Citation Nr: 21013946 Decision Date: 03/10/21 Archive Date: 03/10/21 DOCKET NO. 12-27 454A DATE: March 10, 2021 ORDER Entitlement to a rating in excess of 10 percent for residuals of a partial right knee replacement, exclusive of periods of temporary total rating (TTR), for the appeal period prior to February 11, 2009 is denied. Entitlement to a rating of 30 percent, but no higher, for residuals of a partial right knee replacement, exclusive of periods of TTR, for the appeal period beginning on February 11, 2009 is granted. Entitlement to an increased rating for right knee, mild instability rated as 10 percent disabling from August 28, 2018 is denied. Entitlement to a rating in excess of 10 percent for residuals of left inguinal hernia repair, exclusive of periods of TTR, is denied. Entitlement to a compensable rating for residual scar, post-operative hernia repair, prior to May 3, 2019, and in excess of 10 percent thereafter, is denied. Entitlement to an effective date prior to November 30, 2017 of a TTR for residuals of left inguinal hernia repair is denied. FINDINGS OF FACT 1. For the appeal period prior to February 11, 2009, the Veteran’s residuals of a partial right knee replacement is manifest by objective evidence of slight instability with pain on motion and flexion limited to 140 degrees, at worst, even in contemplation of functional loss due to symptoms such as pain, fatigue, weakness, lack of endurance, or incoordination, or as a result of repetitive motion and/or flare-ups; without ankylosis, dislocation of semilunar cartilage with impairments such as swelling and joint locking, impairment of the tibia and fibula, or genu recurvatum. 2. For the appeal period beginning on February 11, 2009, the Veteran’s residuals of a partial knee replacement was manifested as intermediate chronic knee replacement residuals. 3. For the appeal period beginning on August 28, 2018, the Veteran’s right knee instability was manifested by no more than slight instability. 4. Throughout the appeal period, the Veteran did not have a current hernia. 5. For the appeal period prior to May 3, 2019, the Veteran’s surgical scar was not painful, unstable, or totalling at least 39 square centimeters. 6. For the appeal period beginning on May 3, 2019, the Veteran did not have three painful scars, and her scars were not unstable and did not total at least 39 square centimeters. 7. On November 30, 2017, the Veteran was hospitalized for surgery. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 10 percent for residuals of a partial right knee replacement for the appeal period prior to February 11, 2009 have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1—4.14, 4.40, 4.59, 4.71a, Diagnostic Code 5257. 2. The criteria for a rating of 30 percent disabling for residuals of a partial right knee replacement for the appeal period beginning on February 11, 2009 are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1—4.14, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5055. 3. The criteria for a rating in excess of 10 percent for right knee instability prior to February 11, 2009 are not met. 38 U.S.C. §§ 1155, 5017; 38 C.F.R. §§ 3.102, 4.1—4.14, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5257. 4. The criteria for a rating in excess of 10 percent for residuals of left inguinal hernia repair have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1—4.14, 4.114, Diagnostic Code 7338. 5. The criteria for a compensable rating for a painful scar associated with the residuals of a left inguinal hernia repair prior to May 3, 2019, and a rating in excess of 10 percent thereafter, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1—4.14, 4.118, Diagnostic Codes 7801-7805. 6. The criteria for an effective date prior to November 30, 2017 for a temporary total evaluation have not been met. 38 U.S.C. §§ 1155, 5107, 5110; 38 C.F.R. §§ 3.102, 4.29. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Air Force from January 1991 to September 1994. Her decorations include the National Defense Service Medal. This matter comes to the Board of Veterans’ Appeals (Board) on appeal from rating decisions issued by a Department of Veterans Affairs (VA) Regional Office (RO). A January 2007 rating decision granted a TTR from April 20, 2005 to August 1, 2005, and assigned a 10 percent thereafter under Diagnostic Code 5257, for instability. A March 2007 rating decision assigned a TTR from November 8, 2006 to January 1, 2007, and assigned a 10 percent thereafter. In a July 2009 rating decision, the RO granted a TTR from February 11, 2009 to July 1, 2009. The rating decision also recharacterized the Veteran’s right knee disability and assigned a 10 percent disability rating based on limitation of motion under Diagnostic Code 5260 subsequent the period of TTR. An August 2018 rating decision granted a separate 10 percent disability rating under Diagnostic Code 5257 for instability, effective August 28, 2018. The Veteran appealed the assigned rating for her right knee instability in an October 2018 notice of disagreement. As the Veteran’s increased rating claim for instability is part and parcel of her increased claim for a right knee disability, the Board will consider both issues. The Veteran’s knee claim was previously before the Board in June 2015 and April 2019, when it was remanded to the agency of original jurisdiction (AOJ) for additional development. The June 2015 Board remand instructed that updated VA treatment records be obtained, that the Veteran be given the opportunity to identify any relevant private treatment records and that an updated VA examination be conducted. Updated VA treatment records have been associated with the record, the Veteran was asked to complete an appropriate release to allow VA to obtain relevant private treatment records in a November 2017 letter and an VA examination was conducted in August 2018. The April 2019 Board remand instructed that releases for specific private treatment records be obtained and that the Veteran’s Social Security Administration records be obtained. The Veteran’s Social Security Administration records have been associated with the record and an April 2019 letter to the Veteran requested that she complete an appropriate release form to allow VA to obtain private treatment records. The Veteran did not respond to the April 2019 letter. After taking further action, the Agency of Original Jurisdiction (AOJ) confirmed and continued the prior rating and returned the case to the Board. The Board determines that there has been substantial compliance with its previous remands. Stegall v. West, 11 Vet. App. 268, 271 (1998). An August 2018 rating decision granted a separate 10 percent rating for right knee, mild instability, effective August 28, 2018. An October 2019 rating decision granted a 10 percent rating for a painful scar, post-operative hernia, effective May 3, 2019. However, a higher rating is available for knee instability and scars. The Veteran is presumed to seek the maximum available benefit for a disability. As such, these claims are still considered to be on appeal. See AB v. Brown, 6 Vet. App. 35, 38 (1993). The Veteran testified in a Decision Review Officer (DRO) hearing in July 2009. A transcript is of record. Increased Rating Disability evaluations are determined by evaluating the extent to which a Veteran’s service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing his symptomatology with the criteria set forth in the Schedule for Rating Disabilities (Rating Schedule). 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10. Where there is a question as to which of two evaluations shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that evaluation. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Reasonable doubt as to the degree of disability will be resolved in the Veteran’s favor. 38 C.F.R. § 4.3. It is permissible to switch diagnostic codes to reflect more accurately a claimant’s current symptoms. See Read v. Shinseki, 651 F.3d 1296, 1302 (Fed. Cir. 2011). Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Although a rating specialist is directed to review the recorded history of a disability in order to make a more accurate evaluation, see 38 C.F.R. § 4.2, the regulations do not give past medical reports precedence over current findings. Francisco v. Brown, 7 Vet. App. 55 (1994). Pertinent regulations do not require that all cases show all findings specified by the Rating Schedule, but that findings sufficiently characteristic to identify the disease and the resulting disability and above all, coordination of rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21. Therefore, the Board has considered the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the Veteran, as well as the entire history of the Veteran’s disability in reaching its decision. Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). The Board notes that effective February 7, 2021, the criteria for schedule of ratings for the musculoskeletal system was revised. See 86 Fed. Reg. 8142 (Feb. 4, 2021) (codified at 38 C.F.R. pt. 4). In the instant case, the claims file is absent any medical evidence submitted or associated with the claims file subsequent to the revised rating effective date of February 7, 2021. As of February 7, 2021, under the amended criteria, recurrent subluxation or instability warrants a 30 percent rating for unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribes both an assistive device (e.g., cane(s), crutch(es), walker) and bracing for ambulation. A 20 percent rating is warranted wither one of the following: (a) Sprain, incomplete ligament tear, or repaired complete ligament tear causing persistent instability, and a medical provider prescribes a brace and/or assistive device (e.g., cane(s), crutch(es), walker) for ambulation, or (b) Unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribes either an assistive device (e.g., cane(s), crutch(es), walker) or bracing for ambulation. A 10 percent rating is warranted for sprain, incomplete ligament tear, or complete ligament tear (repaired, unrepaired, or failed repair) causing persistent instability, without a prescription from a medical provider for an assistive device (e.g., cane(s), crutch(es), walker) or bracing for ambulation. Additionally, under the amended criteria, patellar instability warrants a 30 percent disability rating for a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for a brace and either a cane or a walker. A 20 percent rating is warranted for a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for a brace, cane, or walker. A 10 percent disability rating is warranted for a diagnosed condition involving the patellofemoral complex with recurrent instability (with or without history of surgical repair) that does not require a prescription from a medical provider for a brace, cane, or walker. Note (1): For patellar instability, the patellofemoral complex consists of the quadriceps tendon, the patella, and the patellar tendon. Note (2): A surgical procedure that does not involve repair of one or more patellofemoral components that contribute to the underlying instability shall not qualify as surgical repair for patellar instability (including, but not limited to, arthroscopy to remove loose bodies and joint aspiration). The Board also notes that the February 7, 2021 musculoskeletal amendments presented no changes to the rating criteria for Diagnostic Codes 5260 and 5261. In other words, Diagnostic Codes 5260 and 5261 are the same both prior to and after February 7, 2021. Diagnostic Code 5055 was revised to shorten the temporary total rating period after a total replacement surgery; the diagnostic criteria are otherwise unchanged. Compare 38 C.F.R. § 4.71a (December 29, 2020) with 38 C.F.R. § 4.71a (February 7, 2021). In general, all disabilities, including those arising from a single disease entity, are rated separately, and all disability ratings are then combined in accordance with 38 C.F.R. § 4.25. Pyramiding, the evaluation of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when rating a Veteran’s service-connected disability. 38 C.F.R. § 4.14. It is possible for a Veteran to have separate and distinct manifestations from the same injury which would permit rating under several diagnostic codes, however, the critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the conditions is duplicative or overlapping with the symptomatology of the other condition. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). Separate ratings can be assigned for separate periods based on the facts found - a practice known as “staged” ratings. Francisco v. Brown, 7 Vet. App. 55, 58 (1994); Hart v. Mansfield, 21 Vet. App. 505 (2007). Staged ratings are appropriate whenever the factual findings show distinct periods where the service-connected disability exhibits symptoms that would warrant different ratings. Id. The basis of disability evaluation 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. 38 C.F.R. § 4.10. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no obligation to discuss, in detail, the extensive evidence of record. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (holding that the Board must review the entire record but does not have to discuss each piece of evidence). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board’s analysis will focus specifically on what the evidence shows, or fails to show, as it relates to the Veteran’s claims. When evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use and, therefore, not be reflected on range-of-motion testing. 38 C.F.R. § 4.45 requires consideration also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Nonetheless, even when the background factors listed in § 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a (musculoskeletal system) or § 4.73 (muscle injury); a separate or higher rating under § 4.40 or 4.45 itself is not appropriate. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016) (“[I]t is clear that the guidance of § 4.40 is intended to be used in understanding the nature of the veteran’s disability, after which a rating is determined based on the § 4.71a [or 4.73] criteria.”).] Separate ratings can be assigned for knee disabilities when none of the symptomatology overlaps and the separate rating is based on additional disabling symptomatology; this includes separate ratings based on limitation of flexion (Diagnostic Code 5260), limitation of extension (Diagnostic Code 5261), lateral instability or recurrent subluxation (Diagnostic Code 5257), and meniscal conditions (Diagnostic Codes 5258, 5259). See VAOPGCPREC 23-97, 62 Fed. Reg. 63,603 (1997); VAOPGCPREC 9-98, 63 Fed. Reg. 56,703 (1998); VAOPGCPREC 9-2004; 69 Fed. Reg. 59,988 (2004); Lyles v. Shulkin, 29 Vet. App. 107 (2017). The normal range of motion of the knee is from zero degrees extension to 140 degrees flexion. 38 C.F.R. § 4.71, Plate II. Limitation of flexion warrants 10, 20, and 30 percent ratings when limitation is to 45 degrees, 30 degrees, and 15 degrees, respectively. 38 C.F.R. § 4.71a, Diagnostic Code 5260. Limitation of extension warrants 10, 20, 30, 40, and 50 percent ratings when limitation is to 10 degrees, 15 degrees, 20 degrees, 30 degrees, and 45 degrees, respectively. 38 C.F.R. § 4.71a, Diagnostic Code 5261. A 10 percent rating can also be assigned for the knee joint if there is painful motion without compensable limitation of motion. 38 C.F.R. §§ 4.59, 4.71a, Diagnostic Code 5003; see also Burton v. Shinseki, 25 Vet. App. 1 (2011) (holding that the applicability of 38 C.F.R. § 4.59 is not limited to arthritis claims). Recurrent subluxation and lateral instability of the knee warrants a 10, 20, or 30 percent rating if slight, moderate, or severe, respectively. 38 C.F.R. § 4.71a, Diagnostic Code 5257. Ratings can also be assigned when the knee disability affects the meniscus, with a 20 percent rating for dislocated semilunar cartilage with frequent episodes of “locking,” pain, and effusion into the joint and a 10 percent rating for removal of semilunar cartilage (e.g., meniscectomy) and current residual symptoms. 38 C.F.R. § 4.71a, Diagnostic Codes 5258, 5259. Ratings can also be assigned for impairment of the tibia or fibula, genu recurvatum, or ankylosis of the knee. 38 C.F.R. § 4.71a, Diagnostic Codes 5256, 5262, 5263. Ankylosis is stiffening or fixation of a joint as the result of a disease process, with fibrous or bony union across the joint. Dinsay v. Brown, 9 Vet. App. 79, 81 (1996). Ankylosis is also defined as “immobility and consolidation of a joint due to disease, injury, or surgical procedure.” Dorland’s Illustrated Medical Dictionary 93 (30th ed. 2003). When there is an approximate balance of positive and negative evidence as to any issue material to the determination of a matter, VA will resolve reasonable doubt in favor of the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 1. Entitlement to a rating in excess of 10 percent for a residuals of a partial right knee replacement is denied. 2. Entitlement to an increased rating for right knee, mild instability, rated as 10 percent disabling from August 28, 2018. The Veteran contends that she is entitled to a higher rating for her right knee disability. Factual Background In a September 2004 letter from a private examiner, the examiner stated the Veteran had increased right knee pain and low-level effusion. She was markedly tender at the medial joint line. Valgus stress caused slight discomfort and she reported she has some ecchymosis from falling directly. The examiner suspected that her meniscus was torn and that may have been the reason she fell. Her X-ray images were unremarkable with no significant degenerative changes, but there were some mild changes present. The Veteran underwent an arthroscopic loose body removal and microfracture technique in April 2005. The examiner noted the Veteran underwent a previous knee scope in the military in the early 1990s. She had developed unpredictable instability as of late. Because she continued to have catching and buckling episodes, she desired to proceed with a scope. The Veteran was found to have no significant arthritic changes. The meniscus was intact, and the articular surface was okay. There were loose bodies from the medial femoral condyle which were determined to likely be the cause of her catching. During a May 2005 VA examination, the Veteran reported she has occasional sharp pain mainly to the medial aspect of the right knee joint, with trace edema. Prior to surgery, the knee would catch and pop and crack with range of motion. It was not present at the time of the examination. Prior to surgery, she would have pain four to five times per week and it would last anywhere from a couple hours to all day. Since surgery, she has stiffness. She has trace edema currently with slight redness, but no heat. She did not have instability, but she had weakness to the knee prior to the surgery and she would have occasional locking where she would have to try to straighten it out fully. She stated she was undergoing physical therapy. She reported flare-ups about once per week where she had to have a coworker get her a wheelchair to sit in because the pain was so significant. She could still function if she had to. It would usually last all day. Currently, she was using crutches status post-surgery. She could walk 20 to 60 feet prior to the surgery before bringing on pain. Currently, she has sharp pain which is daily and intermittent. Upon physical examination, there was trace edema and mild erythema. She had extension limited to 10 degrees and flexion to 100 degrees secondary to increased pain. She is limited by pain with status post-surgery. She has a significant antalgic gait when ambulating without the crutches. There was significant tenderness. The most limiting factor was pain. She had good coordination with all repetitive range of motion. There was no weakness, decreased endurance, or easy fatigability with repetitive grange of motion. Increased pain against forced active range of motion. In an October 2006 private treatment note, the Veteran reported she developed significant right knee pain in the area which she had the microfracture. Her radiograph was unremarkable. In November 2006, the Veteran underwent an arthroscopic debridement and open osteochondral autograft transfer system procedure. The patellofemoral joint was noted not to have any significant arthritic change despite a previous operative note that seemed to indicate there was a moderate amount of arthritis. The meniscus was fine. During a March 2008 VA examination, the Veteran reported she is employed full time and that her job accommodates her right knee condition. She does have pain due to requirement of the job, sitting, or walking. She stated she underwent physical therapy after each surgery and that she has received cortisone shots, the last was not effective. She reported she continues to have pain, a sharp pain to the medial aspect of the right knee. She rated her pain as 9/10 and described it as daily but intermittent. Certain movements will bring on the pain and it does feel like it is grinding at times. She reported weakness daily with subluxation approximately 5 times per week. The knee will buckle or give out and she will have ot catch herself. She denied stiffness, locking, heat, or redness. She reports swelling 3 to 4 times per week, positive for fatigability and lack of endurance. She denied flare-ups since the pain is at such a high level. She uses a cane for ambulation. There was no instability of the right knee. There was very minimal palpable soft tissue edema. It has negative patella tracking with weightbearing and non. She was not having significant pain with repetitive range of motion other than just when initially beginning range of motion at approximately 10 degrees, but then it would resolve with more movement. Range of motion was noted as flexion to 90 degrees and extension to zero degrees. Absent 60 degrees of full flexion of the right knee secondary to generalized body habitus. There was mild crepitus with passive and active range of motion. There was no increased pain against forced flexion. There was no weakness, decreased endurance, or easy fatigability with repetitive range of motion of the right knee. Repetition did not change degrees or increase pain. X-ray testing showed normal knees. On February 11, 2009, the Veteran underwent a right unicompartmental arthroplasty. In private treatment records dated in April and May 2009, the Veteran’s range of motion of the right knee was noted as flexion to 115 and 122 degrees, respectively, with full extension. The Veteran testified in a DRO hearing in July 2009. The Veteran reported she underwent knee surgery in February 2009 and returned to work in June 2009. She stated her employer has made accommodations for her. She indicated that her physician has not imposed restrictions, but she can hardly stand or sit for even most of the time, like 15 or 20 minutes. She must get up and move or her leg stiffens. She stated she has been going to physical therapy since surgery. In a September 2009 letter, Dr. F., the Veteran’s private treating physician, stated that the Veteran fell on steps in September 2004. The Veteran was evaluated, and an MRI scan showed there was degenerative change. She had a cortisone injection and there was some improvement. She still had catching, buckling, and unpredictable instability. She underwent a scope which found loose bodies. In October 2006, she returned and there were some arthritic changes at the patellofemoral joint as well as osteochondral defect. The Veteran underwent arthroscopy and OATS procedure but did not have significant relief. She complained of significant pain in April 2007. An updated MRI scan showed there was an irregular area at the OATS. She was treated conservatively with injections and a brace. By September 2007, she had a minimal misstep and got significant increased pain. She was given injections. She continued to have significant discomfort. By February 2009, she had enough pain and had decided to proceed with a unicompartmental arthroplasty. Ultimately, she did improve but this took several months. In August 2009, she had made excellent improvement and was back to work and completed physical therapy. The physician noted that she will have chronic residuals consisting of some soreness and weakness in the knee that is moderate to significant. She had not had ongoing instability of the knee but still has some pain and limitation of motion with flexion to about 110 degrees and full extension. Her x-ray no longer showed arthritis to be present. The Veteran underwent an additional VA knee examination in September 2011. The Veteran complained of sharp pain to the medial aspect of her right knee that is daily but intermittent. She reported certain movements will bring on the pain and it does feel like it is grinding at times. She reported weakness daily with subluxation approximate 5 times per week. She stated that the knee will buckle or give out on her and she will have to catch herself around anything stable to avoid falling. She denied stiffness, locking, heat, or redness. She reported swelling three to four times per week which will decrease by the morning, positive for fatigability and lack of endurance. She denied any flare-ups since the pain is at such a high level. She does not use a brace but ambulates with a cane. Range of motion testing showed flexion to 100 degrees (with pain at 100 degrees) and extension to zero degrees. There was no loss of range of motion or additional functional loss on repetitive use test. Joint stability testing was normal. The examiner noted a history of meniscal tear, frequent episodes of joint pain and frequent episodes of joint effusion. The examiner noted the Veteran underwent a meniscectomy in 1991. The Veteran reported she has pain due to requirement of her job to include sitting or walking. An August 2014 private X-ray report showed post medial intercondylar hemiarthroplasty and mild patellofemoral osteoarthrosis. July and September 2017 private treatment notes indicate peripheral joint range of motion was full and pain free without obvious instability or laxity in all four extremities. In a February 2018 letter, Dr. F. indicated that she is about seven years since her unicompartmental arthoplasty. She continues to do well medially but she has developed increased soreness at the patella. Upon physical examination, she had full extension and can flex to 130 degrees. She had good stability. She did have some crepitations and marked tenderness. X-ray examination showed moderate to significant patellofemoral arthritis. She is limited in her ability to do her normal work duties. The Veteran was also evaluated by VA in an August 2018 VA examination. Veteran reported she is currently followed by a private orthopedic specialist on an as needed basis, denied any current treatment except for her daily prescribed meloxicam. She reported her right knee will have pain flare-ups with kneeling or squatting on the knee only. She denied any other flare ups. She reported with a flare-up, her entire right knee joint is painful, and the pain feels like it is “bruised”. She reports the right knee is more painful to the medial and distal patella. She reported the right knee “gave out” on her three times recently after “three walks around the zoo.” She reports the right knee will “give out” approximately once every two months. She denies wearing a knee brace currently. She denies using an assistive device. She denied any weakness to the right knee on exam. There were no clinical exam findings of right knee weakness. The Veteran ambulated with a normal steady gait without an assistive device. She reported she was on workman’s compensation for unrelated medical condition. She reported her job is a clerical job and her right knee does not interfere with her job. The right knee does not interfere with activities of daily life. Upon physical examination, flexion was noted to 120 degrees and extension to zero degrees. No pain was noted on exam, to include with weight bearing and on passive range of motion testing. There was mild tenderness to palpation to the distal and medial patella. The nonservice-connected left knee was also evaluated. There was no additional functional loss or range of motion after three repetitions. Pain, weakness, fatigability or incoordination did not significantly limit functional ability with repeated use over a period of time. Upon flare-ups, range of motion findings were described as flexion 110 degrees and extension to zero. Muscle strength was normal without evidence of atrophy. Joint stability testing indicated there was no history of recurrent subluxation or lateral instability. Upon joint stability testing, medial instability was noted to be 1+, with other tests noted as normal. The examiner noted arthritis is documented in the right knee. In an August 2018 private evaluation, Dr. F. reported diagnoses of intact unicompartmental arthroplasty with early wear, patellofemoral arthritis, and complete regional pain syndrome (CRPS). The examiner noted symptoms of significant right anterior knee pain around the patella, which is daily and worse with activity and exacerbated by CRPS. She had marked tenderness at the patellofemoral joint and patellofemoral compartment degenerative joint disease (DJD). The Veteran is able to walk less than one block, sit more than two hours, and stand 30 minutes. Appeal Period Prior to February 11, 2009 As noted above, the Veteran’s residuals of a partial right knee replacement is rated 10 percent under Diagnostic Code 5257 for instability prior to February 11, 2009. Throughout this appeal period, the Veteran reported unpredictable instability. Although the Veteran reported subluxation as many as five times per week, there was no objective evidence of instability on either the May 2007 or March 2008 VA examinations. The Veteran’s lay assertions do not provide information showing that her instability is moderate. A higher than 10 percent rating is not warranted for instability because the evidence of record does not show that the Veteran had moderate instability or moderate recurrent subluxation of the right knee. A higher rating under Diagnostic Code 5257 is not for application prior to February 9, 2011. 38 C.F.R. § 4.71a. Additionally, range of motion findings of the right knee do not support the award of a separate rating under Diagnostic Codes 5260 or 5261 prior to February 11, 2009. Here, the March 2008 VA examination reflected the flexion of the Veteran’s right knee was limited to at most 90 degrees and extension was measured to zero degrees. Although the May 2005 VA examination noted extension limited to 10 degrees, the Board notes that this examination was within weeks of surgery and during a period of TTR, therefore it is not within the rating period. Thus, a higher rating under Diagnostic Codes 5260 or a separate rating under Diagnostic Code 5261 for the right knee is not warranted. The Board has considered whether a higher disability evaluation for the right knee is warranted based on functional loss due to pain or due to weakness, fatigability, incoordination, or pain on movement of a joint under 38 C.F.R. §§ 4.40 and 4.45. See also DeLuca v. Brown, 8 Vet. App. 202 (1995). In this case, there is no indication in the medical evidence of record, to include VA knee examination reports, that any subjective complaints, such as pain, fatigue, incoordination, or weakness, result in additional limitation of function so as to meet the criteria for a higher evaluation. The Veteran reported flare-ups in the right knee in the May 2005 VA examination in that she would need to use a wheelchair approximately one time per week but she did not report additional range of motion limitations. As such, there has not been a showing that the Veteran’s range of motion in the right knee is so functionally limited as to warrant a rating in excess of 10 percent based on flexion or support a separate disability rating based on extension. The Board also considered whether a separate rating was warranted for arthritis. VA General Counsel also held in VAOPGCPREC 23-97 that a claimant who has arthritis and instability of the knee may be rated separately under Diagnostic Codes 5003 and 5257. However, General Counsel stated that when a knee disorder is already rated under Diagnostic Code 5257, the veteran must also have limitation of motion which at least meets the criteria for a zero percent rating under Diagnostic Code 5260 (flexion limited to 60 degrees or less) or 5261 (extension limited to 5 degrees or more) in order to obtain a separate rating for arthritis. As the Veteran does not meet the minimum criteria for limitation of motion, as separate rating for arthritis is not warranted. Although the Veteran complained of locking in a May 2005 VA examination, that examination was within weeks of the Veteran’s knee surgery and was within the period of a temporary total rating. Subsequent, in a September 2011 VA examination, the Veteran specifically denied locking pain. As such, a separate evaluation is also not warranted for the right knee under either Diagnostic Code 5258. The Board notes the remaining applicable diagnostic codes relating to knee disabilities include Diagnostic Code 5256 (ankylosis of the knee), Diagnostic Code 5262 (impairment of the tibia and fibula), Diagnostic Code 5258 (symptomatic removal of semilunar cartilage), and Diagnostic Code 5263 (genu recurvatum). As there is no evidence of record showing that the Veteran has ankylosis, impairment of the tibia and fibula, or acquired, traumatic genu recurvatum with regard to the right knee, these diagnostic codes are not applicable. Appeal Period Beginning on February 11, 2009 For the Veteran’s claim for an increased rating for her right knee, for the period from February 11, 2009, the Board finds that the evidence of record supports changing the Veteran’s currently assigned Diagnostic Code from 5257 (instability) and 5260 (leg, limitation of flexion) to Diagnostic Code 5055 (knee replacement (prosthesis)). Specifically, the Veteran’s medical records evidence that during the period on appeal, the Veteran underwent a right unicompartmental arthroplasty (partial knee replacement) in February 11, 2009. Of import, with respect to the Veteran’s partial knee replacement, in Hudgens v. McDonald, 823 F.3d 630 (Fed. Cir. 2016), the United States Court of Appeal for the Federal Circuit (Federal Circuit) held that the provisions of Code 5055 were applicable to partial knee replacements. The appeal of the increased rating claim was pending prior to July 16, 2015 the effective date of the regulatory change excluding partial knee replacements from the scope of Diagnostic Code 5055. When the rating criteria are amended during a pending claim, the Board must consider both the pre- and post-amendment criteria and apply the version most favorable to the Veteran. See Karnas v. Derwinski, 1 Vet. App. 308, 313 (1991). In Hudgens, the Federal Circuit rejected the Secretary’s argument that the July 2015 rulemaking was merely a clarification of a longstanding policy. See Hudgens, 823 F.3d at 639 (“Second, we cannot ignore that, during the pendency of this appeal, the agency found the need to clarify the language of a regulation that it now argues has always been clear on its face.”) As a statement of the applicable law as it existed prior to July 16, 2015, the Federal Circuit’s decision in Hudgens is controlling. The Board therefore must apply the more favorable law, as it existed prior to July 16, 2015 in which Diagnostic Code 5055 applied to both partial and total knee replacements to this case. Thus, in rating the Veteran’s right knee under Diagnostic Code 5055, the Board notes the applicable rating criteria: A 100 percent rating is warranted for one year following implantation of the prosthesis. Thereafter, a 60 percent rating is warranted for chronic residuals consisting of severe painful motion or weakness in the affected extremity. Where there are intermediate degrees of residual weakness, pain, or limitation of motion, the disability should be rated by analogy to Diagnostic Codes 5256 (ankylosis), 5261 (limitation of extension), or 5262 (impairment of the tibia and fibula). The minimum rating following replacement of a knee joint is 30 percent. 38 C.F.R. § 4.71a, Diagnostic Code 5055. Upon review there is no objective medical evidence of record to support a finding that during this period on appeal the Veteran experienced chronic residuals consisting of severe painful motion or weakness in the affected extremity. Although the Veteran has argued that a higher rating is warranted due to severe painful motion or weakness, severe painful motion or severe weakness were not found on examination. The September 2009 private opinion from Dr. D.F. noted that there were chronic residual consisting of some soreness and weakness in the knee that is moderate to significant. A September 2011 VA examination reflected the Veteran’s reports of weakness but objective examination did not demonstrate such weakness. However, the Veteran denied weakness and pain on range of motion in the August 2018 VA examination. Therefore, the Board finds that a 30 percent rating under Diagnostic Code 5055 is warranted from February 11, 2009. There is no evidence that the Veteran is entitled to a rating in excess of 30 percent for her right knee starting February 11, 2009. In this regard, there is no indication from the record that she was experiencing chronic residuals consisting of severe or painful motion or weakness. The Board acknowledges that the Veteran did experience pain, and her pain increased during flare-ups; however, there is no indication from the record that those symptoms were severe or chronic. Therefore, the Board finds that a rating in excess of 30 percent is not warranted. 38 C.F.R. § 4.71a, Diagnostic Code 5055. The Board also considered whether the Veteran’s residuals of a partial right knee replacement presents any additional manifestations that would warrant the assignment of a separate rating(s). See 38 C.F.R. §§ 4.25(b), 4.71a, Diagnostic Codes 5256-5263. To this end, the Board notes that Diagnostic Code 5055 contemplates painful motion, weakness, and limitation of motion. 38 C.F.R. § 4.71a. Thus, the rule against pyramiding precludes the assignment of separate ratings for ankylosis (Diagnostic Code 5256), limitation of flexion (Diagnostic Code 5260), and limitation of extension (Diagnostic Code 5261). 38 C.F.R. §§ 4.1, 4.71a; Murray v. Shinseki, 24 Vet. App. 420, 423 (2011) (citing Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994) (holding that the critical element in permitting the assignment of several ratings under various Diagnostic Codes is that none of the symptomatology for any one of the conditions is duplicative or overlapping with the symptomatology of the other condition)). With respect to Diagnostic Codes 5258 and 5259, representing the dislocation of semilunar cartilage and removal of semilunar cartilage, the Board does not find evidence of the same. Instability As noted above, the Veteran is currently in receipt of a separate 10 percent rating under Diagnostic Code 5257 for instability effective August 28, 2018. From February 9, 2011 to August 28, 2018, a separate rating for instability is not warranted. Although the Veteran reported subluxation as many as five times per week, this complaint is inconsistent with the other medical evidence of record. The Board notes there was no objective evidence of instability on the May 2011 VA examination and private treatment records indicated no evidence of obvious instability or laxity. Furthermore, the Veteran’s treating physician Dr. F. also indicated that the Veteran had no had not had ongoing instability of the knee after her February 2009 surgery. The first objective indication of instability after February 2009 is the August 2018 VA examiner which noted medial instability was noted to be 1+. The Veteran’s lay assertions do not provide information showing that her instability is moderate. A higher than 10 percent rating is not warranted for instability because the evidence of record does not show that the Veteran had moderate instability or moderate recurrent subluxation of the right knee. A higher rating under Diagnostic Code 5257 is not for application starting August 28, 2018. Under the new regulations, the Board finds the Veteran’s right knee disability also does not warrant a higher rating for instability. During the August 2018 VA examination, the Veteran denied using an assistive device and the examiner noted she ambulated with a normal steady gait without an assistive device. 3. Entitlement to a disability rating in excess of 10 percent for residuals of left inguinal hernia repair (excluding TTR assignment) is denied. The Veteran was initially service connected for her residuals of left inguinal hernia repair at zero percent, effective September 1994. The Veteran underwent surgery for an infected incision site of service-connected hernia repair in November 2017, and filed the present claim for an increased rating for her service-connected residuals of left inguinal hernia repair in March 2018. In a May 2018 rating decision, the RO awarded the Veteran a TTR, effective November 30, 2017, for her hernia surgery. Effective February 1, 2018, a 10 percent rating was resumed for her residuals of left inguinal hernia repair. The Veteran did not appeal the temporary total evaluation. Accordingly, the present claim for a compensable rating excludes the period during which she was rated at 100 percent. Under Diagnostic Code 7338 for inguinal hernias, a 10 percent rating is warranted for a postoperative hernia that is recurrent, readily reducible and well supported by truss or belt. A 30 percent rating is warranted for a postoperative hernia that is small and recurrent, or unoperated, irremediable hernia that is not well supported by truss or not readily reducible. A 60 percent rating is warranted for a postoperative hernia that is large, recurrent, not well supported under ordinary conditions, and not readily reducible when considered inoperable. Private treatment records show that in November 2017, the Veteran was initially seen due to intermittent episodes of mild left lower quadrant abdominal pain. She stated episodes started about four weeks ago. Ten days later, on November 30, 2017, the Veteran underwent an incision and debridement of left groin abcess cavity with partial resection of infected foreign body. In April 2018, the Veteran was afforded a VA examination. She reported that she had recurrence of the abscess in the left groin last fall. She was hospitalized and had to have a surgery. She complained of intermittent sharp pain at the wound site since the last treatment. She reported the pain occurs rarely every few weeks, that last for a few seconds at a time. The examiner referred to private medical records that show the Veteran was hospitalized in November 2017 for infected stitch abscess at the previous herniorrhaphy site. Her mesh was not involved in the infection. The discharge notes indicate resolution of the infection. Upon physical examination, no hernia was noted on the Veteran’s left side and there was no indication for a supporting belt. During this appeal, the record does not show that the Veteran’s residuals of left inguinal hernia repair arose to the level of assignment of a 30 percent rating as Veteran did not have a current hernia and there was no indication for a supporting belt. These defining characteristics fall squarely within the criteria for a 10 percent rating. Accordingly, the criteria for a rating in excess of 10 percent for residuals of a left hernia repair have not been met and the claim is denied. 4. Entitlement to a compensable rating for residual scar, post-operative hernia repair, prior to May 3, 2019, and in excess of 10 percent thereafter, is denied. The Veteran has a service-connected surgical scar associated with her left inguinal hernia repair. As noted above, the Veteran filed the present claim for an increased rating for her service-connected residuals of left inguinal hernia repair in March 2018. Her scar is rated noncompensable under Diagnostic Code 7801 from October 1, 2008 to May 3, 2019. Starting May 3, 2019, a separate 10 percent rating is assigned under Diagnostic Code 7804 for unstable or painful scars. The Board acknowledges that the rating criteria for many skin disabilities were revised during this appeal, effective from August 13, 2018. They introduce a General Rating Formula for skin conditions and amend Diagnostic Codes 7801 and 7802 by characterizing multiple scars by 6 body zones affected rather than by extremity. Claims pending prior to the effective date, such as this one, may be rated under either the amended or pre-amended criteria, depending on which is more advantageous. Both the pre-amended and amended versions of Diagnostic Code 7800 apply to scars or other disfigurement of the head, face, or neck. As the scar is located on the Veteran’s lower abdomen region, Diagnostic Code 7800 is not for application in this case. The pre-amended version of Diagnostic Code 7801 applies to scars that are deep and nonlinear and provides for a 10 percent disability rating when such scars cover an area or areas of at least 6 square inches (39 sq. cm.). Note (1) states that a deep scar is one associated with underlying soft tissue damage. The amended version also applies to scars that are associated with underlying soft tissue damage. Under the former code, a deep scar is defined as one associated with underlying soft tissue damage. Under pre-amended Diagnostic Code 7802, scars not of the head, face, or neck, that are superficial and nonlinear are assigned a rating of 10 percent with area or areas of 144 square inches (929 sq. cm.) or greater. Under amended DC 7802, scars not of the head, face, or neck, that are not associated with underlying soft tissue damage are assigned a rating of 10 percent with area or areas of 144 square inches (929 sq. cm.) or greater. In this case, the Veteran’s scar covers an area that is significantly less than 144 square inches. Accordingly, this code is not for application. Diagnostic Code 7804 was not affected by the recent amendments. Under that code, scars that are unstable or painful can be assigned a rating of 30 percent with five or more scars that are unstable or painful. A rating of 20 percent requires three or four scars that are unstable or painful. A rating of 10 percent requires one or two scars that are unstable or painful. The Board finds that the preponderance of the evidence is against the assignment of a compensable rating prior to May 3, 2019, and a rating in excess of 10 percent under Diagnostic Code 7804 thereafter. Prior to May 3, 2019, there is no evidence of a painful scar associated with the Veteran’s hernia surgery. Private treatment records show that in November 2017, the Veteran underwent an incision and debridement of left groin abcess cavity with partial resection of infected foreign body. The Veteran underwent a VA examination in April 2018. The VA examiner indicated there is a scar due to treatment for the Veteran’s service-connected hernia. The examiner reported the scar was not painful or unstable, nor does it have a total area equal to or greater than 30 square cm. The examiner noted the scar measured 4.5 cm by 0.3 cm. As such, the Board finds that the Veteran’s hernia repair scar does not warrant a compensable rating prior to May 3, 2019 because it is not painful or unstable, does not measure at least 39 square centimeters, and does not have any other disabling effects. See 38 C.F.R. § 4.118, Diagnostic Codes 7801-7805. Starting May 3, 2019, the Board finds there is evidence of a single painful scar associated with the Veteran’s surgery. The May 2019 VA examiner noted the Veteran has a scar that is healed linear but that she feels pain upon touch. The examiner stated the pain was local to the scar with light touch at the scar linear incision. The Veteran’s scar measured 10 cm by 2 cm at the left groin pubic area. The scar was tender to palpation and has underlying soft tissue damage. The approximate total area was 10 cm. The extremities were not affected. As such, the Board finds that the Veteran’s hernia repair scar does not warrant a rating in excess of 10 percent starting May 3, 2019 because she does not have more than one painful scar. See 38 C.F.R. § 4.118, Diagnostic Codes 7801-7805. In conclusion, the Board finds that the preponderance of the evidence is against the Veteran’s claim for a compensable rating prior to May 3, 2019, and a rating in excess of 10 percent thereafter for a surgical scar. In denying such ratings, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. Other Considerations In reaching its conclusions, the Board acknowledges the Veteran’s belief that her right knee disorder, hernia and scar are more severe than is reflected by the currently assigned disability ratings. The Board must consider the entire evidence of record when analyzing the criteria laid out in the rating schedule. While the Board recognizes that the Veteran is competent to provide evidence regarding her symptomatology, she is not competent to provide an opinion regarding the severity of her symptomatology in accordance with the rating criteria. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). Ultimately, the Board finds the medical evidence in which professionals with medical expertise examined the Veteran, acknowledged her reported symptoms, and described the manifestations of such disability in light of the rating criteria to be more persuasive than her reports regarding the severity of her right knee disorder, hernia and scar. The Board notes that a stage rating is already assigned for the Veteran’s right knee disability and that a further staged rating for that disability, or a staged rating related to the other disabilities, are not warranted. See Hart v. Mansfield, supra. Furthermore, the Veteran has not raised any other issues, nor has any other issues been reasonably raised by the record, with regard to the increased rating claim adjudicated herein. See Doucette v. Shulkin, 28 Vet. App. 366 (2017). Finally, the Board notes the ruling of the Court in Rice v. Shinseki, 22 Vet. App. 447 (2009). In Rice, the Court held that a claim for a TDIU, either expressly raised by the Veteran or reasonably raised by the record, involves an attempt to obtain an appropriate rating for a disability and is part of the claim for an increased rating. In this case, the Veteran’s current employment status is not clear from the record. However, she has not alleged that her right partial replacement, residuals of a left inguinal hernia repair and scar. As such, Rice is inapplicable in this case. In reaching the foregoing determinations, the Board has applied the benefit of the doubt doctrine and resolved all doubt in the Veteran’s favor. However, insofar as the Board has denied higher ratings, the preponderance of the evidence is against such aspects of the claims. Therefore, the benefit of the doubt doctrine is not applicable, and the increased rating claims must be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. Effective Date 5. Entitlement to an effective date prior to November 30, 2017 of a TTR for residuals of left inguinal hernia repair is denied. In May 2018, the RO granted a TTR based on hospitalization for surgery to the Veteran’s service-connected left inguinal hernia, from November 30, 2017, followed by a 10 percent rating as of February 1, 2018. See 38 C.F.R. § 4.29. A temporary total disability rating may be assigned under either 38 C.F.R. § 4.29 or 38 C.F.R. § 4.30. Under 38 C.F.R. § 4.29, a temporary total disability rating will be assigned when it is established that a service-connected disability has required hospitalization at a VA medical center or other approved hospital for more than 21 days or for hospital observation at VA expense for a service-connected disability for more than 21 days. 38 C.F.R. § 4.29. Private treatment records show that in November 2017, the Veteran was initially seen due to intermittent episodes of mild left lower quadrant abdominal pain. She stated episodes started about four weeks ago. Ten days later, on November 30, 2017, the Veteran underwent an incision and debridement of left groin abcess cavity with partial resection of infected foreign body. An effective date prior to November 30, 2017 for the Veteran’s TTR is not warranted. The Veteran has not asserted, and there is no evidence to show, that the Veteran’s hospitalization for her surgery, which took place on November 30, 2017, began prior to November 30, 2017. The evidence indicates that she was evaluated for left groin pain on November 20, 2017, and that she underwent her left groin surgery ten days later. Under these circumstances, there is no basis for an assignment of an effective date for the Veteran’s TTR prior to November 30, 2017. Accordingly, the claim is denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. KRISTY L. ZADORA Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board D. M. Donahue Boushehri, 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.