Citation Nr: 21020762 Decision Date: 04/08/21 Archive Date: 04/08/21 DOCKET NO. 15-10 331A DATE: April 8, 2021 ORDER Entitlement to a rating higher than 20 percent for right shoulder impingement syndrome (right shoulder disability), is denied. Entitlement to a compensable rating for hemorrhoids is denied. REMANDED Entitlement to a rating higher than 10 percent for right knee patellofemoral dysfunction (right knee disability) is remanded. Entitlement to a rating higher than 10 percent for left knee patellofemoral dysfunction (left knee disability) is remanded. FINDINGS OF FACT 1. The most probative evidence demonstrates that the Veteran’s right shoulder disability has been manifested by flexion limited to no less than 145 degrees and abduction limited to no less than 90 degrees; there is no evidence of favorable or unfavorable ankylosis of the shoulder joint, impairment of the humerus, impairment of the clavicle or scapula, or right shoulder motion limited to 45 degrees or less or midway between the side and shoulder level. 2. The most probative evidence of record shows that the Veteran has internal hemorrhoids that are mild in severity. CONCLUSIONS OF LAW 1. The criteria for a disability rating higher than 20 percent for a right shoulder disability, are not met. 38 U.S.C. § 1155; 38 C.F.R. § 4.71a, DC 5201. 2. The criteria for a compensable rating for hemorrhoids have not been met. 38 U.S.C. §§ 1155; 38 C.F.R. § 4.114, DC 7336. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Air Force from June 1979 to June 2004. These matters are on appeal from December 2011 and April 2013 rating decisions. In January 2019, the Board remanded these matters, and claims for service connection for left shoulder and left ankle disabilities, for further development. The claims for service connection for left shoulder and left ankle disabilities, were granted in an August 2020 Decision Review Officer decision. The Veteran did not disagree with the disability evaluations or the effective date assigned. Therefore, these matters are no longer considered to be in appellate status. Increased Rating Claims Disability evaluations (ratings) 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 the 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. In evaluating a disability, the Board considers the current examination reports in light of the whole recorded history to ensure that the current rating accurately reflects the severity of the condition. The Board has a duty to acknowledge and consider all regulations that are potentially applicable. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). The medical and industrial history is to be considered, and a full description of the effects of the disability upon ordinary activity is also required. 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 evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. Reasonable doubt regarding the degree of disability will be resolved in the veteran’s favor. 38 C.F.R. § 4.3. In view of the number of atypical instances it is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified. Findings sufficiently characteristic to identify the disease and the disability therefrom, and above all, coordination of rating with impairment of function will, however, be expected in all instances. 38 C.F.R. § 4.21. At the time of an initial rating, separate ratings can be assigned for separate periods of time based on facts found, a practice known as “staged” ratings. Fenderson v. West, 12 Vet. App. 119, 126 (1999). The evaluation of the same disability under various diagnoses, known as pyramiding, is generally to be avoided. 38 C.F.R. § 4.14. The critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the disabilities is duplicative or overlapping with the symptomatology of the other disability. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). Right shoulder disability 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.”). The intent of the Rating Schedule is to recognize actually painful, unstable or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. As such, painful motion should be considered to determine whether a higher rating is warranted on such basis, whether or not arthritis is present. See Burton v. Shinseki, 25 Vet. App. 1 (2011). In this regard, 38 C.F.R. § 4.59 requires that “[t]he joints involved should be tested for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with the range of the opposite undamaged joint.” Correia v. McDonald, 28 Vet. App. 158 (2016). Further, 38 C.F.R. § 4.59 is applicable to the evaluation of musculoskeletal disabilities involving actually painful, unstable or malaligned joints or periarticular regions, regardless of whether the Diagnostic Code under which the disability is evaluated is predicated on range of motion measurements. Southall-Norman v. McDonald, 28 Vet. App. 346 (2016). When determining the severity of musculoskeletal disabilities, which are at least partly rated on the basis of range of motion, VA must consider the extent of additional functional impairment a veteran may have above and beyond the limitation of motion objectively demonstrated due to pain, limited or excess movement, weakness, incoordination, and premature or excess fatigability, etc., particularly when symptoms “flare up,” to include periods of prolonged use, and assuming these factors are not already contemplated in the governing rating criteria. See 38 C.F.R. §§ 4.40, 4.45, 4.59; Sharp v. Shulkin, 29 Vet. App. 26 (2017). During the pendency of the appeal, the rating criteria for evaluating musculoskeletal disabilities under 38 C.F.R. § 4.71a were amended effective February 7, 2021. 85 Fed. Reg. 230 (Nov. 30, 2020). These amendments revised select diagnostic codes “to ensure that this portion of the rating schedule uses current medical terminology and provides detailed and updated criteria for the evaluation of musculoskeletal disabilities.” Id. If a law or regulation changes during the course of a claim or an appeal, the version more favorable to the Veteran will apply, to the extent permitted by any stated effective date in the amendment in question. 38 U.S.C. § 5110(g). 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. Therefore, the Board will consider the Veteran’s claim under the old criteria prior to February 7, 2021 and both the old and new rating criteria from February 7, 2021. The criteria that is more favorable to the Veteran will be applied. Disabilities and injuries of the shoulder are evaluated under DC 5200, 5201, 5202 and 5203. See 38 C.F.R. § 4.71 (a). The evidence establishes the Veteran is right-handed, so his right shoulder is rated for impairment of the major upper extremity. In this regard, as the evidence does not demonstrate any ankyloses, any identified impairment of the humerus for either shoulder, or malunion of the clavicle or scapula of the arm or nonunion of the clavicle or scapula without loose movement, DCs, 5200, 5202, and 5203 are inapplicable. As such, an increased rating cannot be assigned under DCs 5200, 5202, or 5203. 38 C.F.R. § 4.71a, DCs 5200, 5202 and 5203. As the Veteran is service-connected for right shoulder impingement syndrome and the record reflects limited motion of the shoulder, the Board will consider whether evidence of record warrants the assignment of a higher disability rating for the right shoulder under DC 5201, which contemplates limitation of motion of the arm. The Veteran contends that his service-connected right shoulder disability is more severe than his 20 percent evaluation would indicate. His right shoulder disability is rated pursuant to DC 5201. Prior to February 7, 2021, under DC 5201, for the major side, a 20 percent rating is warranted for limitation of arm motion to shoulder level; a 30 percent rating is warranted for limitation of arm motion to midway between the side and shoulder level; and a maximum 40 percent rating is warranted for limitation of arm motion to 25 degrees from the side. For the minor side, a 20 percent rating is warranted for limitation of arm motion to shoulder level; a 20 percent rating is also warranted for limitation of arm motion to midway between the side and shoulder level; and a maximum 30 percent rating is warranted for limitation of arm motion to 25 degrees from the side. 38 C.F.R. § 4.71a, DC 5201. Effective February 7, 2021, DC 5201 was revised to clarify that loss of motion of the arm includes flexion or abduction and now provides specific range of motion measurements for the ratings. Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 76453, 76462 (Nov. 30, 2020) (to be codified at 38 C.F.R. § 4.71a, Diagnostic Code 5201, 5202). Under the revised criteria for DC 5201, for the major side, a 20 percent rating is warranted for limitation of arm motion to shoulder level (flexion and/or abduction limited to 90 degrees); a 30 percent rating is warranted for limitation of arm motion to midway between the side and shoulder level (flexion and/or abduction limited to 45 degrees); and a maximum 40 percent rating is warranted for limitation of arm motion to 25 degrees from the side. For the minor side, a 20 percent rating is warranted for limitation of arm motion to shoulder level (flexion and/or abduction limited to 90 degrees); a 20 percent rating is also warranted for limitation of arm motion to midway between the side and shoulder level (flexion and/or abduction limited to 45 degrees); and a maximum 30 percent rating is warranted for limitation of arm motion to 25 degrees from the side. 38 C.F.R. § 4.71a, DC 5201. Normal forward flexion of the shoulder is 0 to 180 degrees; abduction is 0 to 180 degrees; and internal and external rotation are from 0 to 90 degrees. 38 C.F.R. § 4.71a, Plate I. Forward flexion and abduction to 90 degrees amounts to shoulder level. Turning to the evidence of record, on March 2013 VA shoulder and arm conditions Disability Benefits Questionnaire (DBQ) examination, the Veteran stated that his right shoulder disability had worsened since the last examination in 2008. He denied any history of hospitalization, surgery, or specialized procedures. Right shoulder symptoms included pain described as burning pressure, decreased range of motion, and right hand pain. However, he did not report any flare-ups. Range of motion measurements of the right shoulder indicated 165 degrees flexion and 170 degrees abduction with no objective evidence of painful motion. The Veteran was able to perform repetitive-use testing with three repetitions with no additional limitation in range of motion following repetitive-use testing. The Veteran had functional loss and/or functional impairment of the right shoulder and arm after repetitive use described as less movement than normal. There was no localized tenderness or pain on palpation of the joint, soft tissue, or biceps of the right shoulder. There was no guarding of the shoulder and muscle strength testing of the right shoulder was normal without evidence of ankylosis. Tests for rotator cuff disabilities were negative. Tests for instability, dislocation, and labral pathology were normal. There was no AC (acromioclavicular) joint disability or any other impairment of the clavicle or scapula or tenderness on palpation of the AC joint. On X-ray examination there was no evidence of degenerative or traumatic arthritis. The examiner diagnosed impingement of the right shoulder which impacted the Veteran’s ability to work. The right shoulder disability had no impact on feeding, bathing, dressing, toileting, or grooming; a mild effect on chores, shopping, recreation, and driving; and a moderate to severe effect on exercise and sports. VA treatment records include an August 2013 X-ray examination of the right shoulder which indicated mild degenerative joint disease (DJD). Records dated in August 2013 reflect the Veteran’s complaint of right shoulder and right hand pain and a diagnosis of right shoulder arthralgia. In October 2013 the Veteran complained inflammation near the rotator cuff, muscles, and ligaments. An October 2013 X-ray examination indicated mild chronic supraspinatus and minimal insertional infraspinatus tendinopathy without a discrete rotator cuff tear and AC joint hypertrophy with moderate mass effect. Records dated in November 2013 include an X-ray examination which showed significant arthritis, a complaint of right shoulder pain, and diagnoses of rotator cuff tendinitis and DJD with possible Hawkins impingement. A December 2013 rheumatology consultation report indicates a complaint of right shoulder pain for years with a crunching sound with movement. The Veteran was provided a brace and an EMG/NCS was scheduled. The impression was right shoulder pain with rotator cuff tendinitis and DJD with possible Hawkins impingement consistent with tendinitis. He was given a right shoulder steroid injection. In May 2014 the Veteran complained of right shoulder flare-ups with pain rated a 7 to 8 out of 10 on the pain scale. A June 2014 physical therapy note indicates active range of motion measurements of 145 degrees flexion, 155 degrees abduction, and 55 degrees extension. The assessment was signs and symptoms consistent with rotator cuff tendonitis with clinical presentation, decreased shoulder range of motion, and decreased strength and joint mobility which limited the Veteran’s ability to perform lifting and reaching tasks. A July 2015 report reflects a diagnosis of worsening right shoulder arthralgia secondary to DJD. Right shoulder throbbing interfered with sleep and caused him to sleep on his left side. It was treated with Capsaicin. In May 2016 the Veteran had full range of motion of the right shoulder and received a steroid injection. A September 2016 report shows decreased range of motion of the right shoulder and mild tenderness to palpation. The Veteran was given a right shoulder steroid injection. The assessment was right shoulder impingement and DJD. Range of motion measurements of the right shoulder in March 2017 indicated 165 degrees forward flexion, 45 degrees external rotation, and 90 degrees abduction with mild to moderate pain. Stability tests were negative for evidence of apprehension or guarding, but there was evidence of tenderness. An X-ray examination indicated mild osteoarthritis. In May 2017, the Veteran complained of right should pain described as a constant ache of variable intensity. Pain did not interfere with work or other activities and the shoulder was stable. On May 2018 VA shoulder and arm conditions DBQ examination, the Veteran presented with a history of right shoulder impingement syndrome. He complained of right shoulder pain with movements and numbness in the right arm. The Veteran also complained of right arm numbness and an inability to lift the arm. Notably, the examiner stated that the Veteran’s subjective during the examination appeared out of proportion to objective examination findings. The Veteran was noted to display poor effort during the examination. Senses were intact to light tough and motor strength was normal. According to the examiner, during the examination the Veteran reported excruciating pain with any attempt to passive range of motion. He threw himself to the floor alleging to be in severe pain and knelt on the floor in a fetal position with both shoulders abducted greater than greater than 90 degrees. The examination was terminated given the Veteran’s alleged symptoms. A June 2018 X-ray examination of the right shoulder indicated stable and mild AC joint osteoarthritis. In January 2019, the Board remanded the claim for an adequate VA examination based on the Veteran’s contentions that the March 2013 VA examination was inadequate because the examiner conducted himself unprofessionally. See May 2014 statement. Pursuant to the Board’s remand, on October 2019 VA shoulder and arm conditions DBQ examination the Veteran complained of worsening right shoulder pain described as a constant aching sensation rated 7 to 8 out of 10 on the pain scale. The pain had been chronic with no reports of recent change/progression of symptoms for the last 15 years. The Veteran received 10 injections in the right shoulder for pain which produced temporary improvement each time lasting 4 to 5 days. The Veteran stated that he used a right shoulder support which helped reduce pain. He did not report any flare-ups of the right shoulder. Functional loss or functional impairment of the joint were described as pain in the right shoulder and functional limitations including pulling, pushing, lifting more than 15 pounds, and lifting the right arm above the head. Range of motion measurements of the right shoulder were normal. Pain was noted on examination, but did not result in or cause functional loss. Pain was noted on flexion, abduction, and internal rotation. There was evidence of pain with weight-bearing, but no objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue. There was no evidence of crepitus. The Veteran was able to perform repetitive use testing with at least three repetition with no additional functional loss or range of motion after three repetitions. Pain significantly limited functional ability with repeated use over a period of time. In terms of range of motion, this was manifested by 175 degrees flexion and abduction, 90 degrees external rotation, and 85 degrees internal rotation. Muscle strength testing of the right shoulder was normal with no muscle atrophy or ankylosis. A rotator cuff disability of the right shoulder was suspected. The empty can test was positive, but Hawkins impingement, external rotation/ infraspinatus strength, and lift-off subscapularis tests were negative. There was no evidence of shoulder instability, dislocation, or labral pathology. There was mild osteoarthritis of the AC joint with no acute bony abnormalities. The Veteran stated that he used a right shoulder support for pain. The examiner diagnosed right shoulder impingement syndrome which the examiner opined impacted his ability to perform any type of occupational tasks. However, he maintained full-time employment as a tutor for a school district. After review of the evidence, the Board finds that a rating higher than 20 percent for right shoulder disability is not warranted under the criteria prior to or since February 7, 2021. For the major extremity or the Veteran’s right shoulder, prior to February 7, 2021, a 30 percent rating is warranted for limitation of arm motion to midway between the side and shoulder level. Since February 7, 2021, a 30 percent rating is warranted for limitation of arm motion to midway between the side and shoulder level (flexion and/or abduction limited to 45 degrees). However, the evidence shows that the Veteran’s right shoulder limitation of range of motion has been to no less than 145 degrees and abduction limited to no less than 90 degrees abduction. Accordingly, a higher evaluation is not warranted for the right shoulder. Regarding the DeLuca factors, the Board observes that the VA examiners noted the Veteran’s complaints such as pain. The Board has taken those complaints into consideration in its above discussion. However, the objective medical evidence of record is of greater probative value as to the Veteran’s level of impairment than his assertions. Even considering his subjective complaints of pain and other symptoms described in DeLuca, limitation of motion of the right shoulder has not been shown such that a higher rating would be warranted. See Thompson v. McDonald, 815 F.3d 781, 786 (Fed. Cir. 2016) (holding that provision describing functional loss due to disability of the musculoskeletal system does not supersede requirements for a higher rating specified in the Rating Schedule). The Board finds that the evidence does not support a finding that the Veteran’s right shoulder disability more closely approximates a 30 percent rating. In sum, the Board finds that the preponderance of the evidence is against the assignment of a rating greater than 20 percent for the right shoulder due to limitation of motion of the shoulder prior to or since February 7, 2021. While the Board accepts the contentions of the Veteran that his right shoulder limitation of motion causes him to experience pain, providing the basis for the 20 percent evaluation, the Board has taken that into account in its consideration of the range of motion of the Veteran’s right shoulder. The rating schedule does not require a separate rating for pain itself. Spurgeon v. Brown, 10 Vet. App. 194 (1997). Accordingly, a greater rating is not warranted based on functional loss due to pain and weakness causing additional disability beyond that reflected on range of motion measurements. Accordingly, the Veteran is not entitled to a higher rating for his right shoulder disability during the period on appeal. Hemorrhoids The Veteran contends that his service-connected hemorrhoids are more severe than his noncompensable evaluation would indicate. The Veteran’s hemorrhoids have been rated as noncompensable (zero percent) disabling under Diagnostic Code 7336. Under DC 7336, a noncompensable rating is warranted for internal or external hemorrhoids which are mild or moderate. A 10 percent rating is warranted for large or thrombotic, irreducible hemorrhoids with excessive redundant tissue evidencing frequent recurrences. A 20 percent rating is warranted for hemorrhoids with persistent bleeding and secondary anemia, or with fissures. 338 C.F.R. § 4.114, Diagnostic Code 7336. Turning to the evidence of record, VA treatment records include a September 2012 emergency department note reflects the Veteran’s complaints of hemorrhoids and bleeding. The assessment was hematochezia. He was referred for a colonoscopy. In November 2012, the Veteran was evaluated for hematochezia and complained of irritation with itching and blood. The assessment was hemorrhoids. On March 2013 VA rectum and anus conditions DBQ examination, the Veteran complained of worsening hemorrhoids with bleeding, swelling, pain, and itching. His treatment plan included continuous medication including hemorrhoidal ointment. The examiner described the hemorrhoids as mild or moderate internal or external hemorrhoids with bleeding, swelling, pain and itching. The Veteran complained of a recent flare-up which improved with medication and a stool softener. The examiner diagnosed internal or external hemorrhoids. The examination was normal with no external hemorrhoids, anal fissures, or other abnormalities. A February 2013 colonoscopy and rectal examination was normal. The examiner opined that the Veteran’s hemorrhoids did not impact his ability to work. VA treatment records include an August 2013 report which shows that the Veteran reported worsening hemorrhoids. The assessment was hemorrhoids, recent flare. A November 2013 surgery outpatient note indicates a healing fissure. The assessment was anal fissure. In a November 2018 notice of disagreement, the Veteran stated that his hemorrhoids were worse than reflected by a March 2013 VA examination. On this basis, in January 2019 the Board remanded the claim for an additional examination is warranted to assess the current severity of the Veteran’s hemorrhoids. See November 2018 Brief. Pursuant to the Board’s remand, on October 2019 VA rectum and anus conditions DBQ examination the Veteran presented with a diagnosis of internal or external hemorrhoids. The Veteran reported that his last flare was approximately one year ago. He stated that he used over-the-county suppositories or ointment with flares. The Veteran took Metamucil daily and consumed increased amounts of fiber. Symptoms of flare-ups consisted of blood on toilet tissue and discomfort during bowel movements. His treatment plan included taking continuous medications for the diagnosed conditions. The signs and symptoms included mild or moderate internal or external hemorrhoids. An examination of the rectal/anal area was normal with no external hemorrhoids or anal fissures. The examiner opined that the hemorrhoids did not impact the Veteran’s ability to work. After review of the evidence, the Board finds that a compensable rating for the Veteran’s hemorrhoids are not warranted at any time during the appeal. The Board finds that there are no indications that the Veteran has had large or thrombotic, irreducible hemorrhoids with excessive redundant tissue evidencing frequent recurrences. Accordingly, the evidence of record does not show that the Veteran's hemorrhoids warrant the assignment of a compensable rating. Additional considerations In this case, the Veteran is competent to report complaints such as pain associated with his right shoulder disability, and itching associated with hemorrhoids, as these observations come to him through his senses. Layno v. Brown, 6 Vet. App. 465, 469 (1994). The Board also acknowledges the Veteran's belief that his symptoms are of such severity as to warrant a higher rating and has taken these contentions seriously. He is not, however, competent to identify a specific level of disability of his right shoulder disability and hemorrhoids, according to the appropriate diagnostic codes. On the other hand, such competent evidence concerning the nature and extent of the Veteran’s 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 examination reports) directly address the criteria under which these disabilities are evaluated. Finally, neither the Veteran nor his representative have raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 369-370 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). REASONS FOR REMAND Bilateral knee disabilities As noted above, during the pendency of the appeal, the rating criteria for evaluating musculoskeletal disabilities under 38 C.F.R. § 4.71a were amended effective February 7, 2021. 85 Fed. Reg. 230 (Nov. 30, 2020). The Veteran’s bilateral knee disability is currently rated under Diagnostic Code 5260, but Diagnostic Code 5257 which rates recurrent subluxation or lateral instability of the knee now adds a rating for patellar instability and is applicable to the Veteran’s bilateral knee claim. Because the record does not contain sufficient evidence to rate the Veteran’s bilateral knee disabilities under the new rating criteria, a new examination is warranted. The matters are REMANDED for the following actions: 1. Obtain all outstanding VA medical records related to the Veteran’s bilateral knee disabilities, dated since September 2020. All records and/or responses received should be associated with the claims file (the Veteran himself can also submit all record he believes to be pertinent). 2. Schedule the Veteran for a VA examination, to ascertain and evaluate the current level of severity of his service-connected bilateral knee disability. All indicated studies and tests should be performed. The claims folder should be made available to the examiner for review of pertinent documents. The examination reports should reflect that such a review was conducted. The AOJ should ensure that the examiner provides all information required for rating purposes, under both the former and revised rating criteria for evaluating musculoskeletal disabilities under 38 C.F.R. § 4.71a effective February 7, 2021. 85 Fed. Reg. 230 (Nov. 30, 2020). KELLI A. KORDICH Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board T. Adams, 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.