Citation Nr: 21021361 Decision Date: 04/12/21 Archive Date: 04/12/21 DOCKET NO. 13-33 876A DATE: April 12, 2021 ORDER Entitlement to an initial evaluation for left knee rheumatoid arthritis with degenerative arthritis and osteopenia status post arthroscopic surgery in excess of 10 percent disabling is denied. Entitlement to an initial evaluation for hypothyroidism in excess of 60 percent disabling is denied. FINDINGS OF FACT 1. During the pendency of the appeal, the most probative evidence does not reflect that the Veteran’s left knee rheumatoid arthritis with degenerative arthritis and osteopenia status post arthroscopic surgery was manifested by flexion limited to 30 degrees or less or extension limited to 15 degrees or less, to include after repetitive motion testing, during a flare-up of symptoms, in weight-bearing and non-weight-bearing positions, and on active and/or passive motion. 2. During the pendency of the appeal, the most probative evidence reflects that the Veteran’s hypothyroidism was manifested by cold intolerance, muscular weakness, cardiovascular involvement, mental disturbance (dementia, slowing of thought, depression), bradycardia (less than 60 beats per minute), and sleepiness as articulated by the old rating criteria and was not manifested by myxedema (cold intolerance, muscular weakness, cardiovascular involvement (including, but not limited to hypotension, bradycardia, and pericardial effusion), and mental disturbance (including, but not limited to dementia, slowing of thought and depression)) as articulated by the new rating criteria. CONCLUSIONS OF LAW 1. The criteria for entitlement to an initial evaluation for left knee rheumatoid arthritis with degenerative arthritis and osteopenia status post arthroscopic surgery in excess of 10 percent disabling have not been met or closely approximated. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.71a, Diagnostic Codes 5002-5260. 2. The criteria for entitlement to an initial evaluation for hypothyroidism in excess of 60 percent disabling have not been met or closely approximated. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.119, Diagnostic Code 7903. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active duty service from December 1985 to March 2011. This appeal comes to the Board of Veterans’ Appeals (Board) from a rating decision, dated August 2011, issued by a Department of Veterans Affairs (VA) Regional Office. The Veteran timely appealed. The Veteran’s appeals have previously been before the Board. In June 2015, June 2018, and October 2019, the Board remanded the Veteran’s claims for entitlement to a rating higher than 10 percent for left knee rheumatoid arthritis with degenerative arthritis and osteopenia status post arthroscopic surgery and entitlement to a rating higher than 10 percent for hypothyroidism to the Agency of Original Jurisdiction (AOJ) for additional development. In an August 2020 rating decision, the RO increased the initial evaluation for hyperthyroidism to 60 percent, effective April 1, 2011 – the day after his discharge from service. As this award did not represent a full grant of the benefits sought, the Veteran’s appealed issue remains in appellate status. AB v. Brown, 6 Vet. App. 35, 38 (1993). Increased Ratings Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (rating schedule), found in 38 C.F.R. Part 4. Disability ratings are intended to compensate impairment in earning capacity due to a service-connected disorder. 38 U.S.C. § 1155. If there is a question as to which evaluation to apply to the Veteran’s disability, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. When reasonable doubt arises as to the degree of disability, such doubt will be resolved in the Veteran’s favor. 38 C.F.R. § 4.3. 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 coordination of rating with impairment of function. 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 his disability in reaching its decision. Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). 1. Entitlement to an initial evaluation for left knee rheumatoid arthritis with degenerative arthritis and osteopenia status post arthroscopic surgery in excess of 10 percent disabling The Veteran generally asserts that the assigned 10 percent rating under Diagnostic Code 5002-5260 does not adequately reflect the severity of his left knee rheumatoid arthritis with degenerative arthritis and osteopenia status post arthroscopic surgery. The period on appeal begins on April 1, 2011, the effective date of the award of service connection for left knee rheumatoid arthritis with degenerative arthritis and osteopenia status post arthroscopic surgery. Traumatic arthritis, substantiated by x-ray findings, is rated as degenerative arthritis. 38 C.F.R. § 4.71a, Diagnostic Code 5010. Degenerative arthritis established by x-ray findings will be rated based on limitation of motion under the appropriate diagnostic code for the specific joint or joints involved. When, however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under diagnostic code 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. 38 C.F.R. § 4.71a, Diagnostic Code 5003. Limitation of flexion of the leg is evaluated as follows: flexion limited to 15 degrees (30 percent); flexion limited to 30 degrees (20 percent); flexion limited to 45 degrees (10 percent); and flexion limited to 60 degrees (0 percent). 38 C.F.R. § 4.71a, Diagnostic Code 5260. Limitation of extension of the leg is evaluated as follows: extension limited to 45 degrees (50 percent); extension limited to 30 degrees (40 percent); extension limited to 20 degrees (30 percent); extension limited to 15 degrees (20 percent); extension limited to 10 degrees (10 percent); and extension limited to 5 degrees (0 percent). 38 C.F.R. § 4.71a, Diagnostic Code 5261. Separate ratings under Diagnostic Codes 5260 and 5261 may be assigned for disability of the same joint, if none of the symptomatology on which each rating is based is duplicative or overlapping. VAOPGCPREC 9-04; 69 Fed. Reg. 59990 (2004); 38 C.F.R. § 4.14. VA regulations set forth at 38 C.F.R. §§ 4.40, 4.45, 4.59 provide for consideration of functional impairment due to pain on motion when evaluating the severity of a musculoskeletal disability. The Court has held that a higher rating can be based on “greater limitation of motion due to pain on use.” DeLuca v. Brown, 8 Vet. App. 202, 206 (1995). Any such functional loss must be “supported by adequate pathology and evidenced by the visible behavior of the claimant.” See 38 C.F.R. § 4.40. The Veteran’s range of motion must be limited to 30 degrees flexion, or 15 degrees extension, to warrant a rating higher than 10 percent. In both a July 2012 Notice of Disagreement (NOD) and a December 2013 Form 9, the Veteran wrote, I believe that my case was decided incorrectly based on my symptoms compared to the ratings I received…I have responded well to therapy resulting in a good range of motion, but I still suffer pain in that motion, particularly when the weather is cold. I am prescribed a biologic drug to slow the advancement of the rheumatoid arthritis taken by injection. My body quit responding to Humira and now I take a stronger biologic…along with methotrexate. My rheumatologist…whom I have been in the care of since 2005, states that I will need a knee replacement. This will not be done until I am past my 55th birthday due to the probability that I would wear it out too fast if I have the procedure done at an earlier date. In the meantime, I cannot take a job that requires standing/weight bearing due to the pain this causes. It also presents a safety issue. I have flare-ups four to five times a year where it is very painful to walk any distance. During these periods I take the Percocet prescribed…to cope. (Air travel is also painful, though I’m not sure why. It could be the pressurization or perhaps the altitude.) I taken an NSAID (MOBIC) for the daily pain. The Mobic helps, but it only takes the edge off the pain. During the flareups, I move like a man 40 years older than I am. I suffer several flare-ups (exacerbations) each year. Fortunately, these only last a few days. By the time I can get in to see the doctor (weeks after the flare-up) there is little to show. The snapping, cracking, and popping sounds my knees make are more pronounced after a flare-up. So, I usually wait until one of my regular appointments to discuss it with the doctor…I am not bedridden by my exacerbations, but I can’t bear much weight on my knees when they flare up. I have fallen from my knees “giving out” on me on several occasions. A January 2014 medical treatment record noted full range of motion throughout the knees. A January 2015 medical treatment record noted painful range of motion of the knees but no effusion. His rheumatoid arthritis was recorded as increasingly symptomatic. The Veteran’s left knee disability claim was remanded in June 2015 for a VA examination. On VA examination in December 2015, the Veteran noted that his knee was better for a while but swelling and pain recurred and it was painful to walk on. He changed to another medication, which failed to continue to work. He was then on a different medication which was better, but not where he would like to be yet. He said he did not have flares-ups of the knee but noted every day was pretty bad with worse days. Flexion of the left knee was noted as 0 to 125 degrees and extension was noted as 125 to 0 degrees. There was pain noted on examination and on weight-bearing but did not result in or cause functional loss. The Veteran was able to perform repetitive use testing with no additional loss of function or range of motion. When asked if pain, weakness, fatigability or incoordination significantly limited functional ability with repeated use over a period of time, the examiner noted she was unable to say without mere speculation. Additional contributing factors of the disability included disturbance of locomotion. It was also noted that the Veteran’s knee was not inflamed and range of motion was close to normal but he did have an antalgic gait. Strength was 5/5 with no ankylosis. In an appellate brief dated June 2018, the Veteran’s representative wrote, “Throughout the pendency of this appeal the Veteran has complained of discomfort, in to additional functional due to stiffness and locking of the knee.” The representative then went on to discuss the inadequacy of the December 2015 VA examination. In June 2018, the Board determined that the December 2015 VA examination was inadequate for rating purposes because the examiner did not document the degree at which pain started during range of motion testing. In addition, the examination failed to indicate whether there was pain on both active and passive motion and/or in weight-bearing and nonweight-bearing. Therefore, the issue was remanded for a new VA examination. In a March 2018 and February 2019 private treatment record, the Veteran reported pain in his knee. On VA examination in March 2019, the Veteran reported his left knee “hurts” daily and constantly. He reported his left knee felt stiff with prolonged standing or sitting, “like driving here today…I can take the edge of it, that’s it.” He reported he had a knee brace in the past, but denied current use of any assistive device for the left knee. He did not report flare-ups of the knee. He did not report any functional loss or functional impairment. Range of motion of the left knee was 0 to 125 degrees for flexion and 125 to 0 degrees for extension. There was pain noted on examination but it did not cause functional loss. There was pain with weight-bearing and evidence of crepitus. The Veteran was able to perform repetitive use testing with no additional loss of function or range of motion. When asked if pain, weakness, fatigability, or incoordination significantly limited functional ability in the left knee with repeated use over a period of time or with flare-ups, the examiner wrote she was unable to say without mere speculation. She provided, It is understood that VBA needs to know the range of motion and exam findings that would be present during a flare up or after repetitive use over time. It is, however, not possible to give this exact data when not having seen the Veteran in person during such time(s) in question. While it may be assured that the exam findings would be worse during a flare or after repetitive use over time, the degree of worsening would not be known without an exam. Thus, this would require speculation and potentially results in under or overestimating any change of ROM, pain, weakness, fatigability or incoordination, etc. Unless otherwise documented in the report: no objective evidence of pain on passive range of motion was noted, passive range of motion was unchanged from active range of motion and there was no evidence of pain when the joint was used non-weight bearing. There were no additional contributing factors of the left knee disability. Strength was 5/5 with no ankylosis. The functional impact was noted as experiencing the knee feeling stiff with prolonged sitting or standing. In an August 2019 appellate brief, the Veteran’s representative wrote, in relevant part, [The Veteran] states that he has several flare-ups (exacerbations) a year that last a few days. [He] stated that after a flare up the snapping, cracking and popping sounds in his knee are more pronounced. [He] further contends that he has fallen from his knee giving out on several occasions. A C&P examination was performed on his knees on March 23, 2019. The examiner marked “no” for whether the Veteran reports flare-ups of the knee. [His] Form 9 notes that he has several flare-ups a year. The examiner also noted that it would be mere speculation to estimate loss of motion during a flare up or after repetitive use over time without observing this during an exam. The examiner continued by saying that this might “potentially result in under or overestimating any change of ROM, pain, weakness, fatigability or incoordination, etc.” [We contend] that this is not an adequate explanation of why the examiner is unable to “estimate” additional loss of motion. Additionally, the examiner marked that joint stability testing was performed and he did not have joint instability. [We contend] that the examiner failed to address his lay evidence that indicates he has fallen several times from his knee giving out. In October 2019, the Board remanded the Veteran’s left knee disability claim providing, In the December 2013 form 9, the Veteran reported four to five flare-ups per year that make it painful to walk… In the August 2019 informal hearing presentation [(IHP)], the Veteran’s representative argued that the March 2019 VA examination was inadequate for rating purposes because the examiner did not address the Veteran’s statements about his experiences of flare-ups. In addition, the Veteran’s representative emphasized that throughout the appeal the Veteran has complained of discomfort, stiffness, and locking of the knee. See IHP dated June 2018. In the December 2013 form 9, the Veteran reported falling several times from his knees “giving out.” Knees giving out is consistent with symptoms of a meniscal tear and the Board observes that a Veteran is competent to provide lay testimony as to knee instability. Therefore, the Board remanded the issue for a new VA examination. In a November 2019 rating decision, the RO granted service connection for dislocated semilunar cartilage of the left knee with an evaluation of 20 percent effective April 1, 2011. In January 2020, the Veteran submitted a statement in support of claim, in which he wrote, “In July 2018, as I was putting my lunch in the refrigerator at work, my left knee buckled and I fell. Seemingly for no reason…I share this as evidence of my knee instability.” The Veteran underwent another VA examination in March 2020. The Veteran reported that the condition had persisted/worsened. His current symptoms included constant pain rated as a three out of 10. His pain increased to a five out of 10 by the end of an average day. His pain increased to an eight out of 10 with prolonged sitting/standing/walking, any impact activity, going up/down steps/incline, and any bending/twisting/rotating. It resolved a few hours after stopping the activity. His knee popped, cracked, and grinded with movement. His knee swelled up daily. He took frequent breaks with prolonged walking/standing/sitting. He avoided impact activities. He used handrails when forced to use steps or getting in and out of a chair or car. He did daily stretching and strengthening. He used ice a few times a week. He also took medication. He reported flare-ups and described them in the same way as addressed above. He also reported functional loss or impairment described in the same way as addressed above. Range of motion of the left knee was 0 to 110 degrees for flexion and 110 to 0 degrees for extension. There was pain noted on examination, which caused functional loss described as reduced bending. There was pain with weight-bearing and evidence of crepitus. The Veteran was able to perform repetitive use testing with no additional loss of function or range of motion. Pain significantly limited functional ability in the left knee with repeated use over a period of time or with flare-ups. This was described in terms of range of motion as 0 to 75 degrees for flexion and 75 to 0 degrees for extension. It was also described in terms of range of motion as 0 to 80 degrees for flexion and 80 to 0 degrees for extension. There were no additional contributing factors of the left knee disability. Strength was 4/5 with no ankylosis. The Board finds that the March 2020 VA examination is adequate and substantially compliant with the October 2019 BVA remand. The examiner adequately addressed the Veteran’s statements about his experiences of flare-ups. In addition, prior to the VA examination, as stated above, the Veteran was awarded service connection for dislocated semilunar cartilage of the left knee. Therefore, the Board finds the March 2020 VA examination adequate for rating purposes. The Veteran’s left knee rheumatoid arthritis with degenerative arthritis and osteopenia status post arthroscopic surgery is currently evaluated under Diagnostic Codes 5002-5260. On review, at no time during the appeal period has flexion been limited to 30 degrees or less or extension limited to 15 degrees or less, and thus, a higher rating is not warranted. In making this determination the Veteran’s complaints of pain and functional impairment are acknowledged. The record does not contain adequate pathology to support a higher rating based on limitation of motion due to pain on motion or other factors. As set forth, the Veteran has undergone three VA examinations during the pendency of the appeal. In this case, range of motion testing throughout has consistently shown active left knee flexion as 75 degrees or greater. There is no indication that his flexion is limited to 30 degrees or less during flare-ups. Additionally, range of motion testing consistently shows active left knee extension as 75 degrees or greater. There is no indication that his extension is limited to 45 degrees or less during flare-ups. The Veteran is competent to report his perceived level of pain and functional impairment and his complaints are acknowledged. On review, the Board does not find adequate pathology to support a higher rating based on functional impairment due to pain on motion or other factors. Considering the duration and severity of the vast majority of reported flare-ups during the appeal period, along with the examination findings, the disability picture does not more nearly approximate flexion limited to 30 degrees, even with pain and on flare-ups, and a rating greater than 10 percent is not warranted. Neither the Veteran nor the record raise the applicability of Diagnostic Codes other than those under which he is already rated. In summary, an initial rating greater than 10 percent is not warranted for the left knee rheumatoid arthritis with degenerative arthritis and osteopenia status post arthroscopic surgery based on limitation of motion. 2. Entitlement to an initial evaluation for hypothyroidism in excess of 60 percent disabling The Veteran contends that the currently assigned 60 percent rating does not adequately reflect the severity of his hypothyroidism. The period on appeal begins on April 1, 2011, the effective date for the award of service connection for hypothyroidism. The Veteran’s hypothyroidism is rated under Diagnostic Code 7903 for hypothyroidism. VA amended the criteria for rating hypothyroidism effective from December 10, 2017. These new regulations apply to all applications for benefits received by VA or that are pending before the AOJ on or after December 10, 2017. Claims pending prior to the effective date will be considered under both old and new rating criteria, and whatever criteria is more favorable to the Veteran will be applied. The Board may not apply a current regulation prior to its effective date, unless the regulation explicitly provides otherwise. Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). However, the Board is not precluded from applying prior versions of the applicable regulation to the period on or after the effective dates of the new regulation if the prior version was in effect during the pendency of the appeal. Prior to December 10, 2017, under Diagnostic Code 7903, a 10 percent rating is assigned when hypothyroidism is manifested by fatigability, or continuous medication is required for control. A 30 percent rating requires fatigability, constipation, and mental sluggishness. A 60 percent rating requires muscular weakness, mental disturbance, and weight gain. A 100 percent rating requires cold intolerance, muscular weakness, cardiovascular involvement, mental disturbance (dementia, slowing of thought, depression), bradycardia (less than 60 beats per minute), and sleepiness. Currently, under Diagnostic Code 7903, a 30 percent rating is warranted for hypothyroidism without myxedema. A 100 percent rating is warranted for hypothyroidism manifesting as myxedema (cold intolerance, muscular weakness, cardiovascular involvement (including, but not limited to hypotension, bradycardia, and pericardial effusion), and mental disturbance (including, but not limited to dementia, slowing of thought and depression)). As addressed above, under both the old and the new rating criteria, the only higher rating the Veteran can attain for his hypothyroidism is 100 percent. Prior to the amendment of the regulation, a 100 percent rating required cold intolerance, muscular weakness, cardiovascular involvement, mental disturbance (dementia, slowing of thought, depression), bradycardia (less than 60 beats per minute), and sleepiness. Under the current regulation, a 100 percent rating is warranted for hypothyroidism manifesting as myxedema (cold intolerance, muscular weakness, cardiovascular involvement (including, but not limited to hypotension, bradycardia, and pericardial effusion), and mental disturbance (including, but not limited to dementia, slowing of thought and depression)). Under both the old and new rating criteria, in order to warrant a 100 percent disability rating, the Veteran must have cold intolerance, muscular weakness, cardiovascular involvement – now called myxedema – and mental disturbance. In this case, the Veteran does not meet the criteria for a 100 percent rating under either the old or the new rating criteria. In a NOD dated July 2012, the Veteran wrote, My hypothyroidism causes me to continually feel weak, tired and fatigued. I cannot stand cold temperatures (which, incidentally, drives my wife nuts and creates a great bit of stress over household temperature settings. She likes it around 75 degrees which I find uncomfortably cold.) I have memory problems and I regularly have trouble thinking clearly much like being in a sluggish mental fog that I did not have before the onset of my hypothyroidism. Even my fingernails have become thin and brittle. Prior to the onset of hypothyroidism I was full of energy. Now I just feel weak and tired all the time. I don’t know whether it is related or not, but I’ve also recently been diagnosed with uveitis. Objective evidence shows that a July 2013 MRI of the pituitary was unremarkable but his prolactin level was increased. In a December 2019 Form 9, the Veteran wrote, Even though the Synthroid controls the thyroid hormone production, I still struggle with weight gain, am easily fatigued, and suffer cold intolerance. I am able to control my constipation through eating a high fiber/low carb diet. I have difficulty holding a conversation because I lose my train of thought and often struggle to find a word I want to use. I am very well educated…Yet I have difficulty finding a job because I struggle through the interviews with this mental sluggishness. They are looking for someone who is a fast thinker. I can’t convey this anymore…I also cannot handle cold temperatures. I wear a sweater or a jacket when the temperature dips below 70 degrees. Granted, this used to be worse. At one point I felt cold at anything less than 80 degrees. When the temperature dips below 60 degrees, it is downright painful. I don’t know if it is related, but my heart is now enlarged. There is a correlation between hypothyroidism and cardiomegaly. The hypothyroid symptoms I continue to have correspond with the higher 30 percent rating. Namely, fatigability, constipation…, and mental sluggishness. I also have symptoms of muscular weakness and weight gain that correspond with the higher 60 percent rating. My symptoms of cold intolerance, cardiovascular involvement (cardiomegaly), slowing of thought, and sleepiness (I am always tired and feel I don’t get enough sleep) all correspond with a 100 percent rating. My resting heart rate is mid- to high- 60’s and does not meet the bradycardia standard (less than 60 beats per minute) but it does not miss it by much. In light of these continuing symptoms, I feel the 10 percent rating I was awarded was too low. Depression screens ranging from May 2015 through August 2017 yielded negative results. During an August 2013 consultation, the Veteran admitted to having significant hot flashes, excessive sweating, especially at night, and increasing headaches for which he had an MRI in March 2013 that came back normal and showed no pituitary tumor. He also admitted to significant weakness, weight gain of 20 pounds, and significant feelings of weakness and fatigue. In an October 2013 follow-up appointment, the Veteran reported feeling better overall, but not completely back to normal. He felt tired and had feelings of weakness. In a February 2014 follow-up appointment, the Veteran’s weight was recorded and it was noted that his hypothyroidism was asymptomatic at the time. In an August 2014 follow-up appointment, the Veteran reported that he had some fatigue and tiredness with a decrease in sexual desire and muscle aches at times, but no significant muscle weakness. A December 2014 private treatment record noted that the Veteran felt relatively well with no weakness. A review of his systems noted feeling tired, and feelings of weakness. A January 2015 treatment record noted that the Veteran did not have depression or sleep disturbance. In a July 2015 private treatment record, the Veteran denied any symptoms consistent with hypothyroidism. In a September 2015 medical treatment record, the Veteran provided, “My only concern is the weight I’ve gained and cold all the time since the medication was lowered.” The physician noted that his labs normal were in May 2015 and no change in dosage was needed for his thyroid medication. In a December 2015 VA examination, the Veteran reported that recently he had been gaining weight again and having cold intolerance. His labs were okay. Per the Veteran, he felt like he had a hoarse voice. He felt tired “terribly so” all the time. He could doze off at a stop light driving home from work. Sometimes it was hard to come up with the right word and he lost his train of thought to say words he wanted to say. He noted he had dry skin and stated his hair broke off and was brittle, but not too terrible. The examiner concluded the Veteran’s laboratory values were normal and symptoms could not be attributed to hypothyroidism. Medical treatment records from March 2018 and August 2018 noted that the Veteran’s hypothyroidism was stable with medication. In a June 2018 appellate brief, the Veteran’s representative provided, The Veteran contends that he has experienced significant increase in symptoms over time, which he has attributed to his service connected hypothyroidism. According to the Veteran’s 2015 VA examination, he reported an increase in weight; decrease in his thought process; intolerance to cold climates; an adjustment to his medication doses; hoarseness of his voice; and extreme fatigue. The medical examiner reported that based on the Veteran’s normal laboratory values, his reported symptoms could not be attributed to his service connected hypothyroidism. However, the Board’s attention is directed to an article published by endocrineweb, positively identifying the Veteran’s reported symptoms associated with hypothyroidism…The report further states that each individual may have any number of these symptoms, and they will vary in severity. Most people will have a combination of these symptoms, as do the Veteran…To this regard, the Veteran contends that his symptoms most accurately reflects a rating of 60 percent. In a VA examination from March 2019, the Veteran reported that his medication had to be adjusted every so often. He had no other treatment. He said sometimes his voice was hoarse and he also reported feeling tired. He said his last TSH lab “was below four…values themselves are pretty good.” His pulse was noted as normal with a heart rate of 90. In an April 2019 addendum opinion, after reviewing the December 2015 examination report and article cited in the June 2018 appellate brief, the examiner was asked to opine whether the Veteran’s reported symptoms of increased weight, decrease in thought process, intolerance to cold climates, adjustment to his medications doses, hoarseness of his voice, and extreme fatigue were symptoms of hypothyroidism at that time. The examiner provided lab results for the thyroid. She opined, “The Veteran[’s] alleged symptoms are less likely as not due to hypothyroidism. His laboratory values were normal (euthyroid) – all labs were within normal limits, alleged symptoms cannot be attributed to hypothyroidism.” In an August 2019 appellate brief, the Veteran’s representative wrote, Some people treated for hypothyroidism may still experience symptoms even if blood tests show that their thyroid stimulating hormone (TSH) levels are well within the normal range. The reasons for this are complex, but the bottom line is that having a normal TSH value doesn’t necessarily mean that all of your symptoms will go away. In fact, your TSH blood tests may say that you are clinically euthyroid (normal), but you may still experience many of the same problems you had prior to treatment, including chronic fatigue, weight gain despite no change in diet, feeling cold all the time, muscle and joint aches, itchy and dry skin, hoarseness, hair loss, depression, difficulty concentrating, chronic constipation, and/or heavy or irregular periods. Evidence suggests that situations like this are not uncommon as one may think. Even when placed on levothyroxine – the drug considered the gold standard of hypothyroid treatment – many people fail to reap the physical benefits of treatment. A 2016 study from Rush University reported that people on levothyroxine alone were an average of 10 pounds heavier than people without thyroid disease, despite eating less, and were more likely to be on antidepressants, beta blockers, and statin drugs. What this tells us is that having “healthy” blood results doesn’t necessarily mean you will feel healthy. This is because the normalization of TSH levels only paints a part of the picture of what “normal” thyroid function is all about. While the mechanisms of thyroid function may seem clear and simple, they can vary from one person to the next. And, oftentimes, the tests used to monitor thyroid function provide only a glimpse of a person’s true clinical picture. The American Legion contends that the C&P examiner lacked the medical knowledge and expertise to provide an adequate opinion for [the Veteran’s] thyroid condition. The examiner discounted [his] symptoms as not related to his hypothyroidism because [his] TSH values were normal. As is indicated in the above medication information, despite having normal TSH values, a person can still experience symptoms such as [he] has. In a March 2020 VA examination, the Veteran reported that the condition has persisted/worsened. He experienced dry skin, always cold, always fatigued, trouble losing weight, and trouble remembering things. His voice was always hoarse. He also had slowed bowel movements. No myxedema was noted. It was noted that he did not have cold intolerance, muscular weakness, or cardiovascular involvement. He had mental disturbance marked as slowing of thought. He did not experience dementia or depression. Limitations due to hypothyroidism were described as trouble remembering and having to write everything down. He always wore a jacket due to being cold. He had to constantly get up and move around to keep from falling asleep. He spoke a lot at his job and sometimes he had to hold back due to the strain on his voice. Additionally, in a March 2020 addendum opinion, the VA examiner noted that she reviewed the specified VA examination dated March 2019 and the specified VA addendum dated April 2019. She wrote, I have nothing to say concerning those exams. I did not complete those exams, was not present at those exams, cannot speak on behalf of the examiner who did complete those exams, nor can I attest to the accurateness of the information reported in the exam. As requested, I have read the 2016 article…My summary of this article is that despite medication normalizing lab values many patients still present as hypothyroid. The Veteran was diagnosed in 1999 with hypothyroidism. There is extensive documentation of the clinically correlating symptoms that started at the same time as the hypothyroidism and have continued despite continued use of Synthroid. So, yes to the asked question are the Veteran’s reported symptoms due to the hypothyroidism. In an August 2020 rating decision, the RO assigned a 60 percent evaluation for hypothyroidism effective April 1, 2011. The Veteran’s hypothyroidism is currently evaluated under Diagnostic Code 7903. On review, at no time during the appeal period has the Veteran experienced cold intolerance, muscular weakness, cardiovascular involvement – now called myxedema – and mental disturbance and a higher rating is not warranted. The record does not contain adequate pathology to support a higher rating. The Board acknowledges that the Veteran experiences a range of symptoms due to his hypothyroidism including slowing of thought, extreme fatigue, weight gain, intolerance to cold climates, and hoarseness of his voice. However, as he does not experience cold intolerance, muscular weakness, cardiovascular involvement – now called myxedema – and mental disturbance, the Board finds that he is not entitled to a 100 percent rating. Neither the Veteran nor the record raise the applicability of Diagnostic Codes other than those under which he is already rated. Therefore, as the Veteran does not exhibit all of the symptoms articulated in the 100 percent disability rating, the Board finds that the Veteran’s symptoms do not meet a higher rating under either the old or the new rating criteria. In summary, an initial rating greater than 60 percent is not warranted for hypothyroidism. SCOTT W. DALE Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board K. Bristor 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.