Citation Nr: 21022982 Decision Date: 04/19/21 Archive Date: 04/19/21 DOCKET NO. 16-13 489 DATE: April 19, 2021 ORDER Entitlement to an initial rating in excess of 10 percent for a bilateral hearing loss disability is denied. For the period prior to January 16, 2020, a rating of 10 percent, but no higher, for a right wrist strain is granted. For the period beginning January 16, 2020, a rating in excess of 10 percent for a right wrist strain is denied. Entitlement to an initial rating in excess of 10 percent for a painful laceration of the medial left thigh is denied. Entitlement to a compensable initial rating for a laceration of the medial left thigh is denied. For the period prior to January 16, 2020, a 10 percent rating, but no higher, for a right knee strain is granted. For the period beginning January 16, 2020, entitlement to a compensable rating for a right knee strain is denied. REMANDED Entitlement to a compensable initial rating for a missile injury residual with numbness 5th finger left hand is remanded. Entitlement to service connection for irritable bowel syndrome (IBS) is remanded. Entitlement to service connection for a skin condition, other than multiple lipomas, is remanded. Entitlement to service connection for a left ankle disability is remanded. FINDINGS OF FACT 1. The Veteran’s bilateral hearing has been manifested by hearing acuity of no worse than Level IV in the right ear and no worse than Level IV in the left ear. 2. For the period prior to January 16, 2020, the Veteran’s right wrist strain was manifested by painful motion and weightbearing. 3. For the entire period on appeal, the Veteran has been awarded the maximum rating provided under Diagnostic Code 5215 for right wrist limitation of motion. 4. The Veteran’s left medial thigh scar was manifested by one painful scar that measured, at most, 17.5 centimeters (cm) by 2.5 cm; it was not unstable or associated with underlying soft tissue damage. 5. The Veteran’s left medial thigh scar was not manifest by any disabling effects not considered under Diagnostic Codes 7800-04. 6. For the period prior to January 16, 2020, the Veteran’s right knee strain was manifested by pain, tenderness to palpation, weakness, and fatigability; it was not manifested by flexion limited to 45 degrees, extension limited to 10 degrees, recurrent subluxation, instability, dislocated semilunar cartilage, symptomatic semilunar cartilage removal, tibia or fibula impairment, or genu recurvatum. 7. For the period beginning January 16, 2020, the Veteran’s right knee strain was manifested by pain, stiffness, locking, and weakness; it was not manifested flexion limited to 45 degrees, recurrent subluxation, instability, dislocated semilunar cartilage, symptomatic semilunar cartilage removal, tibia or fibula impairment, or genu recurvatum. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 10 percent for a bilateral hearing loss have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.85, 4.86, Diagnostic Code 6100. 2. For the period prior to January 16, 2020, the criteria for a 10 percent rating, but no higher, for a right wrist strain have been met. 38 C.F.R. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5214, 5215. 3. For the period beginning January 16, 2020, the criteria for a rating in excess of 10 percent for a right wrist strain have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.71a, Diagnostic Codes 5010, 5215. 4. The criteria for a disability rating in excess of 10 percent for a medial left thigh scar have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.118, Diagnostic Code 7804. 5. The criteria for a compensable disability rating for a medial left thigh scar have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.118, Diagnostic Code 7805. 6. For the period prior to January 16, 2020, the criteria for a 10 percent rating, but no higher, for a right knee strain have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5256-5263. 7. For the period beginning January 16, 2020, the criteria for a compensable rating for a right knee strain have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5256-5263. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from May 2002 to June 2014, to include service in Iraq. He was awarded a Purple Heart, Combat Infantryman Badge, and Senior Parachutist Badge, among other decorations. He also had subsequent National Guard service, including a period of active duty for training from May 2019 to November 2019. These matters are before the Board of Veterans’ Appeals (Board) on appeal from a rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). In December 2018, the Veteran testified before the undersigned Veterans Law Judge at a video conference hearing. A transcript of his testimony is of record. These matters were last before the Board in July 2019, when they were remanded for additional development. Regarding the Veteran’s right knee claim, a September 2014 rating decision granted service connection for a right knee strain and assigned a noncompensable rating under38 C.F.R. § 4.71a, Diagnostic Code 5260. The Veteran timely appealed that rating. An October 2020 rating decision granted service connection for status post right knee patellar tendon repair with limitation of extension and assigned a 10 percent rating, effective January 16, 2020. The Board notes that the October 2020 rating decision did not alter the disability rating associated with the Veteran’s service-connected right knee strain. Rather it granted service connection for a separate right knee disability, assigned a 10 percent rating for that disability, and continued the Veteran’s noncompensable rating for his right knee strain. Accordingly, the Veteran’s right knee strain and status post right knee patellar tendon repair with limitation of extension are distinct service-connected disabilities. As the Veteran did not appeal the October 2020 rating decision and the October 2020 Supplemental Statement of the Case (SSOC) only addressed the right knee strain, the propriety of the right knee patellar tendon repair with limitation of extension rating is not before the Board. Increased Rating Disability ratings are determined by applying the criteria set forth in the VA Schedule of Rating Disabilities (Rating Schedule) and are intended to represent the average impairment of earning capacity resulting from disability. 38 U.S.C. § 1155 (2012); 38 C.F.R. § 4.1 (2020). Disability of the musculoskeletal system is primarily the inability, due to damage or inflammation in parts of the system, to perform normal working movements of the body with normal excursion, strength, speed, coordination and endurance. The functional loss may be due to absence of part or all of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or may be due to pain, supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part which becomes painful on use must be regarded as disabled. See DeLuca v. Brown, 8 Vet. App. 202 (1995); 38 C.F.R. § 4.40; see also 38 C.F.R. §§ 4.45, 4.59. Although pain may be a cause or manifestation of functional loss, limitation of motion due to pain is not necessarily rated at the same level as functional loss where motion is impeded. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011). 1. Entitlement to an initial evaluation in excess of 10 percent for bilateral hearing loss disability The Veteran contends that he is entitled to a higher rating because his hearing loss requires a physical profile and necessitates the use of hearing aids. Evaluations of defective hearing range from noncompensable to 100 percent based on organic impairment of hearing acuity as measured by the results of a controlled Maryland CNC speech discrimination test together with the average hearing threshold level measured by pure tone audiometry tests in the frequencies of 1000, 2000, 3000, and 4000 cycles per second (Hertz). 38 C.F.R. § 4.85, Diagnostic Code 6100 (2020). To evaluate the degree of disability from bilateral service-connected hearing loss, the schedule establishes 11 auditory hearing acuity levels designated from Level I for essentially normal hearing acuity through Level XI for profound deafness. 38 C.F.R. § 4.85, Tables VI and VII. An exceptional pattern of hearing impairment occurs when the pure tone threshold at each of the four specified frequencies (1000, 2000, 3000, and 4000 Hertz) is 55 decibels or more. 38 C.F.R. § 4.86(a) (2020). In that situation, the rating specialist will determine the Roman numeral designation for hearing impairment from either Table VI or Table VIA, whichever results in the higher numeral. Further, when the average pure tone threshold is 30 decibels or less at 1000 Hertz, and 70 decibels or more at 2000 Hertz, the rating specialist will determine the Roman numeral designation for hearing impairment from either Table VI or Table VIA, whichever results in the higher numeral, and that numeral will then be elevated to the next higher numeral. 38 C.F.R. § 4.86(b). At a June 2014 VA audiology examination the Veteran reported that he had difficulty maintaining conversations in the presence of background noise and that he had to watch lips to understand words. 38 C.F.R. § 4.10; Martinak v. Nicholson, 21 Vet. App. 447 (2007). The Veteran’s Maryland CNC Word List speech recognition score and pure tone thresholds, in decibels, were as follows: June 2014 HERTZ 1000 2000 3000 4000 Avg CNC RIGHT 15 40 75 80 53 82% LEFT 15 30 80 95 55 78% Applying the results to Table VI, the findings yield a numeric designation of Level IV in the right ear and Level IV in the left ear. Entering the resulting bilateral numeric designation of Level IV for the right ear and Level IV for the left ear to 38 C.F.R. § 4.85, Table VII, equates to a 10 percent disability rating under Diagnostic Code 6100. An exceptional pattern of hearing impairment under 38 C.F.R. § 4.86 was not shown. A December 2019 VA audiological examination report reveals that the Veteran reported that he constantly had to ask people to repeat themselves and that he had difficulty conversing. He also reported safety concerns related to his hearing loss as he was unable to hear alarms in his house, his front door open, or his child in another room. 38 C.F.R. § 4.10; Martinak v. Nicholson, 21 Vet. App. 447 (2007). The Veteran’s Maryland CNC Word List speech recognition score and pure tone thresholds, in decibels, were as follows: December 2019 HERTZ 1000 2000 3000 4000 Avg CNC RIGHT 10 40 80 90 55 94% LEFT 10 35 90 100 59 90% Applying the results to Table VI, the findings yield a numeric designation of Level I in the right ear and Level III in the left ear. Entering the resulting bilateral numeric designation of Level I for the right ear and Level III for the left ear to 38 C.F.R. § 4.85, Table VII, equates to a noncompensable disability rating under Diagnostic Code 6100. An exceptional pattern of hearing impairment under 38 C.F.R. § 4.86 was not shown. The Board notes that the Veteran’s National Guard service treatment records contain numerous audiology evaluations conducted as part of his H-3 profile and hearing conservation program. While the service treatment records contain audiometric evaluation thresholds and Speech Recognition in Noise Test or “SPRINT” speech discrimination tests, none of the evaluations contained speech discrimination test results pursuant to the Maryland CNC. As such, the audiology evaluations conducted as part of the Veteran’s hearing conservation program are not adequate for rating purposes under § 4.85(a) (2020). Based on the evidence above, a rating in excess of 10 percent for the Veteran’s bilateral hearing loss is not warranted. The Board acknowledges the lay evidence of record, including the Veteran’s reports of requiring a hearing aid, receiving a permanent H-3 profile, having difficulty with conversation, and having safety concerns regarding his decreased hearing acuity. See e.g., February 2015 notice of disagreement (NOD) and June 2014 and December 2019 audiology reports. The Veteran is competent to report difficulty with his hearing; however, disability ratings for hearing loss are derived from a mechanical application of the rating schedule to the numeric designations resulting from audiometric testing. See Lendenmann v. Principi, 3 Vet. App. 345 (1992). The rating criteria contemplate speech reception thresholds and ability to hear spoken words on Maryland CNC testing. The functional impact that the Veteran describes, is contemplated by the rating criteria. Doucette v. Shulkin, 28 Vet. App. 366 (2017). The Veteran’s main complaint is reduced hearing acuity and clarity, which is what is contemplated in the rating assigned. See Rossy v. Shulkin, 29 Vet. App. 142, 145 (2017). Accordingly, the preponderance of the most probative evidence is against the claim of entitlement to a rating in excess of 10 percent for hearing loss. In reaching the conclusion above, the Board considered the doctrine of reasonable doubt, however, as the preponderance of the evidence is against the Veteran’s claim, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 2. Entitlement to an increased rating for a right wrist strain Service connection for a right wrist strain was granted in a September 2014 rating decision. A noncompensable rating was assigned under 38 C.F.R. § 4.71a, Diagnostic Code 5215, effective June 4, 2014. During the pendency of the appeal, an October 2020 rating decision granted a 10 percent rating, effective January 16, 2020 based on painful motion. Under 38 C.F.R. § 4.71a, Diagnostic Code 5215, a maximum 10 percent rating is provided for dorsiflexion limited to less than 15 degrees and for palmar flexion limited in line with the forearm for the major and minor wrist. For the period prior to January 16, 2020, the Veteran’s right wrist was rated as noncompensable. Nevertheless, resolving reasonable doubt in his favor, the Board finds that the Veteran’s right wrist strain was manifested by painful motion prior to January 16, 2020. Specifically, the June 2014 VA wrist examination noted that the Veteran’s right wrist was painful when performing push-ups. A December 22, 2014 service treatment record notes that the Veteran reported ongoing right wrist pain that interfered with daily function. VA treatment records from June 30, 2015, June 16, 2016, March 16, 2017 note that the Veteran reported intermittent right wrist pain and his active problem list includes a diagnosis of wrist pain. Finally, at his January 2020 VA wrist examination, the Veteran reported that he had experienced continued right wrist pain since his discharge from his initial period of active service. As such, a 10 percent rating for the right wrist strain is warranted for the period prior to January 16, 2020. 38 C.F.R. § 4.59 (2020). Nevertheless, as 10 percent is the maximum rating under Diagnostic Code 5215, at no time during the pendency of the appeal has a rating in excess of 10 percent been warranted. The Board has considered the other diagnostic criteria provided for the wrist to determine whether an increased rating is warranted. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). However, the remaining diagnostic code is not applicable in the absence of unfavorable or favorable ankylosis. See 38 C.F.R. § 4.71a, Diagnostic Code 5214 (2020). As the Veteran has motion in his right wrist, ankylosis is not shown. See e.g., August 2014 and January 2020 VA examination reports (noting that the Veteran had active palmar flexion and dorsiflexion). Accordingly, Diagnostic Code 5214 is not applicable. In reaching the conclusion above, the Board considered the doctrine of reasonable doubt, however, as the preponderance of the evidence is against the Veteran’s claim, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 3. Entitlement to an initial evaluation in excess of 10 percent for a painful laceration of the medial left thigh 4. Entitlement to a compensable initial evaluation for a laceration of the medial left thigh The Veteran contends that he is entitled to a higher rating for his left thigh laceration scar. Specifically, he reports that he is entitled to a higher rating because he has a seven inch semi linear scar that is painful. See February 2015 NOD and accompanying photograph. A September 2014 rating decision granted service connection for a painful laceration scar of the medial left thigh and assigned a 10 percent rating under 38 C.F.R. § 4.118, Diagnostic Code 7804. The September 2014 rating decision also granted service connection for other effects of the Veteran’s left medial thigh scar and assigned a noncompensable rating under 38 C.F.R. § 4.118, Diagnostic Code 7805. The Board notes that while service connection was granted under separate diagnostic codes for the Veteran’s medial left thigh scar, there is only one scar on his medial left thigh. See February 2016 Statement of the Case (noting that the Veteran was originally granted two separate evaluations for his laceration (scar) of the medial left thigh, the first as service connection for a painful scar and the second as service connection for the scar “using criteria for which a compensable evaluation might be warranted if your scar met other criteria such as being nonlinear and meeting certain size requirements”). The Board notes that VA amended the criteria for rating skin disabilities effective from August 13, 2018. However, 38 C.F.R. § 4.118, Diagnostic Codes 7804 and 7805 were not changed by the August 13, 2018, amendments. Under Diagnostic Code 7804, one or two scars that are unstable or painful scars warrants a 10 percent rating. Three or four scars that are unstable or painful scars warrants a 20 percent rating. Five or more scars that are unstable or painful warrants a 30 percent rating. 38 C.F.R. § 4.118. Note 1 to Diagnostic Code 7804 instructs that an unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. Id. Diagnostic Code 7805 instructs that any disabling effect(s) not considered in a rating provided under Diagnostic Codes 7800-04 are to be rated under an appropriate Diagnostic Code. A June 2014 VA scar examination report indicates that the Veteran had a medial left thigh laceration scar. The Veteran reported that the scar was the result of a 4.5-inch laceration wherein a tree limb went into his left leg. He reported that he occasionally had a “pulling pain” sensation. The examiner noted that the Veteran had one painful scar. The examiner noted that the Veteran’s medial left thigh laceration scar was not unstable and was not due to a burn. The examiner noted that the scar was on the medial aspect of the Veteran’s left thigh and the scar was linear and was 15 cm by 1 cm. A June 2014 VA hip and thigh examination report noted that the Veteran had an “occasional pulling pain” as a residual of his left thigh laceration. Upon testing, the Veteran had full range of motion in his left hip and full muscle strength for left hip flexion, abduction, and extension. The examiner noted that left femur imaging showed no evidence of soft tissue abnormality. A June 2014 VA muscle injuries examination report indicated that the Veteran did not now have and had not have a diagnosed muscle injury. A May 2018 report of medical history notes that the Veteran had a penetrating trauma to his left thigh in 2013 wherein a tree branch went through his thigh. It was noted that he had “no sequelae” and no chronic thigh pain.” At his December 2018 hearing, the Veteran testified that his thigh scar caused pain when he tried to run and an uncomfortable sensation when cloth rubbed against it. He also noted that there was “a little bit of a fold” in the scar that hurt. He described the pain as an electrical impulse. He also asserted that the scar had adhered to the underlying tissue. A January 2020 VA scar examination report noted that the Veteran had a healed left thigh laceration. The examiner noted that the Veteran had a 17.5 cm by 2.5 cm scar on his left thigh. The examiner indicated that the scar was not tender to palpation, unstable upon inspection, and did not have underlying soft tissue damage. The examiner opined that the Veteran’s scar did not result in limitation of function, to include limitation of motion. The examiner indicated that the approximate total area affected was .1 cm2. Nevertheless, that calculation appears to be a typo or miscalculation as 17.5 cm multiplied by 2.5 cm equates to a total of 43.75 square centimeters. The Veteran was also provided a muscle injuries examination in January 2020. The examiner again indicated that the Veteran did not have a currently diagnosed muscle injury related to his thigh laceration. The Board finds that the preponderance of the evidence is against the assignment of a rating in excess of 10 percent under Diagnostic Code 7804 because the Veteran’s scar is not manifest by three or four scars that are unstable or painful. The Board also finds that the preponderance of the evidence is against the assignment of a compensable rating for the Veteran’s left medial thigh scar under Diagnostic Code 7805 as there are no evidence of disabling effects not considered in a rating provided under Diagnostic Codes 7800-7804. To the contrary, the VA examinations reports consistently indicated that the Veteran’s left medial thigh laceration scar did not result in any functionale impairment other than pain, which is already compensated under Diagnostic Code 7804. The Board acknowledges that the Veteran believes that his left medial thigh laceration scar has been more severe than the assigned disability ratings reflect. The Veteran is competent to report observable symptoms, to include that his scar is painful and appears semi-linear. However, he has not been shown to have appropriate medical training. As such, he is not competent to opine that his scar is “not superficial” (deep) or that it is adhered or stuck to the underlying tissue. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). As such, his assertions in this regard are not probative. As such, the Board affords significantly more probative weight to the medical evidence that consistently indicated that his left thigh scar did not involve tissue damage. The Board considered the other Diagnostic Codes pertaining to scars. However, the Veteran’s scar is not of the head, face, or neck; the scar does not involve underlying soft tissue damage; and it does not cover an area or areas of 929 square cm or greater. Therefore, Diagnostic Codes 7800, 7801, and 7802 both prior to and from August 13, 2018, are inapplicable. In conclusion, the Board finds that the preponderance of the evidence is against the Veteran’s claim for a disability rating in excess of 10 percent for a left medial thigh laceration scar under Diagnostic Code 7804 and entitlement to a compensable rating under Diagnostic Code 7805. In denying such ratings, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107 (2012); 38 C.F.R. §§ 4.3, 4.7 (2020). 5. Entitlement to a compensable initial evaluation for a right knee strain The Veteran contends that he is entitled to a higher rating for his right knee disability. The Veteran asserted that a higher rating is warranted because he had daily right knee pain. See February 2015 NOD. A September 2014 rating decision granted service connection for a right knee strain and assigned a noncompensable rating under38 C.F.R. § 4.71a, Diagnostic Code 5260 for limitation of flexion of the leg. Effective February 7, 2021, VA revised the criteria for evaluating musculoskeletal disorders. See Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 76453, 76464 (Nov. 30, 2020); Correction, 86 Fed. Reg. 8142, 8143 (Feb. 4, 2021) (changing new diagnostic code applicable to plantar fasciitis from 5285 to 5269). These new regulations apply to all applications for benefits received by VA or that are pending before the agency of original jurisdiction on or after February 7, 2021. Claims pending prior to the effective date will be considered under both old and new rating criteria, and whatever criteria is more favorable to the Veteran will be applied. The Board may not apply a current regulation prior to its effective date unless the regulation explicitly provides otherwise. Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). However, the Board is not precluded from applying prior versions of the applicable regulation to the period on or after the effective dates of the new regulation if the prior version was in effect during the pendency of the appeal. Nevertheless, the Board notes that Diagnostic Codes 5260 and 5261 were not changed by the February 7, 2021 amendments. Under Diagnostic Code 5260, a noncompensable rating is warranted for flexion limited to 60 degrees. A 10 percent rating is warranted for flexion limited to 45 degrees. A 20 percent rating is warranted for flexion limited to 30 degrees. A 30 percent rating is warranted for flexion limited to 15 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5260 (2020). Under Diagnostic Code 5261, extension that is limited to 5 degrees warrants a noncompensable rating; extension that is limited to 10 degrees warrants a 10 percent rating; and extension that is limited to 15 degrees warrants a 20 percent rating; extension that is limited to 20 degrees warrants a 30 percent rating; extension that is limited to 30 degrees warrants a 40 percent rating; and extension that is limited to 45 degrees warrants a 50 percent rating. 38 C.F.R. § 4.71a, Diagnostic Code 5261 (2020). Normal motion of a knee is from 0 degrees extension to 140 degrees flexion. 38 C.F.R. § 4.71, Plate II (2020). At his June 2014 VA knee examination, the Veteran reported that his right knee ached with rucking. Upon testing, he was noted to have right knee flexion to 140 degrees and extension to zero degrees without objective evidence of pain. Repetitive use testing was performed without any additional loss of motion. Upon examination, the Veteran was noted to have tenderness or pain to palpation of the joint line or soft tissue. Muscle strength and joint stability testing were within normal limits. The examiner indicated that there was no evidence of recurrent patellar subluxation or dislocation. The examiner indicated that the Veteran did not have any history of any meniscal condition. The Veteran denied using any assistive device for locomotion. X-rays conducted in conjunction with the examination revealed no evidence of fracture, subluxation, or other significant bone, joint, or soft tissue abnormality. The examiner opined that during flare-ups or with repeated use over time, the Veteran had contributing factors of pain, weakness, fatigability, and incoordination without additional limitation of functional ability. A December 2014 service treatment record noted that the Veteran endorsed knee pain that affected his daily function. VA treatment records from June 2015, June 2016, and March 2017 indicate that the Veteran reported chronic right knee pain and was assessed with chronic intermittent right knee pain. Private treatment records from Cross Creek Medical Clinic from February 2017, October 2017, and December 2017 note that the Veteran reported ongoing right knee pain, which he described as moderate discomfort. He reported that the symptoms had been progressive and worsening. It was noted that his gait was affected by a right leg limp, that he had tenderness to palpation of his right knee, and that he had full range of motion in his right knee. At his December 2018 hearing, the Veteran testified that he had right knee pain, weakness, that his leg would sometimes “give out a little bit” when he shifted his weight after standing in one place for a period of time. At his January 16, 2020 VA knee examination, the Veteran was diagnosed with a right knee strain and status post right knee patellar tendon repair. The Veteran reported ongoing right knee pain. He denied using any assistive device for locomotion. He described the pain as a dull aching sensation that was aggravated by movement. He rated the pain as a 5 out of 10 on a daily basis and a 10 out of 10 during flare-ups. He endorsed flare-ups characterized by increased pain, stiffness, and difficulty with movement. He reported that the flare-ups occurred once or twice a week and lasted approximately 12 hours. He endorsed difficulty with prolonged sitting, standing, bending, walking, and squatting. Upon testing, the Veteran had right knee flexion to 125 degrees and extension to 10 degrees. Pain was noted during active motion, passive motion, and weight bearing. Crepitus was also noted. There was no evidence of pain in non-weight bearing. Upon repetitive use testing, the Veteran had flexion to 110 degrees and extension to 10 degrees. The examiner opined that the Veteran would have additional limitations due to pain, weakness, fatigability, or incoordination during flare-ups and after repetitive use over time. The examiner opined that in terms of range of motion, the Veteran would have flexion to 110 degrees and extension to 10 degrees after repetitive use and with flare-ups. Right knee muscle strength was 4/5 for flexion and extension. It was noted that there was no evidence of pain on palpation, muscle atrophy, recurrent subluxation, lateral instability, a meniscal condition, or ankylosis. Anterior instability, posterior instability, medial instability, and lateral instability testing were all within normal limits. Regarding functional loss, the examiner opined that the Veteran would have difficulty with prolonged sitting, standing, bending, walking, and squatting. The examiner opined that the Veteran’s additional diagnosis of status post right knee patellar tendon repair was directly related to the previous service-connected diagnosis and was not a new diagnosis. After reviewing the evidence of record, the Board finds that for the period prior to January 16, 2020, a 10 percent rating, but no higher, is warranted under 38 C.F.R. §§ 4.40, 4.45 and 4.49 pursuant to the guidelines set forth in DeLuca. See also Burton v. Shinseki, 25 Vet. App. 1 (2011) (section 4.59 applies to disabilities other than just arthritis). Specifically, the June 2014 VA knee examination report noted that the Veteran’s right knee ached and the examiner opined there “are contributing factors of pain” during flare-ups and with repeated use over time. VA treatment records, private treatment records, and National Guard records also note that the Veteran endorsed right knee pain that affected his daily function. See e.g., December 2014 service treatment record; VA treatment records from June 2015, June 2016, and March 2017; and Cross Creek Medical Clinic records from February 2017, October 2017, and December 2017. As such, a 10 percent rating is warranted. A rating in excess of 10 percent is not warranted as the evidence is against finding that the Veteran had compensable loss of flexion or extension. To the contrary prior to January 16, 2020, the Veteran had right knee flexion to 140 degrees and extension to zero degrees. See e.g., June 2014 VA knee examination report. See also Cross Creek Medical Clinic records from February 2017, October 2017, and December 2017 and October 13, 2016 VA record (noting that the Veteran had full range of motion). Accordingly, a rating in excess of the currently assigned 10 percent rating for painful motion is not warranted under Diagnostic Code 5260 or 5261. The Board acknowledges the Veteran’s lay reports of symptoms including pain, stiffness, locking, and weakness. However, even considering the Veteran’s lay reports of symptoms, he was consistently noted to have full range of motion and the June 2014 VA examiner expressly opined that despite his pain, weakness, fatigability, and/or incoordination the Veteran would not have any additional limitation of right knee functional ability during flare-ups or repeated use over time. For the period beginning January 16, 2020, the Board finds that the preponderance of the evidence is against assigning a compensable rating for the Veteran’s right knee strain. The evidence of record is against finding that the Veteran had compensable loss of flexion, which requires flexion limited to 45 degrees. See January 16, 2020 VA knee examination report (noting that, at worst, the Veteran would have right knee flexion to 110 degrees). While the January 16, 2020 VA examination report noted that the Veteran had extension limited to 10 degrees, the Veteran was assigned a separate 10 percent rating for right knee patellar tendon repair with limitation of extension effective January 16, 2020. Accordingly, his right knee limitation of extension is already compensated via his separately service-connected right knee patellar tendon repair. While the decision above granted a 10 percent rating based on painful motion for the period prior to January 16, 2020, the Veteran cannot receive a 10 percent disability rating for his right knee strain for painful motion through 38 C.F.R. § 4.59 and a compensable rating under 38 C.F.R. § 4.71a, Diagnostic Code 5261 for his right knee patellar tendon repair. Section 4.59 does not provide a freestanding avenue for disability compensation. See Sowers v. McDonald, 27 Vet. App. 472 (2016). Rather, it ensures that where a Veteran’s disability is not severe enough to warrant a compensable rating, but it nevertheless causes painful motion, the minimum compensable rating will be assigned. Id.; see also Petitti v. McDonald, 27 Vet. App. 415 (2015). As the Veteran is receiving a compensable right knee rating for limitation of extension, continuing a separate 10 percent rating for painful motion would violate the rule against pyramiding. See 38 C.F.R. § 4.14 (2020). Consequently, in the absence of flexion limited to 45 degrees, a compensable rating is not warranted for the Veteran’s right knee strain for the period beginning January 16, 2020. The Board acknowledges the Veteran’s lay reports of symptoms and that there was functional loss due to pain, stiffness, locking, and weakness. However, even considering the Veteran’s lay reports of symptoms and noted functional loss, the degree of additional limitation reported by his bi-weekly flare-ups would not result in limitation of motion more nearly approximating flexion limited to 45 degrees. The Board has considered whether the Veteran is entitled to a higher or separate rating under 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 v. Brown, 6 Vet. App. 259, 261-62 (1994); Lyles v. Shulkin, 29 Vet. App. 107 (2017) (holding that 38 C.F.R. § 4.14 prohibits paying compensation twice for the same symptoms or functional impairment). Nevertheless, the medical evidence consistently indicated that the Veteran did not have ankylosis, recurrent subluxation, lateral instability, a semilunar (meniscal) condition, tibia or fibula impairment, or genu recurvatum. As such, at no time during the pendency of the appeal have higher or separate ratings been warranted under 38 C.F.R. § 4.71a, Diagnostic Codes 5256, 5257, 5258, 5259, 5262, or 5263. The Board acknowledges that there was a single instant where the Veteran reported that his leg will sometimes give out a little bit. VA and private treatment records are silent for any such reports of giving way. Moreover, the VA examination reports consistently indicated that right knee joint stability testing was within normal limits and that he did not have any right knee recurrent subluxation or lateral instability. Accordingly, given the other evidence of record, the Board finds that this single report, that was attributed to the leg generally rather than the knee, is significantly outweighed by the other evidence of record. As noted above VA revised the criteria for evaluating musculoskeletal disorders effective February 7, 2021. These changes included significant revisions to Diagnostic Codes 5257 and 5256. Nevertheless, as the evidence of record is against finding that Veteran’s right knee strain was manifested by recurrent subluxation, instability, or tibia or fibula impairment, these changes are not applicable and need not be discussed. In conclusion, the Board finds that a 10 percent rating, but no higher, is warranted for the period prior to January 16, 2020. Additionally, a compensable rating is not warranted for the period beginning January 16, 2020. In reaching the above conclusions, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against ratings in excess of those assigned, that doctrine is not applicable. See 38 U.S.C. § 5107(b) (2012); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-56 (1990). REASONS FOR REMAND 1. Entitlement to a compensable initial evaluation for a missile injury residual with numbness 5th finger left hand is remanded. 2. Entitlement to service connection for IBS is remanded. 3. Entitlement to service connection for a skin condition, other than multiple lipomas, is remanded. 4. Entitlement to service connection for a left ankle disability is remanded. Regarding the Veteran’s missile injury residual, he has consistently reported weakness, numbness, a vibrating sensation, and a tingling sensation in his left fifth finger that radiated into his left wrist. While he was provided VA hand and muscle injuries examinations in January 2020, no testing was performed to address whether the Veteran’s reported weakness and neurological symptoms were attributable to his fifth finger missile injury residual. As the Veteran has consistently reported neurological symptoms which he asserts are related to his disability, further clarification is required to determine the nature and severity of any neurological symptoms associated with the fifth finger missile injury residual. While the Veteran was provided VA intestinal and skin conditions examinations in January 2020 and July 2020, the VA opinions are not fully responsive to the remand directives. Specifically, the examiners did not address whether the Veteran’s reported intermittent rash and bowel disturbances were objective indications of disability and whether such indications represent an undiagnosed illness consistent with service in the Persian Gulf. Accordingly, there has not been substantial compliance with the Board’s previous remand directives and another remand is required. Stegall v. West, 11 Vet. App. 268, 271 (1998). In rendering the requested addendum opinions, the clinician(s) should also address the service treatment records that were obtained in September 2020, which provide additional documentation of the Veteran’s reported symptoms. While an opinion regarding the Veteran’s left ankle was obtained in August 2020, the Board finds that further clarification is required as the clinician did not provide a sufficient rational. Specifically, the examiner’s only rationale was that there was not “sufficient evidence of left ankle complaints.” Additionally, the examiner did not, as requested, address the Veteran’s assertions regarding his in-service parachuting duties and wear and tear from carrying heavy loads. Accordingly, there has not been substantial compliance with the Board’s remand directives and another remand is required. Stegall v. West, 11 Vet. App. 268, 271 (1998). The matters are REMANDED for the following actions: 1. Schedule the Veteran for an appropriate VA examination to determine the current severity of all neurological symptoms related to his missile injury residual with numbness 5th finger left hand. The claims file should be reviewed by the examiner. All necessary tests, including electromyography (EMG) and nerve conduction studies (NCS) should be performed and the results reported. If the examiner finds that an EMG and/or NCS are not necessary, an explanation should be provided. The examiner must address the Veteran’s reports of pain, weakness, a tingling pain sensation that radiates into the left hand, and an extended vibrating sensation after performing any activity that creates vibrations. If any left hand / finger neurological condition is diagnosed, please opine whether it is at least as likely as not a manifestation or progression of the Veteran's service-connected missile injury residual with numbness 5th finger left hand. In so opining, the examiner should also address the February 24, 2017 and November 30, 2016 records from Cross Creek Medical Clinic noting decreased left hand dexterity, the Veteran’s report that he had been diagnosed with neuropathy, and assessment with paresthesia. A complete rationale should be provided for all opinions and conclusions expressed. 2. Forward the claims file to a VA clinician to obtain an addendum opinion regarding the Veteran's left ankle claim. If an examination is deemed necessary to respond to the questions presented, one should be scheduled. Following review of the claims file, the clinician should opine whether it is at least as likely as not (50 percent probability or greater) that any left ankle disability had its onset during service or is otherwise related to service, to include the Veteran’s in-service parachuting duties and reported in-service ankle sprains while carrying heavy loads. A complete rationale for all opinions expressed should be provided. 3. Forward the claims file to a VA clinician to obtain an addendum opinion regarding the Veteran's IBS claim. If an examination is deemed necessary to respond to the questions presented, one should be scheduled. Following review of the claims file, the clinician should: (a.) Identify any disability manifested by bowel disturbances, including loose bowel movements and constipation, and state whether it is at least as likely as not (50 percent probability or greater) that it arose during service or is otherwise related to service, to include his service in the Persian Gulf and September10, 2003, December 28, 2003, February 28, 2009, September 6, 2012, and January reports of diarrhea. The clinician should address the June 30, 2015 VA record wherein the Veteran reported that he had not had solid bowel movements in a couple of years. (b.) If there is no diagnosis to account for the Veteran’s bowel symptoms, the examiner should indicate whether there are objective indications of disability and whether such indications represent an undiagnosed illness consistent with service in the Persian Gulf. In rendering the above requested opinions, the clinician should address the December 14, 2017 notation of “Gulf War syndrome.” A complete rationale should be provided for all opinions and conclusions expressed. 4. Forward the claims file to a VA clinician to obtain an addendum opinion regarding the Veteran's skin claim. If an examination is deemed necessary to respond to the questions presented, one should be scheduled. Following review of the claims file, the clinician should: (a.) Identify any disability manifested by an intermittent rash on his chest and state whether it is at least as likely as not (50 percent probability or greater) that it arose during service or is otherwise related to service, to include his service in the Persian Gulf. The clinician should address the Veteran’s June 30, 2015, August 15, 2015, August 6, 2016, and October 19, 2018 reports of intermittent papular or nodular skin rash. (b.) If there is no diagnosis to account for the Veteran’s intermittent rash, the examiner should indicate whether there are objective indications of disability and whether such indications represent an undiagnosed illness consistent with service in the Persian Gulf. The clinician should address the December 14, 2017 notation of “Gulf War syndrome.” A complete rationale should be provided for all opinions and conclusions expressed. 5. If the claims remain denied, issue a supplemental statement of the case. K. A. BANFIELD Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Anderson 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.