Citation Nr: 21013948 Decision Date: 03/11/21 Archive Date: 03/11/21 DOCKET NO. 18-22 895 DATE: March 11, 2021 ORDER Entitlement to an effective date prior to August 11, 2015 for the grant of service connection for a left hip scar is dismissed without prejudice. Entitlement to a compensable disability rating for a left hip scar is dismissed without prejudice. A temporary total evaluation beyond November 1, 2015, based upon postoperative convalescence following left hip surgery is denied. A disability rating in excess of 10 percent for a left hip disability is denied. A compensable disability rating for a left thigh disability is denied. A disability rating in excess of 10 percent for a left knee disability based upon recurrent subluxation or lateral instability is denied. A separate disability rating of 10 percent, but no more, for a left knee disability based upon limitation of flexion is granted from June 18, 2019. New and material evidence having been received, the application to reopen a previously denied claim of entitlement to service connection for a back disorder, to include as secondary to service-connected left hip and left knee disabilities, is granted and the claim is reopened. New and material evidence having been received, the application to reopen a previously denied claim of entitlement to service connection for a right knee disorder, to include as secondary to a service-connected left knee disability, is granted. Service connection for rectus femoris syndrome, to include as secondary to a service-connected left knee disability, is granted. Service connection for piriformis syndrome, to include as secondary to a service-connected left hip disability, is granted. Service connection for a right knee disorder, to include as secondary to a service-connected left knee disability, is granted. Service connection for a back disorder, to include as secondary to service-connected left hip and left knee disabilities, is granted. REMANDED Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. FINDINGS OF FACT 1. In a February 2020 brief in support of the Veteran’s appeal, the Veteran’s representative indicated that he wished to withdraw his claims seeking an effective date prior to August 11, 2015 for the grant of service connection for a left hip scar and a compensable disability rating for a left his scar. 2. Post-operative residuals of the Veteran’s August 11, 2015 left hip surgery did not necessitate convalescence beyond November 1, 2015. 3. Throughout the period on appeal, the Veteran’s left hip disability has not been characterized by favorable ankylosis in flexion at an angle between 20 and 40 degrees, and slight adduction or abduction or impairment of thigh abduction to 10 degrees or less. 4. Through the period on appeal, the Veteran’s left thigh disability has not been characterized by limitation of flexion to 45 degrees. 5. Throughout the period on appeal, the Veteran’s left knee disability has not been characterized by moderate symptoms of recurrent subluxation or lateral instability, a sprain, incomplete ligament tear, or repaired complete ligament tear causing persistent instability, or a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair. 6. Since June 18, 2019, flexion of the Veteran’s left knee has been limited to 45 degrees. 7. In an August 2014 rating decision, the Veteran’s claims of entitlement to service connection for a back disorder and a right knee disorder were denied on the ground that neither disorder was etiologically related to his active duty service. 8. The evidence added to the record since the August 2014 rating decision relates to unestablished facts that are necessary to substantiate the claims of service connection for a back disorder and a right knee disorder. 9. Resolving reasonable doubt in the Veteran’s favor, it is at least as likely as not that his rectus femoris syndrome and right knee disorder are proximately due to his service-connected left knee disability, his piriformis syndrome is proximately due to his service-connected left hip disability, and his back disorder is proximately due to his service-connected left hip and left knee disabilities. CONCLUSIONS OF LAW 1. The criteria for withdrawal of the substantive appeal as to the issues of entitlement to an effective date prior to August 11, 2015 for the grant of service connection for a left hip scar and entitlement to a compensable disability rating for a left hip scar by the Veteran’s authorized representative have been met. 38 U.S.C. § 7105; 38 C.F.R. § 19.55. 2. The criteria for a temporary total evaluation beyond November 1, 2015 based upon postoperative convalescence following left hip surgery, have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.30. 3. The criteria for a disability rating in excess of 10 percent for a left hip disability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.7, 4.40, 4.45, 4.59, 4.71, 4.71a, Diagnostic Code (DC) 5253. 4. The criteria for a compensable disability rating for a left thigh disability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.7, 4.40, 4.45, 4.59, 4.71, 4.71a, DC 5252. 5. The criteria for a disability rating in excess of 10 percent for a left knee disability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.7, 4.40, 4.45, 4.59, 4.71, 4.71a, DC 5257. 6. The criteria for a separate disability rating of 10 percent, but no more, from June 18, 2019, for a left knee disability based upon limitation of flexion of the left knee have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.7, 4.40, 4.45, 4.59, 4.71, 4.71a, DC 5260. 7. The August 2014 rating decision that denied the Veteran’s claims of entitlement ot service connection for a back disorder and a right knee disorder is final. 38 U.S.C. § 7105; 38 C.F.R. § 20.1103. 8. Because the evidence received after the August 2014 rating decision is new and material, the requirements to reopen the Veteran’s claims of entitlement to service connection for a back disorder and a right knee disorder have been met. 38 U.S.C. §§ 5108, 7105; 38 C.F.R. §§ 3.102, 3.156. 9. The criteria for service connection for rectus femoris syndrome, to include as secondary to a service-connected left knee disability, have been met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a), 3.304, 3.307, 3.309, 3.310. 10. The criteria for service connection for piriformis syndrome, to include as secondary to a service-connected left hip disability, have been met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a), 3.304, 3.307, 3.309, 3.310. 11. The criteria for service connection for a right knee disorder, to include as secondary to a service-connected left knee disability, have been met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a), 3.304, 3.307, 3.309, 3.310. 12. The criteria for service connection for a back disorder, to include as secondary to service-connected left hip and left knee disabilities, have been met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a), 3.304, 3.307, 3.309, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from July 1993 to July 1997 and October 2002 to April 2003. Withdrawal of Claims 1. Entitlement to an effective date prior to August 11, 2015 for the grant of service connection for a left hip scar 2. Entitlement to a compensable disability rating for a left hip scar A veteran, or his representative, may withdraw an appeal in writing at any time before the Board promulgates a final decision. 38 C.F.R. § 19.55. When a veteran does so, the withdrawal effectively creates a situation in which an allegation of error of fact or law no longer exists. In such an instance, the Board does not have jurisdiction to review the appeal, and a dismissal is then appropriate. 38 U.S.C. § 7105. Here, in a February 2020 brief in support of the Veteran’s appeal, the Veteran’s representative expressly stated that sought to withdraw “the issues of an increased rating for a left his scar and an effective date earlier than August 11, 2015, for service connection of the left his car.” In view of the Veteran’s desire, expressed by his representative in the February 2020 brief in support of his appeal, the Board concludes that his intent was to withdraw these claims and further action concerning these claims is not appropriate. Indeed, no allegation of error of fact or law remains for appellate consideration. Accordingly, the Board no longer has jurisdiction to review these claims and must dismiss the appeal as to these issues. Convalescence 3. Entitlement to a temporary total evaluation beyond November 1, 2015 based upon postoperative convalescence following left hip surgery The Veteran contends that he is entitled to an extension of his temporary total rating for convalescence following his August 2015 left hip surgery. A temporary total rating was previously granted by the RO in a May 2016 rating decision. The temporary total rating was effective August 11, 2015 (date of admission) until November 1, 2015. Specifically, he asserts that he should be granted a temporary total evaluation for the full six-month period provided for by 38 C.F.R. § 4.30 (i.e., until February 11, 2016). In support of that assertion, he contends that the term convalescence encompasses his period of physical therapy or the four to six-month period that the private physician who performed his surgery indicated that it would take for him to return to normal activity. A temporary 100 percent evaluation may be assigned when it is established that a service-connected disability required surgery necessitating at least one month of convalescence, surgery with severe postoperative residuals, or treatment with immobilization by cast of one major joint or more. 38 C.F.R. § 4.30. The Court of Appeals of Veteran’s Claims has defined convalescence as “the stage of recovery following an attack of disease, a surgical operation, or an injury.” Felden v. West, 11 Vet. App. 427, 430 (1998) (citing Dorland’s Illustrated Medical Dictionary 415 (30th ed., 2003)). The Court also defined recovery as “the act of regaining or returning toward a normal or healthy state.” Id. (citing Webster’s Medical Desk Dictionary 606 (1986)). In other words, the purpose of a temporary total evaluation pursuant to 38 C.F.R. § 4.30 is to aid the Veteran during the immediate post-surgical period when he may have incompletely healed wounds or may be wheelchair-bound, or when there may be similar circumstances indicative of transient incapacitation associated with recuperation from the immediate effects of an operation. The Court has also held that notations in the medical record as to the Veteran’s incapacity to work after surgery must be taken into account in the evaluation of a claim brought under the provisions of 38 C.F.R. § 4.30. See Seals v. Brown, 8 Vet. App. 291, 296-297 (1995); Felden v. West, at 430. After a review of the evidence of record, the Board concludes that an extension of the Veteran’s temporary total evaluation beyond November 1, 2015 is not warranted. Although the Veteran continued to experience pinching in his left groin area after November 1, 2015, the evidence of record does not show that the left hip surgical procedure resulted in incompletely healed surgical wounds, stumps or recent amputations, required therapeutic immobilization of one major joint or more, necessitated house confinement or the use of a wheelchair or crutches (regular weight bearing prohibited, or necessitated immobilization by cast. Indeed, a January 2016 private treatment record reflects that the physician who performed the Veteran’s left hip surgery on August 11, 2015 determined that although the Veteran continued to have pinching in his left groin area, that pain was similar to the pain that he had prior to surgery, that the incisions from the surgery were well healed, that he had 90 degrees of flexion, 15 degrees of internal rotation, 35 degrees of external rotation, and 40 degrees of abduction, and that he had good strength to his hip flexors and abductors and no mechanical symptoms. Thus, when compared with the findings set forth in the January 2015 VA examination, which reflects that the Veteran had 110 degrees of flexion, greater than 5 degrees of extension, and no loss of abduction after 10 degrees, the January 2016 private treatment record shows that his left hip range of motion had nearly returned to its pre-surgery state. Additionally, his treatment records do not show that an extension of the Veteran’s temporary total evaluation beyond November 1, 2015 is warranted. For example, a September 2015 treatment record reflected that his hip pain was improving. The Board acknowledges that a June 2016 private treatment record reflects that the private physician who performed his left hip surgery indicated that it would take the Veteran four to six months to return to normal activity. Notwithstanding the physician’s statement, a temporary total rating based on convalescence is not appropriate simply on the basis that the underlying disability continues to be symptomatic following surgery. The June 2016 private treatment record does not show that the surgical procedure resulted in incompletely healed surgical wounds, stumps or recent amputations, required therapeutic immobilization of one major joint or more, necessitated house confinement or the use of a wheelchair or crutches (regular weight bearing prohibited, or necessitated immobilization by cast. The appropriate schedular rating is intended to cover the situation where a veteran continues to be disabled, and the Veteran is in receipt of a 10 percent disability rating for his left hip disability. By virtue of the foregoing, the Board concludes that an extension of the Veteran’s temporary total evaluation beyond November 1, 2015, based upon postoperative convalescence following left hip surgery, is not warranted. Increased Rating The Veteran is seeking increased disability ratings for his service-connected left hip, left thigh, and left knee disabilities. Disability evaluations are determined by the application of a schedule of ratings that is based on average impairment of earning capacity. Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability. See 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities. Where there is a question as to which of two separate evaluations shall be applied, the higher evaluation will be assigned if the disability more closely approximates the criteria required for that particular rating. 38 C.F.R. § 4.7. When a reasonable doubt arises regarding the degree of disability, such doubt will be resolved in favor of the Veteran. 38 C.F.R. § 4.3. Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. It is essential that the examination on which ratings are based adequately portray the anatomical damage, and the functional loss, with respect to all these elements. The functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective enervation, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. §§ 4.10, 4.40, 4.45; see also DeLuca v. Brown, 8 Vet. App. 202 (1995). The provisions of 38 C.F.R. § 4.14 (avoidance of pyramiding) do not forbid consideration of a higher rating based on greater limitation of motion due to pain on use, including during flare-ups. 4. Entitlement to a disability rating in excess of 10 percent for a left hip disability 5. Entitlement to a compensable disability rating for a left thigh disability The Veteran contends that a disability rating in excess of 10 percent is warranted for his left hip disability and that a compensable disability rating is warranted for his left thigh disability. The Veteran contends that increased ratings are warranted because his current ratings fail to account for the pain, loss of endurance, and fatigue that these disabilities cause, and because he receives routine injections for pain in the left hip. The Veteran’s left hip disability has been assigned a 10 percent disability rating under 38 C.F.R. § 4.71a, DC 5010-5253 (addressing limitation of rotation, adduction, or abduction) and his left thigh disability has been assigned a noncompensable disability rating under 38 C.F.R. § 4.71a, DC 5252 (addressing limitation of flexion). In order to warrant a rating in excess of 10 percent for limitation of motion, the evidence must show (i) favorable ankylosis in flexion at an angle between 20 and 40 degrees, and slight adduction or abduction (60 percent under DC 5250) or impairment of thigh abduction to 10 degrees or less (20 percent under DC 5253). In order to warrant a compensable rating for limitation of flexion, the evidence must show flexion limited to 45 degrees. 38 C.F.R. § 4.71a, DC 5252. Based upon the evidence of record, the Board concludes that a disability rating in excess of 10 percent for the Veteran’s left hip disability and a compensable disability rating are not warranted. Here, the report from the November 2016 VA examination reflects that the Veteran reported that he experienced pain in the left hip and lateral thigh, that he described as popping that was worse with standing, and that he experienced flare-ups with pain radiating to his calf. On examination, the examiner determined that he had left hip flexion to 90 degrees, extension to 30 degrees, abduction to 45 degrees, adduction to 20 degrees, external rotation to 30 degrees and internal rotation to 30 degrees. Adduction of the left hip was not limited such that he could not cross his legs. The examination report further reflects that the Veteran was able to perform repetitive-use testing without any additional loss of function or range of motion after three repetitions, that the examiner did not anticipate any additional loss of range of motion as a result of repetitive use over time, and that the examiner did not anticipate any additional loss of range of motion as a result of a flare-up. Additionally, the examination report reflects that the examiner determined that he did not have ankylosis of the left hip. The report from the May 2017 VA examination reflects that the Veteran reported that he experienced pain, and that he experienced flare-ups two to three times per week where his hip pain increased and lasted approximately one minute if he stopped walking. On examination, the examiner determined that he had left hip flexion to 90 degrees, extension to 30 degrees, abduction to 45 degrees, adduction to 20 degrees, external rotation to 40 degrees, and internal rotation to 20 degrees. Adduction of the left hip was not limited such that he could not cross his legs. The examination report further reflects that he was able to perform repetitive-use testing without any additional loss of function or range of motion after three repetitions, that the examiner did not anticipate any additional loss of range of motion as a result of repetitive use over time, and that the examiner did not anticipate any additional loss of range of motion as a result of a flare-up. Additionally, the examination report reflects that the examiner determined that he did not have ankylosis of the left hip. With respect to the 10 percent disability rating assigned to the Veteran’s left hip disability based on limitation of rotation, adduction, or abduction under DC 5253 and the noncompensable disability rating assigned to the Veteran’s left thigh disability based on limitation of flexion under DC 5252, the reports from the November 2016 and May 2017 VA examinations do not show that increased disability ratings are warranted. Specifically, the examination reports do not show that a disability rating in excess of 10 percent is warranted for the Veteran’s left hip disability because they do not show impairment of thigh abduction to 10 degrees or less, instead showing that he had abduction of the left hip to 45 degrees. With respect to the noncompensable disability rating assigned to the Veteran’s left thigh for limitation of flexion, they do not show flexion of the left thigh limited to 45 degrees, instead showing that he had flexion to 90 degrees. Additionally, the examination reports show that a disability rating based upon ankylosis of the hip under DC 5250 is not warranted because both examination reports reflect that he did not have ankylosis of the left and that a disability rating based upon limitation of extension under DC 5251 is not warranted because the examination reports show that he had extension of the left hip to 30 degrees. The Board notes that DC 5254 (addressing the flail joint) and DC 5255 (addressing femur impairment) also pertain to this hip and thigh. However, the evidence does not support such pathology in the case of the Veteran’s left hip and left thigh disabilities. Indeed, the reports from the November 2016 and May 2017 VA examination reflects that the examiners determined that the Veteran’s left hip and thigh disabilities did not involve malunion or nonunion of the femur or flail joint, or any leg length discrepancy. Finally, the Veteran’s treatment records do not reflect limitation of motion that would warrant a higher rating. When considering these ratings, the Board has considered the impact of functional loss in the Veteran’s left hip and left thigh due to flare-ups of fatigability, incoordination, pain on movement, and weakness. 38 C.F.R. §§ 4.40, 4.45, 4.59; see Sharp, 29 Vet. App. 26; Correia, 28 Vet. App. 158; DeLuca, 8 Vet. App. 206. In this case, the Veteran has stated that his left hip and left thigh disabilities cause him pain, loss of endurance, and fatigue, receive pain injections, cause radiating pain during a flare-up, and cause increase pain during a flare-up. However, although the Veteran experienced the aforementioned symptoms, overall, it does not appear that these symptoms result in additional and significant functional loss, and his complaints are adequately contemplated in the ratings he currently receives. See Sharp, 29 Vet. App. 26; Mitchell, 25 Vet. App. 32, 37-43 (2011) (pain must affect some aspect of the normal working movements of the body such as strength, speed, coordination or endurance). Here, there is no evidence from the treatment records or the examination reports of any additional loss of motion or functioning after flare-ups, repetitive testing, or weight bearing that would warrant a higher rating during any period on appeal. Indeed, the report from the May 2017 VA examination reflects that there was no objective evidence of pain on non-weight bearing and that the passive range of motion of the left hip was the same as the active range of motion. Finally, the Board has considered statements by the Veteran that his left hip and left thigh disabilities are worse than the ratings he currently receives. In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency of evidence differs from weight and credibility. Although the Veteran is competent to report symptoms of his left hip and left thigh disabilities such as pain and limitation of motion because this requires only personal knowledge as it comes to him through his senses, he is not competent to identify a specific level of disability of his service-connected disabilities according to the appropriate DCs. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) (“although interest may affect the credibility of testimony, it does not affect competency to testify”). On the other hand, such competent evidence concerning the nature and extent of the Veteran’s left hip and left thigh disabilities has been provided by the medical personnel who have examined him during the current appeal and who have rendered pertinent opinions in conjunction with the evaluations. The medical findings (as provided in the November 2016 and May 2017 examination reports) directly address the criteria under which these disabilities are evaluated. By virtue of the foregoing, a disability rating in excess of 10 percent for the Veteran’s left hip disability and a compensable disability rating for his left thigh disability are not warranted. 6. Entitlement to a disability rating in excess of 10 percent for a left knee disability prior to October 13, 2020 and after November 30, 2020 The Veteran contends that he is entitled to a disability rating in excess of 10 percent for a left knee disability and separate ratings based upon limitation of extension and flexion. Specifically, he contends that a 50 percent disability rating is warranted for limitation of extension because a June 2019 VA examination shows that he had extension limited to 45 degrees. He also contends that a 10 percent disability rating is warranted because the June 2019 VA examination shows that he had flexion limited to 45 degrees. In addition to the principles discussed above, with respect to knee claims, a claimant who has arthritis and instability of the knee may be rated separately under DCs 5003, 5257, and 5258/5259. See VAOPGCPREC 23-97. For example, when a knee disability is already rated under DC 5257 (addressing lateral instability), a separate rating may be warranted if the Veteran’s knee also shows limitation of motion which at least meets the criteria for a zero-percent rating under DC 5260 (flexion limited to 60 degrees or less) or 5261 (extension limited to 5 degrees or more). Moreover, a separate rating could be warranted under 38 C.F.R. § 4.59, based on X-ray findings of arthritis with painful motion. See VAOPGCPREC 9-98; see also Degmetich v. Brown, 104 F.3d 1328, 1331 (Fed. Cir. 1997). In addition, the General Counsel has also held that separate ratings may be granted based on limitation of flexion (DC 5260) and limitation of extension (DC 5261) of the same knee joint. VAOPGCPREC 09-04. It should be noted that, during the course of this appeal, the schedular criteria for evaluating the lateral instability of the knee have been amended. Specifically, the criteria pertaining to lateral instability of the knee under 38 C.F.R. § 4.71a, DC 5257, was amended effective February 7, 2021. See 85 Fed. Reg. 76,453 (November 30, 2020). Where a law or regulation changes during the pendency of a claim for increased rating, the Board should first determine whether application of the revised version would produce retroactive results. In particular, a new rule may not extinguish any rights or benefits the claimant had prior to enactment of the new rule. VAOPGCPREC 07-03 (November 19, 2003). However, if the revised version of the regulation is more favorable, the implementation of that regulation under 38 U.S.C. § 5110(g) can be no earlier than the effective date of that change. If the former version is more favorable, VA can apply the earlier version of the regulation for the period prior to, and from, the effective date of the change. 38 U.S.C. § 5110; Karnas v. Derwinski, 1 Vet. App. 308, 313 (1991), overruled in part, Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). As the Veteran’s claim was received prior to the effective date of the regulation changes, the Board must consider the Veteran’s lateral instability of the knee under both the old and the revised rating criteria and must apply the old rating criteria if the result is more favorable to the Veteran. Id. The Veteran’s left knee disability is currently assigned a 10 percent disability rating under 38 C.F.R. § 4.71a, DC 5257. The Board notes that during the period on appeal, the Veteran was granted a temporary total evaluation from October 13, 2020 to November 30, 2020 based upon left knee surgery. A 10 percent disability rating resumed on December 1, 2020. In order to warrant a disability rating in excess of 10 percent under the old rating criteria, the evidence must show “moderate” symptoms of recurrent subluxation or lateral instability (20 percent). Under the revised rating criteria, the evidence must show (i) either a sprain, incomplete ligament tear, or repaired complete ligament tear causing persistent instability, and that a medical provider prescribed a brace and/or assistive device (e.g., cane, crutches, walker) for ambulation or an unrepaired or failed repair of a complete ligament tear causing persistent instability, and that a medical provider prescribed either an assistive device (e.g., cane, crutches, walker) or bracing for ambulation or (ii) 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. 38 C.F.R. § 4.71a, DC 5257. After a review of the evidence of record, the Board concludes that a disability rating in excess of 10 percent based upon instability under DC 5257 is not warranted. Here, the reports from January 2015, November 2016, May 2017, June 2019 VA examinations reflect that the examiners determined that there was no history of lateral instability or recurrent subluxation of the Veteran’s left knee. Additionally, the report from the June 2019 VA examination reflects that the Veteran did not use any assistive devices as a normal mode of locomotion, or had any ligament tear or surgical procedure involving the left knee. To the extent that the January 2015, November 2016 and May 2017 VA examination reports reflect that he used a brace as a normal mode of locomotion, they did not reflect that had any sprain, incomplete ligament tear, repaired complete ligament tear causing instability of the left knee or a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair. Finally, his treatment records do not show a history of lateral instability or recurrent subluxation of the left knee, or any sprain, incomplete ligament tear, repaired complete ligament tear causing instability of the left knee or a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair. Thus, the clinical evidence fails to establish that a disability rating in excess of 10 percent is warranted under DC 5257. Next, the Board considers whether separate compensable ratings are warranted for the Veteran’s left knee disability based upon limitation of the range of motion of his left knee, injuries to the semilunar cartilage, or impairment of the tibia and fibula. As a preliminary matter, with respect to limitation of the range of motion of his left knee, the Board determines that the evidence is at least in equipoise that a separate 10 percent disability rating from June 18, 2019 is warranted based upon limitation of flexion because the report from the June 2019 VA examination reflects that the flexion of his left knee is limited to 45 degrees during a flareup. Neither the report from the June 2019 VA examination nor the Veteran’s treatment records show that flexion of his left knee was limited to 30 degrees, which is required for the assignment of a 20 percent disability rating. Thus, the 10 percent disability rating assigned from June 18, 2019 is the highest disability rating that can be assigned based upon limitation of flexion of his left knee. Moreover, with respect to flexion, the clinical evidence fails to show that flexion of the Veteran’s left knee was limited to 45 degrees prior to June 18, 2019. Specifically, the report from the January 2015 VA examination reflects that he had flexion to 120 degrees, the report from the November 2016 VA examination reflects that he had flexion to 140 degrees, and the report from the May 2017 VA examination reflects that he had flexion to 140 degrees. Further, no treatment records showed that his left knee flexion was limited to 45 degrees prior to June 18, 2019. Accordingly, a compensable disability rating for limitation of flexion of his left knee is not warranted prior to June 2019. In order to warrant a compensable disability rating based upon limitation of motion (other than flexion) or traumatic arthritis, injuries to the semilunar cartilage, or impairment of the tibia and fibula, the evidence most show: • Limitation of extension to 10 degrees (10 percent under DC 5261); • Favorable ankylosis of the knee at full extension or in slight flexion between 0 and 10 degrees (30 percent under DC 5256); • X-ray evidence of arthritis with the involvement of two or more major joints or two or more minor joint groups (10 percent under DC 5003); • Dislocation of the semilunar cartilage with frequent episodes of “locking,” pain and effusion in the joint (20 percent under DC 5258); • Symptomatic symptoms due to the removal of the semilunar cartilage (10 percent under DC 5259); • Malunion of the tibia and fibula requiring treatment for no less than 12 consecutive months, and unresponsive to either shoe orthotic or other conservative treatment, one or both lower extremities (10 percent under DC 5262); or • Genu recurvatum (acquired, traumatic, with weakness and insecurity in weight bearing objectively demonstrated) (10 percent under DC 5263). 38 C.F.R. § 4.71a. After a review of the evidence of record, the Board concludes that separate disability ratings based on limitation of motion (other than flexion), injuries to the semilunar cartilage, or impairment of the tibia and fibula are not warranted. With respect to limitation of extension, the Board finds that no evidence shows that extension of the Veteran’s left knee was limited to 10 degrees. Specifically, the reports from the January 2015, November 2016, May 2017, and June 2019 VA examinations showed that his left knee was able to extend to 0 degrees and, therefore, was normal. Moreover, the Veteran’s treatment records do not reflect any limitation of extension of the Veteran’s left knee. The Board notes that the Veteran’s representative has contended that the June 2019 VA examination shows that extension of his left knee was limited to 45 degrees and that a 50 percent disability rating for limitation of extension of the Veteran’s left knee is warranted. In making this argument, the Veteran’s representative confused the flexion of the Veteran’s left knee with the extension of the left knee. Although the June 2019 VA examiner determined that flexion of the Veteran’s left knee was limited to 45 degrees during a flareup, he did not determine that there was any limitation of extension, finding that extension to 0 degrees without pain. Thus, a compensable disability rating for limitation of extension of the Veteran’s left knee is not warranted. Next, the Board finds that separate compensable disability ratings are not warranted based upon ankylosis or arthritis. With respect to ankylosis, neither the reports from the January 2015, November 2016, May 2017, and June 2019 VA examinations nor the Veteran’s treatment records reflect that he has had ankylosis in his left knee. With respect to arthritis, the evidence, including the reports from the January 2015, November 2016, May 2017, and June 2019 VA examinations and the treatment records fail to show x-ray evidence of arthritis with the involvement of two or more major joints or two or more minor joints. Finally, the Board finds that compensable disability ratings are not warranted based upon injuries to the semilunar cartilage, impairment of tibia and fibula, or genu recurvatum. With respect to the semilunar cartilage of the Veteran’s left knee, the Board finds that no compensable disability ratings are warranted because no evidence, including the reports from the January 2015, November 2016, May 2017, and June 2019 VA examinations and the treatment records, show dislocation of the semilunar cartilage of the left knee or that he had a surgical procedure to remove the semilunar cartilage of the left knee. With respect to impairment of the left tibia and fibula, the reports from the January 2015, November 2016, May 2017, and June 2019 VA examinations reflect that he did not have and had not ever had shin splints, stress fractures, chronic exertional compartment syndrome, or any other tibial or fibular impairment, and not treatment records show any tibia or fibular impairment. With respect to genu recurvatum, again, neither the reports from the January 2015, November 2016, May 2017, and June 2019 VA examinations nor his treatment records reflect that he has experienced genu recurvatum of the left knee. The Board also considered whether a higher disability evaluation is warranted on the basis of functional loss due to fatigability, incoordination, pain on movement, pain on weight-bearing, flare-ups, and weakness. 38 C.F.R. §§ 4.40, 4.45, 4.59; see Sharp, 29 Vet. App. 26; Correia, 28 Vet. App. 158; DeLuca, 8 Vet. App. 206. In this case, the Veteran has indicated that his left knee disability has caused him to experience pain, that his pain worsened with weight bearing and squatting, that he has experienced pain with walking, and that he has experienced flareups precipitated by overuse. Although he experiences the aforementioned symptoms, overall, it does not appear that these symptoms result in additional and significant functional loss, and his complaints are adequately contemplated in the ratings he currently receives. See Mitchell, 25 Vet. App. At 37-43 (2011) (pain must affect some aspect of the normal working movements of the body such as strength, speed, coordination or endurance). Importantly, the June 2019 VA examiner determined that the Veteran’s left knee flexion ended at 45 degrees and extension ending at 0 degrees during a flareup. Additionally, the November 2016 and June 2019 VA examiners noted that there was no evidence of pain on non-weight bearing testing of the left knee. Thus, the Board finds that the effect of the pain and functional loss in his left knee is already contemplated in the currently assigned evaluation. The Veteran’s statements, while fully credible, do not, when viewed in conjunction with the medical evidence, tend to establish weakened movement, excess fatigability, or incoordination to the degree that would warrant an increased evaluation beyond that already assigned. Finally, the Board has considered statements by the Veteran that his left knee disability is worse than the rating he currently receives. In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. See Gabrielson, 7 Vet. App. at 39-40; Gilbert, 1 Vet. App. at 57. Competency of evidence differs from weight and credibility. Although the Veteran is competent to report symptoms of his left disability such as pain and limitation of motion because this requires only personal knowledge as it comes to him through his senses, he is not competent to identify a specific level of disability of his service-connected disabilities according to the appropriate DCs. Rucker, 10 Vet. App. at 74; Layno, 6 Vet. App. at 469; see also Cartright, 2 Vet. App. at 25. On the other hand, such competent evidence concerning the nature and extent of the Veteran’s left disability has been provided by the medical personnel who have examined him during the current appeal and who have rendered pertinent opinions in conjunction with the evaluations. The medical findings (as provided in the January 2015, November 2016, May 2017, and June 2019 VA examination reports) directly address the criteria under which these disabilities are evaluated. By virtue of the foregoing, a disability rating in excess of 10 percent based upon lateral instability or recurrent subluxation is denied and a separate 10 percent disability rating based upon limitation of flexion from June 18, 2019 is granted. New and Material Evidence 7. Whether new and material evidence has been submitted to reopen the claim of entitlement to service connection for a back disorder, to include as secondary to service-connected left hip and left knee disabilities 8. Whether new and material evidence has been submitted to reopen the claim of entitlement to service connection for a right knee disorder, to include as secondary to a service-connected left knee disability The Veteran contends that his claims of entitlement to service connection for a back disorder and a right knee disorder should be reopened because the record now contains new evidence, which shows that his back disorder is proximately due to or the result of his service-connected left hip and left knee disabilities, and his right knee disorder is proximately due to or the result of his service-connected left knee disability. In order for evidence to be sufficient to reopen a previously disallowed claim, it must be both new and material. If the evidence is new, but not material, the inquiry ends, and the claim cannot be reopened. See Smith v. West, 12 Vet. App. 312, 314 (1999); Manio v. Derwinski, 1 Vet. App. 140 (1991). Under the relevant regulations, “new” evidence is defined as evidence not previously submitted to agency decision-makers. 38 C.F.R. § 3.156(a). “Material” evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. Id. If it finds that the submitted evidence is new and material, VA may then proceed to evaluate the merits of the claim on the basis of all evidence of record, but only after ensuring that the duty to assist the veteran in developing the facts necessary for the claim has been satisfied. See Elkins v. West, 12 Vet. App. 209 (1999). In this case, the Veteran’s claim of entitlement to service connection for a back disorder has been denied on multiple occasions, including in an August 2014 rating decision on the ground that his back disorder was not etiologically related to his active duty service. Similarly, his claim of entitlement to service connection for a right knee disorder has been denied on multiple occasions, including in the August 2014 rating decision on the ground that his right knee disorder was not etiologically related to his active duty service. The Veteran did not appeal the denial of his claims of entitlement to service connection for back and right knee disorders in the August 2014 rating decision, nor did he submit any new and material evidence within a year of receiving those rating decisions. Here, the Board notes that these claims were subsequently denied by March 2015 and December 2015 rating decisions, and that the Veteran did not file a notice of disagreement with those rating decisions, instead submitting new claims seeking service connection for back and right knee disorders. However, although he did not file a notice of disagreement with the March 2015 and December 2015 rating decisions, as explained below, new and material evidence was received within the appeal period for those decisions. Thus, the March 2015 and December 2015 rating decision did not become final, and the August 2014 rating decision that denied his claims seeking service connection for back and right knee disorders represents the last final denial of those claims. After a review of the evidence submitted since the August 2014 rating decision became final, the Board determines that the Veteran’s claims of entitlement to service connection for back and right knee disorders should be reopened. The record now includes new evidence, including a letter submitted in January 2016 referencing the back problems he experienced during his active duty service, new reports from VA examinations in November 2016 and June 2019, and a February 2020 private opinion. This evidence raises the possibility that he has a current back disorder that is proximately due to or the result of his service-connected left knee and left hip disabilities and that he has a current right knee disorder that is proximately due to or the result of his service-connected left knee disability. Not only is this evidence “new” because it was not of record prior to the last final denial of the claims, it is also “material” because it relates to unestablished facts necessary to support the claims. Therefore, his claims seeking service connection for a back disorder and a right knee disorder should be reopened. Shade, 24 Vet. App. at 118-21; see also 38 C.F.R. § 3.156(a). Service Connection 9. Entitlement to service connection for rectus femoris syndrome, to include as secondary to a service-connected left knee disability 10. Entitlement service connection for piriformis syndrome, to include as secondary to a service-connected left hip disability 11. Entitlement to service connection for a right knee disorder, to include as secondary to a service-connected left knee disability 12. Entitlement to service connection for a back disorder, to include as secondary to service-connected left hip and left knee disabilities The Veteran contends that service connection is warranted for rectus femoris syndrome and a right knee disorder because those disorders are proximately due to his service-connected left knee disability. He contends that service connection is warranted for piriformis syndrome because his piriformis syndrome is proximately due to his service-connected left hip disability. Finally, he contends that service connection is warranted for a back disorder because his back disorder is proximately due to his service-connected left hip and left knee disabilities. Under the relevant laws and regulations, service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1110. Generally, the evidence must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004); Caluza v. Brown, 7 Vet. App. 498, 505 (1995). Moreover, service connection is warranted for a disability that is aggravated by, proximately due to, or the result of a service-connected disease or injury. 38 C.F.R. § 3.310. Any additional impairment of earning capacity resulting from an already service-connected condition, regardless of whether the additional impairment is itself a separate disease or injury caused by the service-connected condition, should also be compensated. Allen v. Brown, 7 Vet. App. 439 (1995). Accordingly, when service connection is established for a secondary condition, the secondary condition shall be considered a part of the original condition. Id. Based upon the evidence of record, and resolving all reasonable doubt in favor of the Veteran, the Board determines that service connection is warranted for the Veteran’s piriformis syndrome, rectus femoris syndrome, back disorder, and right knee disorder. 38 U.S.C. §§ 1110, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. §§ 3.303(a), (d), 3.304, 3.307, 3.309, 3.310. First, the Board finds that the evidence is at least in equipoise that the Veteran’s rectus femoris syndrome is proximately due to or the result of his service-connected left knee disability. Here, a February 2020 private opinion reflects that a private physician opined that his rectus femoris is at least as likely as not proximately due to or the result of his service-connected left knee disability. In support of that opinion, the private physician explained that the Veteran’s left knee disability was the origin of his rectus femoris syndrome because his left knee disability caused overuse of the rectus femoris muscle. Regarding overuse, the private physician explained that the rectus femoris muscle is overused when a knee disability is present because the patella cannot fully provide stabilization in full extension, causing the rectus femoris muscle to be overly active. Next, the Board finds that the evidence is at least in equipoise that the Veteran’s piriformis syndrome is proximately due to or the result of his service-connected left hip disability. Here, the February 2020 private opinion reflects that the private physician opined that the Veteran’s piriformis syndrome is at least as likely as not the result of his service-connected left hip disability. In support of that opinion, the private physician explained that hypertrophy of the piriformis muscle, which is the cause of piriformis syndrome, was the result of increased activity of the Veteran’s piriformis muscle to stabilize the hip due to the Veteran’s left hip disability. Further, the private physician stated that because the Veteran’s femoral head was reduced and his femoral neck angle was abnormal, his piriformis muscle was required to work overtime and at higher levels of force to stabilize his left hip joint, causing his piriformis syndrome. The Board also finds that the evidence is at least in equipoise that the Veteran’s right knee disorder is proximately due to or the result of his service-connected left knee disability. Here, the report from the June 2019 VA examination reflects that the examiner opined that the Veteran’s right knee disorder was at least as likely as not proximately due to or the result of his service-connected left knee disability because individuals with unilateral knee osteoarthritis, like the Veteran, are at risk of developing bilateral osteoarthritis, due to such individuals adopting compensatory gait mechanisms that shift the load distribution from the affected limb to the healthy limb. Additionally, the February 2020 private opinion reflects that the private physician opined that the Veteran’s right knee disorder was the result of his service-connected left knee disability because his left leg impairment caused increased stress at the right knee, with later development of the current severity of his right knee disorder. Finally, the Board finds that the evidence is at least in equipoise that the Veteran’s back disorder is proximately due to or the result of his service-connected left hip and left knee disabilities. Here, the February 2020 private opinion reflects that the private physician opined that the Veteran’s back disorder was the result of his service-connected left hip and left knee disabilities. In support of that opinion, the private physician explained that the hip and knee pathology present in the Veteran caused an unusually high level of repeated minor injury to the lumbar spine, essentially occurring with each step he took and each episode of prolonged standing, and that the long-term accumulation of this repeated excess impact on his lumbar spine caused his current back disorder. The Board concludes that the opinions of the June 2019 VA examiner and the private physician who provided the February 2020 opinion are entitled to significant probative weight because of the examiner and the private physician reviewed the claims file, provided thorough rationales, and relied upon their wealth of experience. Moreover, the private physician cited to relevant medical literature in the extensive opinion that he authored. The Board acknowledges that the negative evidence includes the report from a November 2016 VA examination, where the examiner opined that the Veteran’s back disorder was less likely than not proximately due to or the result of his service-connected left hip disability because the location of the Veteran’s subjective pain was close to his hip, indicating that the pathology for the pain was more likely the Veteran’s left hip disability. However, the Board finds that the examiner’s opinion is not as probative as the opinion of the private physician in the February 2020 opinion because the private physician provided a significantly more extensive rationale that relied on medical literature and thorough review of the Veteran’s treatment records that was outlined in the opinion in contrast with the brief discussion set forth in the November 2016 VA examination report. The negative evidence also includes the report from a May 2018 VA examination, where the examiner opined that the Veteran’s piriformis syndrome was less likely than not proximately due to or the result of his service-connected left hip disability because medical literature noted that physical deformities during childhood growth years caused joint pain and damage similar to the pain described by the Veteran. Again, the Board finds that the examiner’s opinion is not as probative as the opinion of the private physician in the February 2020 opinion because the Veteran was sound at entry, so attributing his piriformis syndrome to a physical deformity during childhood was insufficient, and because the private physician provided a thorough review of the treatment records that was outlined in the opinion in contrast with the brief discussion set forth in the May 2018 VA examination report. By virtue of the foregoing, and resolving all reasonable doubt in the Veteran’s favor, the Board concludes that the evidence is at least in equipoise that his current rectus femoris syndrome and right knee disorder are proximately due to or the result of his service-connected left knee disorder, his piriformis syndrome is proximately due to or the result of his service-connected left hip disorder, and his back disorder is proximately due to or the result of his service-connected left hip and left knee disorders. Accordingly, service connection is granted. REASONS FOR REMAND 1. Entitlement to TDIU is remanded. With respect to the Veteran’s claim for TDIU, because the Board has granted service connection for rectus femoris syndrome, a right knee disorder, piriformis syndrome, and a his back disorder, and granted a separate 10 percent disability rating for his left knee disability from June 18, 2019 based upon limitation of flexion of his left knee, the Veteran’s disability picture has now changed. Therefore, it would be prejudicial to evaluate the Veteran’s TDIU claim in the first instance given these changes, and the RO should reevaluate this issue prior to Board consideration. The matters are REMANDED for the following action: 1. Obtain all treatment records from the VA Illiana Health Care System, Danville, Illinois Division, and any other VA facility from which the Veteran has received treatment since October 2019. If the Veteran has received additional private treatment, he should be afforded an appropriate opportunity to submit the medical records of such treatment. 2. The RO should undertake any additional action it deems necessary in order to properly adjudicate the Veteran’s claim of entitlement to TDIU, including any additional VA examinations. B.T. KNOPE Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. Crosnicker, Associate Counsel