Citation Nr: 21022428 Decision Date: 04/15/21 Archive Date: 04/15/21 DOCKET NO. 15-18 928 DATE: April 15, 2021 ORDER Entitlement to a rating in excess of 10 percent prior to April 20, 2016, in excess of 20 percent from April 20, 2016, to February 23, 2020, and in excess of 40 percent from February 24, 2020, for osteoarthritis lumbar spine is denied. Entitlement to a rating in excess of 10 percent for osteoarthrosis, left knee is denied. Entitlement to service connection for hypertension, to include as secondary to service-connected bilateral knee condition, is denied. FINDINGS OF FACT 1. Prior to April 20, 2016, the Veteran’s back condition the Veteran’s low back condition was not manifested by forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. 2. From April 20, 2016, to February 23, 2020, the Veteran’s back condition was not manifested by forward flexion 30 degrees or less or favorable ankylosis of the entire thoracolumbar spine. 3. From February 24, 2020, the Veteran’s back condition was not manifested by unfavorable ankylosis of the entire thoracolumbar spine. 4. The Veteran’s left knee condition has been manifested by flexion limited to no worse than 70 degrees, including following repetitive motion, and pain. 5. The probative and competent evidence of record does not show that the Veteran’s hypertension is etiological related to service or was caused or aggravated by his service-connected bilateral knee condition. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 10 percent prior to April 20, 2016, in excess of 20 percent from April 20, 2016, to February 23, 2020, and in excess of 40 percent from February 24, 2020, for back condition have not been met. 38 U.S.C. §§ 1155, 5107 (b) (2012); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.10, 4.40, 4.45, 4.71a, Diagnostic Code 5237, 5242 (2019). 2. The criteria for a rating in excess of 10 percent for left knee condition have not been met. 38 U.S.C. §§ 1155, 5107 (b); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.10, 4.40, 4.45, 4.71a, Diagnostic Code 5260 (2019). 3. The criteria for service connection for hypertension, to include as secondary to service-connected bilateral knee condition have not been met. 38 U.S.C. §§ 1155, 5107 (b); 38 C.F.R. §§ 3.102, 3.303, 3.309, 3.310 (2019). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from September 1990 to January 1995. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from June 2012 and August 2013 rating decisions issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Columbia, South Carolina. The Veteran testified at a videoconference hearing before the undersigned Veterans Law Judge in May 2019. A transcript of the hearing is of record. The Board remanded this matter in November 2019. The Board finds there has been substantial compliance with its November 2019 remand directives. See D’Aries v. Peake, 22 Vet. App. 97, 105 (2008); see also Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (holding that there was no Stegall (Stegall v. West, 11 Vet. App. 268 (1998)) violation when the examiner made the ultimate determination required by the Board’s remand.) The Board notes that in September 2020 correspondence, the Veteran raised an issue of earlier effective date for the grant of the 40 percent increased rating for the back condition, which was effective February 24, 2020. The Board finds that the Veteran’s claim for an earlier effective date for the increased rating for a back condition is part and parcel of the increased rating claim already on appeal. However, the Board does note that the Veteran requested an effective date for the award of his 40 percent disability rating before 2008. The Board notes that this would predate the August 22, 2011, effective date of the grant of service connection for a lumbar spine disorder. Thus, a motion to revise the prior rating decision of June 2012 which assigned the effective date of service connection based on clear and unmistakable error (CUE) is the only possible path for the Veteran to seek an earlier effective date for the grant of service connection for his back condition. However, the issue of CUE has neither been raised nor adjudicated by the RO; thus, the Board has no jurisdiction over such claim. Increased Rating Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. The percentage ratings are based on the average impairment of earning capacity as a result of a service-connected disability, and separate diagnostic codes identify the various disabilities and the criteria for specific ratings. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. If two disability evaluations are potentially applicable, 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. Separate ratings may be assigned for separate periods of time based on facts found, a practice known as “staged ratings.” See Fenderson v. West, 12 Vet. App. 119, 126-27 (1999). Further, in determining the appropriate disability rating, the Board must consider whether the case should be referred for extraschedular consideration pursuant to 38 C.F.R. § 3.321 (b)(1). See Thun v. Peake, 22 Vet. App. 111, 115-16 (2008). 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. Functional loss may be due to the absence or deformity of structures or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior in 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. § 4.40. In Mitchell v. Shinseki, 25 Vet. App. 32 (2011), the Court held that, although pain may cause a functional loss, “pain itself does not rise to the level of functional loss as contemplated by VA regulations applicable to the musculoskeletal system.” Rather, pain may result in functional loss, but only if it limits the ability “to perform the normal working movements of the body with normal excursion, strength, speed, coordination, or endurance.” Id., quoting 38 C.F.R. § 4.40. Consideration of a higher rating for functional loss, to include during flare ups, due to these factors accordingly is warranted for Diagnostic Codes predicated on limitation of motion. 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202 (1995). With respect to joints, in particular, the factors of disability reside in reductions of normal excursion of movements in different planes. Inquiry will be directed to more or less than normal movement, weakened movement, excess fatigability, incoordination, pain on movement, swelling, deformity or atrophy of disuse. 38 C.F.R. § 4.45. 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. When 38 C.F.R. § 4.59 is raised by the claimant or reasonably raised by the record, even in non-arthritis contexts, the Board should address its applicability. Burton v. Shinseki, 25 Vet. App. 1, 5 (2011). The joints involved should be tested for pain on both active and passive motion, in weight-bearing and non-weight-bearing and, if possible, with the range of the opposite undamaged joint. Correia v. McDonald, 28 Vet. App. 158 (2016). 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. When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. It is the policy of VA to administer the law under a broad interpretation, consistent with the facts in each case with all reasonable doubt to be resolved in favor of the claimant; however, the reasonable doubt rule is not a means for reconciling actual conflict or a contradiction in the evidence. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. When all of the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a fair preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). The Board notes that it has reviewed all of the evidence in the record with an emphasis on the evidence relevant to this appeal. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Hence, the Board will summarize the relevant evidence as appropriate, and the Board’s analysis will focus specifically on what the evidence shows, or fails to show, as to the claim. 1. Entitlement to a rating in excess of 10 percent prior to April 20, 2016, in excess of 20 percent from April 20, 2016, to February 23, 2020, and in excess of 40 percent from February 24, 2020, for osteoarthritis lumbar spine associated with osteoarthritis, right knee with meniscal tear, bakers cyst and arthroscopic repair (back condition) The Veteran asserts that his back condition is more severe than rated. Prior to April 20, 2016, and from April 20, 2016, to February 23, 2020, the Veteran was rated 10 and 20 percent disabling, respectively, for his back condition under Diagnostic Code 5237. From February 24, 2020, the Veteran is rated 40 percent disabling for his back condition under Diagnostic Code 5242. Prior to the regulatory change, and from February 7, 2021, Diagnostic Code 5237 did not change. However, prior to the regulatory change Diagnostic Code 5242 was named Degenerative arthritis of the spine (see also diagnostic code 5003). From February 7, 2021, Diagnostic Code 5242 was renamed Degenerative arthritis, degenerative disc disease other than intervertebral disc syndrome (also, see either 5003 or 5010). There was no change to the rating criteria. Diagnostic Code 5237 rates lumbosacral strain. Diagnostic Code 5242 rates degenerative arthritis of the spine. The Rating Schedule provides that disabilities rated under Diagnostic Code 5237 and Diagnostic Code 5242 should be evaluated under the General Formula for Diseases and Injuries of the Spine (General Formula). 38 C.F.R. § 4.71a, Diagnostic Code 5237. In regard to the General Rating Formula for Diseases and Injuries of the Spine as applied to the lumbar spine disability, a 10-percent rating is assigned for forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height under the General Rating Formula for Diseases and Injuries of the Spine. A 20-percent rating is assigned for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40-percent rating is assigned for forward flexion of the thoracolumbar spine 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. A 50-percent rating is assigned for unfavorable ankylosis of the entire thoracolumbar spine. A 100-percent rating is assigned for unfavorable ankylosis of the entire spine. See 38 C.F.R. § 4.71a. For VA compensation purposes, normal forward flexion of the thoracolumbar spine is zero to 90 degrees; extension is 0 to 30 degrees; left and right lateral flexion and rotation are zero to 30 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion of the thoracolumbar spine is 240 degrees. The normal ranges of motion for each component of spinal motion provided in this note are the maximum that can be used for calculation of the combined range of motion. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Note 2. Any associated objective neurologic abnormalities, including, but not limited to bowel or bladder impairment, should be evaluated separately under an appropriate Diagnostic Code. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Note 1. Prior to April 20, 2016 In a June 2009 statement, the Veteran said his knees caused a lot of strain on his back, which made his lower back much worse over the years. He said he had “great painful and discomfort” his knees and back and he had to use a cane and knee braces to “get by.” In an August 2009 private treatment record, a lumbar spine MRI showed that height and signal intensity of vertebral bodies was preserved. No spondylolysis or spondylolisthesis. There was decreased signal intensity on T2 sequence of disc L4-L5 interbody finding that was in relation to dehydration. There was posterocentrally disc bulging in L5-S1 and L4-L5, in the latter identified fibrous annulus tear. No significant foraminal compromise. There were no major degenerative changes in the posterior elements. The morphology of medullary cone showed normal signal intensity and ended at L1. The posterior muscle mass and roots of the cauda equina showed no abnormalities. In a January 2010 treatment record, examination showed pain and antalgic posture and gait, muscles spasm paravertebral muscles, palpable trigger nodes pain, numbness and tingling radiating to both feet, big toe dorsiflexion weakness, Achilles and patellar reflexes slow response, negative Wadell’s test, and SLR test positive 60 degrees bilaterally. Range of motion was the following: forward flexion to 60 degrees and unable to pass knees level and with pain; extension to 15 degrees; bilateral lateral bending to 15 degrees and with pain; and bilateral lateral rotation to 15 degrees. The examining physician noted abdominal and paravertebral muscles weakness and fatigue from lack of endurance, pain episodes. There was severe muscle spasm with abnormal gait, abnormal spinal contour with reversed lordosis. Antalgic gait and posture, with equilibrium disturbance. In an April 2010 statement, the Veteran reported that his back pain was worse and he continued to be treated by his orthopedist specialist. In a January 2012 VA treatment record, the Veteran reported chronic pain in both knees, low back, upper back, and neck. The Veteran described the pain as aching and constant. He said the pain was a 5 out of 10 currently in his back and at worst was a 7 out of 10; his left knee was a 5 out of 10. The Veteran was recently issued bilateral hinged knee braces and lumbar corset, which he said did assist in controlling his pain. In a July 2012 VA examination, the Veteran reported increasing back pain with difficulty sitting. He said he could not sit longer than 25 minutes without stretching. He reported flare ups and said they occurred with leaning over to pick up objects. He used his cane for assistance with ambulation for his low back pain and knee pain. Upon examination, range of motion was the following: forward flexion to 20 degrees with painful motion to 0 degrees; extension to 20 degrees with painful motion to 0 degrees; right lateral flexion to 15 degrees with painful motion to 0 degrees; left lateral flexion to 15 degrees with painful motion to 0 degrees; right lateral rotation to 15 degrees with painful motion to 0 degrees; and left lateral rotation to 15 degrees with painful motion to 0 degrees. The examiner noted that while the Veteran limited his range of motion in all spheres while testing, he was able to fully flex his back while sitting to untie his shoes and taking off his shoes while both feet were fully planted on the floor. The Veteran was able to perform repetitive use testing with 3 repetitions without additional limitation in range of motion. Additional functional limitation was described as pain on movement and pain in his back when arising from a sitting position. The Veteran had pain to palpation of the soft tissues of his low back at the lumbosacral junction, but there was no muscle spasm, masses, or abnormal curvature of his back to inspection. His lower extremity motor exam was not reproducible on repetitive testing. There was no guarding or muscle spasm. There was no muscle atrophy. There was no evidence of radiculopathy. There was no IVDS. The Veteran used a brace and cane regularly. The examiner concluded that there was no evidence of any discogenic disease or back limitations or radiculopathy on exam. The findings of limited back motion were not reproducible on repeated testing and the Veteran easily flexed his back to greater than 90 degrees to take off and don his shoes when distracted. In a May 2012 private treatment record, the Veteran complained of back pain that was severe at times. The Veteran said he had never been hospitalized for his back and had never received treatment from a chiropractor. In an October 2012 statement, the Veteran’s wife, O.B., stated that the Veteran’s knee and back problems were getting worse. She said she did what she could to help him at home. She also said the Veteran could never get a good night sleep due to his back and knee pain. The Veteran was unable to do regular chores. In a January 2013 private treatment record, the Veteran rated his back as a 7 out of 10. His problem was aggravated when he performed almost any activity. In a February 2013 VA treatment record, the Veteran described numbness, aching, and continuous sharp pain in his back. In a May 2014 VA treatment record, the Veteran said he had back pain for several years. Exercise made it worse and heat and chiropractic treatment had helped alleviate some of his pain. The Veteran complained of difficulty sleeping, right sided paresthesia, difficulty with prolonged ambulation, and difficulty with prolonged sitting. The Veteran had fair range of motion and good lower extremity strength. Primary functional limitations were with activities of daily living and with prolonged ambulation, sitting, and standing. It was recommended that the Veteran get physical therapy in order to increase his lumbar range of motion and decrease pain. In an August 2015 VA treatment record, the Veteran said his back pain was located in the lumbar area, mainly towards the left side, and radiated to the hips. He denied paresthesias of the legs. There was no edema, erythema, warmth, or palpable/visible masses. He had normal lordosis. Range of motion was full in all planes, but the Veteran had painful extension and rotations. From April 20, 2016 to February 23, 2020 In a May 2016 private treatment record, the Veteran complained of knee, low back, neck, and shoulder pain. Regarding his low back pain, the symptoms were severe, described as radiating, stabbing, tightness, and throbbing. The symptoms radiated to the left and right buttock. The Veteran rated these symptoms as a 4 and happened constantly. After the assessment, it was noted that the Veteran was improving, but still had pain with prolonged sitting and standing. In a December 2016 disability benefits questionnaire (DBQ), the Veteran reported flare ups occurred where the pain became so intense that he could not work. There was no reported functional loss or impairment. Upon examination, range of motion was the following: forward flexion to 50 degrees; extension to 20 degrees; bilateral lateral flexion to 20 degrees; and bilateral lateral rotation to 40 degrees. Abnormal range of motion contributed to functional loss. The Veteran was able to perform repetitive use testing; however, there was additional limitation in range of motion. Range of motion was the following: forward flexion to 30 degrees; extension to 10 degrees; bilateral lateral flexion to 10 degrees; left lateral rotation to 10 degrees; and right lateral rotation to 15 degrees. Post-test additional limitations of range of motion contributed to functional loss. There was pain on active, passive and/or repetitive use testing; this pain contributed to functional loss or additional limitation of range of motion. There was pain on weight-bearing or non-weight-bearing; this pain contributed to functional loss or additional limitation of range of motion. The Veteran had localized tenderness or pain to palpation. There was muscle spasm that resulted in abnormal gait and abnormal spinal contour. There was also less movement than normal, excess fatigability, pain on movement, disturbance of locomotion, interference with sitting, and interference with standing. Pain, weakness, fatigability, or incoordination significantly limited functional ability during flare ups or when the joint was used repeatedly over a period of time. Range of motion was the following: forward flexion to 30 degrees; extension to 10 degrees; right lateral flexion to 10 degrees; left lateral flexion to 10 degrees; right lateral rotation to 15 degrees; and left lateral rotation to 10 degrees. There was facet inflammation after continued use decreasing range of motion and strength as well as pain. There was no muscle atrophy. The Veteran had bilateral lower extremity radiculopathy. The Veteran had IVDS with incapacitating episodes at least 1 week but less than 2 weeks. In a January 2017 VA treatment record, an MRI noted history of lower back with radiation down both legs. Impression was mild degenerative changes of the lumbar spine, most notably at L4-L5, where there was loss of disc space height as well as a superimposed central disc protrusion, mild right neural foraminal narrowing and mild to moderate left neural foraminal narrowing. In a December 2017 VA treatment record, the Veteran was seen for evaluation of his low back pain. The Veteran described a recent exacerbation of lower back pain of 2 to 3 weeks and said he was doing more usual work around the house and felt pain. He went to the emergency room in October and given IM Toradol with a good response. He currently described his low back pain as a constant dull/sharp pain of 6 to 7 out of 10 with radiating pain to bilateral lower extremity. His back pain improved with injection. Aggravating factors included prolonged standing and walking. Back pain was relieved with IM Toradol injection, heating pad, TENS, and stretching. In a December 2018 private treatment record, the Veteran was discharged from emergency room with sciatica and was prescribed medication for muscle spasms. At the May 2019 Board hearing, the Veteran testified that his back condition had worsened and he was unable to sleep. He said he was taken to the emergency room last December for back pain and wore a back brace. From February 24, 2020 In a March 2020 DBQ, the Veteran reported severe low back pain that radiated into his legs. He took medication, used patches, heating pads, and a back brace. He was unable to sit for over 15 minutes, stand for over 10 minutes, walk more than 2 minutes, carry or lift over 5 pounds, use stairs, or drive. His sleep was also affected. The Veteran reported flare ups and described them as occurring constantly; they were severe. The flare ups were precipitated by all activity including sitting, standing, and bending. They were not alleviated. The Veteran also reported functional limitations, which are described above. Upon examination, range of motion was the following: forward flexion to 30 degrees; extension to 10 degrees; bilateral lateral flexion to 10 degrees; bilateral lateral rotation to 5 degrees. Range of motion contributed to functional loss which included limited range of motion. Pain was noted on examination at all ranges of motion and caused functional loss. There was no evidence of pain with weight-bearing. There was no evidence of localized tenderness or pain on palpation. The Veteran was able to perform repetitive use testing with at least 3 repetitions without additional loss of function or range of motion. The Veteran was not examined immediately after use over time and the examiner determined that the examination was medically consistent with the Veteran’s statements describing functional loss with repetitive use over time. Pain significantly limited functional ability with repeated use over a period of time. Range of motion was the following: forward flexion to 25 degrees; extension to 5 degrees; bilateral lateral flexion to 5 degrees; and bilateral lateral rotation to 5 degrees. The Veteran was not examined during a flare up and the examiner determined that the examination was medically consistent with the Veteran’s statements describing functional loss during a flare up. Pain significantly limited functional ability with flare ups. Range of motion was the following: forward flexion to 20 degrees; extension to 5 degrees; bilateral lateral flexion to 5 degrees; and bilateral lateral rotation to 5 degrees. There was no guarding or muscle spasm. There was no muscle atrophy, radiculopathy, or ankylosis. There were no other neurologic abnormalities or IVDS. The Veteran used a back brace and cane regularly to ambulate. There was objective evidence of pain on passive range of motion and non-weight-bearing. In an April 2020 DBQ, the Veteran reported constant, tight, stabbing pain in his lower back, rated as an 8 out of 10. He took pain medication, used patches, a TENS unit, heating pad, and a back brace. The Veteran reported flare ups that occurred constantly and described them as severe. They were precipitated by all activity including sitting, standing, and bending. This pain was an 8 to 9 out of 10. The Veteran also reported functional loss where he could not stand, sit, or walk for more than 2 minutes without increasing his pain. He also avoided stairs and looked for an elevator. Upon examination, range of motion was the following: forward flexion to 15 degrees; extension to 10 degrees; right lateral flexion to 20 degrees; left lateral flexion to 15 degrees; and bilateral lateral rotation to 5 degrees. Range of motion itself contributed to functional loss because the Veteran was unable to drive, perform activities, requiring bending forward, and rotating. Pain was noted on exam at all ranges of motion and caused functional loss. There was no evidence of localized tenderness or pain on palpation. There was evidence of pain with weight-bearing. The Veteran was not able to perform repetitive use testing with at least 3 repetitions. The examiner explained that obtaining this was not medically appropriate as it would increase the Veteran’s pain and might cause harm. The Veteran was not examined immediately after repetitive use over time and the examiner determined that the examination was medically consistent with the Veteran’s statements describing functional loss with repetitive use over time. Pain and weakness significantly limited functional ability with repeated use over a period of time. Range of motion was the following: forward flexion to 15 degrees; extension to 10 degrees; right lateral flexion to 20 degrees; left lateral flexion to 15 degrees; and bilateral lateral rotation to 5 degrees. The Veteran was not examined during a flare up and the examiner determined that the examination was medically consistent with the Veteran’s statements describing functional loss during flare up. Pain and weakness significantly limited functional ability with flare ups. Range of motion was the following: forward flexion to 15 degrees; extension to 10 degrees; right lateral flexion to 20 degrees; left lateral flexion to 15 degrees; and bilateral lateral rotation to 5 degrees. Evidence showed muscle spasm resulting in abnormal gait or abnormal spinal contour. Specifically, the Veteran ambulated with a slightly forward flexed gait and the assistance of a cane. There was no muscle atrophy. There was bilateral lower extremity radiculopathy. There was no ankylosis. There were no neurological abnormalities or IVDS. The Veteran used a brace and cane constantly. There was evidence of pain with non-weight-bearing. Passive range of motion testing was not medically appropriate. In a September 2020 statement, the Veteran argued that the 2012 VA examiner made a false statement about him being able to easily untie his shoe. Additionally, the Veteran essentially argued that the VA examiner’s opinions were not as probative as doctors that had seen him for longer periods of time. He said he had severe disabling arthritis of the back and had been unable to reach the middle shelf of the refrigerate for years. He said he used a “grabber stick” to manage. He had had so much pain that he could not sleep. Additional treatment records did not show any findings to support higher disability ratings throughout the periods on appeal. Overall, the Board finds that a rating in excess of 10 percent prior to April 20, 2016, in excess of 20 percent from April 20, 2016, to February 23, 2020, and in excess of 40 percent from February 24, 2020, are not warranted for the Veteran’s back condition. As shown below, and based on there being no real change to the musculoskeletal regulations for Diagnostic Codes 5237 and 5242, the appropriate rating criteria remains that which was prior to February 7, 2021. Prior to April 20, 2016, the Veteran’s range of motion was to, at worst, forward flexion to 60 degrees. The Board acknowledges the January 2010 treatment record that noted severe spasm with abnormal gait, abnormal spinal contour with reversed lordosis. However, the additional treatment records prior to April 2016 make no note of these spasms. In fact, the July 2012 VA examiner did not find any muscle spasms. Further, the Board also acknowledges the July 2012 findings that the Veteran’s forward flexion range of motion was to 20 degrees. But the examiner noted that the findings of limited back motion were not reproducible on repeated testing and the Veteran easily flexed his back to greater than 90 degrees to take off and don his shoes when distracted. The Board acknowledges the Veteran’s allegation that this was a false claim made by the examiner. However, there is no other evidence prior to April 20, 2016, that would suggest the Veteran’s back condition was severe to that extent. In fact, in an August 2015 treatment record, it was noted that the Veteran had full range of motion. The overall evidence does not show symptoms productive of forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees, so as to warrant a 20 percent disability rating. Therefore, the Board finds that there is no evidence showing that the Veteran’s back condition warranted a higher 20 percent rating prior to April 20, 2016. From April 20, 2016, to February 23, 2020, the Veteran’s range of motion was to, at worst, 30 degrees. Additionally, the Veteran had muscle spasm resulting in abnormal gait and abnormal spinal contour. The evidence on file does not show symptoms productive of forward flexion of the thoracolumbar spine limited to 30 degrees or less, or favorable ankylosis, so as to warrant a 40 percent disability rating. The Board acknowledges that the December 2016 examiner found that the Veteran had IVDS. However, IVDS was shown to be incapacitating for at least 1 week but less than 2 weeks. This would warrant a 10 percent rating under Diagnostic Code 5243, under the old criteria prior to February 7, 2021. From February 7, 2021, under the amended Diagnostic Code 5243 regulations, there was no evidence of disc herniation with compression and/or irritation of the adjacent nerve root. Therefore, the Board finds that there is no evidence showing that the Veteran’s back condition warranted a higher 40 percent rating from April 20, 2016, to February 23, 2020. From February 24, 2020, the Veteran’s range of motion was to, at worst, 15 degrees. The evidence on file does not show unfavorable ankylosis, so as to warrant a 50 percent disability rating. Therefore, the Board finds that there is no evidence showing that the Veteran’s back condition warranted a higher 50 percent rating from February 24, 2020. The Board has reviewed and considered the Veteran’s assertions in support of his claim, including his reports of pain, stiffness, as well as his descriptions of painful flare-ups. However, the objective medical evidence of record is of greater probative value as to the Veteran’s level of impairment than his assertions. Therefore, the Board finds that such factors do not result in functional loss requiring a higher disability rating. See DeLuca, 8 Vet. App. 202; Mitchell, supra. The Board notes that the Veteran has offered his own opinion on the severity of his back condition. The Board acknowledges that the Veteran is competent to describe his symptoms without any specialized knowledge or training. Layno v. Brown, 6 Vet. App. 465 (1994). However, as a layperson, the Veteran is not competent to diagnose his symptoms as a specific disease, nor is he competent to render a nexus opinion regarding the etiology of any current disorder; both of these determinations require medical expertise. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Therefore, the Board affords more probative weight to the medical opinions and evidence than the Veteran’s own contentions. Therefore, the preponderance of the evidence is against an increased rating; there is no doubt to be resolved. Entitlement to a rating in excess of 10 percent prior to April 20, 2016, in excess of 20 percent from April 20, 2016, to February 23, 2020, and in excess of 40 percent from February 24, 2020 for a back condition are not warranted. Neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Yancy v. McDonald, 27 Vet. App. 484, 495 (2016); Doucette v. Shulkin, 38 Vet. App. 366, 369-70 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). 2. Entitlement to a rating in excess of 10 percent for osteoarthrosis, left knee associated with osteoarthrosis, left knee associated with osteoarthritis, right knee with meniscal tear, Baker’s cyst and arthroscopic repair (left knee condition) The Veteran asserts that his left knee condition is more severe than rated. The Veteran’s left knee condition is rated 10 percent disabling under Diagnostic Code 5260 based on limitation of flexion. The appropriate diagnostic codes for rating limitation of motion of the right and left knees are Diagnostic Codes 5260 and 5261. 38 C.F.R. § 4.71a. Normal range of motion of the knee is from 0 degrees of extension to 140 degrees of flexion. 38 C.F.R. § 4.71, Plate II. In VAOPGCPREC 9-2004, the VA General Counsel interpreted that when considering Diagnostic Codes 5260 and 5261 together with 38 C.F.R. § 4.71, a Veteran may receive a rating for limitation in flexion only, limitation of extension only, or, if the 10 percent criteria are met for both limitations of flexion and extension, separate ratings for limitations in both flexion and extension under Diagnostic Code 5260 (leg, limitation of flexion) and Diagnostic Code 5261 (leg, limitation of extension). Under Diagnostic Code 5260, limitation of knee flexion is rated 30 percent disabling where flexion is limited to 15 degrees; 20 percent disabling where flexion is limited to 30 degrees; 10 percent disabling where flexion is limited to 45 degrees; and noncompensable where flexion is limited to 60 degrees. 38 C.F.R. § 4.71a. Under Diagnostic Code 5261, limitation of knee extension is rated 50 percent disabling where extension is limited to 45 degrees; 40 percent disabling where extension is limited to 30 degrees; 30 percent disabling where extension is limited to 20 degrees; 20 percent disabling where extension is limited to 15 degrees; 10 percent disabling where extension is limited to 10 degrees; and noncompensable where extension is limited to 5 degrees. 38 C.F.R. § 4.71a. Prior to, and from February 7, 2021, the regulations and rating criteria for Diagnostic Code 5260 has remained the same. The Board notes that assigning multiple ratings for the Veteran’s knee disabilities based on the same symptoms or manifestations would constitute prohibited pyramiding. 38 C.F.R. § 4.14. In a June 2009 statement, the Veteran said his left knee hurt, locked, and popped constantly. He had severe pain and lack of flexibility in both knees and he was unable to bend his knees. He said his knees swelled and would get so bad that he was unable to drive his vehicle. He had “painful and discomfort” in his knees and back and had to use a cane and knee braces to “get by.” In an October 2009 private treatment record, the Veteran presented with symptomatology of meniscopathy of both knees. The Veteran had pain at the lateral compartment level, pain on rising after prolonged sitting and when going up or down stairs. The Veteran was prescribed a cane. In a January 2010 treatment record, examination showed that there was swelling and joint effusion, pain on patellar jerk and on palpation of both joints line and in the superior-medial aspect of the tibia plateau. There was positive apprehension test, negative pivot shift, and negative Lachman’s test. Range of motion was flexion to 120 degrees with pain starting at 100 degrees, and extension to minus 5 degrees. Quadriceps and hamstrings muscles weakness and atrophy. In an April 2010 statement, the Veteran said that his knees were consistently swollen and severely painful. He said he was dependent on his cane and pain medication, but nothing seemed to help. In an August 2010 treatment record, the Veteran said he had pain constantly and was unable to bend his knees or kneel fully. Examination showed swelling and joint effusion, pain on patellar jerk and on palpation of both joints line and superior-medial aspect of the tibia plateau. Positive apprehension test, and subluxation, negative pivot shift, and negative Lachman’s test. Range of motion was flexion to 120 degrees with pain at 100 degrees and extension minus 5 degrees. In a January 2012 VA examination, the Veteran reported clicking, popping, swelling, and decreased bending. He was unable to kneel. There was knee pain at night and he could not sleep. The Veteran said he tried heat and he recently had to take hydrocodone for pain relief. The Veteran experienced pain with sitting in the car for extended periods. The Veteran reported flare ups and said that he could not help out around the house, was unable to do much, and walking and sitting for extended periods hurt. Upon examination, range of motion was flexion to 100 degrees with painful motion to 80 degrees, and extension to 0 degrees with no painful motion. The Veteran was able to perform repetitive-use testing with 3 repetitions flexion to 100 degrees and extension to 0 degrees. The Veteran had functional loss. The examiner also noted less movement than normal and pain on movement. There was tenderness or pain to palpation. There was no evidence or history of recurrent patellar subluxation/dislocation. Meniscal condition was noted. Specifically, it was noted that the Veteran had a meniscus (semilunar) cartilage condition described as frequent episodes of joint locking and joint pain. The Veteran used a brace and cane regularly. In a January 2012 VA treatment record, the Veteran reported chronic pain in both knees, low back, upper back, and neck. The Veteran described the pain as aching and constant. He said the pain was a 5 out of 10 currently in his back and at worst was a 7 out of 10; his left knee was a 5 out of 10. The Veteran was recently issued bilateral hinged knee braces and lumbar corset, which he said did assist in controlling his pain. In an October 2012 statement, the Veteran’s wife, O.B., stated that the Veteran’s knee and back problems were getting worse. She said she did what she could to help him at home. She also said the Veteran could never get a good night sleep due to his back and knee pain. The Veteran was unable to do regular chores. In a January 2013 private treatment record, a history of left knee lateral meniscus tear was noted. The MRI showed mild patellar tendinitis. There was minimal fibrillation involving the medial meniscus with no discrete medial or lateral meniscus tear demonstrated. In another January 2013 private treatment record, the Veteran complained of bilateral knee pain, left greater than right. The Veteran reported two injections in the left knee, but no surgeries. He felt his left knee started to hurt more because of limping due to his right knee. He said his left knee had aching pain that was worse with stairs, and he had pain on the inside of his knee as well. In a February 2013 VA treatment record, the Veteran reported sharp, stabbing/shooting pain, which was worse with activity. In a May 2016 private treatment record, the Veteran complained of knee, low back, neck, and shoulder pain. Regarding his knee pain, the symptoms were moderate, described as dull ache, stabbing, and tightness. The Veteran rated these symptoms as a 5 and happened constantly. After the assessment, it was noted that the Veteran was improving, but still had pain with prolonged sitting and standing. In a June 2018 VA treatment record, the Veteran was seen for follow up of his left knee. He had some slight improvement with Euflexxa, but not a lasting effect. The Veteran was considering Aminofix injections and would hold off on viscosupplementation for now. He also needed his brace reissued as his was stolen. On examination, the Veteran walked with an assisted device and there was no erythema or effusion. There was full, painless knee range of motion with catching or locking. There was no laxity noted. At the May 2019 Board hearing, the Veteran testified that he had increased pain in his left knee. He received injections for his knee. In a March 2020 DBQ, the Veteran reported that he had injections, knee braces, a TENS unit, and used a cane. He described pain in both knees as well as clicking, bending, locking, and limited range of motion. He was limited to standing and sitting over 10 minutes, walking over 2 to 3 minutes, and an inability to bend. The Veteran reported flare ups that occurred 6 times a day and described them as severe, which lasted constantly. They were precipitated by most activities of daily living and were not alleviated. Functional loss was also reported as described above. Upon examination, range of motion was flexion to 90 degrees and extension to 0 degrees. Range of motion contributed to functional loss shown by limited range of motion. Pain was noted at all ranges of motion. There was no evidence of pain with weight-bearing. There was also no localized tenderness, pain on palpation, or crepitus. The Veteran was able to perform repetitive use testing with at least 3 repetitions without additional loss of function or range of motion. The Veteran was not examined immediately after repetitive use over time but the examiner determined that the examination was medically consistent with the Veteran’s statements describing functional loss with repetitive use over time. Pain significantly limited functional ability with repeated use over a period of time. Range of motion was flexion to 85 degrees and extension to 0 degrees. The Veteran was not examined during a flare up and the examiner determined that the examination was medically consistent with the Veteran’s statements describing functional loss during flare up. Pain significantly limited functional ability with flare ups. Range of motion was flexion to 80 degrees and extension to 0 degrees. Additional factors contributing to the disability included guarding. There was no muscle atrophy or ankylosis. There was no history of recurrent subluxation, lateral instability, or recurrent effusion. The Veteran did not have recurrent patellar dislocation, shin splints, stress fractures, chronic exertional compartment syndrome, or any other tibial or fibular impairment. The Veteran did not have, and had never had, a meniscus condition. The Veteran used a brace and cane regularly. There was evidence of pain on passive range of motion testing as well as non-weight-bearing. In a March 2020 statement, the Veteran said that during the knee examination, the examiner pushed his knee beyond the range of motion causing excruciating pain. The Veteran put in a complaint with the QTC. In an April 2020 DBQ, the Veteran was examined for his right knee condition. Regardless, the Board will discuss the relevant left knee findings during this examination. Upon examination, range of motion was flexion to 80 degrees and extension to 0 degrees. Range of motion did not contribute to functional loss. Pain was noted at all ranges of motion. There was evidence of pain with weight-bearing. There was no localized tenderness or pain on palpation. There was crepitus. The Veteran was unable to perform repetitive use testing with at least 3 repetitions because obtaining this was not medically appropriate and would increase the Veteran’s pain and might cause harm. The Veteran was not examined immediately after repetitive use over time but the examiner determined that the examination was medically consistent with the Veteran’s statements describing functional loss with repetitive use over time. Pain and weakness significantly limited functional ability with repeated use over a period of time. Range of motion was flexion to 70 degrees and extension to 0 degrees. The Veteran was not examined during a flare up and the examiner determined that the examination was medically consistent with the Veteran’s statements describing functional loss during flare up. Pain and weakness significantly limited functional ability with flare ups. Range of motion was flexion to 70 degrees and extension to 0 degrees. There was no muscle atrophy or ankylosis. There was no history of recurrent subluxation, lateral instability, or recurrent effusion. The Veteran did not have recurrent patellar dislocation, shin splints, stress fractures, chronic exertional compartment syndrome, or any other tibial or fibular impairment. The Veteran did not have, and had never had, a meniscus condition. The Veteran used a cane constantly. There was evidence of pain on passive range of motion testing as well as non-weight-bearing. Additional treatment records did not show any findings to support a higher disability rating throughout the period on appeal. Overall, the Board finds that a rating in excess of 10 is not warranted for the Veteran’s left knee condition. As shown below and based on there being no real change to the musculoskeletal regulations for Diagnostic Code 5260, the appropriate rating criteria remains that which was prior to February 7, 2021. The Veteran’s left knee condition has been characterized by flexion not worse than 70 degrees, no evidence or history of recurrent patellar subluxation, no “shin splints”, stress fractures, or chronic exertional compartment syndrome. The Board acknowledges that an October 2009 treatment record mentioned the Veteran presented with symptomatology of meniscopathy in both knees, the January 2012 VA examiner noted a meniscal condition evidenced by joint locking and pain, and a January 2013 treatment record noted a history of left knee lateral meniscus tear. However, symptomatology of meniscopathy does not conclude that the Veteran had a meniscus condition. Additionally, despite the January 2012 VA examiner’s finding, the January 2013 physician determined by MRI that there was no meniscal tear, and the March 2020, and April 2020 VA examiners found that the Veteran did not have, and had never had, a meniscal condition. There is no additional evidence throughout the period on appeal confirming that the Veteran suffered from a meniscus condition. Finally, the Board acknowledges the Veteran’s March 2020 statement that the March 2020 VA examiner pushed his knee beyond its limit causing excruciating pain; however, the Veteran was afforded another examination in April 2020, and these findings still do not suggest a higher rating. Additionally, there is no evidence that the Veteran made any complaints during the March 2020 examination or any notations made by the examiner to suggest that the examination was inadequate. Thus, the Board finds the evidence as a whole along with the March 2020 and April 2020 VA examiner’s findings most probative. Therefore, the Veteran is not entitled to a higher 10 percent rating for his left knee conditions. The evidence does not reflect that the Veteran experienced any ankylosis, instability, dislocation or removal of semilunar cartilage, impairment of the tibia or fibula, or genu recurvatum. As such, Diagnostic Codes 5256, 5257, 5258, 5259, 5262, and 5263 are not applicable. See 38 C.F.R. § 4.71a. The Board has reviewed and considered the Veteran’s assertions in support of his claim, including his reports of pain, stiffness, as well as his descriptions of painful flare-ups. However, the objective medical evidence of record is of greater probative value as to the Veteran’s level of impairment than his assertions. Therefore, the Board finds that such factors do not result in functional loss requiring a higher disability rating. See DeLuca, 8 Vet. App. 202; Mitchell, supra. The Board notes that the Veteran has offered his own opinion on the severity of his left knee condition. The Board acknowledges that the Veteran is competent to describe his symptoms without any specialized knowledge or training. Layno, 6 Vet. App. 465. However, as a layperson, the Veteran is not competent to diagnose his symptoms as a specific disease, nor is he competent to render a nexus opinion regarding the etiology of any current disorder; both of these determinations require medical expertise. Jandreau, 492 F.3d 1372. Therefore, the Board affords more probative weight to the medical opinions and evidence than the Veteran’s own contentions. Therefore, the preponderance of the evidence is against an increased rating; there is no doubt to be resolved. Entitlement to a rating in excess of 10 percent for left knee condition is not warranted. Neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Yancy, 27 Vet. App. at 495; Doucette, 38 Vet. App. at 369-70. Service connection Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). Service connection may also be established on a secondary basis for a disability that is shown to be either (a) caused by or (b) aggravated by a service-connected disability. 38 C.F.R. § 3.310; Allen v. Brown, 7 Vet. App. 439 (1995) (en banc). Entitlement to service connection for hypertension, to include as secondary to service-connected bilateral knee condition The Veteran asserts that his hypertension is related to his bilateral knee condition, as his knees forced him to live a more sedentary life, resulting in the development of hypertension. Initially, the Board notes that under VA regulations, hypertension must be confirmed by readings taken two or more times on at least three different days. The regulation also clarifies that the term “hypertension” means that the diastolic blood pressure is predominantly 90mm or greater, and isolated systolic hypertension means that the systolic blood pressure is predominantly 160mm or greater with a diastolic blood pressure of less than 90mm. 38 C.F.R. § 4.104, Diagnostic Code (DC) 7101, Note (1). Service treatment records show that in October 1991, the Veteran had a blood pressure reading of 130/92. In November 1993, the Veteran had a blood pressure reading of 150/78. In January 1994, the Veteran had a blood pressure reading of 149/99. In March 1994, the Veteran had a blood pressure reading of 128/75. In November 1994, the Veteran had a blood pressure reading of 148/100. Overall, the Veteran never had a confirmed diagnosis of high blood pressure or hypertension while in service. The Veteran was afforded a VA examination in November 2012. In the November 2019 remand, the Board determined that the associated VA opinion was inadequate because it did not consider the Veteran’s secondary theory of service connection, and as a whole, the opinion was based on a lack of contemporaneous records. Therefore, the Board although will not discuss the findings from this VA opinion, will discuss the adequate findings from the VA examination. In the November 2012 VA examination, it was noted that the Veteran was diagnosed with hypertension in 2012. It was also noted that the Veteran had borderline hypertension for several years. Service records showed mostly borderline hypertension, always elevated when seen for pain. At the May 2019 Board hearing, the Veteran testified that he did not seek treatment for hypertension in service. He said that he did not have hypertension until he stopped working out. The Veteran said that his hypertension was secondary to his knee conditions because he did not have hypertension until after his surgeries when he was no longer able to exercise. In a March 2020 VA opinion, the examiner opined that the Veteran’s hypertension was less likely than not due to his bilateral knee condition. The examiner based this opinion on medical records containing no clinical notes during active service reporting diagnosis or treatment of hypertension until 2012 (17 years after discharge from active service), clinical notes from 1993 to 2018 reporting normal gait suggesting no compensation or limitations to exercise, and clinical notes in 2012 when hypertension was first diagnosed. This suggested hypertension was not related to bilateral knee joints but incurred over time due to age. The examiner also opined that it was not at least as likely as not that the Veteran’s hypertension was aggravated beyond its natural progression by his bilateral knee condition. The examiner provided the same rationale. Additional post-service treatment records are silent for any nexus between the Veteran’s hypertension and service and hypertension and his service-connected bilateral knee condition. Overall, the evidence of the record does not show that the Veteran’s hypertension is related to service and/or his service-connected bilateral knee condition. There is no diagnosis of or treatment of hypertension in service. The Veteran was not diagnosed with hypertension until several years following separation from service, and the Veteran has conceded that he was not treated in service and that it did not develop until after his knee surgeries. Further, there is no evidence that the Veteran’s hypertension was caused or aggravated by his bilateral knee condition. The Board places great probative weight on the March 2020 VA examiner’s opinion as he considered the evidence of record, including the lay statements that he developed his hypertension after his knee surgeries. There are no medical opinions to the contrary. The Board notes that the Veteran has offered his own opinion on the etiology of his hypertension. The Board acknowledges that the Veteran is competent to describe his symptoms without any specialized knowledge or training. Layno, 6 Vet. App. 465. However, as a layperson, the Veteran is not competent to diagnose his symptoms as a specific disease, nor is he competent to render a nexus opinion regarding the etiology of any current disorder; both of these determinations require medical expertise. Jandreau, 492 F.3d 1372. Therefore, the Board affords more probative weight to the medical opinion and evidence than the Veteran’s own contentions. Therefore, the preponderance of the evidence is against service connection; there is no doubt to be resolved. Entitlement to a service connection for hypertension, to include as secondary to service-connected bilateral knee condition is not warranted. MICHAEL MARTIN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Saudiee Brown 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.