Citation Nr: 21011853 Decision Date: 03/02/21 Archive Date: 03/02/21 DOCKET NO. 15-24 088 DATE: March 2, 2021 ORDER Entitlement to service connection for obstructive sleep apnea is granted. Entitlement to an increased rating of 30 percent, but no higher, for right shoulder strain, impingement syndrome, and tenosynovitis is granted, subject to the laws and regulations controlling the award of monetary benefits. Entitlement to an increased rating of 10 percent, but no higher, for right shoulder scar is granted, subject to the laws and regulations controlling the award of monetary benefits. Entitlement to an increased rating higher than 10 percent for right knee osteoarthritis (except for a period when a temporary 100 percent rating was in effect) is denied. Entitlement to an increased rating higher than 10 percent for left knee osteoarthritis (except for periods when temporary 100 percent ratings were in effect) is denied. Entitlement to a compensable rating for right knee scars is denied. Entitlement to a compensable rating for left knee scars is denied. Entitlement to a compensable rating for sinusitis is denied. FINDINGS OF FACT 1. The Veteran’s obstructive sleep apnea is related to military service. 2. The Veteran’s right shoulder strain, impingement syndrome, and tenosynovitis have been manifested by limitation of motion midway between the side and shoulder level, but has not more nearly approximated limitation of motion to 25 degrees from the side, ankylosis of scapulohumeral articulation, or impairment of the humerus, clavicle, or scapula. 3. The symptoms of the Veteran’s right knee osteoarthritis have not more nearly approximated limitation of flexion to 30 degrees or compensable limitation of extension. 4. The symptoms of the Veteran’s left knee osteoarthritis have not more nearly approximated limitation of flexion to 30 degrees or compensable limitation of extension. 5. The Veteran’s right shoulder scarring more nearly approximates one or two scars that are unstable or painful. 6. The Veteran’s right knee scarring does not involve the head, face, or neck; is not deep; does not affect an area exceeding at least 6 square inches (39 square centimeters); is not painful or unstable; and does not have any other disabling effects. 7. The Veteran’s left knee scarring does not involve the head, face, or neck; is not deep; does not affect an area exceeding at least 6 square inches (39 square centimeters); is not painful or unstable; and does not have any other disabling effects. 8. The Veteran has not had one to two incapacitating episodes of sinusitis requiring prolonged antibiotic treatment per year, three to six non-incapacitating episodes per year, or any history of sinus surgery. CONCLUSIONS OF LAW 1. The criteria for service connection for obstructive sleep apnea have been met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. § 3.303. 2. The criteria for a 30 percent rating, but no higher, for right shoulder strain, impingement syndrome, and tenosynovitis have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5200-5203. 3. The criteria for an increased rating higher than 10 percent for right knee osteoarthritis (except for a period when a temporary 100 percent rating was in effect) have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5003, 5256-5263. 4. The criteria for an increased rating higher than 10 percent for left knee osteoarthritis (except for periods when temporary 100 percent ratings were in effect) have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5003, 5256-5263. 5. The criteria for a 10 percent rating, but no higher, for right shoulder scar have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.21, 4.118, Diagnostic Codes 7800-7805 (in effect prior to and since August 13, 2018). 6. The criteria for a compensable rating for right knee scars have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.118, Diagnostic Codes 7800-7805 (in effect prior to and since August 13, 2018). 7. The criteria for a compensable rating for left knee scars have not been met. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.118, Diagnostic Codes 7800-7805 (in effect prior to and since August 13, 2018). 8. The criteria for a compensable rating for sinusitis have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.97, Diagnostic Code 6513. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from June 2008 to September 2012, to include service in Southwest Asia. Her awards include the Army Commendation Medal. These matters came to the Board of Veterans’ Appeals (Board) on appeal from May 2015 and November 2018 rating decisions. In the May 2015 rating decision, the agency of original jurisdiction (AOJ), inter alia, increased the rating for service-connected right shoulder disability to 20 percent, effective January 26, 2015. The AOJ increased the ratings for service-connected right knee and left knee disabilities to 10 percent, effective January 26, 2015. The AOJ also granted a noncompensable rating for right shoulder scar, effective December 24, 2014. In August 2018, the Board remanded the issues of entitlement to higher ratings for the service-connected left knee disability, right knee disability, right shoulder disability, and right shoulder scar for further evidentiary development. In the November 2018 rating decision, the AOJ denied service connection for obstructive sleep apnea, and denied entitlement to a compensable rating for sinusitis. In a September 2020 rating decision, the AOJ increased the rating for right shoulder disability to 20 percent prior to January 26, 2015 and continued the 20 percent rating thereafter. The AOJ granted a temporary 100 percent disability rating for surgical or other treatment necessitating convalescence for the right knee disability, from May 20, 2016 through June 30, 2016. The AOJ also granted a temporary 100 percent disability rating for surgical or other treatment necessitating convalescence for the left knee disability from January 15, 2016 through February 29, 2016, from August 2, 2017 through November 30, 2017, and from April 5, 2019 through May 31, 2019. As the Veteran is receiving the maximum disability rating for his service-connected right and left knee disabilities during those periods, the Board will not address the issues of entitlement to increased ratings for these disabilities during those periods. AB v. Brown, 6 Vet. App. 35, 38 (1993). As a final preliminary matter, in the August 2018 remand, the Board instructed the AOJ to obtain the Veteran’s outstanding VA treatment records, afford her VA examinations to assess the severity of her service-connected left and right knee disabilities, right shoulder disability, and right shoulder scarring, and readjudicate the issues of entitlement to increased ratings for these disabilities. Pursuant to the Board’s remand, all outstanding VA treatment records were obtained and associated with the claims file and appropriate knee, shoulder, and scar examinations were conducted in May and June 2019. Also, the issues of entitlement to increased ratings for left and right knee disabilities, right shoulder disability, and right shoulder scarring were readjudicated by the AOJ by way of a September 2020 supplemental statement of the case. Therefore, the AOJ substantially complied with the Board’s remand instructions. See Dyment v. West, 13 Vet. App. 141, 146- 47 (1999); Stegall v. West, 11 Vet. App. 268 (1998). I. Service Connection Service connection will be granted if the evidence demonstrates that current disability resulted from an injury or disease incurred in active military service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Establishing service connection generally requires competent evidence of three things: (1) current disability; (2) in-service disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Saunders v. Wilkie, 886 F.3d 1356, 1361 (Fed. Cir. 2018). Consistent with this framework, service connection is warranted for a disease first diagnosed after discharge when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Obstructive Sleep Apnea The Veteran contends that obstructive sleep apnea is due to her military service. In an alternative theory, she contends that obstructive sleep apnea is secondary to service-connected disabilities. For the following reasons, service connection for obstructive sleep apnea is warranted on a direct basis. In this case, the record demonstrates that the requirement for current disability has been met. Specifically, a November 2018 VA examination report shows a diagnosis of obstructive sleep apnea. With respect to the in-service disease requirement, service treatment records (STRs) show multiple complaints of and treatment for sleeping difficulties. In a December 2018 statement, the Veteran reported that she had sleep issues and congestion problems, with difficulty breathing, in service. She also reported that these symptoms have continued in the years since service. In a May 2020 statement, A.S. reported that during deployment, the Veteran snored loudly and always complained of being tired throughout the day. Also, A.S remembered accompanying the Veteran to sick hall for sleep medication. Here, the STRs and the competent and credible lay statements from the Veteran and A.S. are sufficient evidence to establish the second element of the Veteran’s service connection claim. With respect to the third and final requirement, in November 2018, the Veteran underwent a VA examination. The examiner who conducted the examination opined that it was most likely that the Veteran’s obstructive sleep apnea was due to the development of obesity and the occurrence of her upper airway congestion which is documented in her service treatment records. The examiner explained that there are multiple risk factors associated with the development of obstructive sleep apnea, with one of the more significant risk factors being obesity. Other risk factors include nasal congestion, smoking and use of alcohol, benzodiazepines, and narcotics. Another cause of chronic airway obstruction (in addition to congestion) that this Veteran may have been exhibiting was hypertrophy of the lingual tonsil at the base of the tongue. The examiner further explained that during the period of time from 2010 through 2015, the Veteran showed a 15.8 percent increase in her body weight. This was before her diagnosis of sleep apnea in August 2018. The examiner noted that a review of her service medical record showed that she was treated on several occasions for respiratory congestion and colds, and that congestion from upper respiratory infections could always be responsible for chronic increased upper airway resistance. For the foregoing reasons, the Board finds that the competent and credible lay statements from the Veteran and A.S., the Veteran’s STRs, current diagnosis, as well as the probative positive VA medical opinion, provide a sufficient basis to grant service connection for obstructive sleep apnea. Thus, entitlement to service connection for obstructive sleep apnea on a direct basis is warranted. II. Increased Ratings Disability ratings are determined by the application of a schedule of ratings which is based on average impairment of earning capacity. 38 U.S.C. § 1155; 38 C.F.R. § Part 4. Separate diagnostic codes identify the various disabilities. The basis of disability ratings is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life, including employment. Ratings are based upon lack of usefulness of the part or system affected, especially in self-support. 38 C.F.R. § 4.10. Where there is a question as to which of two disability ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability is resolved in favor of the veteran. 38 C.F.R. § 4.3. In considering the severity of a disability, it is essential to trace the medical history of the veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41. Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Where a claimant appeals the denial of a claim for an increased disability rating for a disability for which service connection was already in effect, the present level of disability is the primary concern, and past medical reports should not be given precedence over current medical findings. Francisco v. Brown, 7 Vet. App. 55, 57-58 (1994). Where VA's adjudication of the claim for increase is lengthy and factual findings show distinct time periods where the service-connected disability exhibits symptoms which would warrant different ratings, different or staged ratings may be assigned for such different periods of time. Hart v. Mansfield, 21 Vet. App. 505, 509-510 (2007). The relevant focus for adjudicating an increased rating claim is on the evidence concerning the state of the disability from the time period one year before the claim was filed until VA makes a final decision on the claim. Hart, 21 Vet. App. at 505. Disabilities rated on the basis of limitation of motion require VA to apply the provisions of 38 C.F.R. §§ 4.40, 4.45, pertaining to functional impairment. The United States Court of Appeals for Veterans Claims (Court) has instructed that in applying these regulations VA should obtain examinations in which the examiner determines whether the disability is manifested by weakened movement, excess fatigability, incoordination, pain, or flare-ups. Such inquiry is not to be limited to muscles or nerves. These determinations are, if feasible, to be expressed in terms of the degree of additional range-of-motion loss due to any weakened movement, excess fatigability, incoordination, flare-ups, or pain. The examiner should also determine the point, if any, at which such factors cause functional impairment. Moreover, the joints involved should be tested for pain on both active and passive motion, in weight-bearing and non weight-bearing and, if possible, with the range of the opposite undamaged joint. Correia v. McDonald, 28 Vet. App. 158 (2016); Mitchell v. Shinseki, 25 Vet. App. 32, 43-4 (2011); DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Johnston v. Brown, 10 Vet. App. 80, 84-5 (1997); 38 C.F.R. § 4.59. 1. Entitlement to a rating in excess of 20 percent for right shoulder strain, impingement syndrome, and tenosynovitis In this case, the AOJ has assigned a 20 percent rating for the Veteran's service-connected right shoulder disability under 38 C.F.R. § 4.71A, Diagnostic Code 5201, as limitation of motion of the arm. Recently, VA amended the criteria for rating the musculoskeletal system and muscle injures, effective from February 7, 2021. However, the criteria were not changed in a manner that affects the analysis in this case. See Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 76453, 76463 (Nov. 30, 2020) (to be codified at 38 C.F.R. § 4.71a, Diagnostic Code 5201). The rating criteria for evaluating disabilities of the shoulder distinguish between the major (dominant) extremity and the minor (non-dominant) extremity. See 38 C.F.R. § 4.69. The Veteran’s treatment records establish that she is right-handed. Therefore, the Board will apply the ratings and criteria for the major arm to assess the severity of her service-connected right shoulder disability. Under Diagnostic Code 5201, for the major arm, a 20 percent rating is warranted for limitation of arm motion at shoulder level (flexion and/or abduction limited to 90°); a 30 percent rating is warranted if arm motion is limited to midway between the side and shoulder level (flexion and/or abduction limited to 45°), and; a maximum 40 percent rating is warranted for limitation of arm motion to 25 degrees from the side. 38 C.F.R. § 4.71a, Code 5201. In determining whether a veteran has limitation of motion to shoulder level, it is necessary to consider reports of both forward flexion and abduction. See Mariano v. Principi, 17 Vet. App. 305, 314-16 (2003). Normal shoulder motion is defined as zero to 180 degrees of forward elevation (flexion), 0 to 180 degrees from the side of the body out to the side (abduction), and zero to 90 degrees of internal and external rotation. See 38 C.F.R. § 4.71, Plate I. A July 2012 VA examination report shows the Veteran reported right shoulder flareups that prevented her from lifting. Right shoulder flexion and abduction were both to 180 degrees with pain at that point. There was no additional limitation in range of motion or functional loss upon repetitive use testing. There was localized tenderness and guarding. The Veteran’s muscle strength was normal. There was no evidence of atrophy or ankylosis. There was no shoulder instability, dislocation, or labral pathology suspected. There was no clavicle, scapula, acromioclavicular (AC) joint, or sternoclavicular joint condition. A July 2014 VA examination report shows that the Veteran denied flareups of right shoulder symptoms. Right shoulder flexion and abduction were both to 100 degrees, with pain at 90 degrees. There was no additional loss of range of motion upon repetitive use testing. There was less movement than normal and pain on movement. The Veteran's muscle strength had active movement against some resistance. There was no evidence of atrophy or ankylosis. There was no shoulder instability, dislocation, or labral pathology suspected. There was no clavicle, scapula, acromioclavicular (AC) joint, or sternoclavicular joint condition. A February 2015 VA examination report shows that the Veteran reported that she underwent shoulder surgery in September 2014. She reported flareups of right shoulder symptoms that were worse with prolonged stationary positions, repetitive overhead activities, activities involving vibration (such as mowing the lawn), and repetitive grasping with the right hand. The Veteran noted that her normal activities were limited by 80 percent during a flareup. Right shoulder flexion and abduction were both to 80 degrees with pain. There was no additional functional loss or range of motion loss upon repetitive use testing. There was less movement than normal and pain on movement. There was evidence of pain with weight bearing and global shoulder tenderness. There was no evidence of crepitus. The Veteran’s muscle strength was normal. There was no evidence of atrophy or ankylosis. There was no shoulder instability, dislocation, or labral pathology suspected. There was no clavicle, scapula, acromioclavicular (AC) joint, or sternoclavicular joint condition. There was no flail shoulder or non-union or fibrous union of the humerus. There was no malunion of the humerus. A June 2019 VA examination report shows that the Veteran reported right shoulder flareups of increased pain. She reported difficulties with overhead reaching and lifting, reaching behind the back, lifting and carrying heavy objects, and pain. Right shoulder flexion and abduction were both to 125 degrees with pain. There was no additional functional loss or range of motion loss upon repetitive use testing. There was less movement than normal and pain on movement. There was evidence of pain with weight bearing and crepitus. The examiner indicated that there was no additional loss in range of motion during a flareup. The Veteran’s muscle strength had active movement against some resistance. There was no evidence of atrophy or ankylosis. There was no shoulder instability, dislocation, or labral pathology suspected. There was no clavicle, scapula, acromioclavicular (AC) joint, or sternoclavicular joint condition. There was no flail shoulder or non-union or fibrous union of the humerus. There was no malunion of the humerus. The examiner who conducted the June 2019 examination noted that there was objective evidence of pain when the shoulder was used in both weight-bearing and non weight-bearing, that the passive ranges of shoulder motion were the same as the active ranges of motion, and that pain associated with passive motion was the same as the pain associated with active motion. In light of the above evidence, and resolving reasonable doubt in favor of the Veteran, the Board finds that a 30 percent rating for the service-connected right shoulder disability (which contemplates limitation of arm motion to midway between the side and shoulder level) is warranted during the entire claim period. The Board must consider additional functional loss due to symptoms such as pain, repetitive motion, and flare-ups. 38 C.F.R. §§ 4.40, 4.45. In this case, the July 2012, July 2014, February 2015, and June 2019 VA examination reports show that the Veteran has consistently reported severe pain and limited range of motion in her right shoulder. She has reported weakness and increased pain after minimal use of her shoulder. The examinations have further shown that the Veteran experiences significant flare-ups, described as difficulty with lifting, overhead activities, reaching, and carrying heavy objects. The Veteran noted that her normal activities are limited by 80 percent during a flare-up. The evidence of record further demonstrates that the Veteran was not examined during a flare-up. Overall, the Veteran has provided competent and credible reports of painful motion of the shoulder and significant additional functional impairment of her shoulder during flare ups. Jandreau v. Nicholson, 492 F.3d 1372, 1377, n. 4 (Fed. Cir. 2007). The Veteran is not, however, entitled to a rating higher than 30 percent at any time during the claim period. Specifically, the VA examinations conducted during the claim period do not indicate that her right shoulder pain is so disabling to result in limitation of right arm motion to 25 degrees from the side. The Veteran is competent to report the symptoms associated with her service-connected right shoulder disability and the extent of her impairment during flare ups of symptoms and following repetitive use, and the Board has no reason to challenge the credibility of her contentions. See Jandreau, 492 F.3d at 1377; Buchanan, 451 F.3d at 1337. Regardless of the competent and credible reports of flare ups, pain, and other functional impairments, and despite the fact that painful motion has been documented, the preponderance of the evidence nonetheless supports the conclusion that the Veteran’s shoulder symptoms have most closely approximated the criteria for at most a 30 percent rating for limitation of arm motion under DC 5201 during the entire claim period. Specifically, the above evidence reflects that the flare ups and other functional impairments have not been so severe, frequent and/or prolonged to warrant the next higher percent rating at any time during the claim period. A preponderance of the evidence shows that even considering pain, flare ups, and other functional factors, the Veteran’s shoulder symptoms have not been shown to have been so disabling to actually or effectively result in limitation of arm motion more nearly approximating 25 degrees from the side, which is the requirement for a 40 percent rating for limitation of arm motion under DC 5201. Moreover, the Board has examined all other diagnostic code provisions pertinent to the shoulder for the possible assignment of a greater disability rating. The Board, however, finds that alternative Diagnostic Codes are not applicable. Specifically, the July 2012, July 2014, February 2015, and June 2019 VA examiners found no evidence of ankylosis of the scapulohumeral articulation. Thus, the assignment of a rating under Diagnostic Code 5200 is not warranted. There was also no evidence of impairment of the humerus or clavicle or scapula, warranting higher and/or separate ratings under Diagnostic Codes 5202 or 5203. For the foregoing reasons, the Board concludes that a 30 percent rating, but no higher, is warranted for the service-connected right shoulder strain, impingement syndrome, and tenosynovitis for the entire claim period. 2. Entitlement to ratings in excess of 10 percent for left and right knee osteoarthritis (except for periods when temporary 100 percent ratings were in effect) In this case, the Veteran exhibits arthritis and painful, limited motion of her knees. Therefore, the AOJ assigned 10 percent ratings for her service-connected right and left knee disabilities under 38 C.F.R. § 4.71A, Diagnostic Codes 5003-5260. Hyphenated diagnostic codes are used when a rating under one code requires use of an additional diagnostic code to identify the basis for the rating assigned. 38 C.F.R. § 4.27. Here, the use of DCs 5003-5260 reflects that the Veteran’s knee disabilities are partially described as degenerative arthritis under DC 5003 and that the ratings assigned are based on limitation of knee flexion under DC 5260. Recently, VA amended the criteria for rating the musculoskeletal system and muscle injures, effective February 7, 2021. However, the criteria were not changed in a manner that affects the analysis in this case. See Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 76453, 76463 (Nov. 30, 2020) (to be codified at 38 C.F.R. § 4.71a, Diagnostic Code 5003). Degenerative arthritis that is established by x-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic code for the specific joint or joints involved. 38 C.F.R. § 4.71, Diagnostic Codes 5003. If the limitation of motion is noncompensable, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under Diagnostic Code 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. In the absence of limitation of motion, a 20 percent evaluation is merited for x-ray evidence of involvement of two or more major joints or two or more minor joint groups, with occasional incapacitating exacerbations. A 10 percent evaluation is merited for x-ray evidence of involvement of two or more major joints or two or more minor joint groups. 38 C.F.R. § 4.71A, Diagnostic Code 5003. When there is limitation of motion of the specific joint or joints that is compensable (10 percent or higher) under the appropriate diagnostic code, the compensable limitation of motion should be rated under the appropriate diagnostic code for the specific joint or joints involved. 38 C.F.R. § 4.71A. Ratings for limitation of flexion of a knee are assigned as follows: flexion limited to 60 degrees is noncompensable; flexion limited to 45 degrees is 10 percent disabling; flexion limited to 30 degrees is 20 percent disabling; and flexion limited to 15 degrees is 30 percent disabling. 38 C.F.R. § 4.71A, Diagnostic Code 5260. VA’s General Counsel has held that separate ratings can be provided for limitation of knee extension and flexion. VAOPGCPREC 9-2004; 69 Fed. Reg. 59,990 (2004). Ratings for limitation of knee extension are assigned as follows: extension limited to 10 degrees is 10 percent disabling; extension limited to 15 degrees is 20 percent disabling; extension limited to 20 degrees is 30 percent disabling; extension limited to 30 degrees is 40 percent disabling; and extension limited to 45 degrees is 50 percent disabling. 38 C.F.R. § 4.71A, Diagnostic Code 5261. Normal range of motion of a knee is from zero degrees of extension to 140 degrees of flexion. 38 C.F.R. § 4.71, Plate II. For the following reasons, the Board finds that ratings in excess of 10 percent for the Veteran’s service-connected left and right knee disabilities are not warranted. During a February 2015 VA examination, left knee flexion was to 100 degrees with pain, and extension to zero degrees. Right knee flexion was to 110 degrees with pain, and extension was to zero degrees. A May 2019 VA examination report shows that left knee flexion was to 40 degrees, and extension was to zero degrees. Right knee flexion was to 120 degrees, and extension was to zero degrees. A June 2019 VA examination report shows that both left and right knee flexion were to 100 degrees with pain, and extension was to zero degrees. Based on these findings, and without consideration of functional impairment, ratings in excess of 10 percent for the service-connected left and right knee disabilities under Diagnostic Code 5260 are not warranted. The Board also finds that the evidence is against the assignment of increased ratings based on functional loss. The Veteran has reported difficulty doing lawn work, standing, climbing stairs/ladders, skiing, skating, jogging, running, hiking, playing softball, and driving stick shift vehicles due to her knee disability. She also noted knee stiffness, swelling, and pain. Repeated examinations, however, have shown that the level of additional loss of motion based on functional loss or flare-ups of pain does not rise to the level of higher ratings for limitation of flexion or limitation of extension under Diagnostic Codes 5260 or 5261. Specifically, the February 2015 VA examiner found no additional limitation of motion of the knees after repetitive use. At the February 2015 VA examination, the Veteran reported that knee flareups were affected by repetitive high impact activities and that her activities were limited by 30-40 percent during a flareup. The VA examiner found no additional loss of function or range of motion upon repetitive use. There was no objective evidence of localized tenderness or pain on palpation. There was objective evidence of pain with weight bearing. At the May 2019 VA examination, the Veteran reported being unable to run, negotiate stairs, squat, or stand or walk for long periods. She denied having flare-ups of the knees. The VA examiner found no additional loss of function or range of motion upon repetitive use. There was objective evidence of localized tenderness or pain on palpation, but there was no evidence of pain with weight bearing of the bilateral knees. The examiner found no objective evidence of pain on passive range of motion and non-weight bearing testing. At the June 2019 VA examination, the Veteran reported difficulty bending her knees and utilizing stairs. She reported knee flareups, described as pain which was radiating and achy. The VA examiner found no additional loss of function or range of motion upon repetitive use. There was no objective evidence of localized tenderness or pain on palpation of the knees. There was evidence of pain with weight bearing of the bilateral knees. There was evidence of pain on passive range of motion and non-weight bearing testing. The examiner indicated that there was no additional loss in range of motion during a flareup. Thus, although the Veteran reported flare-ups of her knees, there was no indication that the flare-ups were of such severity so as to result in loss of motion that would more nearly approximate the criteria for the next higher rating. Cf. Sharp v. Shulkin, 29 Vet. App. 26, 33 (2017) (finding orthopedic examination inadequate where flare-ups were not properly addressed). The Veteran is competent to report the symptoms associated with her service-connected knee disabilities and the extent of her impairment during flare ups of symptoms and following repetitive use, and the Board has no reason to challenge the credibility of her contentions. See Jandreau, 492 F.3d at 1377; Buchanan, 451 F.3d at 1337. Regardless of the competent and credible reports of flare ups, pain, and other functional impairments, and despite the fact that painful motion has been documented, the preponderance of the evidence nonetheless supports the conclusion that the Veteran’s knee symptoms have most closely approximated the criteria for at most single 10 percent ratings for limitation of knee flexion under DC 5260 during the entire claim period. Specifically, the above evidence reflects that the flare ups and other functional impairments have not been so severe, frequent and/or prolonged to warrant the next higher percent ratings at any time during the claim period. A preponderance of the evidence shows that even considering pain, flare ups, and other functional factors, the Veteran’s knee symptoms have not been shown to be so disabling to actually or effectively result in limitation of knee flexion more nearly approximating 30 degrees or limitation of knee extension more nearly approximating 10 degrees, which are the requirements for a 20 percent rating for limitation of knee flexion under DC 5260 and a compensable (10 percent) rating for limitation of knee extension under DC 5261, respectively. The Board has also considered whether higher ratings can be assigned under an alternative diagnostic code, however, the Board finds that no other diagnostic codes are applicable. Specifically, a rating is not warranted under Diagnostic Code 5252 because repeated VA examinations have demonstrated no evidence of ankylosis. Additionally, there is no evidence to suggest that the Veteran meets the criteria for compensable ratings for knee instability, cartilage dislocation, cartilage removal, tibia or fibula impairment (to include shin splints), or genu recurvatum under Diagnostic Codes, 5257, 5258, 5259, 5262, and 5263. In sum, as the evidence reflects that the symptoms of the Veteran's service-connected left and right knee disabilities do not more nearly approximate the criteria for a rating higher than 10 percent, the benefit of the doubt doctrine is not for application and ratings in excess of 10 percent for left and right knee osteoarthritis are not warranted. 38 U.S.C. § 5107(b); 38 C.F.R. § 4.3. 3. Entitlement to a compensable rating for a right shoulder scar The Veteran's right shoulder scar is currently rated as noncompensable under 38 C.F.R. § 4.118, Diagnostic Code 7805. The diagnostic codes 7801-7805 (for scars) were revised effective October 23, 2008. The regulatory changes pertaining to the rating of scars apply only to applications received by VA on or after October 23, 2008, or if the Veteran requests review under the clarified criteria. See 73 Fed. Reg. 5470 (Sept. 23, 2008). As the Veteran’s claim was received after that date, the revised criteria are applicable. Recently, VA again amended the criteria for rating the skin that were enacted effective August 13, 2018, but the criteria were not changed in a manner that affects the analysis in this case. See Schedule for Rating Disabilities; Skin, 83 Fed. Reg. 32592 (July 13, 2018). Diagnostic code 7805 instructs to evaluate the effects of scars under Diagnostic Codes 7800, 7801, 7802, and 7804. Diagnostic Code 7800 relates to scars of the head, face, or neck; Diagnostic Code 7801 relates to scars not of the head, face, or neck that are deep and nonlinear; and Diagnostic Code 7802 relates to scars that are superficial and nonlinear. Diagnostic Code 7804 provides a 10 percent rating for one or two scars that are unstable and painful on examination. A 20 percent rating applies to three or four scars that are unstable or painful. A 30 percent rating is for five or more scars that are unstable or painful. Note (1) to Diagnostic Code 7804 provides that an unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. Note (2) provides that if one or more scars are both unstable and painful, add 10 percent to the evaluation that is based on the total number of unstable or painful scars. Note (3) provides that scars evaluated under Diagnostic Codes 7800, 7801, 7802, or 7805 may also receive an evaluation under this Diagnostic Code when applicable. 38 C.F.R. § 4.118. In a December 2018 statement, the Veteran reported that her right shoulder scar was painful. She noted that the most troubled scar was the one in the front. A June 2019 VA examination report indicates that the Veteran exhibited two scars on the anterior and posterior shoulder, which measured 1 centimeter long and 0.025 centimeters wide. These scars were not painful or unstable. In an October 2020 statement, the Veteran asserted that her right shoulder scar, especially the anterior right upper extremity, was painful. The Board finds that a 10 percent rating is warranted under Diagnostic Code 7804. In multiple statements, the Veteran has reported a painful right shoulder scar, with the anterior scar being the most painful. The Veteran, as a layperson, is competent to report on matters observed or within her personal knowledge, to include symptoms such as scar pain. See 38 C.F.R. § 3.159 (a)(2); Jandreau, 492 F.3d at 1376-77. Therefore, the evidence is at least evenly balanced as to whether the Veteran's right shoulder scar more closely approximates one or two scars that are painful or unstable under Diagnostic Code 7804. As the reasonable doubt created by this relative equipoise in the evidence must be resolved in favor of the Veteran, a 10 percent rating for right shoulder scar under Diagnostic Code 7804 is warranted during the entire claim period. The Board also finds, however, that a rating higher than 10 percent is not warranted at any time during the claim period. Specifically, the evidence of record does not reflect, and the Veteran does not contend, that her right shoulder scar more nearly approximates 3 or more scars that are unstable or painful, thus a rating higher than 10 percent for the Veteran’s right shoulder scars is not warranted under DC 7804. There is also no evidence or argument that there are symptoms that more nearly approximate the criteria for a higher rating under any other potentially applicable diagnostic code. The Veteran’s scarring does not involve the head, face, or neck so as to warrant consideration under Diagnostic Code 7800. The scar area is not at least 6 square inches (39 square centimeters) so as to warrant a rating under Diagnostic Code 7801. Also, the scar area is not 144 square inches (929 square centimeters) or greater. Thus a rating under Diagnostic Code 7802 is also not warranted. Overall, the Board finds that as the Veteran’s right shoulder scars more nearly approximate 2 painful scars, entitlement to a 10 percent rating, but no higher, under Diagnostic Code 7804 is warranted during the entire claim period. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. 4. Entitlement to compensable ratings for right and left knee scars The Veteran’s right and left knee scars are currently rated as noncompensable under Diagnostic Code 7805. As noted above, Diagnostic Code 7805 instructs to evaluate scars under Diagnostic Codes 7800, 7801, 7802, and 7804. For the following reasons, the Board finds that entitlement to compensable ratings for right and left knee scars are not warranted. At the June 2019 VA examination, the Veteran exhibited three right knee scars measuring 1.5 centimeters long and 0.5 centimeters wide, 1.5 centimeters long and 0.6 centimeters wide, and 1.5 centimeters long and 0.8 centimeters wide. She exhibited three left knee scars measuring 1.5 centimeters long and 1.2 centimeters wide, 1.5 centimeters long and 0.8 centimeters wide, and 1.5 centimeters long and 0.6 centimeters wide. The bilateral knee scars did not involve the head, face, or neck to warrant consideration under Diagnostic Code 7800. The bilateral knee scar areas were not at least 6 square inches (39 square centimeters) to warrant a rating under Diagnostic Code 7801. The bilateral knee scar areas were not 144 square inches (929 square centimeters) or greater. Thus, a rating under Diagnostic Code 7802 is not warranted. The bilateral knee scars were also not painful or unstable, warranting a compensable rating under Diagnostic Code 7804. Further, the Veteran’s bilateral knee scars were not shown to have any disabling effects. Therefore, compensable ratings for right and left knee scars are not warranted at any time during the claim period. See 38 U.S.C. § 5107 (b); 38 C.F.R. § 4.3. 5. Entitlement to a compensable rating for sinusitis The Veteran’s sinusitis has been rated under 38 C.F.R. § 4.97, Diagnostic Code 6513, as sinusitis, maxillary, chronic. Under Diagnostic Code 6513, a 10 percent rating is assigned where one or two incapacitating episodes of sinusitis per year require prolonged (lasting 4 to 6 weeks) antibiotic treatment or where there are three to six non-incapacitating episodes per year of sinusitis characterized by headaches, pain, and purulent discharge or crusting. A 30 percent rating is assigned when there are three or more incapacitating episodes per year of sinusitis requiring prolonged (lasting four to six weeks) antibiotic treatment, or; more than six non-incapacitating episodes per year of sinusitis characterized by headaches, pain, and purulent discharge or crusting. The next and highest scheduler rating of 50 percent is assigned following radical surgery with chronic osteomyelitis, or; near constant sinusitis characterized by headaches, pain and tenderness of affected sinus, and purulent discharge or crusting after repeated surgeries. 38 C.F.R. § 4.97, Diagnostic Code 6513. A September 2018 VA examination report shows that the Veteran reported that she had episodes of sinusitis and non-service connected rhinitis that occurred every other month during certain times of the year when her rhinitis was worst. There were no complaints of headaches or pain due to chronic sinusitis. The Veteran was not on any current treatment or medications. There were no non-incapacitating episodes or incapacitating episodes in the past 12 months. The Veteran had not had sinus surgery. A January 2020 VA examination report indicates that the Veteran exhibited chronic sinusitis symptoms of headaches, pain, tenderness, nasal drip, and dry cough. The Veteran had not had sinus surgery. A March 2020 addendum to the January 2020 VA examination report shows that the Veteran had one non-incapacitating episode in the past 12 months on June 11, 2019. She was prescribed antibiotics for one week by primary care physician for suspected pneumonia. The Veteran also had an upper respiratory infection/sinusitis at that time as well. The Veteran’s symptoms documented as resolved after one course of antibiotics. There were no incapacitating episodes in the past 12 months. In a May 2020 statement, the Veteran reported a consistent pattern of treatment for nasal congestion and other symptoms of chronic sinusitis and non-service connected allergic rhinitis. She indicated that even with medication, she continued to suffer symptoms, including frequent drainage, forehead and sinus pain, and headaches. She noted symptoms of stuffy nose, and congestion on both sides at night, crusting in the mornings, and runny nose throughout the day. The Veteran noted that surgery had been recommended. Based on the above, the Veteran’s symptoms are contemplated by a non-compensable rating. There is no evidence to suggest that the Veteran experiences incapacitating episodes of sinusitis requiring medication. Moreover, the Veteran has not experienced three to six non-incapacitating episodes per year of sinusitis characterized by headaches, pain, and purulent discharge or crusting. As such, the evidence does not meet the criteria required for a compensable (10 percent) rating and a compensable rating for sinusitis is not warranted at any time during the claim period. (CONTINUED ON NEXT PAGE) 6. Additional Considerations As a final point, the Board notes that in conjunction with the increased rating claims decided herein, the Veteran has not raised any other related issues, and no other such issues have been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 369-70 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). Brian J. Elwood Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board R. Walker, Associate 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.