Citation Nr: 21025421 Decision Date: 04/28/21 Archive Date: 04/28/21 DOCKET NO. 16-05 915 DATE: April 28, 2021 ORDER 1. Entitlement to service connection for left hip disability, to include as secondary to service-connected lumbosacral degenerative disc disease and/or right total knee arthroplasty (right knee disability), is denied. 2. Entitlement to service connection for right hip disability, to include as secondary to service-connected lumbosacral degenerative disc disease and/or right knee disability, is denied. 3. Entitlement to service connection for left knee disability, to include as secondary to service-connected lumbosacral degenerative disc disease and/or right knee disability, is denied. 4. Entitlement to a higher disability rating than the 40 percent assigned for lumbosacral degenerative disc disease from October 2, 2020 is denied. 5. Entitlement to a higher disability rating than the 20 percent assigned for lumbosacral degenerative disc disease prior to October 2, 2020 is denied. 6. Entitlement to a higher disability rating than the 10 percent assigned for right knee disability prior to November 7, 2018 is denied. FINDINGS OF FACT 1. A left hip disability was not present in service and a current left hip disability during the claim period is not causally related to service. Arthritis of the left hip was not present within the first post-service year. A left hip disability was not caused or aggravated by service-connected lumbosacral degenerative disc disease and/or service-connected right knee disability. 2. A right hip disability was not present in service and a current right hip disability during the claim period is not causally related to service. Arthritis of the right hip was not present within the first post-service year. A right hip disability was not caused or aggravated by service-connected lumbosacral degenerative disc disease and/or service-connected right knee disability. 3. A left knee disability was not present in service and a current left knee disability during the claim period is not causally related to service. Arthritis of the left knee was not present within the first post-service year. A left knee disability was not caused or aggravated by service-connected lumbosacral degenerative disc disease and/or service-connected right knee disability. 4. For the rating interval from October 2, 2020, the Veteran’s lumbosacral degenerative disc disease has been equivalent to limitation of motion which is better than unfavorable ankylosis of the thoracolumbar spine. 5. For the rating interval prior to October 2, 2020, the Veteran’s lumbosacral degenerative disc disease has been equivalent to limitation of motion with forward flexion greater than 30 degrees. 6. For the rating interval prior to November 7, 2018, the Veteran’s right knee disability has been manifested by painful motion, but has not been manifested by flexion limited to 45 degrees or extension limited to 10 degrees. CONCLUSIONS OF LAW 1. The criteria for service connection for left hip disability, to include as secondary to service-connected lumbosacral degenerative disc disease and/or right knee disability, have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310. 2. The criteria for service connection for right hip disability, to include as secondary to service-connected lumbosacral degenerative disc disease and/or right knee disability, have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310. 3. The criteria for service connection for left knee disability, to include as secondary to service-connected lumbosacral degenerative disc disease and/or right knee disability, have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310. 4. The criteria for a higher disability rating than the 40 percent assigned for lumbosacral degenerative disc disease from October 2, 2020 have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1-4.14, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5235-5243. 5. The criteria for a higher disability rating than the 20 percent assigned for lumbosacral degenerative disc disease prior to October 2, 2020 have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1-4.14, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5235-5243. 6. The criteria for a higher disability rating than the 10 percent assigned for right knee disability prior to November 7, 2018 have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1-4.14, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5003, 5260. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from December 1983 to November 1993. The Department of Veterans Affairs is grateful for his service. Service Connection Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303 (a). To prevail on a direct service connection claim, there must be competent evidence of (1) a current disability, (2) an in-service incurrence or aggravation of a disease or injury, and (3) a nexus between the in-service disease or injury and the current disability. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009); 38 U.S.C. § 1110; 38 C.F.R. § 3.303 (a). The Board must determine whether the evidence in the record, constitutes “competent evidence that the claimant has a current disability, or persistent or recurrent symptoms of disability” under new section 5103A(d)(2)(A). See also Caluza v. Brown, 7 Vet. App. 498, 504 (1995) (where determinative issue involves either medical etiology or medical diagnosis, competent medical evidence is required), aff’d per curiam, 78 F.3d 604 (Fed. Cir. 1996) (table). Where a veteran served for at least 90 days during a period of war or on or after January 1, 1947, and manifests arthritis to a degree of 10 percent within one year from the date of termination of such service, such disease shall be presumed to have been incurred or aggravated in service, even though there is no evidence of such disease during the period of service. 38 U.S.C. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309. For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as opposed to merely isolated findings or a diagnosis including the word “chronic.” When the fact of chronicity in service (or during any applicable presumptive period) is not adequately supported, then a showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303(b). The term “chronic disease” refers to those diseases, such as hypertension, listed under section 1101(3) of the statute and section 3.309(a) of VA regulations. 38 U.S.C. § 1101(3); 38 C.F.R. § 3.309(a); Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). A disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. 38 C.F.R. § 3.310(a). Any increase in severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the nonservice-connected disease, will be service connected. However, VA will not concede that a nonservice-connected disease or injury was aggravated by a service-connected disease or injury unless the baseline level of severity of the nonservice-connected disease or injury is established by medical evidence created before the onset of aggravation or by the earliest medical evidence created at any time between the onset of aggravation and the receipt of medical evidence establishing the current level of severity of the nonservice-connected disease or injury. 38 C.F.R. § 3.310(b). The claimant bears the burden of presenting and supporting a claim for benefits. 38 U.S.C. § 5107(a); Fagan v. Shinseki, 573 F.3d 1282, 128688 (Fed. Cir. 2009). In making determinations, VA is responsible for ascertaining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether the preponderance of the evidence is against the claim, in which case the claim is denied. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 54 (1990). 1. Entitlement to service connection for left hip disability, to include as secondary to service-connected lumbosacral degenerative disc disease and/or right knee disability 2. Entitlement to service connection for right hip disability, to include as secondary to service-connected lumbosacral degenerative disc disease and/or right knee disability 3. Entitlement to service connection for left knee disability, to include as secondary to service-connected lumbosacral degenerative disc disease and/or right knee disability The Veteran has submitted multiple statements over the course of claim supporting his left knee disability claim with contentions that the disability had its onset in service due to injuries he sustained during service, as well as due to overuse of knees in service involving going up and down ladders aboard ships. The Veteran also provided alternate theories based on secondary causation or aggravation related to service-connected right knee and/or lumbar spine disabilities. The Veteran also contends, in effect, that his claimed bilateral hip disabilities resulted from an injury in service or were caused or aggravated by service-connected lumbosacral degenerative disc disease and/or right knee disability. The Board finds the preponderance of the evidence against the claims based on all theories of entitlement presented, and the Board accordingly denies the claims. The reasons for these determinations follow. At his March 2019 hearing before the undersigned, the Veteran testified that he suffered a fall injuring his knees in February 1985 when he was running and tripped over a wire, and that he suffered another injury in April 1989 when he slipped down a ladder well aboard ship. Service treatment records contain a few records of treatment for the left knee. In December 1985 the Veteran was seen for the left knee, which he reported that it had been sore two weeks ago. The Veteran added that two weeks ago, he had been aboard ship and was told that it was a “chronic knee.” However, upon physical examination, while the Veteran endorsed knee tenderness, no knee pathology was found; tendonitis was assessed. A March 1986 treatment record reflects the Veteran’s subjective complaint of knee pain following the treatment in December 1985, suggesting the March 1986 treatment was addressing the left knee. It was then noted that the Veteran had been given Indocin for tendonitis. The March 1986 treating clinician found mild patellar crepitus and assessed and treated the Veteran for chondromalacia patella. Service treatment records do not contain other records reflecting complaints, findings, treatment, or diagnosis of a left knee disability, including none subsequently between March 1986 and the Veteran’s service separation in November 1993. In fact, in the January 1988 Report of Medical Examination, the examiner documented that the Veteran’s right knee had crepitus, but there was no documentation of left knee symptoms. In the corresponding Report of Medical History that the Veteran completed at that time, he reported a positive history related to his right knee, but did not document symptoms related to the left knee. In the January 1993 Report of Medical Examination, clinical evaluation of the lower extremities was documented as normal, and the Veteran denied a history of trick or locked knee in the corresponding Report of Medical History. Finally, in the November 1993 Report of Medical Examination, it shows that the examiner documented positive findings related to the right knee, but not the left knee, and in the corresponding Report of Medical History, the Veteran documented symptoms associated with the right knee, but did not document symptoms associated with the left knee. Service treatment records include no mention of any difficulties or conditions of the hips. At an October 2020 VA examination, the examiner diagnosed left knee disabilities including arthritis, knee meniscal tear, instability, and patellar subluxation. The examiner then noted a limited history of difficulty with the left knee in service with a diagnosis of tendonitis treated with nonsteroidal antiinflammatory drugs (NSAIDs). The examiner then noted that there was not further documentation of ongoing left knee issues between December 1985 and the Veteran’s service separation eight years later, leading the examiner to conclude that it was unlikely that the condition of the left knee for which the Veteran received treatment in service in December 1985 was chronic or severe. The examiner opined that it was not at least as likely as not that the Veteran’s current left knee disability was incurred in service. The Board finds the above opinion highly probative, as the examiner relied upon facts that the Board finds are accurate. For example, after the Veteran was treated in 1985 for left knee pain, he did not continue to report left knee pain while documenting continued pain in the right knee in Reports of Medical History in January 1988 and November 1993. The Veteran had the wherewithal to document knee pain he was experiencing at those times, and he limited it to the right knee, which the Board finds is affirmative evidence that he was not experiencing ongoing left knee pain at that time. Thus, the October 2020 examiner’s opinion is supported by the evidence. The October 2020 examiner also reviewed the Veteran’s history of right knee disability as well as the left, and concluded that the Veteran’s right knee disability was not of such severity to have caused or aggravated a disability in the left knee. The examiner also concluded that the Veteran’s left knee disability was not caused or aggravated by his lumbosacral degenerative disc disease, explaining that the medical literature did not support one joint causing disability in another joint in the absence of an extremely abnormal gait, such as due to a paralyzed limb or a leg length discrepancy greater than 4 centimeters, neither of which were present in this case. Regarding the hips, the examiner observed that the Veteran began complaining of right hip pain in December 2009 but was not known to have significant osteoarthritis in the right hip until 2017. The examiner noted that similar circumstances were present with the left hip. The examiner concluded that there were not conditions in this case to support the hip disabilities being caused or aggravated by the Veteran’s right knee and/or low back disabilities, again based on medical literature not supporting one joint causing disability in another in the absence of an extremely abnormal gait, such as due to a paralyzed limb or a leg length discrepancy greater than 4 centimeters, neither of which were present. The Board observes that the findings and conclusions of the October 2020 VA examiner are supported by the weight of the balance of the evidence of record and medical knowledge and medical literature, as well as by sound rationale. The historical medical record does not support onset of chronic or ongoing left knee or left and/or right hip disabilities in service or for years following service, and the opinions the Veteran has submitted into the record are not supported by either sound rationale or records of treatment or examination in service and years immediately following service. Submitted into the record in March 2019 is a July 1998 letter in which D.R., a private chiropractor, informed that he has seen the Veteran since 1993 and that he had provided treatment for various complaints, with chiropractic adjustments to the thoracic and lumbar spine, the ribs, the wrists, and the ankles. This is consistent with a letter he wrote in December 1993, where he described treating the Veteran for cervical, thoracic, and lumbar pain. It appears unlikely that this chiropractor would have provided such extensive treatment to multiple joints and would have left out the knees and the hips if the Veteran had had difficulties with his knees and hips during this interval. The lack of documentation in D.R.’s letter addressing the left knee and the hips is consistent with what is documented in the VA treatment records. For example, in November 2011, the Veteran reported pain in his left knee for one month. He reported hunting on loose ground but could not recall an injury. He stated he noticed throbbing knee pain, which was constant. In February 2012, he was still complaining of left knee pain and still could not remember a specific injury. The Veteran’s report of an onset of left knee pain in approximately October 2011 is evidence against the left knee having its onset in service. A June 2012 VA treatment record shows that the Veteran reported having concerns regarding symptoms that had worsened over the last several months, which included pain in his hips. A March 2013 VA treatment record shows that the Veteran was seen for right groin pain, which was discussed had begun in approximately January or February 2012. This is evidence against the bilateral hip disability having its onset in service, as the Veteran’s own words attributed it to approximately 19 years after service discharge. In a March 2014 VA examination report, added to the record in April 2015, the Veteran’s hips, knees, and low back were addressed. The Veteran then reported that he did not participate in combat in service. He reported that his bilateral hip conditions began in 2009 and had become progressively worse over time, with pain on prolonged standing, sitting, or walking. The examiner diagnosed post-traumatic arthritis of the hips, but failed to provide an etiology opinion. At the March 2014 examination, the Veteran reported that his chondromalacia patella of the right knee became symptomatic in 2008 when he sustained a twisting injury to the right knee. He reported that his left knee condition became symptomatic in the late 1980s while deployed aboard ship and when ascending and descending well ladders, with progressive worsening of the condition. The examiner diagnosed post traumatic arthritis of the right knee and patellofemoral pain syndrome of the left knee. The examiner also reported a positive McMurray test for meniscal tear, bilaterally. The examiner provided no opinions of etiology for the knees. In a May 2014 letter submitted into the claims file in June 2015, a private chiropractor, G.R., informs that the Veteran was treated for a leg length discrepancy with the right leg 1/2 inch shorter than the left. This is consistent with and supportive of the October 2020 VA examiner’s opinions that joints of the back and right knee did not cause or aggravate the left knee or hips due to absence of significant conditions such as a leg length discrepancy of greater than 4 centimeters. 1/2 inch is 1.27 centimeters, and hence is considerably less than 4 centimeters. In the May 2014 letter, G.R. informed that records of his treatment of the Veteran between 1990 and 1998 had been destroyed due to legal limits of records retention, but that to the chiropractor’s recollection, the treatments were for an “average number of times per year” and were for conditions resulting from “stresses and strains from everyday life.” Thus, G.R.’s statement does not support treatment between 1990 and 1998 for the Veteran’s claimed disabilities of the hips or left knee or for conditions resulting from specific injuries in military service. Among private treatment records added to the claims file in August 2020, an October 2015 treatment record by Dr. M.B. for the Veteran’s hips notes that the Veteran has a 2 centimeter leg length discrepancy, with the right leg longer, and that this alters the Veteran’s gait, with the Veteran walking with a slight limp favoring the left side. These conditions were in the context of degenerative conditions of the hips, and the Veteran has undergone bilateral hip replacements – in July 2015 on the left and in November 2015 on the right. This reported amount of leg length discrepancy is different from leg length discrepancy noted by chiropractor G.R. in the May 2014 letter, which may be explained by the July 2015 left hip replacement, but is still less than 4 centimeters, and hence does not reflect a discrepancy as would be productive of joint disability accordingly to medical literature, as the October 2020 VA examiner noted. While Dr. M.B. at the October 2015 treatment observed a slight limp, he did not attribute the limp to the leg length discrepancy or the right knee or the low back. In a November 2020 letter, J.L., a private chiropractor, provided opinions favoring the Veteran’s claims. She provided opinions to the effect that the Veteran was injured in multiple parts including the hips when he injured his left knee in February 1985, that his left knee injury in 1985 was more serious than documented and led to left knee arthritis, and that his bilateral hip arthritis resulted from “overcompensating” from his knee and lumbosacral disabilities. The chiropractor noted the Veteran’s reported incident injuring his right knee when tripping over a cable in February 1985, but the chiropractor concluded that not only was the Veteran’s right knee then injured but rather, “He was propelled into the pavement, while his left knee was caught by the cable, with his left foot planted, twisting his body, and landing hard on his left elbow. This jammed into his left shoulder, causing blunt force trauma throughout his cervical, thoracic, and lumbar spine along with his pelvis, hips, and left shoulder.” The Board finds this account of “blunt force trauma” to so many parts due to the Veteran falling when running and hitting his elbow to be inherently incredible. This account is not supported by the service records and post-service record, which do not support any difficulties with these other parts including the pelvis, hips, and left shoulder following this incident. The February 1985 service record described that the Veteran tripped over a cable on the ground and fell onto outstretched arm. This account of the reported in-service incident also conflicts with the Veteran’s own narrative at his hearing in March 2019, when he reported that the cable “hit me right in the hips or right in above the knees.” (Hearing transcript, pg. 4.) Thus, even if the Board were to accept the Veteran’s undocumented, uncorroborated account of an injury in service as valid, the version of the event relied upon by J.L. is materially different from the version the Veteran relayed at the hearing under oath, since, at the hearing, the Veteran did not report the left knee getting caught by the cable. Also in the November 2020 letter, J.L. opines that the left knee tendonitis, which was diagnosed in December 1985 was actually a torn meniscus that was not detected, and to support this the examiner points to an MRI and x-rays in 2012, over 20 years after the incident. While a VA examiner in March 2014 also found a positive McMurray test for meniscal tear bilaterally, it is not reasonable to conjecture on such basis that the meniscal tear occurred over 20 years earlier in service in the absence of treatment records reflecting ongoing impairment in service or in years following service supportive of meniscal tear. Rather, the Veteran suffering a meniscal tear to the knee after service appears more likely based on the Veteran’s own statements and the absence of records supporting ongoing impairment in service. In a March 2019 statement when the Veteran was complaining of difficulties with certain activities due to claimed disabilities, he reported difficulty going downhill on foot over rough terrain while hunting and similar strenuous, physically treacherous activities. Such activities post-service afforded ample opportunities for meniscal tears. The chiropractor in the November 2020 letter also supports her opinion with the Veteran’s report of a history of “continued complaints of knee swelling, locking, snapping, and pain.” However, the service treatment records do not support continued complaints related to the left knee, as Reports of Medical Examination from January 1988 and November 1993 documented complaints only related to the right knee, which would mean that the Veteran was not complaining of left knee problems, which corresponds with the Reports of Medical History that he completed at those times, where he reported a positive history of trick or locked knee and discussed only the right knee. The January 1993 Report of Medical Examination and Report of Medical History both document a normal clinical evaluation of the lower extremities, and the Veteran denying a history of trick or locked knee. Further supporting this finding is the prior chiropractic letter in July 1998 informs of the Veteran’s treatments from 1990 to 1998 with no reported treatment for any difficulties of the knees, though the Veteran was treated based on complaints at the time, for difficulties with his ankles, wrists, lumbar, and cervical spine. Thus, the July 1998 letter undermines the Veteran’s self-reported history of difficulties or treatment for the left knee in service or in years following service. Thus, for these multiple reasons, the Board concludes that the opinion provided by J.L. in November 2020 is based on inaccurate factual premises and is accordingly not probative. A medical opinion based on an inaccurate factual premise is not probative. Reonal v. Brown, 5 Vet. App. 458, 461 (1993); Monzingo v. Shinseki, 26 Vet. App. 97, 107 (2012) (per curiam). The Board additionally finds that the provided rationale of “overcompensation” is not supported by reasoning or medical literature, and is contrary to the opinion of the October 2020 VA examiner, whose contrary opinion is supported by medical knowledge and literature to the effect that one joint disability does not affect another in the lower extremities in the absence of extremely abnormal gait, which has not been present in this case. In short, the Board find the opinions of J.L. to be contrary to medical knowledge and contrary to the weight of the evidence of record, and without rationale supported by medical knowledge or the weight of the evidence. The Board accordingly finds the opinions of J.L. to be non-probative and outweighed by the probative, competent, credible opinions of the October 2020 examiner who contrarily concludes that the evidence of record and medical knowledge do not support a link between events or injury in service or onset in service for the Veteran’s left knee and bilateral hip disabilities, and do not support a link based on causation or aggravation between service-connected right knee and lumbosacral degenerative disc disease and claimed left knee and bilateral hip disabilities. The October 2020 examiner’s opinions are consistent with and supported by the weight of the evidence of record to the effect that the Veteran’s current disabilities of the left knee and bilateral hips developed over years following service and were not causally related to service and were not caused or aggravated by service-connected disabilities. The Board has considered the Veteran’s assertions, including in testimony and in submitted statements, that he developed multiple disabilities including the left knee following his injury in February 1985, but the Board finds the weight of the evidence of record against this allegation. Medical records from service and for years following service do not support development of a chronic or ongoing left knee disability following his reported February 1985 injury, and the October 2020 VA examiner’s opinion against a current knee condition resulting from that reported injury is supported by these records. The Board does not question the Veteran’s beliefs that the injury in February 1985 resulted in current left knee disability or his belief that service-connected disabilities caused or aggravated his left knee disability or bilateral hip disabilities, however, such questions of etiology of or causation or aggravation of degenerative conditions or other complex conditions of joints are distinctly medical in nature, beyond the ambit of lay competence. The Veteran, as a layperson, is without the expertise needed to address such questions which are beyond lay competence. The Veteran has not been shown to possess the requisite expertise or knowledge to address these questions. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Kahana v. Shinseki, 24 Vet. App. 428, 438 (2011). Accordingly, the Board concludes that the weight of the evidence is against the Veteran’s claims for service connection for left knee and bilateral hip disabilities on direct, first-year-post-service presumptive, and secondary bases, based on their occurrence years following service and absence of links to service or service-connected disabilities, and hence service connection for these claimed disabilities is not warranted. 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310. Because the preponderance of the evidence is against the claims, the benefit of the doubt doctrine does not apply. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Disability Ratings The Veteran contends, in effect, that his lumbosacral degenerative disc disease and right knee disabilities warrant higher ratings than those assigned. Disability ratings are determined by the application of the VA's Schedule for Rating Disabilities (Rating Schedule), which is based on the average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Pertinent regulations do not require that all cases show all findings specified by the Rating Schedule, but that findings sufficient to identify the disease and the resulting disability and above all, coordination of the rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21. Disabilities must be reviewed in relation to their history. 38 C.F.R. § 4.1. Other applicable, general policy considerations are: interpreting reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating many accurately reflect the elements of disability, 38 C.F.R. § 4.2; resolving any reasonable doubt regarding the degree of disability in favor of the claimant, 38 C.F.R. § 4.3; where there is a questions as to which of two evaluations apply, assigning a higher of the two where the disability pictures more nearly approximates the criteria for the next higher rating, 38 C.F.R. § 4.7; and, evaluating functional impairment on the basis of lack of usefulness, and the effects of the disability upon the person's ordinary activity, 38 C.F.R. § 4.10. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Because varying, distinct degrees of disability may have been experienced over the course of the claim, the rating may be "staged" higher or lower for segments of time during the period under review in accordance with such variations. Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007). Thus, separate ratings can be assigned for separate periods of time based on the facts found - a practice known as "staged" ratings. Id. at 505. Separate ratings for distinct disabilities resulting from the same injury or disease can be assigned so long as the symptomatology for one condition is not duplicative of or overlapping with the symptomatology of the other condition. See Amberman v. Shinseki, 570 F.3d 1377, 1381 (Fed. Cir. 2009). However, the evaluation of the same disability or its manifestations under various diagnoses, which is known as pyramiding, is to be avoided. 38 C.F.R. § 4.14. The primary concern in a claim for an increased evaluation for service-connected disability is the present level of disability over the rating period in question. While the entire recorded history of a disability is important for more accurate evaluations, the regulations do not give past medical reports precedence over current findings. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. It is essential that the examination upon which ratings are based adequately portray the anatomical damage, and the functional loss, with respect to all these elements. 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 innervations, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. A little used part of the musculoskeletal system may be expected to show evidence of disuse, either through atrophy, the condition of the skin, absence of normal callosity or the like. 38 C.F.R. § 4.40. Evidence of pain, weakened movement, excess fatigability, or incoordination must be considered in determining the level of associated functional loss, taking into account any part of the musculoskeletal system that becomes painful on use. DeLuca v. Brown, 8 Vet. App. 202 (1995). The provisions regarding the avoidance of pyramiding do not forbid consideration of a higher rating based on greater limitation of motion due to pain on use, including flare ups. See 38 C.F.R. § 4.14. However, those provisions should only be considered in conjunction with the diagnostic codes predicated on limitation of motion. 38 C.F.R. §§ 4.40, 4.45. The intent of the rating schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. Painful motion is an important factor of joint disability, which is entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. However, the evaluation of painful motion as limited motion only applies when the limitation of motion is noncompensable under the applicable diagnostic code. Mitchell v. Shinseki, 25 Vet. App. 32 (2011). Complaints of functional difficulties In a March 2019 submitted statement, the Veteran informed that he owned a locksmith business with three service vans. He then reported difficulties he had maintaining his work vans due to his disabilities, and also reported difficulties with getting under steering columns to work on customer’s ignitions. The Veteran has not reported, however, that he has not continued to run his business. In the March 2019 statement, the Veteran also complained of difficulties getting out of work vans due to the nature of their set-up, and of difficulties splitting and stacking firewood for use in his wood stove. The Veteran also then expressed that he developed extreme pain when going downhill traversing uneven terrain on his last hunt, and having difficulties dealing with multiple feet of snow. The Board does not doubt that overly strenuous activities such as splitting wood or dealing with multiple feet of snow or traversing rough terrain downhill is made more difficult due to his service-connected disabilities, but this is recognized by the ratings already assigned. The fact that the Veteran can find things that cause difficulty or aggravation of his service-connected disabilities does not reflect greater severity of such disabilities so much as lack of discretion which a reasonable patient must necessarily exercise if that patient wishes to take adequate care not to cause difficulty or aggravation of a disability. Difficulty splitting wood or working with large amounts of snow or going downhill over rough terrain while hunting may be expected with almost any level of musculoskeletal disability affecting the back and lower extremities, and hence is to be expected given the Veteran’s documented disabilities involving the back, hips, knees, and other parts. Hence, such statements of difficulties with these and other particularly strenuous or challenging activities do not reflect greater difficulty than that already reflect by the ratings assigned for the Veteran’s service-connected lumbosacral degenerative disc disease and right knee disability. 4. Entitlement to a higher disability rating than the 40 percent assigned for lumbosacral degenerative disc disease from October 2, 2020 5. Entitlement to a higher disability rating than the 20 percent assigned for lumbosacral degenerative disc disease prior to October 2, 2020 The Veteran recently submitted a copy of a July 1998 letter in which D. R., a private chiropractor, informed that he has seen the Veteran since 1993 and that he had provided treatment for various complaints, with chiropractic adjustments to the thoracic and lumbar spine, the ribs, the wrists, and the ankles. However, the chiropractor did not inform when any conditions of the low back were first found or treated. The chiropractor informed that upon most recent treatment the Veteran reportedly had difficulty with his low back resulting in his inability to perform normal job duties including any involving lifting or prolonged bending. However, the letter does not reflect of the status of the Veteran’s disability during the claim period, and hence is not probative for purposes of the appealed increased rating claims. In a May 2014 letter, G. R., another private chiropractor, informed that the Veteran was treated at his clinic from 1990 to 1998. This letter also does not reflect of the status of the Veteran’s disability during the claim period, and hence is also not probative. At a March 2014 VA examination of the Veteran’s low back, degenerative disc disease of L5-S1 was diagnosed. The Veteran then reported that the condition began with repetitive lifting in 1988 and that it had progressively gotten worse. The Veteran reported having flare-ups which resulted in pain. The examiner found range of motion of the thoracolumbar spine to 90 degrees or greater forward flexion with no objective evidence of painful motion; to 25 degrees backward extension with painful motion at 25 degrees; to 25 degrees left and right lateral flexion with no objective evidence of painful motion; and to 30 degrees left and right lateral rotation with no objective evidence of painful motion. Repetitive motion did not change these readings for maximum range of motion, and the examiner explicitly stated that she did not find additional limitation in range of motion of the thoracolumbar spine following repetitive use testing. The examiner found thoracolumbar functional impairment to consist of less movement than normal and pain on movement. There was no localized tenderness and no guarding or muscle spasm. The examiner also found all normal strength in the lower extremities with no muscle atrophy. Reflexes were also all normal and straight leg raising test was negative bilaterally. The examiner found no radiculopathy into either extremity. Other neurological abnormality were also not present. The examiner concluded that the Veteran had no intervertebral disc syndrome. The Veteran also used no assistive devices. The examiner concluded that the functional impact of the Veteran’s lumbosacral degenerative disc disease on his ability to work consisted of decreased capacity for lifting and climbing, and for prolonged sitting, standing, or walking. The examiner concluded that while the Veteran’s posture and gait were normal, there were contributing factors of pain, weakness, fatigability and/or incoordination, with additional limitation of functional ability of the low back during flare-ups or with repeated use over time, but that assigning a range of motion to such circumstances could not be done without observing the Veteran during such times. In a submitted February 2019 letter, J.L., a private chiropractor, informed that the Veteran has been under her care since November 1998. She then informed of ongoing and worsening cervical degenerative joint disease and lumbosacral degenerative disc disease over that interval due to increased degenerative joint disease. However, she did not provide objective findings upon which to base rating the Veteran’s lumbosacral degenerative disc disease. At his March 2019 hearing the Veteran testified that he worked as a locksmith and that his service radius was 90 miles, so that he might be driving an hour and a half each way to a service call. He then reported that if he engaged in strenuous activities such as chopping wood or shoveling snow he would be debilitated and then he could not work. As addressed above, the Veteran’s developing debilitation acutely following chopping wood or shoveling snow does not reflect a greater level of disability than that for which he is already rated, since it merely reflects debilitation such as may be expected with anyone who exceeds their capacities given existing disabilities. Rating disabilities on such bases would make no more sense than rating any disability based on loss of ability to perform following exhaustion of a particular human capacity. A person is not blind because they have read nonstop for too many hours and their eyes are tired; a person is not incapable of walking because their legs are tired after walking 20 miles, etcetera. The Board finds that for the claim period prior to October 2, 2020 – including based on the findings upon VA examination in March 2014 and the absence of treatment records over the claim interval providing evidence substantially supportive of greater disability than that reflected by the findings upon VA examination in March 2014, and based on the Veteran’s assertions, which appear to reflect substantial disability principally with engaging in the most strenuous activities such as hunting while traversing downhill over rough terrain or chopping wood or shoveling snow, which indicate that the Veteran had not been precluded from such highly strenuous activities due to his back disability and thus not reflecting substantial functional impairment – the Veteran’s lumbosacral degenerative disc disease warranted no more than the assigned 20 percent under the applicable code, based on disability including when considering symptomatic pain and limitation of functioning during flare-ups and with repetitive use over time, equivalent to limitation of motion with forward flexion greater than 30 degrees. The Board finds that for the claim period beginning October 2, 2020 – including based on findings upon VA examination in October 2020 and the absence of treatment records over the claim interval providing evidence substantially supportive of greater disability than that reflected by the findings upon VA examination in October 2020, and based on the Veteran’s assertions which appear to reflect substantial disability principally with engaging in the most strenuous activities such as hunting while traversing downhill over rough terrain or chopping wood or shoveling snow, indicating that the Veteran’s is not precluded from such highly strenuous activities due to his back disability and thus not reflecting substantial functional impairment – the Veteran’s lumbosacral degenerative disc disease warrants no more than the assigned 40 percent under the applicable code, based on disability including when considering symptomatic pain and limitation of functioning during flare-ups and with repetitive use over time, equivalent to limitation of motion, which is better than unfavorable ankylosis of the thoracolumbar spine. The Board has considered the effects of the Veteran’s symptoms, including pain and functional loss, and the Board concludes that prior to October 2020, the preponderance of the evidence is against a finding of forward flexion of the thoracolumbar spine to 30 degrees or less or favorable ankylosis of the entire thoracolumbar spine prior to warrant the next higher rating of 40 percent and that since October 2020, the preponderance of the evidence is against the Veteran having the functional equivalent of unfavorable ankylosis of the thoracolumbar spine to warrant a 50 percent rating. Thus, higher ratings under the provisions of 38 C.F.R. §§ 4.40 and 4.45 is not approximated in the Veteran’s disability picture during the appeal period. 6. Entitlement to a higher disability rating than the 10 percent assigned for right knee disability prior to November 7, 2018 The Veteran’s right knee was replaced on November 7, 2018; the rating at issue is for the right knee prior to this knee replacement. Medical findings subsequent to the replacement are not pertinent to the Veteran’s right knee status prior to the replacement. The Board notes that some of the rating criteria applicable to the knee was revised effective February 7, 2021. See 38 C.F.R. § 4.71a; 85 Fed. Reg. 76464 (Nov. 30, 2020). When regulations are revised during the course of an appeal, as here, the Board is required to consider the claim in light of both the former and revised schedular criteria and to apply the regulation more favorable to the claimant. However, the change in the criteria would not impact this part of the appeal period, as the changes occurred after 2018. Degenerative and/or traumatic arthritis as shown by x-ray studies are rated based on limitation of motion of the affected joint. 38 C.F.R. § 4.71a, DCs 5003, 5010. Under DC 5260, limitation of flexion of the knee to 60 degrees warrants a noncompensable rating. Limitation of flexion of the knee to 45 degrees warrants a 10 percent rating. Limitation of flexion of the knee to 30 degrees warrants a 20 percent rating. Limitation of flexion of the knee to 15 degrees warrants a 30 percent rating. Under DC 5261, limitation of extension of the knee to 5 degrees warrants a zero or noncompensable rating. Limitation of extension of the knee to 10 degrees warrants a 10 percent rating. Limitation of extension of the knee to 15 degrees warrants a 20 percent rating. Limitation of extension of the knee to 20 degrees warrants a 30 percent rating. Limitation of extension to 30 degrees warrants a 40 percent rating, and extension limited to 45 degrees warrants a 50 percent rating. Under DC 5257, a 10 percent rating is warranted for slight knee impairment, that is, recurrent subluxation or lateral instability. A 20 percent rating is assigned for a moderate degree of impairment, and a maximum rating of 30 percent is assigned for severe impairment. Under DC 5258, a 20 percent rating is warranted for cartilage, semilunar dislocated, with frequent episodes of locking, pain, and effusion into the joint. The 20 percent rating is the only rating available under DC 5258. DC 5259 provides that a 10 percent rating is warranted for surgically removed cartilage that is symptomatic. A semilunar cartilage is one of the menisci of the knee joint. A 10 percent rating is also the highest schedular evaluation allowed under DC 5259. Under DC 5262, pertaining to impairment of the tibia and fibula, malunion with slight knee or ankle disability warrants a 10 percent rating; malunion with moderate knee or ankle disability warrants a 20 percent rating; malunion with marked knee or ankle disability warrants a 30 percent rating; and nonunion of the tibia and fibula, with loose motion, requiring brace warrants a maximum 40 percent rating. 38 C.F.R. § 4.71a. Normal range of motion of the knee is from zero degrees of extension to 140 degrees of flexion. 38 C.F.R. § 4.71, Plate II. Upon VA examination in March 2014 the examiner noted a history of chondromalacia patella of the right knee which the Veteran reported had its onset in service with a twisting injury, and which the Veteran reported had stayed the same since that injury in service. Upon testing, range of motion of the right knee was full, to 140 degrees flexion and 0 degrees extension, with no objective evidence of painful motion. The same was found for the left knee. With repetitive use testing the same results were found. However, the examiner found a positive McMurray test for meniscal tear bilaterally as well as tenderness to palpation bilaterally. Normal strength was present in each lower extremity, and no instability, subluxation, or dislocation was found in either knee. Additional conditions of each knee were also not found. The examiner endorsed the reported presence of frequent episodes of locking bilaterally associated with meniscal tear. There was no history of knee surgery for either knee, and the Veteran used no assistive devices. Arthritis in each knee was confirmed by diagnostic testing. The March 2014 examiner assessed that the Veteran’s functional impairment included pain, weakness, fatigability and/or incoordination during flare-ups or with repeated use over time, which resulted in decreased capacity for prolonged standing, walking, climbing, and kneeling. The examiner would not assign a reduced range of motion during flare-up without observing of the Veteran during flare-up. (The Board at this juncture cannot reasonably further develop the question of reduced range of motion during flare up or with use over time prior to November 7, 2018 without requiring undue speculation of examiners since the pre-replacement knee is no longer present. The Board recognizes some reduction in functioning during flare-ups as best as has been assessed for the joint in question based on existing evidence.) At a January 2016 VA nursing outpatient treatment, the Veteran reported pain present in multiple joints, but reported taking only acetaminophen for pain relief. The Veteran then denied a history of falls. Among private treatment records added to the claims file in August 2020 are records of treatment for the right knee before and after right knee replacement in November 2018. As noted, the Board here only addresses the pre-replacement status of the knee. At a May 2017 private treatment, the Veteran was seen for bilateral knee pain. He reported a knee pain level of 1 out of 10 in each knee. However, he reported that his knees were unstable when he hiked or went up hills, that they were painful when he stepped wrong, and that he had several locking episodes recently. He reported having pain in multiple joints, and he attributed sleep difficulties to pain from other parts and not to the knees. Range of motion of the right knee was from 0 to 130 degrees, equal to the left, with no joint line tenderness, moderate patellofemoral crepitus with range of motion, some pain with stability testing, and good flexion and extension strength. X-rays showed severe degenerative changes in the right knee. At a July 2017 private treatment follow-up, the Veteran reported that his right knee pain was intermittent, and he would not estimate a pain level. Other findings were substantially unchanged from May 2017. The Veteran was not seen again for his knees by the private provider until July 2018, when the Veteran was seeking cortisone injections for the right knee. At that July 12, 2018 visit, the Veteran reported bilateral knee pain for years, more so on the right, and complained of both knees being unstable when he hikes or goes up hills. He reported grinding in the right knee, having several right knee locking episodes, as well as weakness and instability in the knee. He reported aggravation of the knee with walking, squatting, and bending. He described the pain as constant and of 5 to 7 out of 10 intensity, relieved with NSAIDs. Objectively, range of motion of the right knee was from 0 to 130 degrees, with palpable effusion, medial joint line tenderness, crepitus with range of motion, no pain with forced deep-knee bend and rotation, and good flexion/extension strength. MRI of the right knee from March 2017 revealed degenerative change, cartilage loss, a small medial meniscal tear, and mild effusion. X-rays from May 2017 showed well-preserved medial and lateral joint spaces with minimal degenerative changes. The examiner assessed chronic right knee pain secondary to osteoarthritis, noting that the Veteran had been active and experienced increased pain. The Veteran was then treated with steroid injections to the knee. In a private October 2018 treatment, the Veteran was examined for his right knee. The clinician noted that the Veteran had received injections to the knee in July 2018 but that he planned to undergo a knee replacement. Pain was reported at 2 to 4 out of 10 in the right knee. The Veteran reported that both knees were unstable when he hiked or went up hills. He also reported having right knee grinding as well as locking episodes. Physical right knee examination revealed range of motion from 0 to 125 degrees on the right, with the same range of motion on the left. The right knee exhibited mild effusion, mild medial joint tenderness, crepitus with range of motion, good stability, no pain with forced deep knee bend, and good flexion/extension strength. The examiner assessed chronic right knee pain secondary to osteoarthritis which had progressed to “significantly affecting the Veteran’s activity and day-to-day life.” The Veteran was then fitted for a left knee brace at his request. Upon careful review of the record, the Board notes that the Veteran’s right knee disability did not reflect more severe impairment until his July 12, 2018 private treatment visit, when he received cortisone injections to the knee. The Veteran reportedly had then been more active, likely with reported hiking and going up hills, precipitating increased symptoms. Based on the absence of another visit between July and October 2018, it appears likely that the cortisone injections were successful in lessening symptoms. However, even at the October 2018 treatment, only a month prior to his total knee replacement, reported knee pain was 2 to 4 out of 10, still considerably less than that reported at the July 2018 visit when injections were obtained. The Veteran also reported continued activity such as hiking and walking up hills, with increased symptoms from such activities. On balance, based on careful review of the evidence, the Board concludes that with consideration of pain on range of motion which did not preclude significant activity such as hiking and walking hills, but which was nonetheless increased with such more strenuous activity, that the preponderance of the evidence is against an evaluation in excess of 10 percent. Throughout this part of the appeal, the Veteran has full extension, and his flexion was at least 125 degrees. Neither of these ranges of motion warrant more than a 10 percent rating for painful motion. For example, flexion limited to 45 degrees warrants a 10 percent rating, and extension limited to 10 degrees warrants a 10 percent rating. The Board accordingly concludes that the assigned 10 percent evaluation was appropriate, as painful motion of the knee that is not compensable warrants the minimum compensable rating. 38 C.F.R. § 4.59. In considering whether a higher rating is warranted under another Diagnostic Code, the Board notes that the evidence does not support an award for an increased rating for the right knee under DC 5256 for ankylosis of the knee; DC 5262 for impairment of tibia and fibula; or DC 5263 for genu recurvatum, as none of these disabilities have been demonstrated during this part of the appeal period. Additionally, the Veteran had not undergone surgery in his right knee prior to the right knee replacement in November 2018, and thus consideration of Diagnostic Code 5259, which contemplates semilunar cartilage removal (through surgery) is not warranted. A small meniscal tear was documented in the 2014 VA examination report, however, the examiner documented that while there was frequent locking episodes, there was not frequent joint pain or effusion episodes to warrant a 20 percent rating under Diagnostic Code 5258. With respect to lateral instability, the Board has considered the Veteran’s statements describing right knee instability. The Board recognizes that when considering whether lay evidence is competent the Board must determine on a case-by-case basis whether a veteran’s particular disability is the type of disability for which lay evidence may be competent. Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). Here, the Board finds the Veteran is competent to describe symptoms of his right knee disability, such as perceived instability and pain. See Jandreau, 492 F.3d at 1376 (lay witness capable of diagnosing dislocated shoulder); Falzone v. Brown, 8 Vet. App. 398, 403 (1995) (lay person competent to testify to pain and visible flatness of his feet); Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (unlike varicose veins or a dislocated shoulder, rheumatic fever is not a condition capable of lay diagnosis). His statements regarding perceived right knee instability are credible because he made them to medical providers while seeking treatment. See Rucker v. Brown, 10 Vet. App. 67, 73 (1997) (statements made for the purposes of medical treatment may be afforded greater probative value because there is a strong motive to tell the truth to receive proper care). To the extent, however, that medical professionals used specific clinical tests to assess the stability of the Veteran’s right knee, the Board finds the objective medical evidence is more probative than the lay evidence on the issue of instability because the clinical assessment of knee instability made by performing particular joint stability tests falls outside the realm of common knowledge of laypersons. Here, since receipt of the increased rating claim in August 2013, competent medical evidence has consistently documented that the Veteran’s right knee joint was stable to testing, which will be described in more detail below. In Jandreau, the United States Court of Appeals for the Federal Circuit held that “[l]ay evidence can be competent and sufficient to establish a diagnosis of a condition when…lay testimony describing symptoms at the time supports a later diagnosis by a medical professional.” Jandreau, 492 F.3d at 1977. The issue of whether the Veteran’s perceived symptom of right knee instability is competent and sufficient to establish that he has actual instability of the knee sufficient to warrant a separate disability rating under Diagnostic Code 5257 is analogous to the situation described in Jandreau. In this case, the Veteran has described his perception of right knee instability by describing that he feels his right knee is unstable while hiking or walking on uneven ground. However, medical professionals have tested his right knee for instability during the pendency of his appeal and have not found even slight instability on anterior, posterior, medial, or lateral stability testing. Because the Veteran’s perceived symptom of right knee instability has repeatedly not been demonstrated or confirmed on clinical testing by medical professionals, his lay statements are insufficient to establish the presence of anterior, posterior, medial, or lateral instability sufficient to warrant separate disability rating under Diagnostic Code 5257. In English v. Wilkie, 30 Vet. App. 347 (2018), the Unites States Court of Appeals for Veterans Claims held that the Board cannot find objective medical evidence categorically more probative than lay evidence without explaining why that is the case. To be clear, the Board finds the objective medical evidence more probative than the Veteran’s reports of perceived right knee instability for two reasons. First, the clinical findings by the March 2014 VA examiner and the Veteran’s treating physician in July 2017 involved multiple forms of stability testing. For example, at the March 2014 VA examination, the examiner performed anterior stability testing, posterior stability testing, and medial-lateral stability testing, and all testing was normal. When the Veteran’s treating physician saw him in July 2017 and the Veteran reported that his right knee was unstable, the examiner, upon physical examination, documented the right knee had no pseudo-laxity, was stable in full extension, had a negative Lachman’s test, a negative pivot shift, and a negative posterior drawer test. The thorough, repeated stability testing, which did not reveal instability, supports the conclusion that the Veteran’s perceived knee instability is not due to anterior, posterior, medial, or lateral knee joint laxity. Second, the stability testing performed in March 2014 and July 2017 were performed by two, different medical professionals, and each performed multiple forms of stability testing, and each documented the right knee was stable to all stability tests. The examinations were performed more than three years apart. The internal consistency among the examiners bolsters the conclusion that their findings of no right knee joint instability were accurate. For all of these reasons, the Board concludes that a separate rating under Diagnostic Code 5257 for right knee instability is not warranted. The Board has considered whether higher ratings should be assigned pursuant to 38 C.F.R. §§ 4.40, 4.45, 4.59, DeLuca, and Mitchell criteria but determines that higher ratings are not warranted for the Veteran’s disability picture. The Veteran has reported having flare-ups of his symptoms; however, even though there is evidence of flare-ups, limited range of motion, and the presence of arthritis in the right knee, and even after considering the effects of pain and functional loss, the evidence does not show that the Veteran’s right knee manifested by limitation of flexion to 30 degrees or less or extension limited to 10 degrees or more to warrant a separate rating for limitation of extension. The Veteran’s muscle strength has been described as full at 5/5 and within the private records, the examiner documented that the Veteran had good flexion/extension strength. Neither VA nor private medical professionals have documented that the Veteran has atrophy in his right lower extremity. The Board finds that this is evidence against the Veteran having more than mild weakness in the right knee. Thus, a higher rating under these provisions is not approximated in the Veteran’s right knee disability picture. Accordingly, the Board finds the preponderance of the evidence against the Veteran’s right knee disability warrants more than the 10 percent assigned for any intervals prior to November 7, 2018. Hence, an increased rating, to include interval staged ratings, is not warranted. 38 C.F.R. § 4.71a, Diagnostic Code 5260. A. P. SIMPSON Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board D. Schechter 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.