Citation Nr: 21006608 Decision Date: 02/04/21 Archive Date: 02/04/21 DOCKET NO. 10-39 128 DATE: February 4, 2021 ORDER Prior to February 17, 2011, a disability rating greater than 10 percent for lumbar and thoracic musculotendinous strain is denied. As of February 17, 2011, a 40 percent disability rating for lumbar and thoracic musculotendinous strain is granted. As of December 19, 2019, a separate 10 percent rating for left lower extremity tingling and numbness is granted. A disability rating based on limitation of motion for patellofemoral syndrome of the left knee greater than 10 percent prior to February 29, 2020 and greater than 40 percent since February 29, 2020 is denied. As of April 25, 2019, a separate 20 percent rating for symptomatic meniscus of the left knee is granted. A disability rating based on limitation of motion for patellofemoral syndrome with degenerative arthritis of the right knee greater than 10 percent prior to February 29, 2020 and greater than 40 percent since February 29, 2020 is denied. As of November 22, 2017, a separate 20 percent rating for symptomatic meniscus of the right knee is granted. As of February 29, 2020, a total disability rating based on individual unemployability (TDIU) as a result of the Veteran’s service-connected bilateral knee disabilities is granted. As of February 29, 2020, special monthly compensation at the housebound rate is granted. REMANDED Entitlement to service connection for osteoarthritis of the right hip is remanded. Entitlement to service connection for osteoarthritis of the left hip is remanded. FINDINGS OF FACT 1. Prior to February 17, 2011, the Veteran’s lumbar and thoracic strain is manifest by constant moderate pain, stiffness, and tightness, but full range of motion demonstrated on examination. Although some limitation of motion is inferred during flare-ups, the evidence does not reflect that limitation of motion during flare-ups would result in forward flexion of 60 degrees or less, or combined range of motion of 120 degrees or less. There is no evidence of muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour. 2. As of February 17, 2011 the Veteran’s lumbar and thoracic strain is manifest by worsening back pain, fatigue, stiffness, weakness, and decreased motion with severe flare-ups occurring every 1 to 2 months, lasting from 3 to 7 days where the Veteran describes being unable to bend at all and must keep his back straight. The Board will resolve reasonable doubt in favor of the Veteran and find the impairment presented by this disability to more nearly approximate favorable ankylosis of the entire thoracolumbar spine due to the severity and frequency of flare-ups in which a commensurate limitation of motion is credibly described. 3. Unfavorable ankylosis of the entire thoracolumbar spine, or the entire spine, is not shown at any time during the present appeal. 4. As of December 19, 2019, the Veteran is described as having a left leg paresthesia (tingling sensation) or numbness. This symptom has previously been granted service connection as secondary to the Veteran’s lumbar and thoracic strain for the right lower extremity. Considering the record in its entirety, the Board will resolve reasonable doubt regarding secondary causation of the numbness and tingling symptoms for the left lower extremity and find the disability to be most nearly approximate to a mild left lower extremity neuralgia. 5. As of February 29, 2020, the Veteran’s bilateral lower extremity peripheral nerve symptoms of pain, numbness, paresthesias and/or dysesthesias increased to a severity at least moderately severe in degree. However, as of that date and discussed further herein, the Veteran’s bilateral lower extremity symptoms are contemplated by the assigned ratings based on painful limitation of motion, meniscal impairment, and peripheral nerve symptoms affecting each lower leg which combine to the maximum allowable rating of 60 percent if amputation at the knee level were performed. 6. Prior to February 29, 2020, the Veteran’s service-connected left knee patellofemoral syndrome is manifest by pain or soreness, tightness and stiffness, with moderate to severe flare-ups occurring weekly with additional pain lasting from hours to 2 days. Range of motion was not limited to flexion of 30 degrees or less, nor extension limited to 5 degrees or more. 7. As of February 29, 2020, the Veteran’s left knee patellofemoral syndrome was manifest by pain and limitation of motion with severe flare-ups described as occurring every 2 weeks, lasting from 1 to 2 weeks. During such flare-ups, range of motion was limited to approximately 100 degrees of flexion and 30 degrees of extension. 8. As of April 25, 2019, and resolving reasonable doubt in the Veteran’s favor, his service-connected left knee disability is also shown to be manifested by a meniscal injury with subjective feelings of the knee “locking up,” and frequent episodes of joint pain and joint effusion. 9. Prior to February 29, 2020, the Veteran’s service-connected right knee patellofemoral syndrome is manifest by pain, soreness or tenderness, tightness and stiffness, with moderate to severe flare-ups occurring weekly with additional pain lasting from hours to 2 days. Range of motion was not limited to flexion of 45 degrees or less, nor extension limited to 10 degrees or more. 10. As of February 29, 2020, the Veteran’s right knee patellofemoral syndrome was manifest by pain and limitation of motion with severe flare-ups described as occurring every 2 weeks, lasting from 1 to 2 weeks. During such flare-ups, range of motion was limited to approximately 100 degrees of flexion and 30 degrees of extension. 11. As of November 22, 2017, the Veteran’s right knee disability is also shown to involve a symptomatic right knee meniscus injury. 12. As of February 29, 2020, a preponderance of the evidence shows that the Veteran, by reason of his service-connected left and right knee disabilities alone, is precluded from obtaining or maintaining substantially gainful employment. 13. Based on the Veteran’s eligibility for a TDIU rating due to the service-connected knee disabilities alone, the Veteran is entitled to a 100 percent rating with additional service-connected disabilities independently rated at a combined 60 percent. CONCLUSIONS OF LAW 1. Prior to February 17, 2011, the criteria for a rating greater than 10 percent for lumbar and thoracic musculotendinous strain have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5237. 2. As of February 17, 2011, the criteria for a 40 percent rating for lumbar and thoracic musculotendinous strain have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5237. 3. Resolving reasonable doubt in favor of the Veteran, as of December 19, 2019, the criteria for a separate 10 percent disability rating for left lower extremity numbness and tingling have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.124a, Diagnostic Code 8720. 4. The criteria for a disability rating for left knee patellofemoral syndrome greater than 10 percent before February 29, 2020, and greater than 40 percent thereafter, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Codes 5299-5003 (before Feb. 29, 2020) & 5261 (after Feb. 29, 2020). 5. Resolving reasonable doubt in favor of the Veteran, as of April 25, 2019, the criteria for a separate 20 percent rating for left knee meniscal injury have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5258. 6. The criteria for a disability rating for patellofemoral syndrome of the right knee greater than 10 percent before February 29, 2020, and greater than 40 percent thereafter, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Codes 5299-5003 (before Feb. 29, 2020) & 5261 (after Feb. 29, 2020). 7. As of November 22, 2017, the criteria for a separate 20 percent rating for right knee meniscal injury have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5258. 8. As of February 29, 2020, the criteria to establish entitlement to a TDIU rating based on the Veteran’s service-connected bilateral knee disability alone are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.15, 4.16. 9. As of February 29, 2020, the criteria to establish SMC at the housebound rate based on the Veteran’s total plus 60 percent disability rating have been met. 38 U.S.C. §§ 501, 1114, 5107; 38 C.F.R. § 3.350. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from November 1999 to December 2003. A thorough accounting of this appeal’s procedural history was included in the July 2020 remand by the Board of Veterans’ Appeals (Board) and will not be recounted again here. Regarding the action requested to comply with due process requirements in the July 2020 remand, the record has been adequately developed in substantial compliance with all prior Board remand instructions and has now been returned to the Board for further appellate review. Increased Ratings Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. The percentage ratings are based on the average impairment of earning capacity as a result of a service-connected disability, and separate diagnostic codes identify the various disabilities and the criteria for specific ratings. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. All potentially applicable rating criteria and regulations must be considered. If two disability evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. All reasonable doubt as to the degree of disability will be resolved in favor of the claimant. 38 U.S.C. § 5107 (b); 38 C.F.R. § 4.3. Staged ratings must be considered, which are appropriate when the evidence establishes that the claimed disability manifested symptoms that would warrant different ratings for distinct time periods during the appeal. 1. Prior to February 17, 2011, a disability rating greater than 10 percent for lumbar and thoracic musculotendinous strain is denied. The Veteran’s service-connected lumbar and thoracic strain is rated under 38 C.F.R. § 4.71a, Diagnostic Code (DC) 5237. The Board notes that as of February 29, 2020, the agency of original jurisdiction (AOJ) changed the diagnostic code used to evaluate this disability to be 5242-5243, indicating that the rating was for degenerative arthritis of the spine, rated as intervertebral disc syndrome. The Board does not find this change to be appropriate based on the evidence in this case. Specifically, although the Veteran is shown to have degenerative arthritis of the spine, that condition has not been granted service connection at this time. Notably, however, any symptoms of degenerative arthritis or intervertebral disc syndrome are considered here for compensation purposes because where separate effects of service-connected and nonservice-connected conditions cannot be distinguished, then all those symptoms must be attributed to the service-connected condition. Mittleider v. West, 11 Vet. App. 182 (1998). Thus far, the medical evidence does not clearly distinguish the symptoms of the service-connected lumbar and thoracic strain from the nonservice-connected symptoms of arthritis or IVDS, and as such, the Veteran’s back symptoms in general are considered under the assigned rating. Nonetheless, the appropriate diagnostic code remains DC 5237 for lumbosacral strain as the most closely analogous listed disability to that granted service connection in this case. Under the General Rating Formula for Diseases and Injuries of the Spine, a 10 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine. A 20 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. Id. A 40 percent rating is warranted for forward flexion of the thoracolumbar spine to 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. Id. A 50 percent rating is warranted for unfavorable ankylosis of the entire thoracolumbar spine. Id. A 100 percent evaluation is warranted for unfavorable ankylosis of the entire spine. Id. Unfavorable ankylosis is a condition in which the entire cervical spine, the entire thoracolumbar spine, or the entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching. Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. Id. At Note 5. Any associated objective neurological abnormalities, including, but not limited to, bowel or bladder impairment, are to be evaluated separately under an appropriate diagnostic code. Id. at Note 1. When evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use and, therefore, not be reflected on range-of-motion testing. 38 C.F.R. § 4.45 requires consideration also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Nonetheless, even when the background factors listed in § 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a; a separate or higher rating under § 4.40 or 4.45 itself is not appropriate. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016) (“[I]t is clear that the guidance of § 4.40 is intended to be used in understanding the nature of the veteran’s disability, after which a rating is determined based on the § 4.71a criteria.”). Under 38 C.F.R. § 4.59, painful motion is a factor to be considered with any form of arthritis; however, 38 C.F.R. § 4.59 is not limited to disabilities involving arthritis. See Burton v. Shinseki, 25 Vet. App. 1 (2011). The Board finds that the preponderance of the evidence is against a rating greater than 10 percent for lumbar and thoracic strain before February 17, 2011. Upon VA examination in August 2009, the Veteran’s back disability was manifested by daily pain in the mid and low back that he rated as a 6-7 on a severity scale of 1-10. The Veteran described being very cautious about his back with any movements, posture and how he moved. Pain was worse in the mornings and later in the day. The Veteran described experiencing moderate flare-ups about every 2 to 3 weeks, lasting 1 to 2 days. These flare-ups were brought on by lifting, straining his back, or driving long distances. He received good pain relief with a TENS unit and intermittent use of medication. The examiner found the Veteran’s posture, head position, gait, and spinal curvatures to be normal. He did not exhibit muscle spasm or guarding. Motor and sensory examinations were normal. Range of motion of the thoracolumbar spine was measured to be full forward flexion of 90 degrees with pain at 90 degrees on active and passive motion, and full extension from zero to 30 degrees with pain at 20-30 degrees. Full bilateral lateral flexion and lateral rotation were also demonstrated. VA examination, August 2009. A February 2010 thoracic spine x-ray confirmed normal alignment of the spine and maintenance of the vertebral bodies and intervertebral disc spaces. The thoracic spine was evaluated as normal. A lumbar spine MRI in November 2010 found an L5-S1 central disc protrusion, for which service connection has not been established, but otherwise confirmed normal lumbar spine vertebral body height and normal alignment. A February 2011 notation from the Veteran’s primary care physician noted a lumbar spine curvature that was convex to the right. This was not identified on the diagnostic imaging. Furthermore, there is no indication that the described spinal contour abnormality, if present, was the result of any muscle spasm or guarding, as required to establish the next higher rating at 20 percent. Indeed, symptoms of muscle spasm or guarding are not indicated by the Veteran’s spine examinations or treatment records for the relevant period. The Board acknowledges the Veteran’s lay reports of symptoms and that there was functional loss due to pain, stiffness, and decreased motion reported during flare-ups, and with repetitive use over time. However, even considering the Veteran’s lay reports of symptoms and noted functional loss, the degree of additional limitation reflected by the statements that he experienced flare-ups with moderate pain every 2 to 3 weeks, lasting 1 to 2 days would not result in limitation of motion more nearly approximating forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees or the combined range of motion of the thoracolumbar spine not greater than 120 degrees. Consideration has also been given to assigning a rating under the Formula for Rating IVDS Based on Incapacitating Episodes. However, the evidence of record is against a finding that the Veteran was ever prescribed bed rest by a physician for a duration that meets the criteria for a higher rating. See 38 C.F.R. § 4.71a, Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes. Regarding neurological impairment, the Veteran has already been granted service connection for “right leg sciatica” associated with his lumbar and thoracic strain. The Board will discuss a separate comparable rating granted for left lower extremity numbness and tingling below. For the foregoing reasons, the preponderance of the evidence is against the Veteran’s claim for a rating greater than 10 percent for lumbar and thoracic musculotendinous strain prior to February 17, 2011. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. 2. As of February 17, 2011, a 40 percent disability rating for lumbar and thoracic musculotendinous strain is granted. The Regional Office previously determined that the Veteran’s lumbar and thoracic strain warranted an increased disability rating of 20 percent as of a February 17, 2011 Decision Review Officer (DRO) hearing, and an additional increase to 40 percent as of a February 29, 2020 examination showing a commensurate limitation of range of motion. However, considering the evidence in its entirety, the Board finds that the preponderance of the evidence supports a 40 percent rating, and no higher, dating back to February 17, 2011. At the hearing held by the DRO on that date, the Veteran described constant pain in his back, sometimes shooting pain running up the spinal cord, that required him to lean back and stretch every five or ten minutes. He described his level of pain on a scale of severity of 1-10 as being a 5 on a good day, an 8 on a bad day, and maybe once a month a 10 for a couple of days. About two months later, at an April 2011 VA examination, the Veteran described soreness and pain that feels like a cramp in his lower and mid back. He described flare-ups of lower lumbar pain as being severe, occurring every 1 to 2 months, lasting from 3 to 7 days, and that during such a flare-up, he could not bend at all, and had to keep his back straight. The examination continued to show normal posture, head position, and spinal curvatures, with a slow and steady gait. He did not exhibit muscle spasm or guarding. Motor and sensory examinations remained normal. Range of motion of the thoracolumbar spine was measured as full flexion of 90 degrees, extension from zero to 20 degrees, bilateral lateral flexion to 20 degrees, and full bilateral lateral rotation of 30 degrees. However, based on the entirety of the evidence, the Board will resolve reasonable doubt in the Veteran’s favor and find that the symptoms he describes as regularly occurring for up to one week out of every month where he could not bend at all and had to keep his back in a straight position to more nearly approximate fixation in a neutral position, otherwise known as favorable ankylosis of the thoracolumbar spine. This equates to a 40 percent disability rating. Although the Veteran described this particular inability to bend during the April 2011 examination, the Board must interpret reports of examination in light of the whole recorded history and reconcile the various reports into a consistent picture so that the rating accurately reflects the elements of disability present. 38 C.F.R. § 4.2. In so doing, the Board finds that the 40 percent rating should date back to the closely contemporaneous February 17, 2011 DRO hearing in which the Veteran described worsening of his back symptoms. The Board further finds that the preponderance of the evidence is against a rating greater than 40 percent at any time during the period on appeal. Even considering the Veteran’s lay reports of symptoms and noted functional loss, the degree of additional limitation reflected by his statements would not result in symptoms more nearly approximating unfavorable ankylosis of the entire thoracolumbar spine or the entire spine at any time. Neither the Veteran, nor his examination or treatment records have described his spine disability as resulting in limited line of vision, restrictions for his mouth and chewing, or impairments in breathing or swallowing, or any other symptoms defined as unfavorable ankylosis. In all, the Board finds that a 40 percent rating for lumbar and thoracic strain, and no higher, is warranted as of February 17, 2011. The appeal is granted. 3. As of December 19, 2019, a separate 10 percent rating for left lower extremity tingling and numbness is granted. The Board notes that the AOJ has previously granted service connection for right leg sciatica associated with the Veteran’s lumbar and thoracic strain. The Board notes that peripheral nerve examinations have not identified impairment with the sciatic nerve. The Veteran has inconsistently described the presence of any numbness or paresthesias versus pain radiating from his back. In August 2009, the Veteran described no radiation of pain, and on examination in February 2011, he described no numbness or paresthesias but a dull throbbing radiating pain across the lower back and hips. Sensory examination findings were normal. In August 2011, the Veteran was treated for back pain lasting several days when he reached down to pick up a shoe and his back “went out,” but there was no radiation of pain and no loss of bowel or bladder control. An April 2014 VA examination identified radicular pain and numbness with involvement of the sciatic nerve, but only for the right lower extremity. No such symptoms were identified involving the left lower extremity, and the absence of such left lower extremity symptoms was explicitly noted in the examination report. The left side was noted to be “not affected.” A June 2019 VA examination found no radicular pain or any other signs or symptoms due to radiculopathy for either lower extremity. This absence of radiculopathy was again reiterated in a February 2020 spine examination. An October 2019 consultation for traumatic brain injury identified a subjective report of mild numbness or tingling, but did not identify what part or parts of the Veteran’s body experienced such symptoms. Neurological review of symptoms as of this date did not identify a left lower extremity impairment. On December 19, 2019, the Veteran sought treatment with his primary care clinic for upper extremity pain. During this visit, however, the physician noted “paresthesias elicited past the knee in both lower limbs with straight leg raise. Please evaluate for radiculopathy.” VA treatment record, December 2019. Thereafter, a peripheral nerves examination in February 2020 also explicitly found that the Veteran did not have a peripheral nerve condition. However, under the report heading of “Symptoms” the examiner found that the Veteran did have symptoms attributable to a peripheral nerve condition affecting both lower extremities. Mild constant pain and severe intermittent pain as well as severe paresthesias and/or dysesthesias and moderate numbness were identified in the left lower extremity. VA examination, February 2020. The Board will resolve the discrepancies in the February 2020 report to find that even in the absence of a clearly diagnosed peripheral nerve disability, the Veteran’s described peripheral nerve symptoms in the left lower extremity constitute an objective neurologic abnormality and result in a functional impairment of earning capacity. See Saunders v. Wilkie, 886 F. 3d 1356 (2018). The Board finds that it must similarly resolve reasonable doubt in the Veteran’s favor with regard to the claimed association between the left lower extremity neurologic impairment and the service-connected back disability, particularly as the AOJ has already done so with regard to the right lower extremity neurologic abnormality. The Board assigns an effective date for peripheral nerve symptoms in the left lower extremity as of the December 19, 2019 VA treatment report finding paresthesias past the knee in both lower limbs. The Board acknowledges the opinion of the February 2020 VA examiner that the Veteran “had difficulty distinguishing between his knee pain and the [numbness/tingling type] pain in his lower legs.” The examiner opined that the described pain was most likely coming from the knees, the altered gait due to knee pain, or to deconditioning in avoiding pain-causing activities. The examiner further stated that the lower leg pain was not consistent with radiculopathy because the Veteran did not describe dermatomal pain along the length of his legs. In this regard, compensating the lower leg pain/numbness/tingling could be duplicative of the compensation provided for the Veteran’s pain and functional limitations due to his bilateral knee disabilities discussed below. However, as the Veteran has also described the numbness/tingling sensation in other areas above the knee, including the upper leg areas, the Board will resolve reasonable doubt in favor of the Veteran to find this condition to be separate from that compensated as knee pain and consistent with the existing right lower extremity ratings previously granted by the AOJ. Based on the entirety of the evidence, the Board finds that the left lower extremity numbness and tingling symptoms are most nearly analogous to a neuralgia of the sciatic nerve, and thus will be evaluated under DC 8720. 38 C.F.R. § 4.124A. Neuralgia is characterized usually by a dull and intermittent pain, of typical distribution to identify the nerve, and is to be rated on the same scale, with a maximum equal to moderate incomplete paralysis. 38 C.F.R. § 4.124. In this regard, mild incomplete paralysis is rated as 10 percent disabling. Moderate incomplete paralysis is rated as 20 percent disabling. 38 C.F.R. § 4.124A. The words “mild” and “moderate,” as used in the various diagnostic codes are not defined in the Rating Schedule. Regulations provide that ratings for peripheral neurological disorders are to be assigned based on the relative impairment of motor function, trophic changes, or sensory disturbance. 38 C.F.R. § 4.120. Consideration is also given for loss of reflexes, pain, and muscle atrophy. See 38 C.F.R. §§ 4.123, 4.124. The term “incomplete paralysis” indicates a degree of lost or impaired function substantially less than the type picture for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating is for the mild, or at most, the moderate degree. The disability ratings for the peripheral nerves are for unilateral involvement; when bilateral, the ratings combine with application of the bilateral factor. 38 C.F.R. § 4.124a, Note at “Diseases of the Peripheral Nerves.” The Note to 38 C.F.R. § 4.124a establishes a maximum disability rating for conditions that are wholly sensory, as opposed to a minimum disability rating for conditions that are more than wholly sensory. See Miller v. Shulkin, 28 Vet. App. 376 (2017). Here, there is no impairment of motor function, trophic changes, sensory disturbance, muscle atrophy, or complete paralysis shown. Instead, there are hypoactive deep tendon reflexes shown in all extremities, a limping gait favoring the left side due to knee pain, and significant symptoms of pain, numbness and paresthesias/dysesthesias as described above. The February 2020 examiner indicated that the lower leg symptoms including numbness were out of proportion to the abnormalities seen on imaging and could not rule out rheumatologic disease. Nonetheless, the Board has found that there is a neurologic abnormality associated with the left lower extremity and resolved reasonable doubt that the condition is related to the Veteran’s service-connected back disability. In so doing, the Board also finds that the most probative evidence of record supports a level of impairment most analogous to mild incomplete paralysis. The Veteran describes relieving the peripheral nerve pain in his lower extremities by propping up his feet, stretching his legs, or taking a hot bath. In all, and with consideration of the Veteran’s lay statements regarding the described pain, tingling, and numbness, the Board finds this condition more nearly approximates mild rather than moderate incomplete paralysis. The Board acknowledges the variable lay assertions of radiating pain, including that occurring before December 19, 2019. However, in this regard, the Board finds the medical of evidence of record to be more probative because although the Veteran is competent and credible in describing his own symptoms, he is not competent to distinguish between the various symptoms to establish neurologic abnormality as this involves the interaction between various body systems and complex diagnostic testing. For this reason, the medical evidence is afforded greater probative value. The Board has considered all other potentially applicable diagnostic codes, but there is no evidence showing the Veteran has neurological impairment associated with any other peripheral nerves that have not already been service-connected. Therefore, a separate or higher rating under a different diagnostic code is not warranted. In conclusion, the Board finds that, as of December 19, 2019, the preponderance of the evidence supports a separate 10 percent rating, and no higher, for the Veteran’s left lower extremity numbness and tingling as a neurologic abnormality associated with his lumbar and thoracic strain. 4. A disability rating based on limitation of motion for patellofemoral syndrome of the left knee greater than 10 percent prior to February 29, 2020, and greater than 40 percent thereafter, is denied. 5. As of April 25, 2019, a separate 20 percent rating for symptomatic meniscal injury of the left knee is granted. The Veteran contends that he is entitled to higher ratings for his bilateral knee disabilities because the current ratings do not adequately capture the extent of his disability. The Board will first address the left knee symptoms, then the right knee. Knee disabilities are unique in the rating code, as they are one of a few orthopedic disabilities in which a Veteran may receive multiple ratings based on separate symptoms in the same joint. While the law generally prevents considering the same symptoms under various diagnoses to support separate ratings, some of the relevant diagnostic codes for the knee have been interpreted to apply to different functions of the knee, therefore warranting separate consideration. Specifically, the evidence may warrant separate ratings for limitation of flexion of the knee, limitation of extension of the knee, lateral instability and recurrent subluxation of the knee, and meniscal disabilities. However, the critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the disabilities is duplicative or overlapping with the symptomatology of the other disability; thus “pyramiding” is to be avoided. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994); see also 38 C.F.R. § 4.14. The Board will explore all possibilities in this case, beginning with limitation of motion of the affected joint. Prior to February 29, 2020, the Veteran was assigned a 10 percent rating based on painful limitation of motion of the left knee. The assigned Diagnostic Code 5299-5260 indicates that the left knee patellofemoral syndrome is a disability not explicitly listed in the Rating Schedule, but rated based on compensable limitation of flexion (DC 5260). 38 C.F.R. §§ 4.27, 4.71a. A review of the evidence reflects that the left knee patellofemoral syndrome has been rated based on painful noncompensable limitation of motion, and that the disability has not had compensable limitation of motion (i.e. limitation of flexion or extension) at any time during the rating period prior to February 29, 2020. Therefore, the diagnostic code assigned should have been DC 5299-5003 to show that the service-connected patellofemoral syndrome is being rated based on noncompensable limitation of motion that is painful. For this reason, the Board is changing the diagnostic code to reflect the actual rating already assigned prior to February 29, 2020. 38 C.F.R. § 4.71a. Of note, under 38 C.F.R. § 4.59, painful motion is a factor to be considered with any form of arthritis; however, 38 C.F.R. § 4.59 is not limited to disabilities involving arthritis and therefore remains applicable here with service-connected patellofemoral syndrome. See Burton v. Shinseki, 25 Vet. App. 1 (2011). Prior to February 29, 2020, the Veteran’s left knee patellofemoral syndrome is rated based on noncompensable painful limitation of motion because 38 C.F.R. § 4.59 mandates that the intent of the rating schedule is to recognize painful motion with joint or periarticular pathology as productive of disability, and that it is the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. The Board thus finds the 10 percent minimum rating for the left knee joint to be the appropriate rating for this time period. In contrast, to award a higher compensable rating based on limitation of motion of the knee joint, the Veteran’s left knee range of motion would need to exhibit extension limited to 10 degrees or more and/or flexion limited to 45 degrees or less. 38 C.F.R. § 4.71a, Diagnostic Codes 5260, 5261. Under Diagnostic Code 5260, a noncompensable rating is warranted for flexion limited to 60 degrees. A 10 percent rating is warranted for flexion limited to 45 degrees. A 20 percent rating is warranted for flexion limited to 30 degrees. A 30 percent rating is warranted for flexion limited to 15 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5260. Under Diagnostic Code 5261, a noncompensable rating is warranted for extension limited to 5 degrees. A 10 percent rating is warranted for extension limited to 10 degrees. A 20 percent rating is warranted for extension limited to 15 degrees. A 30 percent rating is warranted for extension limited to 20 degrees. A 40 percent rating is warranted for extension limited to 30 degrees. A 50 percent rating is warranted for extension limited to 45 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5261. The Board has also considered the other diagnostic codes pertaining to the knee and leg, and as applicable these are discussed further herein. Other disability ratings may be assigned only if the symptomatology for a disability is not duplicative or overlapping with the symptomatology of any other disability. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994); Lyles v. Shulkin, 29 Vet. App. 107 (2017) (holding that 38 C.F.R. § 4.14 prohibits paying compensation twice for the same symptoms or functional impairment). Standard range of knee motion is from zero degrees (on extension) to 140 degrees (on flexion). See 38 C.F.R. § 4.71, Plate II. Prior to February 29, 2020, the Veteran did not exhibit a compensable limitation of motion of the left knee. At no time did he exhibit extension limited to 10 degrees or more, or flexion limited to 45 degrees or less. Instead, upon VA examination in August 2009, both knees measured with flexion from zero to 125 degrees with pain from 40 to 125 degrees, and extension to zero degrees with pain from 40 to 20 degrees. There was no additional limitation of motion found on repetitive use of the joint due to pain, fatigue, weakness, incoordination, or lack of endurance. VA examinations in April 2011 and September 2019 confirmed further limitation of motion of the knees over time, but the range of motion continued not to reach the compensable threshold for the left knee. The left knee had flexion from zero to 110 degrees with full extension in April 2011. There was pain following repetitive motion, but that did not result in additional limitation. In September 2019, the left knee demonstrated flexion from zero to 85 degrees, with full extension. Pain was noted on both flexion and extension, and the Veteran was unable to squat or kneel due to the decreased flexion. The additional functional loss due to pain after repetitive-use testing in September 2019 was estimated to result in flexion to 75 degrees with full extension remaining. Greater range of motion was then demonstrated upon examination the following month in October 2019 with full extension and 130 degrees of flexion, with no additional functional loss after repetitive use. The Veteran denied flare-ups at the October 2019 examination. In all, prior to February 29, 2020, the Board finds that the preponderance of the evidence is against a rating in excess of 10 percent for left knee patellofemoral syndrome based on limitation of motion. The existing 10 percent rating is appropriate based on painful noncompensable limitation of motion. The Board acknowledges the Veteran’s lay reports of symptoms and that there was additional functional loss due to increased pain during flare-ups. The record is inconsistent as to the presence, frequency and duration of flare-ups. The Veteran did typically describe the pain during such flare-up as being moderate to severe. However, even considering the Veteran’s lay reports of symptoms and noted functional loss, the degree of additional limitation reflected by his statements would not result in limitation of motion more nearly approximating extension limited to 10 degrees or flexion limited to 45 degrees. Although the Veteran described flare-ups with increased pain that is alleviated by rest, laying down, a hot bath, ice, or elevating the knee, he did not describe the flare-ups as further limiting the range of motion of the knee joint, nor did the examining practitioners make such a finding. Considering the lay and medical evidence in its entirety, prior to February 29, 2020, the Veteran is not shown to have a compensable loss of motion of the left knee joint. The existing 10 percent rating based on a noncompensable painful loss of motion is appropriate. Upon examination on February 29, 2020, however, the Veteran’s left knee demonstrated flexion to 105 degrees and extension limited to 15 degrees. There was no additional functional loss after repetitive use testing during the examination. This range of motion would result in a 20 percent rating based on extension limited to 15 degrees. However, although the Veteran was not examined immediately after repetitive use over time, the examiner estimated that additional functional loss due to pain and weakness with repetitive use over time would result in flexion limited to 100 degrees and extension limited to 30 degrees. Flare-ups were estimated as resulting in the same functional loss in terms of range of motion. This limitation of extension on repetitive use over time, or during a flare-up, equates to an increased 40 percent rating and is the basis for the rating assigned by the AOJ as of this date. In sum, based on limitation of motion, the Veteran’s left knee patellofemoral disability warrants a 10 percent rating prior to February 29, 2020, and a 40 percent rating since February 29, 2020. At no time during the present appeal is limitation of flexion or extension shown at 45 degrees to warrant a higher rating. The Board now turns to other bases by which an additional left knee rating may be warranted. The medical record also indicates bilateral meniscus injuries. Therefore, additional diagnostic codes are potentially applicable. Specifically, under Diagnostic Code 5259, a 10 percent rating is available for removal of the semilunar cartilage (meniscus) that is symptomatic. Under Diagnostic Code 5258, a dislocated meniscus with symptoms of “locking,” pain, and effusion into the joint warrants a 20 percent rating. Significantly, § 4.71a does not expressly prohibit separate evaluation under Diagnostic Codes 5261 and 5258. See Lyles, Esteban, supra. Based on the evidence present here, the Board finds that applying a rating based on limitation of extension (DC 5261) and a rating based on symptomatic injury to the semilunar cartilage, also known as the meniscus, (DC 5258) is warranted. Upon VA examination in August 2009, there was no meniscus abnormality found for either knee. An April 25, 2019 VA orthopedic clinic notation is the first evidence available that the Veteran had a “bilateral knee meniscus injury.” As such, this is the effective date assigned for a separate 20 percent rating based on the left knee meniscal injury. The Board acknowledges that a meniscal dislocation or meniscal tear as identified by diagnostic imaging or other means is not shown for the left knee during the present appeal, only for the right knee. However, because the evidence demonstrates a left knee meniscal “injury” identified by medical practitioners that is manifest by frequent episodes of locking, pain, and effusion, the Board resolves reasonable doubt in the Veteran’s favor and assigns a separate rating on the basis of that meniscal injury, although the precise nature of that meniscal injury may be poorly described. The 20 percent rating is the only available rating under this diagnostic code. The Veteran has also described complaints of both knees feeling as though they are unstable or giving way at times. Under Diagnostic Code 5257, a 10 percent rating is warranted for slight recurrent subluxation or lateral instability. A 20 percent rating is warranted to moderate recurrent subluxation or lateral instability. A 30 percent rating is warranted for severe recurrent subluxation or lateral instability. However, the Board interprets the Veteran’s descriptions of bilateral knee instability as consistent with the locking, pain, weakness and related symptoms resulting from his symptomatic menisci disabilities. It would be impermissible to grant additional separate ratings under DC 5257 for instability as this would compensate the same symptoms under separate diagnostic codes and violate the rule against pyramiding. In conclusion, the Board finds that the preponderance of the evidence is against the Veteran’s claim for a rating greater than 10 percent prior to February 29, 2020 and greater than 40 percent since that date, as based on limitation of motion of the left knee. However, a separate 20 percent rating based on left knee meniscal injury is warranted. 6. A disability rating based on limitation of motion for patellofemoral syndrome with degenerative arthritis of the right knee greater than 10 percent prior to February 29, 2020, and greater than 40 percent thereafter, is denied. 7. As of November 22, 2017, a separate 20 percent rating for symptomatic meniscal injury of the right knee is granted. The same knee ratings available under the Rating Schedule as discussed above are also for application with the right knee. As iterated above in the left knee discussion, the Board finds it appropriate to change the diagnostic code in use for the right knee prior to September 30, 2019 to DC 5299-5003 to reflect the actual rating already assigned based on painful but noncompensable limitation of motion. When a compensable right knee limitation of extension is demonstrated as of February 29, 2020, the diagnostic code used should be changed to DC 5261 to most accurately reflect the bases of the assigned ratings. 38 C.F.R. § 4.71a. The Board further notes that the increase to 20 percent that was granted by the AOJ effective as of September 30, 2019 under DC 5261 was in error. The AOJ explicitly based this increase upon findings of “dislocated semilunar cartilage with frequent episodes of ‘locking,’ pain, and effusion into the joint” which should have been awarded a separate 20 percent rating under DC 5258, rather than increasing the rating under the inapplicable DC based on limitation of motion. As the AOJ has previously applied the ratings, this deprived the Veteran of the proper 10 percent rating based on limitation of motion and a 20 percent rating for the meniscal injury which would provide a greater combined rating to the Veteran. As such, the Board returns the Veteran’s 10 percent rating based on painful limitation of motion under DC 5299-5003 for the period prior to February 29, 2020 and grants a separate 20 percent rating based on meniscal injury as further discussed below. See also Lyles, Esteban, supra. Prior to February 29, 2020, a right knee compensable limitation of motion is not shown. Instead, as discussed above, the August 2009 examination showed flexion from zero to 125 degrees with full extension bilaterally. There was no additional limitation of motion on repetitive use, although pain was identified on examination in both flexion and extension. VA examination in April 2011 continued to show noncompensable right knee limitation of motion with flexion to 100 degrees and full extension. VA treatment records also show noncompensable limitation of motion with up to 120 degrees of flexion and full extension bilaterally. See, e.g., VA treatment record, August 2019. While additional examinations in September and October 2019 reflect worsening limitation of motion of the right knee joint with full extension shown on both examinations, and flexion measured at 80 degrees in September and 110 degrees in October, these both remain significantly greater than the limitation to 45 degrees of flexion that is required to establish a compensable rating based on limitation of flexion. The Veteran also describes more significant flare-ups occurring every 3-4 months and lasting 4-6 weeks in duration, saying he is unable to walk due to “excruciating” pain and treats this at home with ice and elevation. VA examination, September 2019. He describes being “almost housebound” during such times. Id. The September 2019 examiner is unable to describe any additional functional limitation with flare-ups stating “Following further review of the Veteran’s records and giving consideration to their subjective complaints and objective exam findings, given my clinical knowledge and medical expertise, there remains no rational basis to make a notation regarding any additional losses of function or motion during a flare up.” Id. The Board accepts this explanation that an estimation of further loss of motion during a flare-up is not possible based on the evidence before the examiner. The examination in the following month notes that the Veteran did not report flare-ups of the knee, thus no further estimation is offered in October 2019. In all, the Board finds that a preponderance of the evidence weighs against a rating greater than 10 percent based on limitation of motion prior to February 29, 2020 because the Veteran does not exhibit a compensable range of motion that is 45 degrees or less of flexion or limitation to 10 degrees or more on extension. While the Veteran describes significant levels of pain during a flare-up, he does not describe functional loss in terms of any restriction or limitation of motion during a flare-up, and the examinations for this period also do not indicate a compensable limitation of motion as represented by additional functional loss after repetitive use or during a flare-up. In other words, although the Veteran describes being unable to walk at times during a severe flare-up, he describes this as being due to the level of pain not an inability to bend or other expressed limitation of motion of the knee. As such, the Board is not able to contrive an estimated limitation of motion due to increased pain during a flare-up. Instead, based on limitation of motion, a 10 percent rating based on noncompensable yet painful limitation of motion is appropriate prior to February 29, 2020. However, as mentioned above with the left knee, as of the February 29, 2020 examination, the examiner first identified a compensable limitation of extension. At this time, the right knee exhibited flexion to 100 degrees (still noncompensable) but extension limited to 20 degrees. This would equate to a 30 percent rating under DC 5261 for limitation of extension. Yet, during a flare-up, the examiner finds that pain, weakness, fatigability or incoordination would significantly limit the Veteran’s functional ability, and describes this functional loss in terms of a further limitation of extension at 30 degrees, with 100 degrees of flexion remaining. On this basis, based on limitation of motion, the Board finds that a 40 percent rating, and no higher, is warranted based on limitation of extension as of February 29, 2020. A rating greater than 40 percent is nor warranted as extension limited to 45 degrees is not indicated at any time during the present appeal. The Board acknowledges the Veteran’s lay reports of intense pain during flare-ups. However, even considering the Veteran’s lay reports of symptoms and noted functional loss after February 29, 2020, the degree of additional limitation reflected by his statements would not result in limitation of motion more nearly approximating compensable limitation of flexion, or extension limited to 45 degrees. The Veteran does not describe this type of limitation of motion during a flare-up, nor do the many examinations during the appeals period. However, as above with the left knee, in addition to a painful limitation of motion, to include the compensable limitation of extension established as of February 29, 2020, the evidence also reflects a right knee meniscal impairment that warrants a separate 20 percent rating. On November 22, 2017, a VA treatment notation reflects that an MRI performed on that date shows inflammation of muscles and tendons that attach to the outer side of the right knee and that the Veteran’s right knee outer meniscus was displaced but did not appear torn. The Board finds this to be the earliest date at which a dislocated right meniscus is shown and assigns the 20 percent rating on this basis as of this effective date. 8. As of February 29, 2020, a TDIU rating as a result of the Veteran’s service-connected bilateral knee disabilities alone is granted. The Board acknowledges that the Veteran is already in receipt of a combined 100 percent disability rating as of February 29, 2020. However, as established in Bradley v. Peake, 22 Vet. App. 280 (2008), although no higher percentage of disability compensation may be paid when a total schedular disability rating is already in effect, a separate award of TDIU predicated on a single disability that is not ratable at the schedular 100 percent level may be warranted when there is another disability separately rated, singly or in combination, at 60 percent or more as that circumstance would warrant payment of special monthly compensation under 38 U.S.C. § 1114(l) and 38 C.F.R. § 3.350(i). For this reason, and given the facts of this case where the February 2020 examiner described the Veteran’s bilateral knee disability as resulting in functional impairment that impact the Veteran’s ability to perform occupational tasks in that he is prevented from using stairs, running, walking long distances, and sitting or standing for long periods of time due to knee disability, the Board finds that the Veteran’s knee disabilities alone would render him unable to secure or follow a substantially gainful occupation. As a result, a TDIU rating would be warranted based on the Veteran’s service-connected bilateral knee disability alone. Although this does not alter the existing disability rating or the associated disability compensation directly, it does then provide eligibility for SMC as discussed further below. 9. As of February 29, 2020, special monthly compensation at the housebound rate, also known as total plus 60 percent, is granted. A veteran may receive special monthly compensation at the housebound rate under 38 U.S.C. § 1114(s) if he or she has a single service-connected disability rated as total, and has additional service-connected disability or disabilities independently ratable at 60 percent or more. 38 U.S.C. § 1114(s); 38 C.F.R. § 3.350(i). A TDIU rating based on a single disability satisfies the statutory requirement of a “total rating.” Bradley v. Peake, 22 Vet. App. at 293. In this case, as a result, the Board finds that the Veteran is entitled to SMC at the housebound rate based on total disability plus 60 percent as of February 29, 2020. A TDIU rating has been established based on the Veteran’s service-connected bilateral knee disability alone. He also has existing ratings of 50 percent for obstructive sleep apnea, and 50 percent for migraine headaches, 30 percent for sleep disturbance with daytime sleepiness, 10 percent for tinnitus, and others that combine to greater than a 60 percent rating that are separate and distinct from the service-connected bilateral knee disability upon which the TDIU rating is based. Thus, SMC at the housebound rate is warranted as of February 29, 2020. REASONS FOR REMAND 1. Entitlement to service connection for osteoarthritis of the right hip is remanded. 2. Entitlement to service connection for osteoarthritis of the left hip is remanded. The Veteran has previously asserted that his bilateral hip osteoarthritis is attributable to his service-connected knee or back strain disabilities and an altered gait resulting therefrom. Medical opinions have been sought and obtained on those matters. However, via a January 2021 brief to the Board, the Veteran’s representative now asserts that there is a connection between the Veteran’s osteoarthritis and his service-connected sleep apnea. The representative submitted two medical journal articles in support of the allegation “on aggravation of osteoarthritis.” Brief by Veteran’s representative, January 2021. As the representative has explicitly raised this theory of entitlement, and the Board cannot make a fully-informed decision on the issue of secondary service connection because no VA examiner has opined whether the Veteran’s bilateral hip osteoarthritis is caused or aggravated by his service-connected obstructive sleep apnea, an additional medical opinion on the newly presented theory is required. The matters are REMANDED for the following action: Obtain an addendum opinion regarding whether the Veteran’s bilateral hip osteoarthritis is at least as likely as not proximately due to or aggravated beyond its natural progression by the Veteran’s service-connected obstructive sleep apnea. In rendering this opinion, the provider is expressly asked to consider and discuss the European Respiratory Journal and Journal of Clinical Sleep Medicine articles referenced by the Veteran’s representative in the January 4, 2020 written brief presentation. K. J. ALIBRANDO Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board K. McDonald, 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.