Citation Nr: 21022944 Decision Date: 04/19/21 Archive Date: 04/19/21 DOCKET NO. 17-56 357 DATE: April 19, 2021 ORDER Entitlement to an initial rating in excess of 20 percent for right knee status post-surgical repair of meniscus tear (right knee condition) is denied. Entitlement to separate rating in of 10 percent for right knee status post-surgical repair of meniscus tear, limitation of flexion, is granted. Entitlement to an initial rating of 10 percent for instability right knee status post-surgical repair of meniscus tear is granted effective November 14, 2017. Entitlement to an initial rating in excess of 10 percent for instability right knee status post-surgical repair of meniscus tear is denied. Entitlement to an initial compensable rating for right knee scars is denied. REMANDED Entitlement to service connection for a colon condition is remanded. Entitlement to service connection for fibromyalgia is remanded. Entitlement to service connection for a left knee condition is remanded. Entitlement to service connection for a right-hand condition is remanded. Entitlement to service connection for a left-hand condition is remanded. Entitlement to service connection for a neck and/or upper back condition is remanded. Entitlement to service connection for a fallopian tube condition, other than bilateral tubal ligation is remanded. Entitlement to a compensable rating for endometriosis is remanded. FINDINGS OF FACT 1. The Veteran’s right knee condition has resulted in limitation of extension no more than 15 degrees, even in consideration of additional functional loss due to flare-ups of pain, fatigability, pain on movement, and/or weakness, or on repetitive motion. 2. The Veteran’s right knee condition has resulted in subjective complaints of pain and objective evidence of painful motion with functional loss causing limitation of flexion to no less than 125 degrees, even in consideration of additional functional loss due to flare-ups of pain, fatigability, pain on movement, and/or weakness, or on repetitive motion. 3. Beginning November 14, 2017, the Veteran’s right knee instability has been manifested by slight lateral instability but not worse. 4. For the entire appeal period, the Veteran’s scars of the right knee are asymptomatic, do not affect an area or areas warranting a compensable rating, or result in any limitation of function or disabling effects. CONCLUSIONS OF LAW 1. The criteria for entitlement to an initial rating excess of 20 percent for a right knee status post-surgical repair of meniscus tear have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.21, 4.40, 4.45, 4.59, 4.71(a), DC 5261. 2. The criteria for entitlement to an initial rating of 10 percent, but no higher, under Diagnostic Code 5260 for right knee status post-surgical repair of meniscus tear have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.40, 4.45, 4.59, 4.71(a), DC 5003, 5260. 3. Beginning November 14, 2017, the criteria for entitlement to an initial rating of 10 percent, but no higher, for instability of the right knee status post-surgical repair of meniscus tear have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.21, 4.40, 4.45, 4.59, 4.71a, DC 5257. 4. The assignment of a separate rating for surgical scar of the right knee, evaluated as noncompensable as of February 23, 2012, is proper. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.118, DC 7802. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the U.S. Army from September 1984 to January 1992. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from January 2013 and March 2018 rating decisions of a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran’s claim for service connection for a colon condition were denied in a December 2019 Board decision. In November 2020, the parties filed a Joint Motion for Partial Remand (JMPR). The United States Court of Appeals for Veterans Claims (the Court) granted the JMPR in November 2020. The JMPR, in pertinent part, vacated and remanded the Board’s December 2019 decision to the extent it denied the Veteran’s claim for service connection for a colon condition. For the reasons discussed below, the Board remands the Veteran’s claim for further development. The claims were previously remanded by the Board for additional development in December 2019 and now return for further appellate review. The Board finds that there was substantial compliance with the remand directives. Dyment v. West, 13 Vet. App. 141 (1999); Stegall v. West, 11 Vet. App. 268 (1998). While on remand, in an August 2020 rating decision, the Agency of Original Jurisdiction (AOJ) granted an increased rating to 20 percent for the Veteran’s right knee condition effective February 23, 2012. The AOJ also granted a separate noncompensable rating for the Veteran’s right knee scar effective February 23, 2012 and a separate 10 percent rating for the Veteran’s right knee instability effective July 23, 2020. While the Veteran has not entered a notice of disagreement as to the propriety of the assigned rating for her instability and scar of the right knee, the Board has assumed jurisdiction over such matters as part and parcel of the claim for an increased rating for the right knee condition. As the increases did not satisfy the appeal in full, such issues remain on appeal. AB v. Brown, 6 Vet. App. 35 (1993). The Board also remanded issues of entitlement to service connection for a gynecological condition and a total disability rating based on individual unemployability (TDIU). Those claims were subsequently granted on remand. Accordingly, those matters are no longer before the Board. 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 rating schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of, or incident to, military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. When evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use and, therefore, not be reflected on range-of-motion testing. 38 C.F.R. § 4.45 requires consideration also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Nonetheless, even when the background factors listed in § 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a (musculoskeletal system) or § 4.73 (muscle injury); a separate or higher rating under § 4.40 or 4.45 itself is not appropriate. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016) (“[I]t is clear that the guidance of § 4.40 is intended to be used in understanding the nature of the veteran’s disability, after which a rating is determined based on the § 4.71a [or 4.73] criteria.”). Painful motion is deemed to be limitation of motion and warrants the minimum compensable rating for the joint, even if there is no actual limitation of motion. 38 C.F.R. § 4.59; Lichtenfels v. Derwinski; 1 Vet. App. 484, 488 (1991). The provisions of 38 C.F.R. § 4.59 relating to painful motion are not limited to arthritis and must be considered when raised by the claimant or when reasonably raised by the record. Burton v. Shinseki, 25 Vet. App. 1 (2011). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise the lower rating will be assigned. 38 C.F.R. § 4.7. After consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. The evaluation of the same disability under various diagnoses, and the evaluation of the same manifestation under different diagnoses, are to be avoided. 38 C.F.R. § 4.14. The Veteran’s entire history is reviewed when making disability evaluations. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where the question for consideration is the propriety of the initial evaluation assigned, evaluation of the medical evidence since the grant of service connection and consideration of the appropriateness of a “staged rating” (assignment of different ratings for distinct periods of time, based on the facts found) is required. See Fenderson v. West, 12 Vet. App. 119, 126 (1999). Where an increase in the level of a service-connected disability is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Nevertheless, the Board acknowledges that a claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007). When, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding service origin, the degree of disability, or any other point, such doubt will be resolved in favor of the claimant. 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). “Although pain may cause a functional loss, pain itself does not constitute functional loss.” Mitchell v. Shinseki, 25 Vet. App. 32, 37 (2011) (emphasis in original). The Board must also consider whether VA examiners have elicited information concerning the “severity, frequency, duration, or functional loss manifestations” of such flare-ups. Sharp v. Shulkin, 29 Vet. App. 26 (2017). The United States Court of Appeals for Veterans Claims (Court) also has issued the opinion of Correia v. McDonald, 28 Vet. App. 158 (2016), which clarifies additional requirements that VA examiners should address when assessing musculoskeletal disabilities, holding specifically, that the joints involved should be tested for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with the range of the opposite undamaged joint. 1. Entitlement to an initial rating in excess of 20 percent for right knee condition 2. Entitlement to an initial rating in excess of 10 percent for right knee instability 3. Entitlement to a separate 10 rating for right knee limitation of flexion The Veteran has been assigned a 20 percent rating under DC 5261 for his right knee degenerative joint disease as well as a separate 10 percent for right knee instability. Separate ratings can be assigned for knee disabilities when none of the symptomatology overlaps and the separate rating is based on additional disabling symptomatology; this includes separate ratings based on limitation of flexion (Diagnostic Code 5260), limitation of extension (Diagnostic Code 5261), lateral instability or recurrent subluxation (Diagnostic Code 5257), and meniscal conditions (Diagnostic Codes 5258, 5259). See VAOPGCPREC 23-97, 62 Fed. Reg. 63,603 (1997); VAOPGCPREC 9-98, 63 Fed. Reg. 56,703 (1998); VAOPGCPREC 9-2004; 69 Fed. Reg. 59,988 (2004); Lyles v. Shulkin, 29 Vet. App. 107 (2017). The normal range of motion of the knee is from 0 degrees extension to 140 degrees flexion. 38 C.F.R. § 4.71, Plate II. Limitation of flexion warrants 10, 20, and 30 percent ratings when limitation is to 45 degrees, 30 degrees, and 15 degrees, respectively. 38 C.F.R. § 4.71a, Diagnostic Code 5260. Limitation of extension warrants 10, 20, 30, 40, and 50 percent ratings when limitation is to 10 degrees, 15 degrees, 20 degrees, 30 degrees, and 45 degrees, respectively. 38 C.F.R. § 4.71a, Diagnostic Code 5261. A 10 percent rating can also be assigned for the knee joint if there is painful motion without compensable limitation of motion. 38 C.F.R. §§ 4.59, 4.71a, Diagnostic Code 5003; see also Burton v. Shinseki, 25 Vet. App. 1 (2011) (holding that the applicability of 38 C.F.R. § 4.59 is not limited to arthritis claims). Ratings can also be assigned when the knee disability affects the meniscus, with a 20 percent rating for dislocated semilunar cartilage with frequent episodes of “locking,” pain, and effusion into the joint and a 10 percent rating for removal of semilunar cartilage (e.g., meniscectomy) and current residual symptoms. 38 C.F.R. § 4.71a, Diagnostic Codes 5258, 5259. Ratings can be assigned for impairment of the tibia or fibula, genu recurvatum, or ankylosis of the knee. 38 C.F.R. § 4.71a, Diagnostic Codes 5256, 5262, 5263. Ankylosis is stiffening or fixation of a joint as the result of a disease process, with fibrous or bony union across the joint. Dinsay v. Brown, 9 Vet. App. 79, 81 (1996). Ankylosis is also defined as “immobility and consolidation of a joint due to disease, injury, or surgical procedure.” Dorland’s Illustrated Medical Dictionary 93 (30th ed. 2003). Ratings can be assigned for knee subluxation or instability under Diagnostic Code 5257. 38 C.F.R. § 4.71a. During the pendency of the appeal, the rating criteria for evaluating musculoskeletal disabilities under 38 C.F.R. § 4.71a, including Diagnostic Code 5257, were amended effective February 7, 2021. 85 Fed. Reg. 76453 (Nov. 30, 2020). Prior to February 7, 2021, the Board will consider the old version of the diagnostic codes only; however, for the period beginning February 7, 2021 the Board will consider both the old and amended version (amended code) of the diagnostic code and rate based on whichever is most favorable to the Veteran. Prior to the regulatory change, recurrent subluxation and lateral instability of the knee warranted a 10, 20, or 30 percent rating if slight, moderate, or severe, respectively. 38 C.F.R. § 4.71a, Diagnostic Code 5257 (2020). “Slight,” as relevant to a physical condition, is defined as “small of its kind or in amount.” Merriam-Webster’s Dictionary (merriam-webster.com/dictionary, accessed February 8, 2021). It is similar to “mild,” which is defined as “not severe” or temperate; with “Temperate” being defined as “keeping or held within limits” and “not extreme or excessive.” “Moderate” is defined as “tending toward the mean or average amount,” “not violent, severe, or intense,” and “limited in scope or effect.” Id. “Severe” is defined as “very painful or harmful” or “of a great degree.” Id. The term “severe” is used throughout the rating schedule, including in Diagnostic Code 5257, to indicate a very great degree of the specific listed disability, in order to differentiate between lesser (or sometimes greater) cases of that same disability within the specific diagnostic code. Within the context of Diagnostic Code 5257, which establishes a successive, tiered rating structure, it represents the highest or most extreme level. As of February 7, 2021, Diagnostic Code 5257 contains two sections for rating other impairment of the knee. 38 C.F.R. § 4.71a, Diagnostic Code 5257. The first is for recurrent subluxation or instability. The second is for patellar instability. Regarding recurrent subluxation and instability, a compensable rating requires persistent instability. Id.; see also 38 C.F.R. § 4.31. “Persistent” is defined as “continuing or inclined to persist in a course” with “continuing” defined as “constant” and “persist” defined as “to continue to exist.” Merriam-Webster’s Dictionary (merriam-webster.com/dictionary, accessed February 8, 2021). Under these criteria, a 30 percent rating is assigned with unrepaired or failed repair of complete ligament tear which causes persistent instability and a medical provider prescribes both an assistive device (e.g., cane(s), crutch(es), walker) and bracing for ambulation. A 20 percent rating is assigned with either (a) Sprain, incomplete ligament tear, or repaired complete ligament tear causing persistent instability, and a medical provider prescribes a brace and/or assistive device for ambulation, or (b) Unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribes either an assistive device or bracing for ambulation. A 10 percent rating is assigned for sprain, incomplete ligament tear, or complete ligament tear (repaired, unrepaired, or failed repair) causing persistent instability, without a prescription from a medical provider for an assistive device or bracing for ambulation. Lastly, regarding patellar instability, a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for a brace and either a cane or a walker warrants a 30 percent rating, which is the highest allowable rating for patellar instability. A diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for a brace, cane, or walker warrants a 20 percent rating. A diagnosed condition involving the patellofemoral complex with recurrent instability (with or without history of surgical repair) that does not require a prescription from a medical provider for a brace, cane, or walker warrants a 10 percent rating. The patellofemoral complex consists of the quadriceps tendon, the patella, and the patellar tendon. 38 C.F.R. § 4.71a, Diagnostic Code 5257, Note (1). A surgical procedure that does not involve repair of one or more patellofemoral components that contribute to the underlying instability shall not qualify as surgical repair for patellar instability (including, but not limited to, arthroscopy to remove loose bodies and joint aspiration). Id. Note (2). According to the August 2012 VA examination report, the Veteran was noted to have had right knee arthritis having had knee arthropathy in November 1987 and arthroscopic repair of a meniscus tear in 1992. She complained of having pain in the right knee with activity. She denied having flare-ups. Tenderness or pain on palpation was noted in the right knee. The Veteran denied and the evidence does not reflect any deformity, effusion, subluxation, or drainage. Upon examination, the Veteran’s right knee range of motion was noted to be 130 degrees flexion and zero degrees extension without evidence of painful motion. There was tenderness or pain on palpation of the joint line or soft tissue in the right knee. The Veteran performed repetitive use testing with at least three repetitions without additional functional loss or range of motion. The examiner also noted that the Veteran did not have functional loss/functional impairment with contributing factors of less movement than normal, excess fatigability, and pain on movement. There was no history of recurrent subluxation. The examination did not indicate malunion of the tibia and fibula. Joint instability was not observed in either knees as all stability testing was reported ot be normal. The examiner noted that the impact on the Veteran’s ability to work is that it may affect prolonged standing and walking. In the February 2017 VA examination report, the Veteran complained that the right knee condition had worsened due to persistent pain. She reported having flare-ups consistent with swelling, tenderness, stiffness, pain with rest, loss of motion, difficulty walking, climbing stairs and pain when standing for long periods. She also complained reported that functional loss and functional loss or functional impairment included spasms and radiating pain. The Veteran’s range of motion in each knee was reported to be 130 degrees in flexion and zero degrees in extension with objective evidence of pain on flexion causing functional loss. The Veteran performed repetitive use testing with at least three repetitions without additional functional loss or range of motion. The examiner noted that there was no crepitus or pain with weight bearing. However, tenderness or pain to palpation was noted in the right knee. Additionally, there was no history of recurrent subluxation or and no instability. The examination did not indicate malunion of the tibia and fibula. The examiner erroneously stated that the Veteran had not had a meniscus condition. The February 2017 VA examination did not completely evaluate the Veteran’s flare-ups and incorrectly noted that the Veteran did not report flare-ups. See Sharp v. Shulkin, 29 Vet. App. 26, 36 (2017). However, there was no additional loss of function or range of motion following repetitive motion. Further, the Board remanded the claim for an examiner to fully address the Veteran’s flare-ups and any additional limitations that may result. According to a November 2017 VA examination report, the Veteran reported that her right knee was unstable and that she had fallen several times but denied having flare-ups. Range of motion testing revealed flexion to be to 140 degrees and extension to zero degrees. Pain was noted on extension. There was no evidence of localized tenderness or pain on palpation, or pain with weight bearing. Crepitus was noted. Additionally, there was no history of recurrent subluxation or and no instability. The examination did not indicate malunion of the tibia and fibula. The Veteran performed repetitive use testing with at least three repetitions without additional functional loss or range of motion. The examiner reported that he was unable to say without mere speculation whether pain, weakness, fatigability, or incoordination significantly limited functional ability with repeated use over time or on flare-ups because the Veteran was not observed after repetition over time. While the Veteran denied flare-ups, the examiner’s finding that it would be speculative to estimate additional loss of function merely because such was not observed is deficient. Sharp v. Shulkin, 29 Vet. App. 26 (2017) Pursuant to the Board remand, the Veteran underwent a VA examination in July 2020. The Veteran reported that her bilateral knee pain had gotten worse and complained of constant bilateral grinding pain, knee instability, and swelling in the knees. The Veteran again denied flare-ups or having functional loss or functional impairment. Upon examination, the Veteran’s right knee range of motion was measured and reported to be 130 degrees in flexion and 10 degrees in extension with objective evidence of pain on flexion. There was objective evidence of crepitus and pain was noted on flexion and extension as well as on palpation of the joint or associated soft tissues, but not on weight-bearing. The Veteran performed repetitive use testing with at least three repetitions without additional functional loss or range of motion. The examiner estimated that pain and weakness caused functional loss with repeated use over time, limiting flexion to 125 degrees and extension to 15 degrees. However, it was noted that functional loss and functional ability was not limited with flare-ups as the Veteran denied flare-ups. There was no history of recurrent subluxation, effusion, and lateral instability. The examination did not indicate malunion of the tibia and fibula. Anterior, posterior, medial, and lateral instability was observed in the right knee. The examiner observed that the Veteran had no current symptoms of the right knee meniscal condition. The examiner also noted that the functional impact was that the Veteran is unable to squat and stand for long periods. The RO issued 20 percent evaluation under Diagnostic Code 5261 for the entire period on appeal based on limitation of extension of 15 to 19 degrees. The evidence does not indicate that the Veteran’s extension has been limited to 20 degrees or more at any point on appeal or that she had other symptoms that would equate to a higher rating for limitation of extension during the period on appeal. Under DC 5260, the Veteran’s right knee disability would be noncompensable because flexion is generally not limited to 45 degrees or less in right knee for the entire period on appeal. Under DC 5260, evaluations of 10 percent are only warranted for flexion limited to 31-45 degrees. Thus, 10 percent evaluation or higher under DC 5260 has not been warranted for the right knee for the entire period on appeal based on the range of motion measured. Treatment records do not show greater limitation of motion than the examination findings during that time. Even with consideration of other factors such as flare-ups and functional loss or impairment, including less movement that normal, weakened movement, pain, and disturbance of locomotion, the Board cannot find that the Veteran’s left knee limitation of flexion equates to a compensable rating under DC 5260. However, the Board finds that an additional 10 percent rating is warranted for “limitation of flexion” in the right knee pursuant to painful motion of the knee under the provisions of 38 C.F.R. § 4.59. A review of the medical and lay evidence reveals complaints of pain on motion in the right knee. According to the 2012 VA examination report, the Veteran reported having pain in the right knee with activity and the August 2020 VA examination report reflects that the Veteran had pain with flexion. Specifically, the August 2020 VA examiner estimated that pain caused functional loss with repetitive motion, limiting flexion to 125 degrees in the right knee. Under the circumstances, 38 C.F.R. § 4.59 dictates that at least the minimum compensable evaluation for the joint is warranted. Thus, an additional 10 percent rating is warranted for “limitation of flexion” in the right knee pursuant to painful motion of the knee under the provisions of 38 C.F.R. § 4.59. A higher rating is not warranted under DC 5260 as flexion has not been limited to 30 degrees or less. Notably, the 2020 VA examiner estimated range of motion after repetitive use over time would be at worst 125 degrees of flexion in the right knee. Although the 2017 VA examiner did not provide an estimate regarding limitation of motion after flare-ups, range of motion was unchanged after repetitive use testing. The Veteran has otherwise denied having flare-ups. Given the above, even when considering the knee pain’s impact on physical activities, higher ratings are not warranted based on limitation of motion. 38 C.F.R. § 4.71a, Diagnostic Code 5260, 5261. Regarding the Veteran’s separate rating under DC 5257, while the AOJ granted a separate rating of 10 percent effective July 23, 2020, the Board finds that the 10 percent rating is warranted effective November 14, 2017. At that time, the Veteran reported that her knee was unstable although joint stability testing revealed no instability. To the extent that the Veteran reports any giving way or instability, the 10 percent rating assigned addresses her reported objective symptomatology and a higher rating is not warranted for the right knee. Regarding the version of Diagnostic Code 5257 in effect prior to February 7, 2021, a rating in excess of 10 percent for right knee instability is not warranted as the evidence does not reflect instability described as moderate or worse. Regarding the version of Diagnostic Code 5257 in effect since February 7, 2021, a rating for recurrent subluxation or instability is not warranted because the Veteran has not demonstrated persistent instability, sprain, incomplete ligament tear, or complete ligament tear. A compensable rating is not warranted for patellar instability either. The evidence does not show surgical repair involving the patellofemoral complex (quadriceps tendon, the patella, and the patellar tendon). Thus, considering both the old and new rating criteria, the Board finds that a rating in excess of 10 percent is not warranted for instability of the right knee. A separate rating under DC 5257 is not warranted for the period on appeal prior to November 14, 2017. Of note, the right knee disability has not manifested in recurrent subluxation and joint instability prior to that time as such was not reported nor observed in the August 2012 or February 2017 VA examinations. Notably, the specific medical tests that are designed to reveal instability of the joints were normal in the right knee. Additional ratings for the right knee under DC 5258 or 5259 are not warranted in this case. Under DC 5258, a 20 percent rating is warranted for dislocation of semilunar cartilage, which encompasses a meniscus tear, with frequent episodes of joint locking, pain, and effusion. 38 C.F.R. § 4.71a, DC 5258. The Veteran’s right knee is clearly shown to have a meniscal condition throughout the appeal period. As noted above, the Veteran had arthroscopic repair of a tear in 1992. However, the appellant has denied instances of “locking” and objective clinical examination has shown no effusion. Although she has complained of pain, as discussed above, that symptom is contemplated in the ratings currently assigned. Under these circumstances, a separate compensable rating under Diagnostic Code 5258 is not warranted. Similarly, a rating under DC 5259 is not warranted because the evidence does not reflect the removal of semilunar cartilage. The Board has also considered the other diagnostic codes pertaining to the knee and leg. Other disability ratings may be assigned only if the symptomatology for a disability is not duplicative or overlapping with the symptomatology of any other disability. See Esteban, 6 Vet. App. at 261-62; Lyles, 29 Vet. App. 107. In this case the evidence does not reflect and the Veteran does not allege that he has tibia or fibula impairment, genu recurvatum, or ankylosis involving either knee. As such, those diagnostic codes are not for application. The competent and probative evidence shows the Veteran has bilateral degenerative joint disease of the right knee with instability and repaired meniscus tear with pain. The evidence is against a finding of right knee extension limited to more than degrees or any limitation in flexion more than 125 degrees. Thus, rating in excess of 20 percent is not warranted for the right knee for the entire period on appeal under DC 5261. The evidence reflects painful flexion but is against a finding of right knee flexion limited to less than 50 degrees. Thus, rating in excess of 10 percent under DC 5260 is not warranted for the left knee for the entire period on appeal. However, a separate rating of 10 percent is warranted for each knee under DC 5261 effective the entire period on appeal based on painful extension. For the reasons stated above, a rating in excess of 10 percent for right knee instability is not warranted. Separate 10 percent ratings are warranted under DC 5257 effective November 14, 2017. Notably, MRI evidence specifically noted that the Veteran had meniscal tears and most examination reports showed frequent episodes of pain. In reaching the above conclusions, the Board has appropriately applied the benefit of the doubt doctrine in this case. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. 4. Propriety of the assignment of a separate rating for surgical scar of the right knee, evaluated as noncompensable as of February 23, 2012. As previously noted, in an August 2020 rating decision, the AOJ granted a separate noncompensable rating for the Veteran’s right knee scars, effective February 23, 2012, the day of entitlement to service connection for the right knee condition. The Board finds the assignment of February 23,2012, as the effective date for the separate rating for the Veteran’s surgical scars to be proper. 38 U.S.C. § 5110; 38 C.F.R. § 3.400. Such scarring was assigned a noncompensable rating under 38 C.F.R. § 4.118, DC 7802. In this regard, as in effect as of February 23, 2012, such provides for a 10 percent rating for burn scars or scars due to other causes not of the head, face, or neck, that are superficial and nonlinear and affect an area or areas of 144 square inches (929 square cms) or greater. In the instant case, the 2012 and 2017 VA examination reports reflects the presence of two scars on the Veteran’s right knee. Upon examination, it was noted that such scarring was not painful or unstable, and the total area was not greater than 39 square centimeters (6 square inches). Specifically, it was observed that the scars measured no greater than 2 cm by 0.5 cm. Furthermore, at no time during the appeal period has the Veteran reported any symptoms or functional impairment/disabling effects associated with scarring of the right knee. Therefore, in light of the fact that the Veteran’s right knee scars are not of a size so as to warrant a compensable rating under DC 7802 as in effect through the present time, an initial compensable rating under such DC is not warranted at any time pertinent to the appeal period. Furthermore, as such scarring is not shown to be symptomatic or result in any limitation of function or disabling effects, a higher or separate rating is not warranted under any other potentially applicable DC pertaining to the evaluation of scars. See DC 7800-7805. Thus, based on the foregoing, the Board finds that the assignment of a separate rating for scars of the right knee, evaluated as noncompensable as of February 23, 2012, is proper. REASONS FOR REMAND 1. Entitlement to service connection for a colon condition is remanded. According to an August 2017 VA opinion, the Veteran had multiple episodes of abdominal discomfort associated with gynecological problems in service. The VA examiner further noted that there was an episode of enteritis noted but this occurs with viruses and that there were no reports of alternating diarrhea and constipation noted suggestive of IBS. Thus, it was opined that the claimed condition is less likely than not incurred in or caused by the stomach complaints during service. However, as noted in the November 2020 JMPR, in light of assertions made by Veteran’s representative in November 2017 and statements made in the March 2015 private DBQ indicating that the colon condition had been overlooked and misdiagnosed as a gynecological condition during service, the adequacy of the rationale contained in the August 2017 VA nexus opinion is in question. Thus, remand is warranted for additional VA examination and opinion to reconcile the March 2015 private DBQ and the November 2017 assertions along with the August 2017 medical nexus opinion. 2. Entitlement to service connection for fibromyalgia is remanded. 3. Entitlement to service connection for a left knee condition is remanded. 4. Entitlement to service connection for a right-hand condition is remanded. 5. Entitlement to service connection for a left-hand condition is remanded. The claims for service connection for fibromyalgia, a left knee condition, and bilateral hand conditions, were previously remanded for examinations and opinions regarding etiology. The Veteran was provided VA examinations in July 2020. The examiner noted the Veteran’s in-service findings and opined that the Veteran’s claimed conditions were not related to service, noting the gap between service and current diagnoses. The opinions are inadequate because they did not consider the lay statements of record indicating problems since service. See Dalton v. Peake, 21 Vet. App. 23, 39-40 (2007) (a medical opinion is inadequate if it does not consider the appellant’s reports of symptoms and history, even if recorded in the course of the examination). According to the July 2020 VA examinations, the Veteran reported that she started having symptoms of fibromyalgia in 1984 after her back injury and knee pain starting in 1987. She further reported that symptoms have gotten worse since service. Regarding the hand conditions, private treatment record dated in February 2008 reflects that the Veteran had long standing pain, specifically, a 10 year history of persistent severe pain at the base of the right and left thumbs. Further, private treatment record dated in June 2019 indicates that the Veteran was seen between 1992 and 2002 but such records were not available. Accordingly, remand is warranted to obtain additional VA medical opinion. 6. Entitlement to service connection for a neck and/or upper back condition is remanded. The Veteran has not been afforded a VA examination related to the claimed neck/upper back condition. According to the private May 2012 treatment report, the Veteran’s clinician Dr. M.M. opined that the claimed conditions, including that of the cervical spine was related to military service and injuries suffered during that time. As noted in the prior December 2019 Board remand, the Board finds this opinion conclusory as the rationale for the opinion was simply that it was based on a careful review of the Veteran’s records, several weeks of treatment and observation, and his 26 years of training and experience. He did not specifically explain how he came to his opinion. Thus, the Board finds the opinion insufficient to grant this claim. Nonetheless, in light of the foregoing, a VA examination should be obtained on remand to determine the nature and etiology of the Veteran’s claimed neck/upper back pain. See 38 C.F.R. § 3.159 (c)(4); McLendon v. Nicholson, 20 Vet. App. 70 (2006). 7. Entitlement to service connection for a fallopian tube condition, other than bilateral tubal ligation is remanded. 8. Entitlement to a compensable rating for endometriosis is remanded. Per the Board’s December 2019 remand, the Veteran was afforded VA examination to determine the nature and severity of the claimed fallopian tube condition and severity of the service-connected endometriosis. VA examinations and opinions were obtained in July 2020, September 2020, and October 2020. While no specific fallopian tube condition was noted in 2020, the Veteran was noted to have other diagnoses including fibroids and FSAD (female sexual arousal disorder). The Veteran also reported symptoms including pain and painful intercourse. In an October 2020 rating decision, service connection was granted for hysterectomy (claimed as cervix and uterus condition) as well as left ovarian cyst, both effective February 23, 2012. Regarding etiology of additional diagnoses, the VA examiner opined that the Veteran’s FSAD less likely than not had onset in or is otherwise related to service noting the medical records were silent for a diagnosis of fibroids or FSAD and that FSAD was not confirmed in the claims file. The examiner also stated that the Veteran had a diagnosis of sexual dysfunction in 2006 and found that the Veteran did not have any findings, signs, or symptoms due to endometriosis. The Board notes that in a private March 2015 DBQ, it was noted that Veteran suffered from pelvic inflammatory disease as well as sexual dysfunction since 2004. Remand is warranted for additional VA examination to clarify whether there are any additional diagnoses regarding the fallopian tubes including reconciliation with the previously noted diagnoses as well as clarification whether any current symptoms are related to the service-connected endometriosis or other current diagnoses. The examiner also opined that the Veteran’s fibroids were not incurred in or caused by military service, or proximately due to or the result of or permanently aggravated beyond its usual condition by the service-connected endometriosis. Unfortunately, the examiner employed the incorrect standard in addressing the etiology of the Veteran’s fibroids. In Ward v. Wilkie, the Court held that, for secondary service connection, aggravation need not be permanent in nature. 31 Vet. App. 233, 241-42 (2019). The standard of “permanently aggravated” is used for service connection of a disorder noted on the medical examination upon entry into service, which is not the case here. 38 C.F.R. § 3.306. Therefore, as the examiner employed the incorrect standard, a new medical opinion should be obtained on remand. The matters are REMANDED for the following actions: 1. Arrange to obtain from the physician who provided the August 2017 opinion, another appropriate physician, an addendum opinion addressing the etiology of diagnosed colon condition, based on claims file review (if possible). Arrange for the Veteran to undergo VA examination, by an appropriate physician, if one is deemed necessary in the judgment of the physician designated to provide the addendum opinion. The contents of the entire, electronic claims file, to include a complete copy of this REMAND, must be made available to the designated physician, and the addendum opinion/examination report should include discussion of the Veteran’s documented medical history and assertions. If the Veteran is examined, all indicated tests and studies should be accomplished (with all results made available to the requesting physician prior to the completion of his or her report), and clinical findings should be reported in detail. The examiner is asked to opine whether it is at least as likely as not (a 50 percent or greater probability) that the Veteran’s colon condition had its onset in, or is otherwise related to, active service, to include the stomach complaints during service. A complete rationale must be provided for all opinions expressed. The rationale must consider and discuss the pertinent evidence of record, to include the Veteran’s lay statements. The examiner must also address the Veteran’s reports of continued pain that began in service and continued to the present and the assertions made by Veteran’s representative in November 2017 and statements made in the March 2015 private DBQ indicating that the colon condition had been overlooked and misdiagnosed as a gynecological condition during service. 2. Obtain an addendum opinion from the physician who provided the 2020 VA opinion, another appropriate physician, addressing the nature and etiology of her fibromyalgia, left knee condition, and bilateral hand condition. If deemed necessary in the judgment of the physician designated to provide the addendum opinion, arrange for the Veteran to undergo VA examination. The contents of the entire, electronic claims file, to include a complete copy of this REMAND, must be made available to the designated physician, and the addendum opinion/examination report should include discussion of the Veteran’s documented medical history and assertions. The examiner should: a) Clarify all current diagnoses related to the bilateral hands. b) Opine whether it is at least as likely as not (a 50 percent or greater probability) that the Veteran’s left and/or right hand condition had its onset in, or is otherwise related to, active service, to include the reported fall in service or the April 1990 left thumb strain. c) Opine whether it is at least as likely as not (a 50 percent or greater probability) that the Veteran’s left knee condition had its onset during or within one year of, or is otherwise related to, active service. d) Opine whether it is at least as likely as not (a 50 percent or greater probability) that the Veteran’s fibromyalgia had its onset in, or is otherwise related to, active service, to include the January 1984 report of unresolved muscular pain. A complete rationale must be provided for all opinions expressed. The rationale must consider and discuss the pertinent evidence of record, to include the Veteran’s lay statements. The examiner must also address the Veteran’s reports of continued pain that began in service and continued to the present. 3. Obtain an addendum opinion from the physician who provided the 2020 VA opinion, another appropriate physician, addressing the nature and etiology of her claimed fallopian tube condition. If deemed necessary in the judgment of the physician designated to provide the addendum opinion, arrange for the Veteran to undergo VA examination. The contents of the entire, electronic claims file, to include a complete copy of this REMAND, must be made available to the designated physician, and the addendum opinion/examination report should include discussion of the Veteran’s documented medical history and assertions. The examiner is asked to: (a) Clarify what diagnoses, if any, does the Veteran have that are separate and distinct from any hysterectomy residuals, left ovarian cyst and endometriosis. (b) For each diagnosis the examiner finds that are separate and distinct from the Veteran’s hysterectomy residuals, left ovarian cyst, and endometriosis, he/she must opine whether it is at least as likely as not (a 50 percent or greater probability) that the Veteran’s diagnosis had its onset in, or is otherwise related to, active service, to include the gynecological complaints in service. (c) Opine whether it is at least as likely as not that the Veteran’s previous uterine fibroids were caused or aggravated by her service-connected endometriosis. The term “aggravation” means a worsening of a disability beyond its natural progression. (d) Determine the current severity of her service-connected endometriosis. The examiner must provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran’s disability under the rating criteria. A complete rationale must be provided for all opinions expressed. The rationale must consider and discuss the pertinent evidence of record, to include the Veteran’s lay statements. The examiner is asked to consider the diagnoses of previously noted pelvic inflammatory disease and female sexual arousal disorder as well as the Veteran’s reported symptomatology. 4. Schedule a VA examination to determine the nature and etiology of the Veteran’s claimed neck/upper back disability. The contents of the entire, electronic claims file, to include a complete copy of this REMAND, must be made available to the designated physician, and the addendum opinion/examination report should include discussion of the Veteran’s documented medical history and assertions. Clarify all current diagnoses related to the neck/upper back. Opine whether it is at least as likely as not (a 50 percent or greater probability) that the Veteran’s neck/upper back disability had its onset in, or is otherwise related to, active service, to include the reported fall in service. A complete rationale must be provided for all opinions expressed. The rationale must consider and discuss the pertinent evidence of record, to include the Veteran’s lay statements. The examiner must also address the Veteran’s reports of continued pain that began in service and continued to the present. Cynthia M. Bruce Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board R. Williams, Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.