Citation Nr: 21006703 Decision Date: 02/05/21 Archive Date: 02/05/21 DOCKET NO. 19-22 295A DATE: February 5, 2021 ORDER Service connection for erectile dysfunction is granted. Service connection for bilateral hearing loss is denied. Service connection for tinnitus is denied. Service connection for right hip osteoarthritis is denied. Service connection for right lower extremity radiculopathy is denied. An increased rating in excess of 10 percent for left tibia fracture residuals, sclerosis intramedullary cavity, is denied. An increased rating in excess of 10 percent for right knee osteoarthritis is denied. An increased rating in excess of 10 percent for chronic gastritis is denied. Special monthly compensation based on loss of use of a creative organ is granted. FINDINGS OF FACT 1. The Veteran has erectile dysfunction that was caused by his medications for the now service-connected mental health disorder. 2. The Veteran’s current bilateral hearing loss and tinnitus did not have their onset during service, manifest to a compensable degree during service or within one year after service, and are not otherwise related to in-service injury or disease. 3. The Veteran’s current right hip osteoarthritis was not caused or aggravated by a service-connected disability; the current disability did not have its onset during service or manifest to a compensable degree during service or within one year after service, and it is are not otherwise related to in-service injury or disease. 4. There is no current right lower extremity radiculopathy diagnosis or disability. 5. Throughout the appeal period, the Veteran’s left tibia fracture residuals resulted in painful or limited motion at times due to pain and other factors at times, but with flexion to greater than 45 degrees and extension to greater than 10 degrees; with no more than slight knee impairment due to the tibia; and no recurrent subluxation or lateral instability, meniscal impairment, or other left knee or leg impairment. 6. Throughout the appeal period, the Veteran’s right knee arthritis resulted in painful or limited motion at times due to pain and other factors at times, but with flexion to greater than 45 degrees and extension to greater than 10 degrees; with no recurrent subluxation or lateral instability, meniscal impairment, or other knee or leg impairment. 7. Throughout the appeal period, the Veteran has had no more than mild symptoms or manifestations of clinical chronic gastritis under any potentially applicable code. 8. There is loss of use of a creative organ due to service-connected disability. CONCLUSIONS OF LAW 1. The criteria for service connection for erectile dysfunction are met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.310. 2. The criteria for service connection for bilateral hearing loss are not met. 38 U.S.C. §§ 1110, 1112, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309. 3. The criteria for service connection for tinnitus are not met. 38 U.S.C. §§ 1110, 1112, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309. 4. The criteria for service connection for right hip osteoarthritis are not met. 38 U.S.C. §§ 1110, 1112, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309, 3.310. 5. The criteria for service connection for right lower extremity radiculopathy are not met. 38 U.S.C. §§ 1110, 1112, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309. 6. The criteria for an increased rating in excess of 10 percent for left tibia fracture residuals are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5262-5260. 7. The criteria for an increased rating in excess of 10 percent for right knee osteoarthritis are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5003-5260. 8. The criteria for an increased rating in excess of 10 percent for chronic gastritis are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.7, 4.10, 4.20, 4.27, 4.113, 4.114, Diagnostic Code 7399-7304. 9. The criteria for special monthly compensation based on loss of use of a creative organ are met. 38 U.S.C. §§ 1114, 5107; 38 C.F.R. §§ 3.350, 4.3. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had honorable active duty from January 1962 to January 1964. This matter is before the Board of Veterans’ Appeals on appeal from a January 2019 rating decision. In January 2021, the Veteran’s representative waived initial review by the agency of original jurisdiction (AOJ) of evidence added to the claims file after the June 2019 statement of the case (SOC). There is no argument or indication that additional evidentiary development is needed for a fair decision. Although the Veteran specifically referenced the denial of special monthly compensation (SMC) for loss of use of a creative organ in his April 2019 notice of disagreement (NOD), he claimed service connection for erectile dysfunction on the same basis, as secondary to medications for his mental health disorder. The January 2019 rating decision only vaguely addressed direct service connection for erectile dysfunction and stated vaguely that the criteria for SMC were not met. It appears that the Veteran intended to appeal from both denials, and the evidence supports a grant of secondary service connection and SMC. Accordingly, the Board also takes jurisdiction over the issue of service connection for erectile dysfunction on appeal. Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. § 3.303. Generally, service connection requires three elements: (1) a current disability diagnosis; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). Arthritis and organic disease of the nervous system, which VA considers to include sensorineural hearing loss and tinnitus, are considered chronic diseases that will be presumed related to service if they were noted or diagnosed as chronic in service; or if they manifested to a compensable degree within one year after active duty discharge; or if chronicity or continuity of the same symptomatology has existed since service, with no intervening cause. 38 U.S.C. §§ 1101, 1112, 1113, 1137; Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2012); Fountain v. McDonald, 27 Vet. App. 258 (2015); 38 C.F.R. §§ 3.303(b), 3.307, 3.309(a)(3). Secondary service connection will be granted if the evidence demonstrates that a current disability is proximately due to or the result of, or is aggravated beyond its natural progression, by service-connected disability. 38 C.F.R. § 3.310. In adjudicating such claims, reasonable doubt that exists because of an approximate balance of positive and negative evidence concerning any point will be resolved in favor of the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 1. Service connection for erectile dysfunction The Veteran contends that he has erectile dysfunction and loss of a creative organ as a side effect of medications to treatment his service-connected mental health disability. See, e.g., November 2018 claim; July 2020 appellate brief. The medical evidence supports a diagnosis and secondary service connection. Specifically, the December 2018 VA examiner noted a diagnosis of erectile dysfunction in 2005, although the penis was normal upon examination. The Veteran reported suffering from erectile dysfunction for 14 years. Until 2013, oral medications helped achieve adequate erections. After receiving hormonal therapy and radiotherapies from 2013 to 2015 for prostate cancer, his condition got worse. He became fully impotent, with no help from medications or a vacuum pump. The examiner stated that the etiology of the Veteran’s erectile dysfunction was psychogenic (depressive disorder), anti-depressive medications, and hormonal therapies and radiotherapies for prostate cancer. The examiner further opined that the Veteran’s erectile dysfunction was at least as likely as not proximately due to or the result of medication for his mental condition. The examiner gave a rationale that the medical records show that by the time the Veteran started suffering from erection problems, he was already suffering from depressive disorder and taking anti-depressive medications. It is well documented in medical literature that depression can interfere with sexual feelings and cause or worsen erectile dysfunction, and certain anti-depressive medications used as part of treatment for depressive disorders have been related to sexual dysfunction. The examiner noted that medical records also show that the Veteran’s erectile dysfunction was worsened by the hormonal and radiotherapies for prostate cancer, which is not service-connected. Nevertheless, the condition began with his psychiatric medications. After an initial denial, a July 2020 rating decision granted service connection for the Veteran’s mental health disorder of depression with anxiety. Accordingly, the underlying condition is now service-connected. Thus, reasonable doubt is resolved in the Veteran’s favor, and the appeal is granted. 2. and 3. Service connection for bilateral hearing loss; service connection for tinnitus The Veteran submitted a claim in November 2018 for bilateral hearing loss and tinnitus. He generally contends that his current disabilities are due to noise exposure during service. See, e.g., December 2018 VA examination. The Veteran’s current bilateral hearing loss and tinnitus did not have their onset during service, manifest to a compensable degree during service or within one year after service, and are not otherwise related to in-service injury or disease. Specifically, the evidence establishes current disability diagnoses. The December 2018 VA examiner diagnosed sensorineural hearing loss bilaterally and recorded pure tone thresholds of 40 decibels or above at the 3000 and 4000 Hertz levels in both ears. This meets the VA disability criteria in 38 C.F.R. § 3.385. The Veteran’s report of having recurrent tinnitus is sufficient to establish this disability, as he is competent to identify and diagnose this subjective condition. Concerning the in-service incurrence element, the Veteran has not described any particular type of noise exposure or other relevant injury or disease in service. A March 2017 VA audiology consult noted that the Veteran reported military noise exposure for two years, but no history of ear pathology. The December 2018 VA examiner also generally noted military noise exposure. The Veteran’s DD Form 2014 reflects a military occupational specialty of machine accounting specialist, which does not appear to involve excessive noise. However, the Veteran as likely as not had some noise exposure during training for general military duties. Service treatment records do not document any treatment or complaints for hearing difficulties, ear complaints, or tinnitus symptoms, such as ringing in the ears. In his October 1963 separation examination, the Veteran denied ear, nose, or throat trouble, which would reasonably include tinnitus or ear symptoms such as ringing in the ears, and “running ears.” There was no specific option for hearing loss. The Veteran’s hearing was tested through a whisper test for both the 1961 entrance and 1963 discharge examinations, which both had results of 15/15 bilaterally. The December 2018 VA examiner noted that a whisper test is not reliable to identify whether there is hearing loss that is typically found with military noise exposure. There is also no indication of complaints to a medical provider or treatment for hearing difficulties or tinnitus until many years after the Veteran’s discharge from service. Contemporary medical evidence is not required to show a disability or incurrence during service. However, the lack of treatment or corroborating medical evidence for many years may be considered as one of several factors in determining whether a disability was incurred during service. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000); Fagan v. Shinseki, 573 F.3d 1282, 1289 (Fed. Cir. 2009). Post-service treatment records do not specify a date of onset for the Veteran’s noticeable hearing difficulties and tinnitus. Instead, he repeatedly denied hearing difficulties and tinnitus for review of systems from 2004 forward, including in October 2012. A September 2012 VA ENT consult noted that the right ear (AD) was tender, and the canal had wax that was cleaned with suction. The impression was acute otitis externa of the right ear and mixed hearing loss. Several years later, a January 2017 VA treatment record reflects that the Veteran was referred to the audiology clinic for occasional ear congestion, popping, and ringing in the ears. A March 2017 VA audiology consult noted that the Veteran reported that he “hears well” but had noise exposure in service. His ear canals were free of cerumen (wax). Testing showed pure tones above 20 decibels at all levels from 500 to 4000 Hertz bilaterally and met the VA disability criteria. Amplification (hearing aids) was recommended, but the Veteran declined. Other than in relation to the right ear infection in 2012, there is no other notation of mixed hearing loss (or conductive and sensorineural hearing loss). These medical notations suggest that the Veteran had temporary hearing loss at times related to ear infections or congestion, but he did not notice ongoing or chronic hearing loss or tinnitus symptoms for years. Similarly, during the December 2018 VA examination, the Veteran did not identify a date of onset for his hearing loss. He reported having recurrent tinnitus for many years, but he could not recall the date or circumstances of onset of tinnitus. As noted above, however, he expressly denied having tinnitus for treatment in 2012 and otherwise, and he reported having only occasional ringing in the ears in 2017. The Veteran is competent to report the nature and timing of his observable symptoms. However, he has not asserted that he had noticeable hearing difficulties or tinnitus symptoms in service, within one year after service, or continuously since service. Instead, he asserts only that current conditions are related to service. To the extent that his claim may be construed as an assertion of continuous symptoms since service, those reports are not credible due to inconsistency with the other available evidence, as summarized above. The records during service and for treatment after service are more probative than the Veteran’s more recent statements because they were contemporaneous in time to the events and symptoms when his recollection was fresh. His reports for post-service treatment were also made under circumstances when he had an incentive to give an accurate history as to the nature and timing of his symptoms to receive proper medical care. Concerning the nexus element, the Veteran is not competent to provide an opinion as to the cause of his current hearing loss or tinnitus, in the absence of credible reports of continuity of symptomatology. This is a medically complex question that requires knowledge of the involved otologic and neurologic system in the body, as well as interpretation of the Veteran’s medical history and any required testing. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). There is no medical evidence indicating that the current disabilities may be related to service. Instead, the December 2018 VA examiner opined that the Veteran’s hearing loss and tinnitus were less likely than not related to service. The examiner noted the absence of complaints in service, the normal whisper tests at service entrance and discharge (which he noted were not reliable to identify hearing loss from noise exposure), no complaints of hearing loss or tinnitus for more than 40 years after service, and the March 2017 VA audiology results showing bilateral mild to moderate high frequency hearing loss. The examiner stated that medical literature indicates that exposures to high intensity noise can cause permanent or progressive hearing loss during prolonged periods of exposure. Examples include military noise, industrial noise, music, and other types of non-military noise. No retroactive hearing effects are expected after years of being exposed to high intensity noise. The examiner stated that it is highly probable that the Veteran’s VA evaluations (or post-service testing) showed bilateral high frequency hearing loss that is due to presbycusis, or hearing loss expected as a normal aging progress, or a combination of both factors, or the aging process and noise exposure. It is apparent from the examiner’s full rationale and report as a whole that this final statement of a combination of factors was referring to the Veteran’s noise exposure over the many years after service. See Monzingo v. Shinseki, 26 Vet. App. 97 (2012) (noting that an examination report must be “read as a whole,” and a medical examiner is not required to provide a detailed review of medical history or comment on every piece of favorable evidence in the record); Acevedo v. Shinseki, 25 Vet. App. 286 (2012) (noting that VA examiners do not have a reasons or bases requirement, and where the opinion is lacking in detail the Board may draw inferences from the report so long as it does not result in a medical determination). Additionally, the examiner opined that the Veteran’s tinnitus is at least as likely as not a symptom associated with his diagnosis of clinical hearing loss. The examiner explained that tinnitus is known to be a symptom associated with hearing loss. These medical opinions have high probative value because they are based on an accurate medical history and provide explanations that contain clear conclusions and supporting data, including application of medical expertise to the facts of this case. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). In particular, the examiner’s rationale is consistent with the Board’s credibility findings concerning the timing of the Veteran’s symptoms, and the opinions were not based solely on the lack of a disability during service. Instead, the examiner considered potential exposures during and after service, the timing of noticeable symptoms, and medical literature as applied to this Veteran. There is no indication of reliance on the 2006 Institute of Medicine (IOM) study that contained qualifying or contradictory findings and may not be adequate to support a negative opinion. Cf. McCray v. Wilkie, 31 Vet. App. 243 (2019). There is also no argument that the opinions are inadequate or other medical evidence to suggest a link to service. As noted above, VA considers sensorineural hearing loss and tinnitus to be organic diseases of the nervous system for the chronic disease presumption. Because there is no showing of hearing loss or tinnitus during service, symptoms to a compensable degree within one year after service, or continuity of symptoms since service, the chronic disease presumption does not establish service connection. In summary, the preponderance of the evidence is against service connection for current bilateral hearing loss or tinnitus under any reasonably raised theory. There is no reasonable doubt to resolve in the Veteran’s favor, and the appeals are denied. 4. Service connection for right hip osteoarthritis The Veteran contends that he has right hip osteoarthritis as secondary to his service-connected right knee disability. See, e.g., November 2018 claim. The Veteran’s current right hip osteoarthritis was not caused or aggravated by a service-connected disability; the current disability did not have its onset during service or manifest to a compensable degree during service or within one year after service, and it is are not otherwise related to in-service injury or disease. Specifically, there is a current diagnosis of right hip osteoarthritis based on an August 2013 bone scan, as noted in the December 2018 VA examination, which also noted left hip osteoarthritis from the same study. VA treatment records include the August 2013 bone scan results in relation to prostate cancer, although there were no hip-specific complaints. The bone scan results state that there was a solitary osteogenic lesion in the inferior aspect of the sacroiliac joint anteriorly, and upon correlation with X-rays, this was compatible with inflammatory sacroiliitis. However, an October 2013 MRI found degenerative changes of the sacroiliac joints. The Board notes that the sacroiliac joints connect the spine to the hips. Concerning the nexus element, the Veteran is not competent to provide an opinion as to the cause of his claimed disability. This is a medically complex question that requires knowledge of the musculoskeletal system in the body and interactions between various joints, as well as interpretation of the Veteran’s medical history and any required testing. There is no medical evidence indicating that a current right hip disability may be caused or aggravated by a service-connected disability. Instead, the December 2018 VA examiner noted a diagnosis of right hip osteoarthritis and the Veteran’s report that he has bilateral hip pain that is worse when walking. The examiner opined that the Veteran’s right hip condition was less likely than not proximately due to or the result of his service-connected knee conditions. The examiner explained that the right hip condition is not related pathophysiologically or anatomically to the knee conditions. The examiner did not address secondary aggravation. However, there is no medical suggestion of aggravation or worsening beyond the natural progression, and the Veteran’s broad conclusory assertions are insufficient to trigger such an opinion. See McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006); Waters v. Shinseki, 601 F.3d 1274, 1276-77 (Fed. Cir. 2010). VA treatment records from January 2004 to May 2020 do not reflect any hip-specific complaints or a potential relationship to either knee. Although the Veteran asserts that his right hip osteoarthritis is secondary to his low service-connected right knee disability, there is also no suggestion in lay or medical evidence any of right hip symptoms during service, within one year after service, or continuously since service. Therefore, the chronic disease presumption for arthritis does not establish service connection, and there is no indication that there may be a direct nexus to service to warrant a medical opinion for this theory. In summary, the preponderance of the evidence is against service connection for current right hip osteoarthritis under any reasonably raised theory. There is no reasonable doubt to resolve in the Veteran’s favor, and the appeal is denied. 5. Service connection for right lower extremity radiculopathy The Veteran contends that he has right lower extremity radiculopathy as secondary to his service-connected right knee disability. See, e.g., November 2018 claim. There is no current diagnosis or disability, to include during the pendency of the appeal or recent in time to the filing of the claim. Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). Specifically, the Veteran is not competent to provide a diagnosis or opinion as to the cause or etiology of his right lower extremity disability. These are complex questions that require medical training or expertise and knowledge due to the potentially involved neurologic and musculoskeletal systems in the body, as well as interpretation of the Veteran’s medical history and any necessary tests. There is no medical evidence suggesting a diagnosis of right lower extremity radiculopathy, or that any such disability may have been caused or aggravated by the Veteran’s right knee disability. Treatment records from 2004 to 2020 contain no reference to radiculopathy, and he repeatedly denied lower extremity symptoms such as tingling, numbness, or weakness, such as in October 2012. Although the Veteran complained of right or leg knee pain, such as in March 2008, this was noted to be right knee pain and is already contemplated under his rating for right knee osteoarthritis. There is no suggestion of a separate right leg diagnosis. The December 2018 VA examiner for the spine found no signs or symptoms or diagnosis of right lower extremity radiculopathy, and did not give a nexus opinion due to no diagnosis. Additionally, there is no suggestion of right lower extremity symptoms other than right knee pain, which is already separately compensated, that result in functional impairment of earning capacity for a disability. See Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018); Martinez-Bodon v. Wilkie, 32 Vet. App. 393 (2020) (both concerning disability without underlying diagnosis). Moreover, the January 2019 rating decision that denied service connection for this disability also denied service connection for a back or lumbar spine disability. The Veteran did not appeal from the denial of the back disability. There is no argument or indication that the disability may be related to service, to include no right lower extremity complaints or neurologic symptoms during service. There is also no suggestion of a chronic disease to a compensable degree within one year after service discharge, or continuity of symptoms since service. In summary, the preponderance of the evidence is against service connection for right lower extremity radiculopathy under any reasonably raised theory. There is no reasonable doubt to resolve in the Veteran’s favor, and the appeal is denied. Disability Ratings VA’s percentage ratings are based on the average impairment of earning capacity as a result of service-connected disability. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. 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 will be resolved in favor of the claimant. 38 C.F.R. § 4.3. A separate or higher rating may be assigned based on non-overlapping conditions and symptoms, if the compensable criteria under applicable diagnostic codes are met, including with consideration of additional functional loss after repetitive use or flare-ups for musculoskeletal conditions based on range of motion. See 38 C.F.R. §§ 4.14, 4.40, 4.45, 4.59, 4.71a; Amberman v. Shinseki, 570 F.3d 1377 (Fed. Cir. 2009); Thompson v. McDonald, 815 F.3d 781 (Fed. Cir. 2016). Pain itself does not constitute functional loss, and painful motion must result in functional loss to constitute limited motion for a rating under diagnostic codes based on limitation of motion. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011). Where an increase in the level of a service-connected disability is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet. App. 55 (1994). Staged ratings may be awarded if there are decreases or increases in symptomatology that meet the criteria for a different rating for a distinct period. Hart v. Mansfield, 21 Vet. App. 505 (2007). An increased or staged rating should be assigned based on when the increase in disability can be factually ascertained, not simply the date of the medical report. See id; Swain v. McDonald, 27 Vet. App. 219, 224 (2015); 38 C.F.R. § 3.400. This decision focuses on the evidence pertinent to the rating criteria and severity during the appeal period, but the Board has considered the entire record to have a full picture of the disability. See 38 C.F.R. §§ 4.1, 4.2, 4.41; Gonzales v. West, 218 F. 3d 1378 (Fed. Cir. 2000). 6. and 7. Increased rating in excess of 10 percent for left tibia fracture residuals; increased rating in excess of 10 percent for right knee osteoarthritis The Veteran seeks an increased rating in excess of 10 percent for his left tibia fracture residuals and right knee osteoarthritis due to increased pain and functional impairment. See, e.g., November 2018 claim; December 2018 VA examination. As the law and some facts overlap, they are summarized first, followed by analysis. The December 2015 rating decision that granted service connection for left leg tibia fracture residuals and right knee osteoarthritis also denied service connection for left knee osteoarthritis, as separate from left tibia fracture residuals. The Veteran did not appeal from this denial. Therefore, distinguishable symptomatology for the left knee may not be considered in determining the rating. 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. Although the law generally prevents considering the same symptoms under various diagnoses to support separate ratings, some of the relevant DCs 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, and lateral instability and recurrent subluxation of the knee. A rating may also be assigned for meniscal impairment if there are non-overlapping symptoms. The Board will explore all possibilities in this case. The Veteran’s left leg disability is rated under DC 5262-5260 or 5260, for impairment of the tibia with resulting painful or limited flexion of the leg. His right knee is rated under DC 5260-5003, for arthritis with painful or limited flexion. Under DC 5003 for degenerative arthritis, when limitation of motion of the specific joint is noncompensable under the appropriate DC, a rating of 10 percent will be assigned for each major joint or group of minor joints affected by limitation of motion, to be combined, not added under DC 5003. If there is no limitation of motion, ratings of 10 or 20 percent are available if there is x-ray evidence of two or more major joints or two or more minor joint groups, requiring occasional incapacitating exacerbations for a 20 percent rating. 38 C.F.R. § 4.71a. Similarly, where limitation of motion is not compensable under the diagnostic code for a joint, 38 C.F.R. § 4.59 provides for a minimum compensable rating for actually painful joints in conjunction with a diagnostic code based on limitation of motion, whether or not there is arthritis. Sowers v. McDonald, 27 Vet. App. 472, 479 (2016); Southall-Norman v. McDonald, 28 Vet. App. 346, 354 (2016). Normal knee range of motion is from 0 degrees of flexion to 140 degrees of extension. 38 C.F.R. § 4.71, Plate I. Under DC 5262, impairment of the tibia or fibula is assigned a 10 percent rating for slight knee or ankle disability, 20 percent for moderate knee or ankle disability, 30 percent for marked knee or ankle disability, or 40 percent for nonunion of the tibia or fibula with loose motion requiring a brace. 38 C.F.R. § 4.71a. Under DC 5260, a 10 percent rating is assigned for limitation of flexion of the leg to 45 degrees. A 20 percent rating is assigned for flexion limited to 30 degrees. A 30 percent rating is assigned for flexion limited to 15 degrees. Id. Under DC 5261, a 10 percent rating is assigned for limitation of extension of the leg to 10 degrees. A 20 percent rating is assigned for extension limited to 15 degrees. A 30 percent rating is assigned for extension limited to 20 degrees. A 40 percent rating is assigned for extension limited to 30 degrees. A 50 percent rating is assigned for extension limited to 45 degrees. Id. Where there is painful or limited motion with both flexion and extension, but the compensable criteria are not met for either flexion (DC 5260) or extension (DC 5261), only one minimum rating of 10 percent should be assigned. Separate ratings may not be assigned for painful or noncompensable limitation of motion using DC 5003 or section 4.59 in connection with 5260, and compensable limitation of extension under DC 5261. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011). Throughout the appeal period, the Veteran’s service-connected left tibia residuals and right knee disability have manifested by pain, painful motion, and limited motion at times, with increased pain after prolonged standing and walking. He received physical therapy and steroid injections for bilateral knee pain at times. Historically, approximately 18 months before his current claim, an April 2017 VA treatment record noted left knee pain for many years with a history of left leg trauma in service. The Veteran denied current pain medications or recent physical therapy. He stated that his pain was aggravated by prolonged standing or walking and associated with knee “give away weakness,” but no swelling or locking. Anterior and posterior drawer tests were negative, and varus/valgus stress tests showed no laxity. However, a McMurray’s test was positive for pain in the medial joint line, and the left patella and hip were higher than the right side, with a 4.5 cm leg length discrepancy. The provider noted that the Veteran history was consistent with left knee degenerative joint disease. The Veteran had adapted to his leg length discrepancy and did not want it corrected. He was given steroid injections. In August 2017, the Veteran was again provided injections in both knees. A December 2018 VA examination noted diagnosed of right knee degenerative arthritis or moderate osteoarthritis and left tibia fracture residuals. The Veteran reported bilateral knee pain that was worse after prolonged walking or standing and described flareups and functional loss as limitation of standing or ambulation. Range of motion testing showed right knee extension to 0 degrees and flexion to 120 degrees. Pain was noted on flexion but did not cause functional loss, and there was no pain with weightbearing. The left knee had extension to 0 degrees and flexion to 90 degrees. Pain was noted on both flexion and extension but did not cause functional loss, and there was also pain with weightbearing. For both knees, there was objective crepitus and no pain with non-weightbearing or at rest. There was no change after repetition. There was also pain with passive range of motion but no resulting functional loss. The Veteran’s main complaint was the left knee. For both knees, tests for stability were normal, and the examiner noted no meniscal condition. The Veteran used a brace and cane on a regular basis for his left knee pain and low back pain. Work impact was no prolonged standing or ambulation. A March 2019 VA treatment record noted left knee degenerative joint disease, and that an MRI showed a meniscus tear, but no mechanical symptoms were reported. The Veteran had full range of motion, and the provider stated that all tests including McMurray’s test were negative, with valgus pain but no laxity. A May 2019 VA treatment record gave an impression of bilateral knee pain from low-grade patellofemoral chondromalacia and meniscal tears. The history noted that the left knee MRI showed a meniscus tear, but there was no meniscal problem noted for the right knee. The Veteran reported improved strength and tolerance to activities, but still with moderate pain. Similarly, the history noted an improvement in strength, range of motion, and flexibility, but continued pain of 6 out of 10. On physical examination, both knees had full active and passive range of motion, and knee tests were again negative, including the McMurray’s test. A July 2019 VA treatment record again noted left knee degenerative joint disease. In August 2019, the Veteran submitted a private examination report (DBQ), which noted a left knee meniscal tear and osteoarthritis of both knees, with bilateral knee pain since 2015. The Veteran described flare-ups of decreased activity due to pain and reported using crutches constantly due to osteoarthritis in both knees. Range of motion and stability tests were not conducted. The examiner noted a work impact of decreased time walking or standing due to pain, similar to the VA examination. Although this examiner noted the use of crutches due to both knees, this is not consistent with the recent VA treatment records that noted an increase in strength despite pain, and the Veteran also previously reported using assistive devices due to left knee and nonservice-connected low back pain. Otherwise, the DBQ notations are generally consistent with the VA examination and treatment records. Therefore, they do not suggest an increase to trigger a new VA examination. As summarized above, the varying degrees of measured motion are consistent with increased impairment at times due to pain and other factors during flare-ups and after repeated use, primarily with flexion as described by the Veteran. There is no suggestion or argument of additional loss of the Veteran’s flexion or extension due to pain or other factors after repetitive use or during flare-ups other as noted above. The guidance on how to evaluate flare-ups has not been particularly clear. As a consequence, it is determined that the holding in Mitchell v. Shinseki, 25 Vet. App. 32 (2011), will be expanded and flare-ups must be quantifiable and must result in limitation of motion of function beyond that contemplated by the already provided evaluation. Additionally, because there is a regulation addressing the stabilization of ratings, flare-ups must be of such length as to establish that the overall impairment is more severe than currently evaluated. Under 38 C.F.R. § 4.1, the degrees of disability specified by the ratings in diagnostic codes are considered adequate to compensate for considerable loss of working time from exacerbations or illness proportionate to the severity of the several grades of disability. In this case, the statements do not show that flare-ups or repeated use over time additionally limited function in a quantifiable way, or that they are of such length or duration that a higher or staged rating would not violate the rule regarding stabilization of ratings. The VA examiner attempted to elicit this information, and the Veteran primarily reported pain with activities but no additional impact, and the private examiner similarly noted only decreased activities due to pain. This does not suggest a quantifiable additional loss of range of motion, and an opinion to estimate any additional degree of limitation during flare-ups or repeated use would have no reasonable possibility of assisting in substantiating the claims. Therefore, the lack of any such opinion is not prejudicial to the Veteran’s claims. See Sharp v. Shulkin, 29 Vet. App. 26 (2017). As noted above, pain alone is not sufficient to constitute limitation of motion without resulting additional functional loss, and painful motion alone does not constitute limited motion for the purposes of rating under the codes pertaining to limitation of motion for a particular disability, as opposed to assigning a minimum rating under DC 5003 or section 4.59. Therefore, the Veteran’s reports of exacerbation after repeated use or during flare-ups are not quantifiable and not of sufficient duration to warrant a change in evaluation without violating the spirit of Mitchell, 38 C.F.R. § 4.1, and the rule regarding stabilization of ratings. As the evidence reflects significant flexion and extension despite increased pain or other contributing factors, these factors did not result in a greater degree of functional loss or limitation than noted above for either knee. For the left tibia fracture residuals, the Veteran does not meet the compensable criteria under either DC 5260 or DC 5261, as he retained flexion to more than 45 degrees and extension to more than 10 degrees even during periods of increased pain or other contributing factors. Instead, he had full extension and his left knee flexion ranged from 90 degrees to full flexion, which is more than half of the normal 140 degrees of full flexion. Accordingly, a single 10 percent rating is appropriate for slight knee disability under DC 5262, or painful or limited motion applying section 4.59 in combination with DC 5260, because he primarily complained of difficulty with knee flexion. A higher or separate rating is denied. Although the April 2017 VA treatment record, prior to the relevant period for the appeal, noted “give away weakness” due to increased left knee pain, tests for instability were negative at that time, as well as in December 2018 and March 2019. Moreover, the May 2019 treatment record noted improved strength despite pain. These notations both reflect that there was no actual instability and, instead, the Veteran’s complaints of weakness were due to pain, which is already contemplated by the assigned rating. Moreover, the Veteran’s complaints were attributed to left knee osteoarthritis, which is not service-connected. Similarly, there were notations of a left knee meniscal tear shown on MRI in March 2019, May 2019, and August 2019. Historically, an April 2017 record showed positive symptoms of pain on a McMurray’s test, although the Veteran denied swelling or locking. Subsequent records also noted no mechanical symptoms of meniscal impairment and negative McMurray’s tests. Therefore, there is no suggestion of surgical removal of the meniscus (or semilunar cartilage) or of meniscal injury or symptomatic meniscal impairment. Moreover, these complaints were again attributed to left knee degenerative joint disease, arthritis, or patellofemoral chondromalacia, which is not service-connected. Although the Veteran is competent to describe his observable sensations, he is not competent to state whether there is actual subluxation or lateral instability, or the underlying etiology of these complaints or his meniscal impairment. These matters require medical training or expertise to interpret the Veteran’s history and tests due to the complex nature of the interaction between bones in the lower leg (tibia and fibula) and the knee, as well as the multiple potential causes of symptoms. Therefore, the medical evidence is the most probative, and a separate rating is not appropriate on these bases under DC 5257 (recurrent subluxation or instability) or under DC 5258 or 5259 (addressing semilunar or meniscal conditions). For the right knee osteoarthritis, the Veteran also does not meet the compensable criteria under either DC 5260 or DC 5261, as he retained flexion to more than 45 degrees and extension to more than 10 degrees even during periods of increased pain or other contributing factors. Instead, he had full extension and his right knee flexion ranged from 120 degrees to full flexion. Accordingly, a minimum 10 percent rating for painful or limited motion under DC 5003 or section 4.59 in combination with DC 5260 is appropriate, because he primarily complained of difficulty with knee flexion. A higher or separate rating is not warranted. Finally, there no argument or indication of ankylosis or genu recurvatum of the Veteran’s right knee or left leg, or tibia or fibula impairment of the right leg, to warrant a separate or higher rating under DCs 5256, 5262, or 5263. There is also no argument or suggestion of subluxation or instability (DC 5257) or meniscal removal or impairment (DCs 5258 or 5259) for the right knee disability. In summary, the Veteran’s service-connected left tibia and right knee disabilities remained relatively stable throughout the appeal period. Any increases in severity were not sufficient to meet the criteria for a higher or separate rating. Therefore, the preponderance of the evidence is against a higher or separate rating, and there is no reasonable doubt to be resolved in his favor. The appeals are denied. 8. Initial rating in excess of 10 percent for chronic clinical gastritis The Veteran submitted a claim for increase for his gastritis in November 2018. Neither he nor his representative has specified why a higher rating is warranted. The Veteran’s clinical chronic gastritis is rated under DC 7399-7304, for an unlisted condition analogous to a gastric ulcer. See 38 C.F.R. §§ 4.20, 4.27, 4.114. DC 7304 for gastric ulcer provides for a maximum 60 percent rating for a severe disability, with pain that is only partially relieved by standard ulcer therapy, periodic vomiting, recurrent hematemesis or melena, with manifestations of anemia and weight loss productive of definite impairment of health. A 40 percent rating is provided for a moderately severe disability, which is less than severe but with impairment of health manifested by anemia and weight loss; or recurrent incapacitating episodes averaging 10 days or more in duration at least four or more times a year. A 20 percent rating is assigned for a moderate disability, with recurring episodes of severe symptoms two or three times a year averaging 10 days in duration; or with continuous moderate manifestations. A 10 percent rating is assigned for a mild disability, with recurring symptoms once or twice yearly. Id. The December 2018 VA examiner noted a diagnosis of clinical chronic gastritis based on the Veteran’s report of stomach problems related to medications for pain related to his service-connected knee conditions, which can damage the gastric mucosa and cause gastritis. The Veteran described current symptoms of recurrent dyspepsia (or indigestion), hyperacidity, and stomachaches that occurred several times weekly, but he denied nausea or vomiting. He reported using Maalox as needed. The examiner noted recurring episodes that are not severe that occur four or more times per year and last for less than one day per episode. The examiner also noted abdominal pain at least monthly that was pronounced and periodic. There were no incapacitating episodes, other related conditions, or work impact. For VA treatment, an October 2017 record (shortly before one year prior to his claim), noted heartburn and gastric reflux in the problem list. However, the Veteran repeatedly denied gastrointestinal symptoms on review of systems from November 2017 through February 2020. These reports specified dysphagia, abdominal pain, nausea, vomiting, hematemesis, diarrhea, constipation, melena, or hematochezia, which were all negative. A January 2018 review of systems was positive for gastrointestinal complaints, but this was noted as radiation proctitis. From January 2018 to April 2018 the Veteran underwent studies, including a lower gastrointestinal tract endoscopy, for radiation proctitis. There are also notations of sporadic rectal bleeding and colonoscopy results that showed a benign polyp. These focused on the rectum and colon, with no notations of an ulcer or gastritis. The Veteran has not described other gastrointestinal symptoms or impairment for his claim. Resolving reasonable doubt in the Veteran’s favor, the evidence reflects recurrent dyspepsia (or indigestion), heartburn or acid reflux, hyperacidity, and stomachaches. These symptoms generally are not severe, but they have occurred several times weekly throughout the appeal period, despite using Maalox at times for relief. There has also been pronounced abdominal pain at least monthly. Applying DC 7304 by analogy, these manifestations most nearly approximate the assigned 10 percent rating for mild disability. Although the Veteran has recurring symptoms more than once or twice yearly, he does not have episodes of severe symptoms with an average of 10 days in duration or continuous moderate manifestations, as required for the next higher 20 percent rating. Instead, the Veteran’s symptoms are mild overall. He has more severe abdominal pain or stomachache at least monthly, but there is no suggestion that they last for 10 days at a time. Instead, the VA examiner noted that they are periodic in nature, and the Veteran repeatedly denied any such symptoms when he sought treatment. There is also no suggestion of vomiting, hematemesis, melena, anemia, weight loss, incapacitating episodes, or definite impairment of health due to this condition. There are diagnostic codes for hypertrophic or atrophic gastritis, as well as several types of ulcers and hiatal hernia with gastric symptoms. However, as noted above, the medical evidence does not diagnose a gastric or other type of ulcer, hypertrophic or atrophic gastritis shown by gastroscope, or hernia hiatal hernia. Instead, the Veteran reported recurring symptoms that were clinically diagnosed as gastritis. Therefore, other potentially applicable rating codes will be considered. There are diseases of the digestive system, particularly within the abdomen, which, while differing in the site of pathology, produce a common disability picture characterized in the main by varying degrees of abdominal distress or pain, anemia and disturbances in nutrition. Consequently, certain coexisting diseases in this area do not lend themselves to distinct and separate disability evaluations without improper pyramiding. 38 C.F.R. § 4.113. Accordingly, ratings under DCs 7301 to 7329, inclusive, 7331, 7342, and 7345 to 7348, inclusive, will not be combined with each other. A single rating will be assigned under the DC which reflects the predominant disability picture, with elevation to the next higher rating where the severity of the overall disability warrants such elevation. 38 C.F.R. § 4.114. Under DC 7306, a marginal (gastrojejunal) ulcer may be assigned ratings from 10 to 100 percent based on similar symptoms or impairment as DC 7304. A 20 percent or higher rating also requires at least moderate disability, which is not shown. Under DC 7307, hypertrophic gastritis (identified by gastroscope) may be assigned ratings from 10 to 60 percent based on the presence of symptoms with nodular lesions, ulcerated or eroded areas, or hemorrhages. DC 7307 further notes that atrophic gastritis is a complication of a number of diseases, including pernicious anemia, which should be rated based on the underlying condition. As there is no argument or medical indication of eroded or ulcerated areas or lesions or hemorrhages, a higher rating is noted appropriate under this code. Under DC 7346, hiatal hernia will be assigned a maximum 60 percent rating where there are symptoms of pain, vomiting, material weight loss and hematemesis or melena with moderate anemia; or other symptom combinations productive of severe impairment of health. A 30 percent disability rating is assigned for persistently recurrent epigastric distress with dysphagia, pyrosis (or heartburn), and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health. A 10 percent disability rating is assigned for two or more of the symptoms for the 30 percent evaluation of less severity. Id. In this case, although the Veteran’s symptoms amount to persistently recurrent epigastric distress, they are not accompanied by substernal or arm or shoulder pain, and they do not result in considerable impairment of health. Therefore, this code would also result in a 10 percent rating, and it is not a more appropriate code. The ameliorative effect of medications may not be considered in determining the appropriate rating because medication is not listed in the applicable rating criteria. However, the evidence does not reflect a greater degree of severity without medication. As noted above, the Veteran reported having symptoms for which he took over-the-counter Maalox at times. There is no argument or suggestion of more severe or frequent symptoms or resulting impairment without such medication. In summary, the Veteran’s manifestations of his clinical gastritis have been relatively stable. A staged or higher rating is not appropriate because any increases in severity were not sufficient to more nearly approximate the criteria for the next higher rating, even when resolving doubt in his favor. The appeal is denied. 9. Special monthly compensation based on loss of use of a creative organ The Veteran contends that he has loss of use of a creative organ due to medications to treat his now service-connected mental health disability to warrant special monthly compensation (SMC). This Board decision grants service connection for erectile dysfunction, which is generally rated by analogy under 38 C.F.R. § 4.115b, Diagnostic Code 7522. A Note further states that SMC for loss of use of a creative organ should be considered. See 38 U.S.C. § 1114(k); 38 C.F.R. § 3.350(a). The December 2018 VA examiner noted that the Veteran now has complete impotence, and found that the condition began with psychiatric medications but worsened with prostate cancer therapy. Resolving reasonable doubt in the Veteran’s favor, loss of use of a creative organ due to service-connected disability is shown. Thus, reasonable doubt is resolved in the Veteran’s favor, and the appeal is granted. Bethany L. Buck Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board C. Wheatley 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.