Citation Nr: 21025294 Decision Date: 04/27/21 Archive Date: 04/27/21 DOCKET NO. 07-19 141 DATE: April 27, 2021 ORDER Entitlement to an initial 20 percent rating from October 1, 2006, through October 28, 2009, for a lumbar spine disability is granted. Entitlement to a rating in excess of 20 percent for a lumbar spine disability for the entire period on appeal is denied. Entitlement to an initial 30 percent rating for a left shoulder disability is granted. Entitlement to an initial 20 percent rating for a left knee limitation of flexion is granted. Entitlement to an initial compensable rating for a left ring finger disability is denied. REMANDED Entitlement to an initial rating in excess of 10 percent for radiculopathy of the left lower extremity is remanded. FINDINGS OF FACT 1. Throughout the period on appeal, the Veteran had forward flexion to 60 degrees, at worse, without evidence of ankylosis of the lumbar spine. 2. Resolving reasonable doubt in favor of the Veteran, the severity of his left shoulder disability more nearly approximates limitation of motion of the arm to 25 degrees from side for the entire period on appeal. 3. Resolving reasonable doubt in favor of the Veteran, the severity of his left knee limitation of flexion more nearly approximates limitation of flexion with painful motion limited to 30 degrees. 4. Throughout the appeal period, the Veteran’s service-connected left ring finger limitation of motion manifests by painful motion, but ankylosis and amputation at the proximal interphalangeal joint is not demonstrated. CONCLUSIONS OF LAW 1. The criteria for an initial 20 percent rating from October 1, 2006, through October 28, 2009, for a lumbar spine disability have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5242. 2. The criteria for a rating in excess of 20 percent for a lumbar spine disability for the entire period on appeal have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5242. 3. The criteria for an initial 30 percent rating for a left shoulder disability have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5201. 4. The criteria for an initial 20 percent rating for left knee limitation of flexion have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5260. 5. The criteria for entitlement to a compensable evaluation for left ring finger limitation of motion have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.2, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5230. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from September 1984 to September 2006. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a November 2006 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). In July 2009, the Veteran testified at a hearing before the undersigned Veterans Law Judge. A copy of the hearing transcript is associated with the claims file. The Board notes that following the Veteran’s appeal of the lumbar spine, left knee, left shoulder, and radiculopathy claims to the Court of Appeals for Veterans Claims (the Court), the Court granted a Joint Motion for Partial Remand in December 2019. These matters were most recently remanded by the Board in August 2020. There was substantial compliance with the Board’s remand directives. See Stegall v. West, 11 Vet. App. 268 (1998); Dyment v. West, 13 Vet. App. 141, 146-47 (1999). Increased Rating Disability evaluations are determined by the application of a schedule of ratings which is based on the average impairment of earning capacity. 38 U.S.C.§1155; 38 C.F.R., Part 4. Separate diagnostic codes identify the various disabilities. 38 C.F.R.§4.1 requires that each disability be viewed in relation to its history and that there be emphasis upon the limitation of activity imposed by the disabling condition. 38 C.F.R.§4.7 provides that, where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. The Veteran’s entire history is to be considered when making disability evaluations. See 38C.F.R.§4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). With the initial rating assigned with the award of service connection for a disability, “staged” ratings to reflect distinct periods when different levels of impairment were shown are for consideration. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Pertinent regulations do not require that all cases show all findings specified by the Rating Schedule, but that findings sufficiently characteristic to identify the disease and the resulting disability and above all, coordination of rating with impairment of function will be expected in all cases. 38C.F.R.§4.21. Therefore, the Board has considered the potential application of various other provisions of the regulations governing VA benefits, irrespective of whether they were raised by the Veteran, as well as the entire history of the Veteran’s disability in reaching its decision. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). 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; 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 criteria.”). Under 38 C.F.R. § 4.59, painful motion is a factor to be considered with any form of arthritis; however, 38 C.F.R. § 4.59 is not limited to disabilities involving arthritis. See Burton v. Shinseki, 25 Vet. App. 1 (2011). In Correia v. McDonald, 28 Vet. App. 158 (2016), the Court held that the final sentence of 38 C.F.R. § 4.59 requires that the examiner record the results of range of motion testing “for pain on both active and passive motion [and] in weight-bearing and non-weight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint.” The spine has no opposite joint. In Sharp v. Shulkin, 29 Vet. App. 26 (2017), the Court held that VA examiners must obtain information about the severity, frequency, duration, precipitating and alleviating factors, and extent of functional impairment of flares from the veterans themselves, when a flare-up is not observable at the time of examination. 1. Entitlement to an initial rating in excess of 10 percent from October 1, 2006, through October 28, 2009, and in excess of 20 percent from October 29, 2009, for a lumbar spine disability The Veteran contends that he is entitled to higher disability ratings for his service-connected lumbar spine disability. His lumbar spine disability was rated as 10 percent disabling from October 1, 2006, through October 28, 2009, and rated as 20 percent disability since October 29, 2009. The Veteran’s lumbar spine degenerative arthritis and stenosis is rated under 38 C.F.R. § 4.71a, Diagnostic Code 5242. Under the General Rating Formula for Diseases and Injuries of the Spine, a 10 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height. A 20 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent rating is warranted for forward flexion of the thoracolumbar spine to 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is warranted for unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent evaluation is warranted for unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine. Any associated objective neurological abnormalities, including, but not limited to, bowel or bladder impairment, are to be evaluated separately under an appropriate diagnostic code. Id. at Note 1. Ankylosis is defined as “immobility and consolidation of a joint due to disease, injury, or surgical procedure.” Dorland’s Illustrated Medical Dictionary, 94 (32nd ed. 2012). Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. Id. at Note 5. The Board finds that for the entire period on appeal, the Veteran is entitled to a 20 percent disability rating, and no higher, for his service-connected lumbar spine disability. In April 2006 the Veteran submitted a statement describing his back pain. He indicated that he experiences daily back pain, including when sitting, standing, or laying in one position for more than 20 minutes. The Veteran was afforded a VA examination in July 2006, during which the Veteran reported symptoms of chronic pain and stiffness. Upon range of motion testing, the Veteran demonstrated forward flexion of the lumbar spine to 70 degrees, and a combined range of motion of 190 degrees. He was noted to experience pain with motion, and there was no evidence of an additional loss of range of motion following repetitive use testing. In March 2009 the Veteran attended another VA examination. He reported having flare-ups two to three times each month. The VA examiner noted tenderness of the lumbar muscles without muscle spasm. During range of motion testing, the Veteran was only able to complete two repetitions due to pain. He was noted to demonstrate forward flexion of the lumbar spine to 65 degrees, and a combined range of motion of 185 degrees. The Veteran’s employer submitted a lay statement in June 2009, wherein she discussed that the Veteran has to modify his job duties to accommodate his back pain since October 2006. Specifically, she noted that the Veteran has to shift positions approximately every 20 minutes, and that when he experiences flare-ups, he must leave work early. In an October 2009 statement, the Veteran also indicated that his back pain interferes with his work, and that he is unable to sit, walk or stand for prolonged periods of time. Overall, the Veteran stated his active lifestyle decreased due to his lumbar spine disability. At an October 2009 VA examination, the Veteran again reported having lumbar spine flare-ups two to three times per month, along with daily pain. The examiner noted that since the March 2009 examination, the Veteran’s low back was slightly more symptomatic. Upon examination, the Veteran demonstrated forward flexion to around 60 to 65 degrees. Combined range of motion measurements are not available, as it appears the Veteran was not tested for all planes of movement. In private treatment notes from February 2015, the Veteran’s private physician stated that due to his lumbar spine disability, the Veteran continues to have marked restriction of movement and severe pain. The physician also stated that the Veteran’s condition requires high-dose pain medication and physiotherapy. The Veteran’s next VA examination took place in February 2018. He described having worsening, consistent back pain, and denied having flare-ups. Additionally, the Veteran reported having difficulty with standing and sitting for prolonged periods. The Veteran demonstrated forward flexion to 60 degrees, and a combined range of motion of 160 degrees. He was noted to have pain on rest/non-movement, and he did not have an additional loss of range of motion fowling observed repetitive use testing. The examiner also determined that the Veteran would experience pain following repeated use over time, and while the same range of motion measurements were listed, the examiner did not specifically say whether the Veteran would experience any functional loss of the lumbar spine after repeated use over time. The Veteran provided another lay statement in March 2020 detailing the symptoms associated with his lumbar spine disability. The Veteran stated that he continues to live with constant pain, stiffness, and discomfort. He also stated he is unable to participate in certain recreational activities, and that he is unable to run, walk, sit, or stand for more than 20 to 30 minutes. In September 2020, the Veteran attended his most recent VA examination, during which he described having stiffness and intermittent pain of the lumbar spine. He denied having flare-ups. Range of motion testing showed the Veteran demonstrated forward flexion of the lumbar spine to 75 degrees and had a combined range of motion of 215 degrees. The examiner stated that the Veteran’s limited flexion causes functional loss by interfering with his ability to pick up objects. Otherwise, no pain was noted during the examination, and he was not found to have any additional loss of function or range of motion following observed repetitive use testing. The examiner determined that following repeated use over time, there would be no additional loss of range of motion or functional ability. Lastly, the examiner indicated that there was no objective evidence of pain on non-weight bearing testing, and there was no pain or additional loss of range of motion during passive range of motion testing. The Board finds that for the entire period on appeal, the severity of the Veteran’s lumbar spine disability more closely approximates the 20 percent rating criteria. As noted above, to warrant a 40 percent rating, forward flexion of the thoracolumbar spine must be limited to 30 degrees or less; or there must be evidence of favorable ankylosis of the entire thoracolumbar spine. At worst, the Veteran demonstrated forward flexion of the lumbar spine to 60 degrees. Even considering his reports of pain and stiffness, the Veteran’s range of motion was not limited to an extent that more closely approximates the 40 percent rating. The medical treatment notes and VA examination reports fail to show ankylosis of the lumbar spine at any point during the appeal period. However, given that the Veteran reported having flare-ups occurring two to three times per month in 2009, and such flare-ups were noted in a letter from his employer to have occurred since October 2006, we find that granting a 20 percent rating for the entire period on appeal beginning in October 2006 more appropriately reflects the severity of the Veteran’s lumbar spine disability. At every VA examination dated after 2009, the Veteran denied experiencing flare-ups, nor was the evidence of his lumbar spine disability worsening to a degree that would warrant a higher disability evaluation. The Board also acknowledges the 2015 assessment from the Veteran’s private physician, who stated the Veteran experiences marked restriction of the lumbar spine. However, this assessment does not include range of motion measurements of the lumbar spine to support the finding of “marked restriction.” In fact, since the 2015 private assessment, the Veteran was noted to have an improved range of motion of the lumbar spine, demonstrating forward flexion to 75 degrees. In addressing the JMPR, the February 2018 VA examiner noted that the Veteran would experience pain with repeated use over time that would significantly limit his functional ability but did not describe any additional limitation of motion as a result. However, the functional impairment was described as causing other limitations such as difficulty with standing or sitting for a long while. Thus, the examiner did consider that pain resulted from repeated use over time, which resulted in functional impairment, even if it was not described in terms of limited range of motion. The JMPR also noted that the Board did not consider the finding on examination in March 2009 that the Veteran could not complete more than two repetitive movements in the spine due to pain. While the Veteran reported that his back was painful after two repetitions on examination in March 2009, the medical findings on examination did not indicate that the Veteran had ankylosis in the lumbar spine or forward flexion limited to 30 degrees or less due to the pain caused by the repetitive use testing. Therefore, even considering the Veteran’s complaints of pain due to the repetitive use testing in March 2009 and that the Veteran’s pain caused significant functional impairment as noted on examination in February 2018, the medical findings do not more closely approximate the criteria for a 40 percent rating under the General Rating Formula for Diseases and Injuries of the Spine. Consideration has also been given to assigning a rating under the Formula for Rating Intervertebral Disc Syndrome (IVDS) Based on Incapacitating Episodes. However, the Veteran does not have IVDS and the evidence of record is against a finding that the Veteran was ever prescribed bed rest by a physician for a duration that meets the criteria for a higher rating. See 38 C.F.R. § 4.71a, Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes. Regarding neurological impairment, the lay and medical evidence of record is against a finding that the Veteran has any other neurological abnormality associated with his spine disability aside from radiculopathy, which is addressed in the remand portion of this decision. Based on the foregoing, the Board finds a 20 percent disability rating is warranted for the entire period on appeal for the Veteran’s lumbar spine disability. The Board also finds the preponderance of the evidence is against the Veteran’s claim for a rating in excess of 20 percent for the entire period on appeal. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. 2. Entitlement to an initial rating in excess of 20 percent for a left shoulder disability The Veteran seeks a higher disability rating for his left shoulder disability, currently rated as 20 percent disabling under Diagnostic Codes 5003-5201. A hyphenated diagnostic code is used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the rating assigned. The additional diagnostic code is shown after the hyphen. Diagnostic Code 5003 rates degenerative arthritis and instructs to rate based on limitation of motion under the appropriate diagnostic code for the specific joint involved, with a 10 percent rating for application when limitation of motion of the joint or joints involved is noncompensable. 38 C.F.R. § 4.71a, Diagnostic Code 5003. Diagnostic Code 5201 rates limitation of motion of the arm. Under Diagnostic Code 5201, limitation of motion of the arm at shoulder level warrants a 20 percent rating for both the major and minor extremity. Limitation of motion of the arm midway between side and shoulder warrants a 20 percent rating for the minor extremity and a 30 percent rating for the major extremity. Limitation of motion of the arm to 25 degrees from side warrants a maximum 30 percent rating for the minor joint and a maximum 40 percent rating for the major joint. 38 C.F.R. § 4.71a, Diagnostic Code 5201. Diagnostic Code 5201 “does not provide separate ratings for limitation of motion in the flexion and abduction planes, but rather is addressed generically to limitation of motion of the arm.” Yonek v. Shinseki, 722 F.3d 1355, 1358 (Fed. Cir. 2013). Normal range of motion of the shoulder is flexion and abduction from 0 to 180 degrees, and internal and external rotation each to 90 degrees. 38 C.F.R. § 4.71, Plate I. Abduction is the motion of lifting the arm from the side, with 0 degrees representing the arm at the side and 90 degrees representing the arm at the shoulder level. 38 C.F.R. § 4.71. The “major” rating is for the dominant hand, whereas the “minor” rating is for the non-dominant hand. Under 38 C.F.R. § 4.69, handedness is determined by the evidence of record, or by testing on VA examination. Here, the record reflects that the Veteran is right-handed, and therefore his right arm is his major (dominant) extremity and his left arm is his minor (non-dominant) extremity for rating purposes. In a May 2018 rating decision, the RO stated that a 20 percent evaluation was warranted for the Veteran’s left shoulder degenerative joint diseased based on painful motion of the arm at the shoulder in accordance with 38 C.F.R. § 4.59. The Board finds that for the entire period on appeal, the Veteran is entitled to a 30 percent disability rating, and no higher, for his service-connected left shoulder disability. At a July 2006 VA examination, the Veteran stated his left shoulder disability symptoms consisted of pain, soreness, and occasional “popping” after prolonged overhead activities. He denied having flare-ups. During range of motion testing, the Veteran was noted to have reduced extension, but demonstrated normal range of motion for all other planes of motion. The examiner did not observe pain during range of motion testing. The Veteran was afforded another VA examination in October 2009. He reported experiencing moderate pain on a daily basis, and flare-ups twice each week. The Veteran stated his left shoulder disability impacted his work and made it difficult to reach overhead. During range of motion testing, the Veteran demonstrated flexion to 82 degrees, abduction to 75 degrees, and internal and external rotation to 70 degrees each. However, the examiner noted that the Veteran could only complete two repetitions due to pain. In an October 2009 lay statement, the Veteran indicated that the July 2006 examination report did not appropriately reflect the severity of his left shoulder disability. He explained that during range of motion testing, he experienced pain, stiffness, popping, and grinding of the left shoulder. His next VA examination occurred in February 2018. The Veteran reported having intermittent left shoulder pain, occurring with movement and when bearing heavy weights. He denied experiencing flare-ups. Range of motion measurements show normal range of motion for flexion, abduction, and external rotation. However, the Veteran was noted to have only 60 degrees of internal rotation, with evidence of pain. The examiner stated the Veteran could perform three repetitions of repetitive use testing without an additional loss of function or range of motion. Regarding repeated use over time, the examiner stated that pain, weakness, fatigability, or incoordination would not limit function ability, and estimated there would be no additional loss of range of motion. Lastly, the examiner indicated there was no ankylosis of the left shoulder, there was no objective evidence of pain on non-weight bearing, and passive range of motion was the same as active range of motion. The February 2018 VA examiner was also asked to respond to specific questions, including whether the Veteran’s left shoulder disability is manifested by limitation of motion of the left arm at shoulder level, midway between the left side and shoulder level, or limited to 25 degrees from the left side. The examiner responded that the Veteran’s left shoulder is limited to 25 degrees from the left side. In a March 2020 statement, the Veteran stated his left shoulder hurts throughout the day, and that lifting and overhead reaching cause discomfort. The Veteran indicated that he has difficulty with getting dressed, sleeping on his left side, and pulling open doors. He again stated that his left shoulder pops and grinds, and that the condition was not adequately evaluated during the February 2018 VA examination. The Veteran’s most recent examination occurred in September 2020. He reported experiencing stiffness and intermittent pain of the left shoulder and denied having flare-ups. During range of motion testing, the Veteran demonstrated normal internal and external rotation of the left shoulder, but he had only 130 degrees of flexion, and 100 degrees of abduction. The examiner stated there was no objective evidence of pain during range of motion testing, nor was the evidence of pain with weight bearing. The Veteran completed repetitive use testing without an additional loss of function or range of motion. Regarding repeated use over time, the examiner estimated that the Veteran’s range of motion of the left shoulder would remain the same, and that no other symptomatic factors would result in additional functional loss. Lastly, the examiner indicated there was no objective evidence of pain when using the left shoulder in non-weight bearing, and passive range of motion was the same as active range of motion. The Board finds that, after resolving reasonable doubt in favor of the Veteran, the maximum 30 percent rating is warranted for the service-connected left shoulder disability for the entire period on appeal. 38 C.F.R. § 4.71a, Diagnostic Code 5201. The February 2018 VA examiner specifically stated that the Veteran’s left shoulder disability limits motion to 25 degrees from the side, which is consistent with the 30 percent rating under Diagnostic Code 5201 for a minor extremity. This determination conflicts with the additional February 2018 VA examination reported submitted by the same VA examiner, as well as the other VA examination reports of record. The JMPR noted that it was unclear whether the February 2018 examiner adequately addressed the Veteran’s functional loss due to pain because the examination did not specify whether functional loss resulted in any additional loss of range of motion or whether it began at 60 degrees as indicated in the initial range-of-motion measurements. In order to resolve the conflicting evidence, the Board has carefully considered the Veteran’s reports about his left shoulder impairment. English v. Wilkie, 30 Vet. App. 347 (2018) (the Board must adequately explain how it considered functional loss due to pain, including during flare-ups); 38 C.F.R. §§ 4.40, 4.45, 4.59. As discussed above, the Veteran has repeatedly indicated that the severity of his left shoulder disability is worse than what has been assessed during the VA examinations. Throughout the period on appeal, he has reported symptoms of pain, popping, and grinding, as well as difficulty with lifting and overhead reaching. The Veteran is competent to report symptoms he has experienced, as these observations come to him through his senses. Layno v. Brown, 6 Vet. App. 465, 469 (1994). The Board finds the reports are credible. Caluza v. Brown, 7 Vet. App. 498, 506 (1995). Although the Veteran does not detail the precise amount of left arm motion loss, it is reasonable to infer that he had significantly restricted ability to move his left arm due to left shoulder pain. The Board finds the Veteran’s left shoulder disability more nearly approximates the 30 percent rating criteria for the entire period on appeal. As this is the highest rating available under Diagnostic Code 5201 for a minor joint, a rating in excess of 30 percent is not warranted at any time during the appeal period. Additionally, the Board has considered whether higher or separate ratings are warranted for the left shoulder under alternate diagnostic codes. However, there is no indication of ankylosis, impairment of clavicle or scapula, or humerus conditions. As such, ratings under Diagnostic Codes 5200, 5202, and 5203 are precluded. For the above stated reasons, the Board finds that the left shoulder disability more nearly approximated the 30 percent rating criteria, but no higher, for the entire period on appeal. As the preponderance of the evidence is against a rating in excess of 30 percent, the benefit of the doubt doctrine is not for application and such portion of this claim must be denied. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. 3. Entitlement to an initial rating in excess of 10 percent for a left knee limitation of flexion The Veteran contends that he is entitled to an increased rating for service-connected left knee degenerative join disease, resulting in limitation of flexion. The Veteran’s left knee disability is rated under 38 C.F.R. § 4.71a, Diagnostic Code 5260, for limitation of flexion of the leg. 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. In a May 2018 rating decision, the RO stated that a 10 percent evaluation was granted for the Veteran’s left knee limitation of flexion based on painful motion in accordance with 38 C.F.R. § 4.59. The Board notes that the Veteran is also in receipt of separate ratings for left knee instability, rated as 10 percent disabling under Diagnostic Code 5257, and left knee limitation of extension, rated as 10 percent disabling under Diagnostic Code 5261. Only the rating regarding left knee limitation of flexion was appealed to the Court and subsequently remanded by the Board in August 2020. The Board finds that for the entire period on appeal, the Veteran is entitled to a 20 percent rating for left knee limitation of flexion. In April 2006, the Veteran submitted a lay statement that included a description of his left knee disability symptoms. He stated that he has left knee pain when walking, running, bending, or walking downstairs. The Veteran also reported having constant left knee popping and grinding. During a left knee VA examination in July 2006, the Veteran reported experiencing intermittent left knee pain, as well as grinding and popping. He demonstrated full range of motion of the left knee. The examiner also noted there was no evidence of pain. VA treatment notes from October 2006 show the Veteran complained of left knee pain and grinding that occurs when bending or using stairs. The Veteran was afforded another VA examination in March 2009. He again reported having daily pain, popping, and grinding. Additionally, the Veteran stated he had left knee flare-ups two to three times each week, as well as left knee instability two to three times each month. During range of motion testing, the Veteran was only able to complete two repetitions due to pain. He demonstrated left knee flexion to 105 degrees. In an October 2009 lay statement, the Veteran indicated that he did not believe the March 2009 VA examination report reflected an adequate assessment of the severity of his left knee disability. He stated that his left knee is weak, and that he was not tested for repetitive motion. Subsequently, the Veteran attended a VA examination in October 2009. The Veteran reported that he wore a left knee brace, but the examiner noted that the brace was not issued by a physician. Additionally, the Veteran stated that occasionally his left knee swells, and that he continues to have left knee popping, clicking, and instability. Range of motion testing revealed flexion to 105 degrees. The Veteran’s next VA examination occurred in February 2018. He reported that he was unable to flex his left knee, and he denied having flare-ups. During range of motion testing, the Veteran demonstrated left knee flexion to 120 degrees, and he was noted to exhibit pain with movement. He completed three repetitions during repetitive use testing without any additional loss of function or range of motion. The examiner also indicated that the Veteran would not experience any additional functional loss or range of motion following repetitive use over time. He stated that swelling is a contributing factor regarding the Veteran’s left knee disability. Lastly, the examiner stated there was no objective evidence of pain on non-weight bearing, and passive range of motion is the same as active range of motion. The February 2018 VA examiner also provided additional determinations regarding the Veteran’s left knee. He was asked to state whether the Veteran’s left knee flexion is manifested by flexion limited to 45 degrees, 30 degrees, or 15 degrees. The examiner responded that left knee flexion is limited to 30 degrees, and that left knee flexion is painful. In a March 2020 lay statement, the Veteran again asserted that his prior VA examinations failed to accurately measure his left knee movement and strength. He stated that over time, his left knee pain has significantly worsened and interferes with his ability to walk, stand, run, and perform other physical activities. At the Veteran’s most recent VA examination in September 2020, he reported having left knee stiffness and intermittent pain, which the examiner determined results in functional loss. The Veteran denied having flare-ups. He demonstrated left knee flexion to 100 degrees during initial range of motion testing and did not have any additional loss of function or range of motion following repetitive use testing. The examiner determined the Veteran would maintain the same range of motion of the left knee following repetitive use over time, without any other factors resulting in limited functional ability. There was no objective evidence of pain with weight bearing and non-weight bearing, and left knee passive range of motion was the same as active range of motion. After resolving reasonable doubt in favor of the Veteran, the Board finds the Veteran’s left knee limitation of flexion warrants a 20 percent rating for the entire period on appeal. The February 2018 VA examiner stated that the Veteran’s left knee flexion is painful and limited to 30 degrees. This assessment is consistent with a 20 percent rating under Diagnostic Code 5260. The VA examiner’s finding regarding left knee flexion conflicts with the additional February 2018 VA examiner report the same examiner also completed, as well as with range of motion measurements from prior VA examinations. The JMPR noted that it was not clear whether the February 2018 VA examiner adequately addressed the Veteran’s functional loss due to pain because the examiner did not specify whether the functional loss resulted in any additional loss of range of motion or whether it began at 120 degrees as indicated in the initial range-of-motion measurements. Nonetheless, as noted, the Board will resolve any doubt in the Veteran’s favor based on the findings reported above that a 20 percent rating is warranted for the left knee disability based on his range of motion studies. The Board has thoroughly reviewed the Veteran’s lay statements regarding his left knee pain. As noted above, the Veteran has consistently indicated that the severity of his left knee disability is not adequately reflected in the VA examination reports. During the period on appeal, he has consistently reported symptoms of swelling, weakness, pain, popping and grinding. The Veteran is competent to report the symptoms he has experienced and observed through his symptoms, and the Board finds the reports are credible. Layno v. Brown, 6 Vet. App. 465, 469 (1994). Therefore, the Board finds that the Veteran’s left knee limitation of flexion resulted in painful motion that more nearly approximates the 20 percent rating criteria, and no higher, for the entire period on appeal. 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 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). The Veteran currently has separate ratings for left knee instability, rated as 10 percent disabling under Diagnostic Code 5257, and left knee limitation of extension, rated as 10 percent disabling under Diagnostic Code 5261. To warrant a 20 percent or higher rating under Diagnostic Code 5257, the severity of the Veteran’s left knee instability must be either moderate or severe. Throughout the period on appeal, the Veteran has stated his knee gives way only when ambulating downhill or descending stairs. The medical evidence of record does not indicate that the severity of his left knee instability is considered moderate or severe. Additionally, at no point during the period on appeal was the Veteran noted to have limitation of extension at 15 degrees or more to warrant a rating higher than 10 percent under Diagnostic Code 5261. Therefore, increased ratings are not warranted for left knee instability and limitation of extension. 38 C.F.R. § 4.71a, Diagnostic Codes 5257, 5261. The evidence also fails to show the Veteran has left knee ankylosis, an impairment of the tibia and fibula, or genu recurvatum. Therefore, ratings under Diagnostic Codes 5256, 5262, or 5263 are not warranted. The JMPR noted that since the February 2018 VA examination report noted left knee meniscal tear with swelling and painful motion, Diagnostic Code 5258 should be considered, which provides a 20 percent rating for dislocated semilunar cartilage with frequent episodes of “locking,” pain, and effusion into the joint. However, applying a separate rating under Diagnostic Code 5258 would be compensating the Veteran twice for the same impairment that he is rated for under Diagnostic Code 5260, namely painful motion. There also is no benefit to changing the diagnostic code to Diagnostic Code 5259 because the highest rating under that code is 10 percent. A separate rating under Diagnostic Code 5259 for symptomatic removal of the semilunar cartilage is not warranted in the present case, as to do so also would constitute pyramiding. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). The requirements for a rating under Diagnostic Code 5259 are that the semilunar cartilage or meniscus must have been removed, and it must be symptomatic. Looking to the plain meaning of the terms used in the rating criteria, “symptomatic” means indicative, relating to or constituting the aggregate of symptoms of disease. STEDMAN’S MEDICAL DICTIONARY, 1743 (27th ed., 2000). A symptom is any morbid phenomenon or departure from the normal in a structure, function, or sensation, experienced by a patient and indicative of disease. Id. at 1742. Thus, the second Diagnostic Code 5259 requirement of being “symptomatic” is broad enough to encompass symptoms including pain, limitation of motion, stiffness, and instability. The manifestation of such symptoms is contemplated by the criteria associated with limitation of flexion, extension, and instability under Diagnostic Codes 5260, 5261, and 5257. Therefore, an assignment of a separate rating under 5259 would constitute pyramiding as it would compensate the Veteran twice for the same symptomatology. See Esteban, at 261-62; 38 C.F.R. § 4.14. Based on the reasons discussed above, the Board finds that the left knee limitation of flexion more nearly approximated the 20 percent rating criteria, but no higher, for the entire period on appeal. As the preponderance of the evidence is against a rating in excess of 20 percent, the benefit of the doubt doctrine is not for application and such portion of this claim must be denied. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. 4. Entitlement to an initial compensable rating in excess of 0 percent for a left ring finger disability The Veteran also seeks a compensable rating for his service-connected left-hand ring finger limitation of motion. The Veteran was assigned a 0 percent rating effective October 1, 2006, under Diagnostic Code 5230. Limitation of motion of individual digits is rated under Diagnostic Codes 5228 through 5230, and ankylosis of individual digits is rated under Diagnostic Codes 5224 through 5227. Specifically, limitation of motion of the ringer finger or 4th digit is rated under Diagnostic Code 5230 and ankylosis of the ring finger is rated under Diagnostic Code 5227. A Note to Diagnostic Code 5227 provides that rating as amputation should be considered and whether an additional rating is warranted for any resulting limitation of motion of other digits or interference with the overall function of the hand. See 38 C.F.R. § 4.71a, Diagnostic Codes 5224-5230. Under the Rating Schedule, a compensable rating for a ring finger disability requires amputation. 38 C.F.R.§ 4.71a, Diagnostic Code 5155. Under Diagnostic Code 5155, a 10 percent rating is warranted for amputation of the ring finger on the major or minor hand, without metacarpal resection, at the proximal interphalangeal joint or proximal thereto. 38 C.F.R. § 4.71a, Diagnostic Code 5155. It is noted that single finger amputation ratings are the only applicable ratings for amputations of whole or part of single fingers. 38 C.F.R. § 4.71a, Diagnostic Code 5155, at Note. In order for ankylosis to be rated as amputation, the condition must manifest with extremely unfavorable ankylosis. See Note (3)(i) preceding 38 C.F.R. § 4.71a, Diagnostic Code 5216, unfavorable ankylosis of five digits of one hand. In other words, in order to be evaluated as amputation, there must be ankylosis of both the metacarpophalangeal and proximal interphalangeal joints either in extension or full flexion or with rotation or angulation of a bone. Id. Note (3)(ii) explains that if both the metacarpophalangeal and proximal interphalangeal joints of a digit were ankylosed, it should be evaluated as unfavorable ankylosis even if each joint was individually fixed in a favorable position. Note (3)(iii) indicates that if only the metacarpophalangeal or proximal interphalangeal joints were ankylosed and there was a gap of more than 2 inches (5.1 cm.) between the fingertips and the proximal transverse crease of the palm, with the fingers flexed to the extent possible, the condition should be evaluated as unfavorable ankylosis. The RO granted service connection for the Veteran’s left-hand ring finger for partial amputation of the tip with surgical reattachment. Throughout the period on appeal, the Veteran has attended multiple VA examinations, including the most recent examination in March 2018. The Veteran reported having symptoms of pain and numbness, but he did not have ankylosis of the left hand or any of the left-hand fingers. A review of additional medical records fails to show the Veteran has ankylosis of the ring finger, or amputation at the proximal interphalangeal joint. The Board finds no higher rating is available for the Veteran’s disability under Diagnostic Code 5230. The Veteran is already in receipt of a noncompensable rating, the maximum rating available under Diagnostic Code 5230 for any limitation of motion of the ring finger. See 38 C.F.R. § 4.71a, Diagnostic Code 5230. Further, the Veteran’s left-hand ring finger is not ankylosed, nor is it amputated at a joint that would warrant a compensable rating under Diagnostic Codes 5227 or 5155. The Board acknowledges that the Veteran has reported experiencing pain in his left ring finger. Unfortunately, the Veteran cannot be compensated for painful motion under Diagnostic Code 5230. For a painful joint, a Veteran can be awarded at least the minimum compensable rating. See 38 C.F.R. § 4.59; Burton, 25 Vet. App. at 5. But a higher rating for pain is not available under Diagnostic Code 5230 because there is no minimal compensable rating. See Sowers v. McDonald, 27 Vet. App. 472, 480 (2016) (“Reading § 4.59 in conjunction with [Diagnostic Code] 5230, [the veteran] is not entitled to a compensable rating under this [code].”). Because a preponderance of the evidence is against the claim, the Board finds the Veteran is not entitled to a compensable disability evaluation for his left-hand ring finger disability and the claim must be denied. REASONS FOR REMAND 1. Entitlement to an initial rating in excess of 10 percent for radiculopathy of the left lower extremity is remanded. The Veteran seeks an increased rating for his Veteran’s left lower extremity radiculopathy, which is currently rated at 10 percent disabling. In March 2020, the Veteran submitted a statement explaining that he experiences numbness in both legs when sitting, standing, and walking. At the Veteran’s most recent VA examination in September 2020, the examiner determined the Veteran has mild radiculopathy symptoms of only the left lower extremity. The JMPR noted that the Board failed to address the Veteran’s report on an October 2009 VA examination report that pain radiated to the right lower extremity to below-the-knee with numbness in the front of the thigh. The JMPR also noted that since an EMG reported in 2006 that the Veteran had indicated worsening symptoms. Throughout the entire period on appeal, the Veteran has not been afforded a separate VA examination to fully evaluate his reports of radiculopathy of the bilateral lower extremities. While an examination was provided in September 2020, the examiner relied, in part, on the same EMG findings in 2006. Thus, the Board finds remand is required for further development in order to adjudicate the claim. The matters are REMANDED for the following action: 1. Schedule the Veteran for an appropriate VA examination to determine the current nature and severity of the Veteran’s radiculopathy of the bilateral lower extremities. Updated clinical studies should be performed, including any indicated EMG testing on the left and right lower extremities. Please consider the Veteran’s subjective complaints of numbness in both legs when sitting, standing, and walking; and the Veteran’s report on an October 2009 VA examination report that pain radiated to the right lower extremity to below-the-knee with numbness in the front of the thigh The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran’s disability under the rating criteria. Sarah Richmond Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board N. Miller, Associate 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.