right knee. Functional impact or impairment was noted as difficulty with tasks requiring prolonged standing or walking, repetitive kneeling or squatting, and difficulty descending stairs. With regard to the claim of instability, the examiner noted that there is no objective clinical evidence of instability or laxity noted on the examination or the available imaging, which document that all ligaments of the knee are intact. The examiner stated that there is no diagnosis of instability and, although the Veteran has symptoms there is not objective evidence of a diagnosable disease or pathology related to the claim of instability of the knee. No evidence of pain on passive ROM or when the joint is used in non-weight bearing was indicated. A December 2018 private medical record indicates that x-rays of the Veteran’s bilateral knee showed no fracture lytic lesion or blastic abnormality, no evidence of dislocation, no joint effusion, no acute abnormality, and no degenerative changes of either knee. The examiner noted that the degenerative pattern of both knees corresponds to a Kellgren-Lawrence grade 0 pattern, indicating an assessment of “0” as “no presence of” osteoarthritis. See Clinical Orthopaedics and Related Research, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4925407/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4925407/. In a December 2018 DBQ, the examiner noted that an in-person examination was conducted and that a review of the Veteran’s VA e-folder was conducted in conjunction with the examination. The examiner noted a diagnosis of bilateral patellofemoral pain syndrome with healed tibia stress fracture. Current symptoms were reported as daily sharp stabbing pain, stiffness, and decreased ROM. The Veteran reported treatment with the use of bilateral knee braces and Motrin. Flare-ups were denied. Functional loss or impairment were reported. Specifically, the Veteran reported that he is unable to run, that he has increased pain with walking and standing longer than 15 minutes, climbing stairs, inclines, and bending or kneeling. Initial ROM measurements were recorded. Right knee flexion was recorded as 0 to 100 degrees and extension from 100 to 0 degrees. Left knee flexion was recorded as 0 to 80 degrees and extension from 80 to 0 degrees. Pain was noted on flexion and extension bilaterally that causes functional loss. ROM was noted to contribute to functional loss in that the Veteran has difficulty with climbing, sitting, standing, kneeling, and walking. Evidence of pain with weight bearing was noted bilaterally as was crepitus. Objective evidence of localized tenderness or pain on palpation was also noted bilaterally due to DJD, which causes pain around the joint line of moderate intensity. No additional loss of function or ROM was noted with observed repetitive use testing. Repetitive use over time testing was not performed. No additional contributing factors were indicated. Muscle strength testing was performed and revealed muscle strength of four out of five on all testing on each knee. Muscle atrophy was denied. Ankylosis was denied. The examiner noted no history of recurrent subluxation or lateral instability of either knee. Recurrent effusion was denied. Joint stability testing was performed and yielded normal results on all tests. No joint instability was indicated bilaterally. Bilateral shin splints were noted to affect the ROM of each knee, but not affect the ROM of either ankle. The Veteran specifically denied having then had or ever having had a meniscus condition of either knee. No other pertinent findings were noted. No scars were noted. The constant use of bilateral knee braces was noted. The examiner noted that imaging studies are available, but that they do not show arthritis of either knee. No other significant diagnostic findings were noted. The examiner noted that the Veteran’s condition impacts his ability to perform occupational tasks. Specifically, the examiner noted that the Veteran has missed up to one week of work time in the last 12 months in his employment as a deputy U.S. Marshall. The examiner noted that the Veteran reported that it is difficult to chase after a suspect and climb. Objective evidence of pain on passive ROM bilaterally and objective evidence of pain when the both knees are used in non-weight bearing was endorsed. An August 2020 private medical record indicates that the Veteran was evaluated for bilateral patellofemoral pain syndrome. The examiner noted that imaging showed no fracture lytic lesion or blastic abnormality, no evidence of dislocation, no joint effusion, no acute abnormality, and no degenerative changes of either knee. The examiner noted that the degenerative pattern of both knees corresponds to a Kellgren-Lawrence grade 0 pattern. An August 2020 DBQ is of record. The examiner noted that an in-person examination was conducted and that a review of the Veteran’s VA e-folder was conducted in conjunction with the examination. The examiner noted a bilateral meniscus tear and degenerative arthritis. Bilateral patellofemoral pain syndrome with healed tibia stress fracture was also noted. The examiner noted the August 2020 private medical record, in which x-rays of the bilateral knee showed no acute abnormality or degenerative changes in either knee. The Veteran reported that his current symptoms consist of constant pain, limited mobility, throbbing pain, swelling, and stabbing pain. The Veteran rated his pain as eight out of ten. Current treatment was reported as the use of bilateral knee braces, Thermazone cold packs, and Ibuprofen. No flare-ups were reported and were specifically denied. Functional loss or impairment was reported in that the Veteran’s bilateral knee prevents him from engaging in prolonged standing, walking, running, and he has limited ROM. The examiner noted that initial ROM testing was unable to be completed due to a lumbar spine flare-up that prevented the Veteran from laying on his back. The examiner noted that the Veteran grimaced during manipulation of both knees. The Veteran reported pain which was moderate in severity. No objective evidence of pain with weight bearing was indicated. The examiner noted that the Veteran refused observed repetitive use testing. However, the examiner noted that pain, fatigue, and weakness significantly limit functional ability with repeated use over a period of time. The examiner described the limitation in terms of ROM as flexion from 0 to 120 degrees and extension from 120 to 0 degrees bilaterally. No additional contributing factors were noted. Muscle strength testing was performed and revealed muscle strength of four out of five on all testing on each knee. Muscle atrophy was denied. Ankylosis was denied. The examiner noted no history of recurrent subluxation or lateral instability of either knee. Recurrent effusion was denied. The examiner noted that joint stability testing was not able to be performed because the Veteran was having a lumbar spine flare-up which does not allow him to lay supine. The examiner noted that the healed bilateral tibia stress fractures do not impact the ROM of either ankle. The examiner noted that a January 2008 MRI indicated a right knee meniscal injury and a left knee meniscal tear, but no current intervention or treatment was noted. No other pertinent findings were noted. No scars were noted. The regular use of bilateral knee braces was noted. The examiner noted that bilateral degenerative arthritis is indicated on the January 2008 MRI. The examiner noted that the Veteran’s condition impacts his ability to perform occupational tasks. Specifically, the examiner noted that the Veteran has missed two to four weeks of work time in the last 12 months in his employment as a deputy U.S. Marshall. The examiner noted that the Veteran is limited in bending, stooping, pushing, pulling, carrying, lifting moderate objects, standing, sitting, walking, climbing stairs, running, squatting, and standing, walking, and driving for long periods. The examiner noted that the Veteran’s condition impacts his emotional well-being, negatively impacts his quality of life, and interferes with his normal activities. Objective evidence of pain on passive ROM bilaterally was denied. Objective evidence of pain when the both knees are used in non-weight bearing was denied. The examiner noted that the Veteran’s bilateral patellofemoral pain syndrome with damaged cartilage has progressed to arthritis. The examiner also noted that the meniscal tears were reported on the January 2008 MRI are due to the bilateral patellofemoral pain syndrome. Aside from the May 2014 private DBQ, which recorded right knee muscle strength as three out of five, the remaining evidence of record indicates that the Veteran has had muscle strength of either four out of five or five out of five bilaterally throughout the entire period. The Board has considered as to whether the Veteran would be entitled to a rating in excess of 10 percent, during the applicable period, for his left and right knee based on limitation of motion. However, the evidence does not show limitation of extension to 15 degrees for either knee and does not show limitation of flexion of either knee to 30 degrees or less. Even with consideration of DeLuca factors, at worst, the Veteran had limitation of extension of his left knee from 80 to 0 degrees and limitation of his right knee from 90 to 0 degrees. At worst, the Veteran had 90 degrees of flexion in his right knee and 80 degrees of flexion in his left knee, during the time period. Consequently, the Veteran is not entitled to a compensable rating under DC 5260 (limitation of flexion) or 5261 (limitation of extension) for the left or right knee, during the applicable period. A higher rating under DC 5258 is also not warranted. As the evidence discussed indicates, the clinical evaluations and imaging studies consistently show no joint effusion or dislocation bilaterally. As there is no evidence of ankylosis, impairment of the tibia and fibula, or genu recurvatum of the left or right knee, at any time during this period, DCs 5256, 5262, and 5263 are not for application in this case. Based on the above, the Veteran is not entitled to a rating in excess of 10 percent for left or right knee patellofemoral pain syndrome with healed tibia stress fracture, from January 10, 2006 to the present, and the claims are denied. 3. An initial rating in excess of 10 percent, from September 30, 2014 to the present, for left knee subluxation, is denied. 4. An initial rating in excess of 10 percent, from September 30, 2014 to the present, for right knee subluxation, is denied. As noted above, the Veteran also has current 10 percent ratings, from September 30, 2014 to the present, for left and right knee subluxation assigned under DCs 5003-5257, based on slight recurrent subluxation or lateral instability. Under DC 5257, knee impairment with recurrent subluxation or lateral instability warrants a 10 percent rating if it is slight, a 20 percent rating if it is moderate, or a 30 percent rating if it is severe. As outlined above, the record first evidences slight recurrent bilateral subluxation in 2014. Since 2014, the record consistently evidences no recurrent subluxation and joint stability testing has been consistently normal bilaterally. Based on the available evidence, the Veteran’s left and right knee subluxation has manifested as, at worst, slight recurrent subluxation. Therefore, the Veteran is not entitled to a rating in excess of 10 percent for left or right knee subluxation at any time, to include the period from September 30, 2014 to the present, and the claims are denied. Vito A. Clementi Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Timothy T. Emmart 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.