Citation Nr: 21028149 Decision Date: 05/10/21 Archive Date: 05/10/21 DOCKET NO. 12-05 332 DATE: May 10, 2021 ORDER Entitlement to an initial compensable rating for iritis, keratitis, and uveitis is denied. Entitlement to an initial compensable rating for a keratoderma blennorrhagica is denied. Entitlement to an initial compensable rating for a left thumb scar is denied. Entitlement to a rating higher than 10 percent for residuals of a left thumb gamekeeper's tear is denied. Entitlement to an initial rating higher than 10 percent prior to July 29, 2015, for right knee synovitis is denied. Entitlement to a 10 percent rating, but not higher, as of July 29, 2015, but not earlier, for right knee synovitis is granted. Entitlement to an initial compensable rating for right knee synovitis with limitation of extension is denied. Entitlement to a rating higher than 20 percent for Reiter's Syndrome with low back, right shoulder, and right hand pain prior to November 18, 2020, is denied. Entitlement to a 60 percent rating, but not higher, for Reiter's Syndrome with low back, right shoulder, and right hand pain as of November 18, 2020, but not earlier, is granted. Entitlement to a separate rating for a right shoulder disability is denied. Entitlement to a separate rating for a right hand disability is denied. Entitlement to a separate rating of 10 percent, but not higher, for a left hand disability is granted. Entitlement to an initial rating higher than 10 percent for chronic testalgia, epididymitis, and urethritis prior to October 24, 2018, is denied. Entitlement to a 40 percent, but not higher, for testalgia, epididymitis, and urethritis as of October 24, 2018, but not earlier, is granted. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) as of May 6, 2007, is granted. Entitlement to special monthly compensation (SMC) under 38 U.S.C. § 1114 (k) for loss of use of the legs is denied. FINDINGS OF FACT 1. Throughout the appeal period, the Veteran's iritis, keratitis, and uveitis has manifested with no more than occasional irritation; the evidence does not indicate decreased visual acuity or other visual impairment, or incapacitating episodes. 2. Throughout the appeal period, the Veteran's keratoderma blennorrhagica covered less than 5 percent of the entire body and less than 5 percent of exposed areas affected. 3. The Veteran's left thumb scar has not been shown to be deep, unstable, painful, covered an area of 144 square inches or greater, or that they adversely affected any function. 4. Throughout the appeal period, the Veteran's residuals of a left thumb gamekeeper's tear are manifested by pain, but are not manifested by gap between the thumb pad and the fingers, with the thumb attempting to oppose the fingers. 5. Prior to July 29, 2015, the Veteran's right knee synovitis resulted in painful motion with flexion to 70 degrees and extension to greater than 10 degrees; with no recurrent subluxation or lateral instability, meniscal impairment, or other knee or leg impairment. 6. As of July 29, 2015, the Veteran's right knee synovitis resulted in painful motion with flexion to 70 degrees and extension to greater than 10 degrees; with no recurrent subluxation or lateral instability, meniscal impairment, or other knee or leg impairment. 7. As of November 18, 2020, the Veteran's right knee synovitis manifested with limited extension, at worst, to 5 degrees. 8. Prior to November 18, 2020, the Veteran's Reiter's syndrome with low back, right shoulder, and right hand pain has manifested by pain and painful motion, but with forward flexion of the thoracolumbar spine to greater than 30 degrees, no ankylosis, and non-incapacitating exacerbations. 9. As of November 18, 2020, the Veteran's Reiter's syndrome with low back, right shoulder, and right hand pain has manifested by pain and painful motion, but with forward flexion of the thoracolumbar spine to greater than 30 degrees, no ankylosis, and more than four incapacitating exacerbations per year. 10. Throughout the appeal period, the Veteran's right shoulder disability has manifested with pain, discomfort, and limited motion; it has not manifested with not manifested by motion limited to 90 degrees. 11. Throughout the appeal period, the Veteran's right hand disability has manifested with mild pain that results in mild impairment of flexion of the right hand. 12. Throughout the appeal period, the Veteran's left hand disability has manifested with moderate pain that results in moderate impairment of flexion of the left hand. 13. Prior to October 24, 2018, the Veteran's chronic testalgia, epididymitis, and urethritis was manifested by awakening to void two times per night. 14. As of October 24, 2018, the Veteran's chronic testalgia, epididymitis, and urethritis was manifested by awakening to void five or more times per night. 15. Resolving all reasonable doubt in the Veteran's favor, he has been unable to secure and follow a substantially gainful occupation by reason of his service-connected disabilities as of May 6, 2007. 16. The Veteran does not have loss of use of his legs. CONCLUSIONS OF LAW 1. The criteria for an initial compensable rating for iritis, keratitis, and uveitis have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § § 4.1, 4.3, 4.7, 4.79, DC 6001. 2. The criteria for an initial compensable rating for keratoderma blennorrhagica have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.321(b)(1), 4.1, 4.3, 4.7, 4.10, 4.118, Diagnostic Code 7899-7816. 3. The criteria for entitlement to an initial compensable disability rating for a scar on the left thumb have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.118, Diagnostic Code 7805. 4. The criteria for a rating higher than 10 percent for residuals of a left thumb gamekeeper's tear are have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.71a, Diagnostic Code 5228. 5. Prior to July 29, 2015, the criteria for an initial 10 percent rating for right knee synovitis limitation of flexion were not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5009-5260. 6. As of July 29, 2015, the criteria for a 10 percent rating, but not higher, for right knee synovitis limitation of flexion are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5009-5260. 7. The criteria for an initial compensable rating for right knee synovitis limitation of extension are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5009-5261. 8. Prior to November 18, 2020, the criteria for a rating higher than 20 percent for Reiter's syndrome with low back pain were not met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 4.7, 4.71a, Diagnostic Code 5009-5237. 9. As of November 18, 2020, the criteria for a 60 percent rating, but not higher, for Reiter's syndrome with low back pain are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5009-5237. 10. The criteria for a separate compensable rating for a right shoulder disability have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.303, 3.310, 4.1, 4.3, 4.7, 4.10, 4.71a Diagnostic Code 5201. 11. The criteria for a separate compensable rating for a right hand disability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.303, 3.310, 4.1, 4.2, 4.3, 4.7, 4.10, 4.73, Diagnostic Code 5307. 12. As of May 6, 2007, the criteria for a separate rating of 10 percent, but no higher, for a left hand disability have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.303, 3.310, 4.1, 4.2, 4.3, 4.7, 4.10, 4.73, Diagnostic Code 5307. 13. Prior to October 24, 2018, the criteria for an initial rating higher than 10 percent for chronic testalgia, epididymitis, and urethritis, were not been met. 38 U.S.C. §§ 1110, 1155, 5103, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.3, 4.7, 4.14, 4.115a, 4.115b, Diagnostic Code 7518. 14. As of October 24, 2018, the criteria for a disability rating of 40 percent, but not higher, for chronic testalgia, epididymitis, and urethritis, have been met. 38 U.S.C. §§ 1110, 1155, 5103, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.3, 4.7, 4.14, 4.115a, 4.115b, Diagnostic Code 7518. 15. As of May 6, 2007, the criteria for a TDIU have been met. 38 U.S.C. § 1155, 5107; 38 C.F.R. §§ 3.340, 3.341, 3.400, 4.16. 16. The criteria for SMC under 38 U.S.C. § 1114 (k) for loss of use of the legs have not been met. 38 U.S.C. §§ 1114 (k), 5107; 38 C.F.R. § 3.350 (a). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from June 1995 to April 2004, and from August 2005 to May 2007. This matter comes from the Board of Veterans' Appeals (Board) on appeal from July 2008 and January 2012 rating decisions of the Department of Veterans Affairs (VA Regional Office (RO) in Pittsburgh, Pennsylvania. In June 2013, the Veteran testified at a hearing before the undersigned Veterans Law Judge. A transcript is of record. In December 2013 and June 2020, the Board remanded the appeal for additional development. Increased Ratings Disability ratings are determined by the application of VA's Schedule for Rating Disabilities, which is based on average impairment of earning capacity resulting from a service-connected disability. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. The Veteran's entire history is to be considered when assigning disability ratings. 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). A claimant may experience multiple distinct degrees of disability that may result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Hart v. Mansfield, 21 Vet. App. 505 (2007). The following analysis is undertaken with consideration of the possibility that different ratings may be warranted for different time periods. When evaluating joint disabilities rated on the basis of limitation of motion, VA must consider granting a higher rating in cases in which functional loss due to pain, weakness, excess fatigability, or incoordination is demonstrated, and those factors are not contemplated in the relevant rating criteria. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202 (1995). The rating of the same disability under various diagnoses is to be avoided. 38 C.F.R. § 4.14. That does not preclude the assignment of separate ratings for separate and distinct symptomatology where none of the symptomatology justifying a rating under one diagnostic code is duplicative of or overlapping with the symptomatology justifying a rating under another diagnostic code. Esteban v. Brown, 6 Vet. App. 259 (1994). 1. Entitlement to an initial compensable rating for iritis, keratitis, and uveitis The Veteran's iritis, keratitis, and uveitis are assigned a noncompensable rating under 38 C.F.R. § 4.79, Diagnostic Code 6001, for keratitis. A January 2012 rating decision granted a separate rating for iritis, keratitis, and uveitis, assigning a noncompensable rating with an effective date of May 6, 2007. Throughout the appeal period, the Veteran has reported decreased visual acuity and dry eyes. The Board notes that during the pendency of the appeal, the Veteran was service-connected for Sjogren's syndrome, which caused dry eyes. During the pendency of the appeal, VA issued two final rules revising the portion of the VA Schedule for Rating Disabilities that addresses the organs of special sense and schedule of ratings-eye in 2008 and 2018. 73 Fed. Reg. 66543; 83 Fed. Reg. 15316. The final rules went into effect November 10, 2008, and May 13, 2018. Where there is a change in the rating criteria during the appeal period, the Board will consider the claim using the former and revised schedular rating criteria, although an increased rating based on the revised criteria cannot predate the effective date of the amendments. Under the former criteria, Diagnostic Code 6001 was evaluated from 10 percent to 100 percent for impairment of visual acuity or field loss, pain, rest-requirements, or episodic incapacity, combining an additional rating of 10 percent during continuance of active pathology. A minimum rating of 10 percent was assigned during active pathology. Under the 2008 revised criteria, the General Rating Formula for Diagnostic Codes 6000 through 6009 instructs to evaluate on the basis of either visual impairment due to the particular condition or on incapacitating episodes, whichever results in a higher evaluation. Where incapacitating episodes have a total duration of at least 1 week, but less than 2 weeks, during the past 12 months, a 10 percent rating is warranted. Where incapacitating episodes have a total duration of at least 2 weeks, but less than 4 weeks, during the past 12 months, a 20 percent rating is warranted. Where incapacitating episodes have a total duration of at least 4 weeks, but less than 6 weeks, during the past 12 months, a 40 percent rating is warranted. Where incapacitating episodes have a total duration of at least 6 weeks during the past 12 months, a 60 percent rating is warranted. A Note following the General Rating Formula indicates that, for VA purposes, an incapacitating episode is a period of acute symptoms severe enough to require prescribed bed rest and treatment by a physician or other healthcare provider. Under the 2018 revised criteria, the General Rating Formula for Diseases of the Eye instructs to evaluate on the basis of either visual impairment due to a particular condition or on incapacitating episodes, whichever results in a higher evaluation. Where there are documented incapacitating episodes requiring at least 1 but less than 3 treatment visits for an eye condition during the past 12 months, a 10 percent rating is warranted. Where there are documented incapacitating episodes requiring at least 3 but less than 5 treatment visits for an eye condition during the past 12 months, a 20 percent rating is warranted. Where there are documented incapacitating episodes requiring at least 5 but less than 7 treatment visits for an eye condition during the past 12 months, a 40 percent rating is warranted. Where there are documented incapacitating episodes requiring 7 or more treatment visits for an eye condition during the past 12 months, a 60 percent rating is warranted. Note (1) indicates that, for the purposes of evaluations under 38 C.F.R. § 4.79, an incapacitating episode is an eye condition severe enough to require a clinic visit to a provider specifically for treatment purposes. Note (2) indicates that examples of treatment may include but are not limited to: systemic immunosuppressants or biologic agents; intravitreal or periocular injections; laser treatments; or other surgical interventions. Note (3) indicates that, for the purposes of evaluating visual impairment due to a particular condition, refer to 38 C.F.R. § 4.75-4.78 and to § 4.79, DCs 6061-6091. The rating of visual impairment is based on impairment of visual acuity, excluding developmental errors of refraction; visual field; and muscle function. 38 C.F.R. § 4.75(a). To determine the rating for visual impairment when both decreased visual acuity and visual field defect are present in one or both eyes and are service-connected, visual acuity and visual field defects are evaluated separately, and then combined under the provisions of 38 C.F.R. § 4.25. The rating of visual acuity is based on corrected distance vision with central fixation. 38 C.F.R. § 4.76(b)(1). The measurements for each eye are applied to the table for Impairment of Central Visual Acuity. Subject to the provisions of 38 C.F.R. § 3.383(a), if visual impairment of only one eye is service-connected, the visual acuity of the other eye will be considered to be 20/40 for purposes of rating the service-connected visual impairment. 38 C.F.R. § 4.75(c). Diagnostic Code 6066 provides ratings where vision in one eye (the poorer eye) is 10/200 or better. Where the visual acuity in both eyes is 20/40, a 0 percent rating is warranted. Where the visual acuity in the poorer eye is 20/50, a 10 percent rating is warranted where vision in the other eye is either 20/50 or 20/40. The Board notes that the medical evidence does not indicate any visual field or muscle function impairments. At a February 2010 VA examination, the Veteran reported a halo effect around lights at night, a mild itch in the left eye, and dry eyes. He experienced stabbing pains in both eyes. There was no abnormality or decreased visual acuity in either eye. At a November 2016 examination, the Veteran reported photophobia and very dry eyes. The examiner diagnosed keratitis and keratoconjunctivitis sicca. Corrected distance testing was not reported. The examiner indicted that the Veteran maintained good vision and there was no decrease in visual acuity. Both eyes experienced pain, photophobia, and glare sensitivity. There was no scarring or disfigurement. The Veteran did not experience any incapacitating episodes. At an October 2018 VA examination, the examiner diagnosed keratoconjunctivitis sicca and nummular keratitis post-adenoviral keratoconjunctivitis. There was no evidence of iritis. Corrected distance measured 20/20 or better in both eyes. The corneas showed punctate epithelial erosions with faint subepithelial opacities on the left side. There was no visual field defect. The examiner indicated that there was no decrease in visual acuity or other visual impairment. At a November 2020 VA examination, the Veteran reported the vision in the left eye had become slightly frosty for distance and increased dry eye symptoms in the last five years. Corrected distance measured 20/20 or better in both eyes. There was no decrease in visual acuity or visual impairment attributable to the keratoconjunctivitis sicca. In addition, the examiner explained there was no evidence of nummular keratitis, and the condition had resolved. Further, the service-connected keratitis had resolved. There was no visual field defect or incapacitating episodes. The examiner indicated that it was not possible to differentiate the symptomatology caused by keratoconjunctivitis sicca and Sjogren's syndrome as both disabilities cause dry eyes. The examiner noted that severe Sjogren's syndrome with keratitis and uveitis could potentially cause foggy, blurred vision similar to early cataracts. However, the recent examination showed that the Veteran's corneas were clear with the left lens slightly opaque. The symptoms of foggy and blurry vision were due to an early cataract, which is unrelated to the service-connected eye disabilities. After review of the record, the Board finds that the preponderance of the evidence is against a finding that a compensable rating for the Veteran's eye disability is warranted. Visual acuity has remained normal throughout the appeal period. While the Board acknowledges the Veteran's reports of eye irritation, frosty vision, and photophobia, these statements do not constitute incapacitating episodes supporting a higher rating under the rating criteria. The evidence clearly reflects that the majority of the Veteran's eye complaints concern the dry eyes. As the dry eye symptomatology is reflected in the rating for Sjogren's syndrome, assigning an increased rating based on dry eyes symptoms would constitute improper pyramiding. 38 C.F.R. 4.14. The November 2020 VA examiner indicated that it was not possible to differentiate the symptomatology caused by keratoconjunctivitis sicca and Sjogren's syndrome as both disabilities cause dry eyes. Further, the October 2018 VA examiner found there was no evidence of iritis, and the November 2020 VA examiner found that the keratitis had resolved. Significantly, the bilateral eye disability has not been shown to manifest in decreased visual acuity or other visual impairment, or to involve any incapacitating episodes. Therefore, the Board finds that the evidence does not demonstrate that the service-connected disability meets or more nearly approximates the criteria for a higher rating under Diagnostic Code 6001 or any other potentially applicable diagnostic code. Accordingly, the Board finds that the preponderance of the evidence is against a finding that an initial compensable rating is warranted for the Veteran's service-connected iritis, keratitis, and uveitis disability. Therefore, the claim for increased rating must be denied. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 2. Entitlement to an initial compensable rating for a keratoderma blennorrhagica The Veteran contends a compensable rating is warranted for the skin disability under Diagnostic Code7899-7816. He asserts that the disability causes the skin would open and bleed, which restricts his activities. In addition, he has used various lotions to treat his disability. A January 2012 rating decision granted a separate rating for psoriasis/keratoderma blennorrhagica, assigning a noncompensable rating with an effective date of May 6, 2007. The Board noted that the record shows two diagnoses, psoriasis and keratoderma blennorrhagica, for the service-connected skin disability. However, the November 2020 VA examiner clarified that the correct diagnosis is keratoderma blennorrhagica, which can mimic psoriasis. VA amended the criteria for rating skin disabilities effective from August 13, 2018. These new regulations apply to all applications for benefits received by VA or that are pending before the AOJ on or after August 13, 2018. Claims pending prior to the effective date will be considered under both old and new rating criteria, and whatever criteria is more favorable to the Veteran will be applied. The Board may not apply a current regulation prior to its effective date, unless the regulation explicitly provides otherwise. Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). The Board is not precluded from applying prior versions of the applicable regulation to the period on or after the effective dates of the new regulation if the prior version was in effect during the pendency of the appeal. Prior to August 13, 2018, under Diagnostic Code 7816, a 10 percent rating is assigned for at least 5 percent, but less than 20 percent, of the entire body, or; at least 5 percent, but less than 20 percent, of exposed areas affected, or; intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of less than six weeks during the past 12-month period. A 30 percent rating is assigned for 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected, or; systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of six weeks or more, but not constantly during the past 12-month period. A 60 percent rating is assigned for more than 40 percent of the entire body or more than 40 percent of exposed areas affected, or; constant or near- constant systemic therapy such as corticosteroids or other immunosuppressive drugs required during the past 12- month period. Or rate as disfigurement of the head, face, or neck (Diagnostic Code 7800) or scars (Diagnostic Codes 7801, 7802, 7803, 7804, or 7805), depending on the predominant disability. For claims filed prior to August 13, 2018, the Court held that a systematic therapy is one that that affects the entire body in its treatment of the condition at issue, and that the Board must determine (1) whether a topical treatment affects the body as a whole in treating a veteran's skin condition; and (2) whether the given treatment is "like a corticosteroid or other immunosuppressive drug." Burton v. Wilkie, 30 Vet. App. 286 (2018). Only the second question need be addressed if the treatment is clearly systemic. Effective August 31, 2018, VA regulations explicitly state that systemic therapy is treatment that is administered through any route other than the skin, and topical therapy is treatment that is administered through the skin. 38 C.F.R. § 4.118(a). Additionally, effective August 13, 2018, a new General Rating Formula for the Skin applies to Code 7816. Under this formula, a 10 percent rating is assigned for at least one of the following: characteristic lesions involving at least 5 percent, but less than 20 percent, of the entire body affected; or at least 5 percent, but less than 20 percent, of exposed areas affected; or intermittent systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, PUVA, or other immunosuppressive drugs required for a total duration of less than 6 weeks over the past 12- month period. A 30 percent rating is assigned at least one of the following: characteristic lesions involving more than 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected; or systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, PUVA, or other immunosuppressive drugs required for a total duration of 6 weeks or more, but not constantly, over the past 12-month period. A 60 percent rating is assigned for at least one of the following: characteristic lesions involving more than 40 percent of the entire body or more than 40 percent of exposed areas affected; or constant or near-constant systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, psoralen with long-wave ultraviolet-A light (PUVA), or other immunosuppressive drugs required over the past 12-month period. Or rate as disfigurement of the head, face, or neck (Diagnostic Code 7800) or scars (Diagnostic Codes 7801, 7802, 7803, 7804, or 7805), depending on the predominant disability. 38 C.F.R. § 4.118, General Rating for the Skin for Code 7816. In a March 2008 VA examination, the Veteran reported flare-ups with two to six episodes per year. He did not use any medication. The examiner suspected the palm and sole skin lesions were not psoriasis, but keratoderma blennorrhagica. In a February 2010 VA examination, the Veteran reported large areas of skin loss on the palms of the hands, soles of the feet, and knuckles. The skin was not itchy and there was no rash. The Veteran indicated that an episode responded well to steroid ointment. There were large areas of skin desquamation on the palms of both hands, but the soles of the feet were normal. There was no redness or rash. In an October 2016 VA examination, the Veteran had a rash on palms and soles of the Veteran's feet. The examiner indicated less than 5 percent of exposed surfaces, and less than 5 percent of total skin was affected. No treatment was noted for the last 12 months. At a November 2020 VA examination, the Veteran reported the skin disability had stayed the same, but there were times when it was worse. He was not currently using any medication or treatment. The disability manifested with red, thickened dry skin on the hands and feet and affected less than 5 percent of the total body are and exposed area. There was no scarring or disfigurement. The examiner changed the diagnosis to keratoderma blennorrhagica, which can mimic psoriasis. Private treatment records indicate the presence of psoriasis and are consistent with findings in the March 2008, February 2010, October 2016, and November 2020 VA examination reports. After review of the record, the Board finds that an initial compensable rating is not warranted at any point during the appeal period. The evidence indicates that the Veteran's skin disability affects less than 5 percent of the entire body and exposed areas affected. The record shows that the Veteran used topical treatment at various times. Although the Veteran mentioned treatment with various lotions at the June 2013 hearing and October 2016 examination, the medical evidence has not indicated use of intermittent systematic therapy. As the evidence does not show at least 5 percent of the entire body exposed areas affected, or the use of intermittent systemic therapy, a higher rating is not warranted. Under both the former and present rating criteria, this results in a noncompensable rating. Accordingly, there is no probative evidence to show symptoms that would warrant a higher rating. Accordingly, the Board finds that the preponderance of the evidence is against an initial compensable rating for keratoderma blennorrhagica. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 3. Entitlement to an initial compensable rating for a left thumb scar The Veteran was assigned a noncompensable rating for a scar at the base of his left thumb under Diagnostic Code 7802 pertaining to burn scars in a January 2021 rating decision. The scar was discovered during the course of the appeal at the November 2020 VA examination of the service-connected left thumb. As the scar is from surgery, the Board finds that it is more appropriately rated under Diagnostic Code 7805 for other scars. VA amended the criteria for rating skin disabilities effective from August 13, 2018. These new regulations apply to all applications for benefits received by VA or that are pending before the agency of original jurisdiction on or after August 13, 2018. Claims pending prior to the effective date will be considered under both old and new rating criteria, and whatever criteria is more favorable to the veteran will be applied. The Board may not apply a current regulation prior to its effective date, unless the regulation explicitly provides otherwise. Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). However, the Board is not precluded from applying prior versions of the applicable regulation to the period on or after the effective dates of the new regulation if the prior version was in effect during the pendency of the appeal. The 2018 amendments did not affect Diagnostic Code 7805. The diagnostic criteria for disorders of the scars are found at 38 C.F.R. § 4.118, Diagnostic Codes 7801-7805. Under Diagnostic Code 7801, burn scar(s) or scar(s) due to other causes, not of the head, face, or neck, that are deep and nonlinear in an area or areas of at least 6 square inches (39 sq. cm.) but less than 12 square inches (77 sq. cm.) warrant a 10 percent rating. Under Diagnostic Code 7802, burn scar(s) or scar(s) due to other causes, not of the head, face, or neck, that are superficial and nonlinear in an area or areas of 144 square inches (929 sq. cm.) or greater warrant a 10 percent evaluation. Note (2) under that code provides that if multiple qualifying scars are present, assign a separate evaluation for each affected extremity based on the total area of the qualifying scars that affect that extremity. Under Diagnostic Code 7804, one or two scars that are unstable or painful warrant a 10 percent evaluation, three or four scars that are unstable or painful warrant a 20 percent evaluation, five or more scars that are unstable or painful warrant a 30 percent evaluation. Note (2) for that code provides that if one or more scars are both unstable and painful, add 10 percent to the evaluation that is based on the total number of unstable or painful scars. Note (3) under that provides that scars evaluated under Diagnostic Codes 7800, 7801, 7802, or 7805 may also receive an evaluation under Diagnostic Code 7803, when applicable. Diagnostic Code 7805 provides that other scars (including linear scars) and other effects of scars evaluated under Diagnostic Codes 7800, 7801, 7802, and 7804 require the evaluation of any disabling effect(s) not considered in a rating provided under Diagnostic Codes 7800-04 under an appropriate Diagnostic Code. 38 C.F.R. §§ 4.118, Diagnostic Codes 7801-7805.At a November 2020 VA examination, the examiner noted a scar at the base of the left thumb that was "V" shaped. It measured 4.5 centimeters by 1 centimeter. There were no symptoms noted. At a November 2020 VA examination, the examiner noted a scar at the base of the left thumb that was "V" shaped. It measured 4.5 centimeters by 1 centimeter. There were no symptoms noted. The Veteran nor the Veteran's representative have asserted that a higher rating is warranted. The Board finds that the preponderance of the evidence is against the assignment of a compensable evaluation under Diagnostic Code 7805. The Veteran's scar on the left thumb was not deep, unstable, painful, lost their covering repeatedly, covered an area of 144 square inches or greater, or that they adversely affected any function. It is well-healed and stable, does not involved the underlying tissue, and there is no indication from the Veteran or in the evidence of record that the scar was painful. Therefore, a compensable rating for the Veteran's left thumb scar is not warranted. Accordingly, the Board finds that the preponderance of the evidence is against a finding that an initial compensable rating is warranted for the Veteran's service-connected left thumb scar. Therefore, the claim for increased rating must be denied. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 4. Entitlement to a rating higher than 10 percent for residuals of a left thumb gamekeeper's tear The Veteran's residuals of a left thumb gamekeeper's tear are rated at 10 percent under Diagnostic Code 5228, on the basis of painful motion. A July 2008 rating decision granted service connection for residuals of gamekeeper's tear in the left thumb, assigning a noncompensable rating with an effective date of May 1, 2004. A January 2021 rating decision granted an initial compensable rating for residuals of gamekeeper's tear in the left thumb, assigning a 10 percent rating with an effective date of November 18, 2020. Under Diagnostic Code 5228, a noncompensable rating is warranted for a gap of less than one inch (2.5 cm) between the thumb pad and the fingers, with the thumb attempting to oppose the finger. A 10 percent rating is warranted for a gap of 1 to 2 inches (2.5 to 5.1 cm) between the thumb pad and the fingers with the thumb attempting to oppose the fingers. A 20 percent rating is assigned when there is a gap of more than 2 inches (5.1 cm) between the thumb pad and the fingers with the thumb attempting to oppose the fingers. 38 C.F.R. § 4.71a, Diagnostic Code 5228. There is no differentiation between the ratings assigned for the major (dominant) and minor (nondominant) hands under Diagnostic Code 5228. In a March 2008 examination, the left thumb had a full range of motion with normal strength. There was no tenderness. At the June 2013 hearing, the Veteran reported that he is left hand dominant. He stated that he experienced reduced strength in grip, weakness, and pain. In an October 2016 examination, the examiner indicated there was no current diagnosis and no records were reviewed. Range of motion testing was not reported, and the examiner reported the measurements were normal. No functional loss was reported. At a November 2020 VA examination, the Veteran reported that gamekeepers thumb symptoms improved a little after surgery and have remained the same. His current symptoms include weakness and a dull ache. He did not have flare-ups. The Veteran is left-handed. However, the Veteran had functional loss that required him to write with his right hand, and he had difficulty opening jars. Range of motion testing showed full range of motion with no gap between the pad of the thumb and fingers. There was pain on examination with opposition with thumb. In addition, there was evidence of pain with use of the hand and pain around the base the first proximal phalanx and diffuse hand tenderness. The examiner noted this pain and tenderness was moderate to mild. There was no additional loss with repetitive use testing. Although the Veteran was not examined after repetitive use over time, the examiner found pain limited functional ability. The Veteran would have the same movement, but he would have to rest and could not lift heavier things. Strength testing was normal. Based on review of the evidence, the Board finds that a rating higher than 10 percent for a left thumb disability is not warranted. Specifically, the evidence does not show that the Veteran had any gap between the thumb pad and the fingers, with the thumb attempting to oppose the fingers. The Veteran complained of pain in the hand which caused functional limitation with reduced strength in grip and weakness. That credible assertion shows that the pain resulted in some level of limitation of motion. However, the preponderance of the evidence is against the assignment of any higher rating, as limitation of the thumb sufficient to warrant a compensable rating was not shown. Further, a rating based on limitation of motion would need to exceed 10 percent to warrant any higher rating as the limitation of motion rating cannot be combined with a rating based on arthritis. Furthermore, no additional higher or alternative ratings under different Diagnostic Codes can be applied in this case. The evidence also does not show ankylosis, or amputation, or that the Veteran would be equally well served by amputation with prosthesis. Accordingly, the Board finds that the preponderance of the rating is against the assignment of a rating higher than 10 percent for the left thumb disability. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Right knee disabilities The Veteran seeks increased ratings for the right knee disabilities. A September 2004 rating decision granted service connection for Reiter's Syndrome with recurrent right knee synovitis, low back pain, urethritis, and iritis, assigning a 20 percent rating with an effective date of May 1, 2004. A July 2008 rating decision continued the 20 percent rating. In February 2017, a rating decision decreased the rating for Reiter's syndrome with recurrent right knee synovitis and low back pain to a noncompensable rating, effective July 29, 2015. The RO stated the reduction was to avoid pyramiding with the grant of service connection for chronic fatigue syndrome rated at 100 percent disabling. In March 2018, the RO corrected the ratings assigned in February 2017. The right knee synovitis was granted a separate rating with staged ratings of 10 percent prior to July 29, 2015, and a noncompensable from July 29, 2015. A January 2021 rating decision granted an increased rating of 10 percent for right knee synovitis due to objective evidence of arthritis, and the Diagnostic Code was changed from 5020 (synovitis) to 5260-5009 (limitation of flexion/other types of arthritis). A separate rating was granted for right knee synovitis with limitation of extension assigning noncompensable rating with an effective date of November 18, 2020. The Board notes that the regulations pertaining to rating arthritis and the knees have been amended, effective February 7, 2021. See 85 Fed. Reg. 76453, 76464 (Nov. 30, 2020) (to be codified at 38 C.F.R. § 4.71a, DCs 5002, 5003, 5257). These amendments provide specific conditions required to meet the diagnostic criteria for instability. The Board notes that these amendments are not applicable any earlier than their effective date. As relevant to this case, these changes result in new method for evaluating chronic residuals of arthritis rated under Diagnostic Code 5009. Under Diagnostic Code 5009 for other types arthritis, the former criteria instructed that evaluation of the types of arthritis listed under Diagnostic Codes 5004 through 5009 are rated as rheumatoid arthritis. 38 C.F.R. § 4.71a, Diagnostic Code 5009. Under Diagnostic Code 5002 for rheumatoid arthritis, a 20 percent rating is warranted for one or two exacerbations a year in a well-established diagnosis. 38 C.F.R. § 4.71a, Diagnostic Code 5002. A 40 percent rating is warranted for symptom combinations productive of definite impairment of health objectively supported by examination findings or incapacitating exacerbations occurring 3 or more times a year. A 60 percent rating is warranted for less than criteria for 100 percent but with weight loss and anemia productive of severe impairment of health or severely incapacitating exacerbations occurring 4 or more times a year or a lesser number over prolonged periods. A 100 percent rating is warranted for constitutional manifestations associated with active joint involvement, totally incapacitating. Id. For chronic residuals, such as limitation of motion or ankylosis, favorable or unfavorable, the evaluator is to rate under the appropriate diagnostic codes for the specific joints involved. Where, however, the limitation of motion of the specific joint or joints involved is noncompensable under the codes a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under diagnostic code 5002. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. Note indicates that the ratings for the active process will not be combined with the residual ratings for limitation of motion or ankylosis. The evaluator is to assign the higher evaluation. The 2021 amended criteria provides that chronic residuals are rated under Diagnostic Code 5003, arthritis, other than post-traumatic. Degenerative arthritis established by X-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved (DC 5200 etc.). When however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under diagnostic code 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. In the absence of limitation of motion, a 10 percent rating warranted for X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups. A 20 percent rating warranted for X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups, with occasional incapacitating exacerbations. Note (1) indicates that the 20 percent and 10 percent ratings based on X-ray findings, above, will not be combined with ratings based on limitation of motion. Note (2) indicates that the 20 percent and 10 percent ratings based on X-ray findings, above, will not be utilized in rating conditions listed under diagnostic codes 5013 to 5024, inclusive. Under Diagnostic Code 5260, a noncompensable rating is assigned when flexion of the leg is limited to 60 degrees. A 10 percent rating is assigned for limitation of flexion of the leg to 45 degrees. A 20 percent rating is assigned for flexion limited to 30 degrees. A 30 percent rating is assigned for flexion limited to 15 degrees. Id. Under Diagnostic Code 5261, a noncompensable rating is assigned when extension of the leg is limited to 5 degrees. A 10 percent rating is assigned for limitation of extension of the leg to 10 degrees. A 20 percent rating is assigned for extension limited to 15 degrees. A 30 percent rating is assigned for extension limited to 20 degrees. A 40 percent rating is assigned for extension limited to 30 degrees. A 50 percent rating is assigned for extension limited to 45 degrees. Id. Normal knee range of motion is from 0 degrees of flexion to 140 degrees of extension. 38 C.F.R. § 4.71, Plate I. Where there is painful or limited motion with both flexion and extension, but the compensable criteria are not met for either flexion (Diagnostic Code 5260) or extension (Diagnostic Code 5261), only one minimum rating of 10 percent should be assigned. Separate ratings may not be assigned for painful or noncompensable limitation of motion using Diagnostic Code 5003 or 38 C.F.R. § 4.59 in connection with 5260, and compensable limitation of extension under DC 5261. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011). Throughout the appeal period, the Veteran's service-connected right knee disability has manifested by pain, painful motion, and limited motion at times, with increased pain after prolonged standing and walking. Evidence relevant to the current level of severity of the Veteran's right knee disabilities includes VA examinations dated in March 2008, February 2010, October 2016, and November 2020. Private records show reports of pain and inflammation. Similarly, where limitation of motion is not compensable under the diagnostic code for a joint, 38 C.F.R. § 4.59 provides for a minimum compensable rating for actually painful joints in conjunction with a diagnostic code based on limitation of motion, whether or not there is arthritis. Sowers v. McDonald, 27 Vet. App. 472, 479 (2016); Southall-Norman v. McDonald, 28 Vet. App. 346, 354 (2016). At a March 2008 VA examination, the Veteran reported episodic knee pain with no swelling or inflammation. The pain varied. On some days he could walk a mile and on others he would stop after 100 yards. A musculoskeletal evaluation was normal. The right knee had a full range of motion. The knee was stable and there was no tenderness or swelling. Although the examiner stated the musculoskeletal evaluation was normal, the examination report also indicated that knee pain was frequent but intermittent. However, the intermittent arthritis pains impaired mobility. At a February 2010 VA examination, the examiner indicated instability due to pain but no locking. The Veteran had flare-ups. He could not exercise largely because of knee pain. Range of motion testing showed full extension. Repetitive use testing reduced motion with flexion to 90 degrees on active motion and flexion to 95 degrees with passive motion. The Veteran had tenderness on patella pressure. There was right knee swelling, but no effusion. At the June 2013 hearing, the Veteran reported incapacitating flare-ups to the point of needing crutches. He stated that he experienced pain and inflammation with visible swelling two to three times a year. At an October 2016 VA knee examination, the Veteran reported flare-ups and constant pain that could vary in severity. The examiner indicated there was no current diagnosis and no records were reviewed. Range of motion testing was not reported because the measurements were normal. Repetitive use testing did not result in additional limitation. There was pain on movement. Joint stability and strength testing were normal. At an October 2016 VA arthritis examination, the Veteran occasionally used a wheelchair and regularly used crutches to walk. At a November 2020 VA examination, the Veteran reported pain, stiffness, discomfort, and swelling. He had flare-ups that caused increased pain. The Veteran indicated functional loss with difficulty walking. He can walk about 20 yards at a time before having to take a rest and can repeat the 20 yards a couple of times. Range of motion testing showed flexion to 90 degrees and extension to 0 degrees. The abnormal range of motion did not contribute to functional loss. There was pain and tenderness on examination. There was evidence of pain with weight-bearing and nonweight-bearing. Passive range of motion was the same as active range of motion. Repetitive use testing showed motion with flexion to 70 degrees and extension to 5 degrees. The pain on examination caused functional loss. Pain, weakness, fatigability, or incoordination significantly limited functional ability with repeated use over a period of time. Although the examination was not conducted during a flare-up, the examiner described the range of motion as the same demonstrated on repetitive use testing, with pain contributing to functional loss. Joint stability and strength testing were normal. There were no meniscal conditions. 5. Entitlement to an initial rating higher than 10 percent for right knee synovitis 6. Entitlement to an initial compensable rating for right knee synovitis with limitation of extension as of November 18, 2020 Upon review, the Board finds that a 10 percent rating, but not higher, is warranted for the entire appeal period for right knee synovitis with limited flexion. A compensable initial rating for limited extension is not warranted at any point during the appeal period. While the Veteran was assigned stage ratings for limited flexion, the evidence indicates that the Veteran experienced painful motion throughout the appeal. Specifically, the March 2008 examination showed knee pain and limited walking. In addition, the examiner stated that intermittent arthritis pains impaired mobility. At the February 2010 VA examination, the Veteran reported that he could not exercise due to knee pain. Further, the Veteran used a wheelchair and regularly used crutches to walk. However, the Veteran has maintained flexion at worst, to 70 degrees, and full extension. For the right knee arthritis, the Veteran does not meet the compensable criteria under either Diagnostic Code 5260 or Diagnostic Code 5261, as he retained flexion to more than 45 degrees and extension to more than 10 degrees even during periods of increased pain or other contributing factors. Instead, he had full extension, except for repetitive use testing in November 2020, and his right knee flexion ranged from 70 degrees to full flexion. Accordingly, a minimum 10 percent rating for painful or limited motion under Diagnostic Code 5003 or 38 U.S.C. § 4.59 in combination with Diagnostic Code 5260 is appropriate, because he primarily complained of difficulty with knee flexion. A higher rating is not warranted. With regard to Diagnostic Code 5261, extension has been full, to zero degrees, at all times during the appeal period. The Board notes that a January 2021 rating decision granted a separate rating on the basis of reduced extension to 5 degrees during repetitive use testing and during flare-ups. As there is no indication of extension limited to 10 degrees or more, a compensable rating is not warranted. Therefore, there is no basis to warrant a compensable disability rating for the right knee under Diagnostic Code 5261. With regard to flare-ups of the knees pursuant to Sharp, the Board notes that the November 2020 VA examiner estimated additional loss during flare-ups or after repeated use to be flexion to 70 degrees and extension to 5 degrees. However, there is no indication that any flare-ups or repeated use for the right knee disability results in any additional loss of motion. Thus, the evidence does not support a disability rating higher than 10 percent for the Veteran's right knee synovitis at any point during the appeal period. As for the potential for a separate disability rating pursuant to Diagnostic Code 5257, there is no objective evidence of lateral instability or recurrent subluxation. Although the record shows complaints of instability and swelling, tests for instability were negative at the October 2016 and November 2020 VA examinations. The Board notes that the Veteran's representative also contends a separate rating for knee instability should be granted. The February 2010 VA examination indicated instability due to pain but no locking. The November 2020 VA examination showed that pain caused functional loss. Moreover, that examination also indicated that pain, weakness, fatigability, or incoordination significantly limited functional ability with repeated use over a period of time and during flare-ups. These notations reflect that there was no actual instability and, instead, the Veteran's complaints of weakness were due to pain, which is already contemplated by the assigned rating. As he has complained of constant pain and the February 2010 examination noted that instability was due to pain, the Board finds that a separate rating on the basis of instability for pain violates the prohibitions against pyramiding (that is, duplicate compensation for the same symptom), as pain would be the basis for the compensable rating under Diagnostic Code 5260 and Diagnostic Code 5257. 38 C.F.R. § 4.14. Therefore, the Board finds that the Veteran is not entitled to a separate compensable rating for instability of the right knee. As for the potential for a separate disability rating pursuant to Diagnostic Code 5258, there is no objective evidence of a meniscal condition. While the February 2010 VA examination indicated swelling, there was no locking or effusion. The Board notes that the Veteran has reported swelling throughout the appeal period with episodes of visible swelling two to three times a year. However, the October 2016 and November 2020 VA examinations showed no evidence that the Veteran had or had ever had a meniscal condition. The Board finds the preponderance of the evidence is against the fact that the Veteran had a meniscal condition. Although the Veteran is competent to describe his observable sensations, he is not competent to state whether there is actual subluxation or lateral instability, or the underlying etiology of these complaints or his meniscal impairment. These matters require medical training or expertise to interpret the Veteran's history and tests due to the complex nature of the interaction between bones in the knee, as well as the multiple potential causes of symptoms. Therefore, the medical evidence is the most probative, and a separate rating is not appropriate on these bases under Diagnostic Code 5257 (recurrent subluxation or instability) or under Diagnostic Code 5258 or 5259 (addressing semilunar or meniscal conditions). Finally, there no argument or indication of ankylosis or genu recurvatum of the Veteran's right knee, or tibia or fibula impairment of the right leg, to warrant a separate or higher rating under Diagnostic Codes 5256, 5262, or 5263. There is also no argument or suggestion of meniscal removal or impairment (Diagnostic Codes 5258 or 5259) for the right knee disability. The Board notes that the October 2016 VA examiner did not review the record, and found there was no knee disability. As such, the Boards this report of limited probative value. The Board acknowledges the Veteran's consistent reports of constant pain, stiffness, discomfort, swelling, and flare-ups. Recent records show that the Veteran now uses crutches and mobility scooter due to a combination of the knee back disabilities. The record shows he has flexion to at least 70 degrees in the right knee and full extension. These range of motion findings consider additional functional loss and clinical findings from the VA examination reports and do not suggest that range of motion would change to the degree required for a higher rating with repeated use over time, due to pain, with weight bearing, or during flare-ups. Given that his complaints do not prevent him from achieving substantial measured range of motion, they do not support a finding of additional functional loss for higher ratings. The Veteran's complaints have been taken into consideration, but there is no evidence that his right knee synovitis with limitation of flexion and extension caused significant or additional functional loss beyond that contemplated by the assigned 10 percent evaluation. See 38 C.F.R. § 4.71, DCs 5260, 5261; 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca, Mitchell, Correia, and Sharp, all supra. In summary, the Veteran's service-connected right knee disabilities remained relatively stable throughout the appeal period. Any increases in severity were not sufficient to meet the criteria for any higher ratings for limited flexion and extension for right knee synovitis. Therefore, the preponderance of the evidence is against higher ratings, and there is no reasonable doubt to be resolved in his favor. The appeals for any higher or separate ratings are denied. Reiter's Syndrome with low back, right shoulder, and right hand pain The Veteran seeks a higher disability rating for Reiter's syndrome with low back pain. The disability is rated 20 percent disabling throughout the appeal period under Diagnostic Code 5009-5237. As discussed below, the disability will incorporate noncompensable ratings for a right shoulder and right hand disability. A September 2004 rating decision granted service connection for Reiter's Syndrome with recurrent right knee synovitis, low back pain, urethritis, and iritis, assigning a 20 percent rating with an effective date of May 1, 2004. A July 2008 rating decision continued the 20 percent rating. In February 2017, a rating decision decreased the rating for Reiter's syndrome with recurrent right knee synovitis and low back pain to a noncompensable rating, effective July 29, 2015. The same rating decision granted a 100 percent rating for chronic fatigue syndrome. In March 2018, the RO corrected the ratings assigned in February 2017. The 20 percent rating for Reiter's syndrome with low back pain was restored. The Board notes that the regulations pertaining to rating arthritis have been amended, effective February 7, 2021. See 85 Fed. Reg. 76453, 76464 (Nov. 30, 2020) (to be codified at 38 C.F.R. § 4.71a, DCs 5002, 5009). These amendments provide that the diagnostic criteria for chronic residuals be rated under Diagnostic Code 5003. The Board notes that these amendments are not applicable any earlier than their effective date. Under the General Rating Formula for Diseases and Injuries of the Spine, a 20 percent rating is assigned for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent rating requires evidence of forward flexion of the thoracolumbar spine to 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating will be assigned with evidence of unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent rating requires evidence of unfavorable ankylosis of the entire spine. For VA compensation purposes, normal forward flexion of the thoracolumbar spine is 0 to 90 degrees, extension is 0 to 30 degrees, left and right lateral flexion are 0 to 30 degrees, and left and right lateral rotation are 0 to 30 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal ranges of motion for each component of spinal motion provided in this note are the maximum that can be used for calculation of the combined range of motion. 38 C.F.R. § 4.71a, Plate V, General Rating Formula for Diseases and Injuries of the Spine, Note (2). The rater is to round each range of motion measurement to the nearest five degrees. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Note (4). In exceptional cases, an examiner may state that because of age, body habitus, neurologic disease, or other factors not the result of disease or injury of the spine, the range of motion of the spine in a particular individual should be considered normal for that individual, even though it does not conform to the normal range of motion. Provided that the examiner supplies an explanation, the examiner's assessment that the range of motion is normal for that individual will be accepted. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Note (3). For VA compensation purposes, unfavorable ankylosis is a condition in which the entire cervical spine, the entire thoracolumbar spine, or the entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching. Fixation of a spinal segment in neutral position (0 degrees) always represents favorable ankylosis. The rater is to round each range of motion measurement to the nearest five degrees. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Note (5). Reiter's syndrome is rated under Diagnostic Code 5009 for other types arthritis, the former criteria instructed that evaluation of the types of arthritis listed under Diagnostic Codes 5004 through 5009 are rated as rheumatoid arthritis. 38 C.F.R. § 4.71a, Diagnostic Code 5009. Under Diagnostic Code 5002 for rheumatoid arthritis, a 20 percent rating is warranted for one or two exacerbations a year in a well-established diagnosis. 38 C.F.R. § 4.71a, Diagnostic Code 5002. A 40 percent rating is warranted for symptom combinations productive of definite impairment of health objectively supported by examination findings or incapacitating exacerbations occurring 3 or more times a year. A 60 percent rating is warranted for less than criteria for 100 percent but with weight loss and anemia productive of severe impairment of health or severely incapacitating exacerbations occurring 4 or more times a year or a lesser number over prolonged periods. A 100 percent rating is warranted for constitutional manifestations associated with active joint involvement, totally incapacitating. Id. For chronic residuals, such as limitation of motion or ankylosis, favorable or unfavorable, the evaluator is to rate under the appropriate diagnostic codes for the specific joints involved. Where, however, the limitation of motion of the specific joint or joints involved is noncompensable under the codes a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under diagnostic code 5002. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. Note indicates that the ratings for the active process will not be combined with the residual ratings for limitation of motion or ankylosis. The evaluator is to assign the higher evaluation. The 2021 amended criteria provides that the acute phase is rated under Diagnostic Code 5002, and chronic residuals are rated under Diagnostic Code 5003, arthritis, other than post-traumatic. Degenerative arthritis established by X-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved (DC 5200 etc.). When however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under diagnostic code 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. In the absence of limitation of motion, a 10 percent rating warranted for X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups. A 20 percent rating warranted for X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups, with occasional incapacitating exacerbations. Note (1) indicates that the 20 percent and 10 percent ratings based on X-ray findings, above, will not be combined with ratings based on limitation of motion. Note (2) indicates that the 20 percent and 10 percent ratings based on X-ray findings, above, will not be utilized in rating conditions listed under diagnostic codes 5013 to 5024, inclusive. Evidence relevant to the level of severity of the Veteran's lumbar spine disability during the pendency of this appeal includes VA examination reports dated March 2008, February 2010, October 2016, March 2017, and November 2020. Throughout the appeal period, the Veteran's low back disability has manifested by varying degrees of back pain, tenderness, and painful or limited motion at times. In a March 2008 examination, the examiner indicated no back pain. A musculoskeletal evaluation was normal. The back and sacroiliac joints were normal. In a February 2010 VA examination, there was tenderness to deep palpation in the mid-lumbar spine. The Veteran had full range of motion with pain at the extremes of flexion and extension. The examiner did not indicate the degree at which pain began. At the June 2013 hearing, the Veteran reported that he had low back pain for three years. At an October 2016 VA arthritis examination, the Veteran had pain in both knees. There were four or more non-incapacitating exacerbations per year. He had limited walking ability and used crutches. The Board notes the examiner did not review any records. At a March 2017 VA examination, the Veteran reported pain at a 6 out of 10 in severity. He experienced flare-ups with pain and limited movement. The examiner diagnosed a lumbosacral strain and arthritis. Range of motion measurements were abnormal with forward flexion to 80 degrees, extension to 20 degrees, right lateral flexion to 30 degrees, left lateral flexion to 30 degrees, right lateral rotation to 30 degrees, and left lateral rotation to 30 degrees. Pain was noted on forward flexion and extension. There was pain with weight bearing and non-weight bearing. Passive and active range of motion were the same. There was objective evidence of pain on palpation. The Veteran could not perform repetitive use testing due to pain. His pain caused functional loss. Although pain limited function, there was no change in range of motion. He was unable to comfortably bend forward or backwards without pain. During flare-ups, pain affected function, but it did not decrease range of motion. Painful spasms resulted in abnormal gait or spine contour. Localized tenderness resulted in abnormal gait or spine contour with joint pain on extension and muscular pain on palpation. There was guarding due to pain. The examiner did not find additional factors contributed to the disability. Muscle strength testing indicated active movement against some resistance on the right side for hip flexion, knee extension, and great toe extension; and on the left side in hip flexion. Reflex testing showed hyperactive knee reflexes and hypoactive ankle reflexes. The Veteran was unable to perform the straight leg test. At a November 2020 VA arthritis examination, the Reiter's Syndrome manifested with painful joints with flare-ups. It did not require continuous use of medication. The Veteran did not lose weight or have anemia due to Reiter's Syndrome. There was pain and limitation of joint movement in the thoracolumbar spine, right shoulder, hand/fingers, knee and foot/toes, and left hand/fingers, knee, and foot/toes. The Veteran's urological disabilities were also attributable to Reiter's Syndrome. There were four or more non-incapacitating and incapacitating episodes in the past 12 months. The incapacitating episodes totaled 6 weeks or more. At a November 2020 VA spinal examination, the Veteran reported pain and stiffness. He experienced flare-ups that were worse at night. The back disability manifested with functional loss that included discomfort sitting for longer periods, taking breaks, and discomfort at night. Range of motion testing showed forward flexion to 70 degrees, extension to 25 degrees, right lateral flexion to 25 degrees, left lateral flexion to 25 degrees, right lateral rotation to 25 degrees, and left lateral rotation to 25 degrees. The abnormal range of motion contributed to functional loss because bending, washing, and dressing were slowed and uncomfortable. There was pain on examination with flexion and extension. There was evidence of pain with weight-bearing and nonweight-bearing. Passive range of motion was the same as active range of motion. Repetitive use testing showed additional loss with forward flexion to 50 degrees, extension to 20 degrees, right lateral flexion to 20 degrees, left lateral flexion to 20 degrees, right lateral rotation to 20 degrees, and left lateral rotation to 20 degrees. Pain contributed to the functional loss. Although the examination was not conducted during a flare-up, the examiner described the range of motion as the same demonstrated on repetitive use testing. There was no guarding, muscle spasm, or other factors contributing to the disability. Strength, reflex, and sensory testing was normal. The Veteran regularly used crutches and constantly used a mobility scooter due to the knee and back disabilities. 7. Entitlement to a rating higher than 20 percent for Reiter's Syndrome with low back, right shoulder, and right hand pain prior to November 18, 2020 Prior to November 18, 2020, the Board finds that a disability rating greater than 20 percent is not warranted for lumbar spine osteoarthritis because there is no medical evidence of limitation of forward flexion to 30 degrees or less, or evidence of favorable ankylosis of the entire thoracolumbar spine. During flare-ups, the Veteran experienced functional loss. The March 2017 VA examiner noted that pain affected function, but it did not decrease range of motion. However, the examiner was unable to describe the range of motion. The November 2020 VA examiner estimated additional loss of motion in the lumbar spine, and that the Veteran's range of motion was limited to forward flexion to 50 degrees, extension to 20 degrees, right lateral flexion to 20 degrees, left lateral flexion to 20 degrees, right lateral rotation to 20 degrees, and left lateral rotation to 20 degrees. Based on limitation of motion, a higher rating is not warranted. To warrant a rating higher than 20 percent, forward flexion to less than 30 degrees or ankylosis would have to be shown. Here, objective medical evidence by the VA examiners shows no ankylosis of the entire lumbosacral spine. There is no suggestion of favorable or unfavorable ankylosis of any portion of the spine at any point to warrant a 40, 50, or 100 percent rating. VA examiners consistently found no ankylosis, and there was range of motion despite pain. Thus, a higher rating than 20 percent is not warranted. In the alternative, Diagnostic Code 5002 addresses the chronic residuals of Reiter's syndrome as rheumatoid arthritis, a 40 percent rating is warranted for symptom combinations productive of definite impairment of health objectively supported by examination findings or incapacitating exacerbations occurring 3 or more times a year. While the Veteran's diagnosis for Reiter's syndrome is well-established, the evidence does not indicate consistent exacerbations. At the June 2013 hearing, the Veteran reported that he had not had low back pain for three years. Although the October 2016 examination showed four or more exacerbations per year, the episodes were non-incapacitating. Further, the examiner indicated that the Reiter's syndrome manifested by symptom combinations productive of definite impairment of health objectively supported by examination findings, but no explanation was provided. As the October 2016 VA examiner did not review the record, the Board finds this report of limited probative value. Accordingly, the Board finds that the preponderance of the evidence is against the assignment of a rating higher than 20 percent prior to November 18, 2020. 8. Entitlement to a 60 percent rating, but not higher, for Reiter's Syndrome with low back, right shoulder, and right hand pain as of November 18, 2020 As of November 18, 2020, the Board finds a 60 percent rating for Reiter's syndrome with low back pain is warranted. The record shows four or more incapacitating exacerbations per year. However, in this case, a 60 percent rating is warranted for less than criteria for 100 percent but with weight loss and anemia productive of severe impairment of health or severely incapacitating exacerbations occurring 4 or more times a year or a lesser number over prolonged periods. A 100 percent rating is warranted for constitutional manifestations associated with active joint involvement, totally incapacitating. As the November 2020 examiner found the Veteran's Reiter's syndrome was not manifested by constitutional manifestations associated with active joint involvement, totally incapacitating, a higher rating is not warranted. Therefore, a higher evaluation is not available. There are no other applicable codes available for consideration. Based on limitation of motion, a higher rating is not warranted. Forward flexion was shown at worst, to 50 degrees. Further, the objective medical evidence by the VA examiners shows no ankylosis of the lumbosacral spine. The VA examiners consistently found no ankylosis, and range of motion warranted a 20 percent rating at worst despite pain. Thus, a higher rating based on limited motion is not warranted. In denying higher disability ratings for the Veteran's Reiter's syndrome with low back, right shoulder, and right hand pain, the Board has considered the Veteran's statements that his low back pain is constant, as well as his report of flare-ups. While he is competent to provide evidence regarding matters that can be perceived by the senses, he is not shown to be competent to render medical opinions regarding whether his symptoms meet the next higher rating criteria under VA regulations. Such competent evidence concerning the nature and extent of the Veteran's Reiter's syndrome has been provided by the medical personnel who have examined him during the current appeal. The medical findings (as provided in the examination reports and clinical records) directly address the criteria under which this disability is evaluated. The specific clinical measures of ranges of motion, including examiners' findings and opinions regarding additional limitations of motion due to such factors, have been weighed and considered by the Board. Such specific measures and findings are of more probative value in determining specific ranges of motion than are general histories or general descriptions of symptoms of pain or limitations, such as this Veteran's report of pain and limitation of function. Thus, the overall evidence does not show that pain or other factors have resulted in additional functional limitation or limitation of motion such as to enable a finding that the disability picture more nearly approximates the next-higher disability ratings either prior to or beginning November 18, 2020. Despite the Veteran's contention of constant pain, the disability ratings assigned herein indicate a significant impact on his functional ability. Such disability evaluation assigned by VA recognizes his painful motion. The critical question in this case, however, is whether the problems he has cited meet an even higher level under the rating criteria. For reasons cited above, the Board finds they do not. Accordingly, the Board finds that the preponderance of the evidence is against the assignment of a rating higher than 60 percent for Reiter's syndrome with low back, right shoulder, and right hand pain as of November 18, 2020. Therefore, the claim for an increased rating must be denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C. § 5107; 38 C.F.R. § 3.102. Separate Ratings During the course of the appeal, several disabilities have been identified that are secondary to the service-connected Reiter's syndrome. The Board notes that three disabilities have not been addressed by the RO. 9. Entitlement to a separate rating for a right shoulder disability As for the potential for separate compensable ratings for loss of motion of the right shoulder, the Board notes that the medical evidence fails to show any compensable loss of motion of the right shoulder. The standard ranges of motion for shoulder abduction and forward elevation (flexion) are 180 degrees. 38 C.F.R. § 4.71, Plate I. Shoulder level is 90 degrees. Pursuant to Diagnostic Code 5201, a 20 percent evaluation is warranted for motion of each arm limited to shoulder level (90 degrees). The medical evidence shows the right shoulder disability manifested with pain, discomfort, and limited motion. In a February 2010 VA examination, the Veteran had intermittent pain in the right shoulder. The Veteran had full range of motion with no swelling or pain. The November 2020 VA examination showed ongoing discomfort and stiffness, with additional discomfort when reaching. However, flexion was limited to, at worst, 120 degrees. There is no indication that motion of the Veteran's right arm was limited to shoulder level to warrant a 20 percent disability rating during the rating period. As the Veteran does not meet the criteria for a compensable rating, a separate rating not warranted. The right shoulder disability will be considered with the Reiter's syndrome with low back pain. 10. Entitlement to separate ratings for a bilateral hand disability As for the potential for separate compensable ratings for a bilateral hand disability, the Board finds a separate 10 percent rating for the left hand is warranted. The right hand disability has manifested to a noncompensable degree, and thus a separate rating is not warranted. Flexion of the wrist and fingers, when rated as a muscle injury under 38 C.F.R. § 4.73, Diagnostic Code 5307 (muscle group VII), a noncompensable rating is assigned for a slight disability and 10 percent is assigned for a moderate disability. A moderately severe disability warrants a 30 percent rating for the dominant extremity and a 20 percent rating for the nondominant extremity. Finally, the maximum 40 percent is assigned for severe disability of the dominant extremity, and a 30 percent rating is assigned for severe disability of the nondominant extremity. 38 C.F.R. § 4.73, Diagnostic Code 5307. The evidence demonstrates that the Veteran's left hand is his dominant extremity. The record shows the Veteran experiences pain, difficulty with gripping items, and writes with his non-dominant hand. At the June 2013 hearing, he reported decreased grip strength and being unable take a lid off of a jar. In addition, his hands would swell to the point that he could not open a doorhandle. The problem was more severe with the left hand. At a November 2020 VA examination, the Veteran reported background discomfort in both hands. The examiner attributed the diffuse hand tenderness to the service-connected Reiter's syndrome. The right fingers had normal range of motion with no pain noted on examination. However, there was pain with use of the hands. The left fingers also had normal range of motion with no pain noted on examination, but there was mild diffuse hand tenderness. The Veteran could perform repetitive use testing without additional loss. Repeated use over time caused mild pain in the right hand and moderate pain in the left hand. Although the movements remained the same, the pain meant the Veteran had to rest and could not lift heavier things. The pain was across the hand. There were no flare-ups reported. As the right hand disability does not meet the criteria for a compensable rating, a separate rating is not warranted. The right hand pain will be considered with the Reiter's syndrome with low back pain. Accordingly, a separate 10 percent rating, but not higher, is warranted for the left hand disability. Chronic testalgia, epididymitis, and urethritis The Veteran contends higher ratings are warranted due to pain, tenderness, and flare-ups. In January 2012, the RO granted a separate rating for chronic testalgia, urethritis, epididymitis, assigning a noncompensable rating with an effective date of May 6, 2007. A January 2019 rating decision granted an initial compensable rating, assigning a 10 percent rating prior to October 24, 2018, and a 20 percent rating from October 24, 2018. A January 2021 rating decision granted an increased rating of 40 percent with an effective date of November 18, 2020. Prior to November 18, 2020, the Veteran's disability was rated under Diagnostic Codes 7525-7518, which directs the evaluator to rate pursuant to urinary tract infection and voiding dysfunction. It is currently rated under Diagnostic Code 7518 pertaining to voiding dysfunction. Under 38 C.F.R. § 4.115a, voiding dysfunction is rated with regard to urine leakage, frequency, or obstructive voiding. Continual urine leakage, post-surgical urinary diversion, urinary incontinence, or stress incontinence requiring the wearing of absorbent materials which must be changed less than two times per day warrants a 20 percent rating. The need to wear absorbent materials which must be changed two to four times per day warrants a 40 percent rating. The use of an appliance or wearing of absorbent materials which must be changed more than four times per day warrants a 60 percent rating. Urinary frequency with a daytime voiding interval between two and three hours or awakening to void two times per night warrants a 10 percent rating. A daytime voiding interval between one and two hours or awakening to void three to four times per night warrants a 20 percent rating. A daytime voiding interval of less than one hour or awakening to void five or more times per night warrants a 40 percent rating. Obstructive voiding symptomatology with marked obstructive symptomatology with any one or combination of: post void residuals greater than 150 cc, a markedly diminished peak flow rate of less than 10 cc/sec, recurrent urinary tract infections secondary to obstruction, or stricture disease requiring periodic dilatation every two to three months, warrants a 10 percent rating. Urinary retention requiring intermittent or continuous catheterization warrants a 30 percent rating. Diagnostic Code 7525 provides that chronic epididymo-orchitis shall be rated under the criteria for urinary tract infection, or, for tubercular infections, it should be rated according to 38 C.F.R. § 4.88b (infectious diseases, immune disorders, and nutritional deficiencies) or 38 C.F.R. § 4.89 (ratings for inactive non-pulmonary tuberculosis in effect on August 19, 1968), whichever is appropriate. See 38 C.F.R. § 4.115b, Diagnostic Code 7525. The rating criteria for urinary tract infection provides that a 10 percent rating is warranted if the condition requires long-term drug therapy, 1-2 hospitalizations per year, and/or intermittent intensive management. A 30 percent rating is warranted if the condition is manifested by recurrent symptomatic infection requiring drainage and/or frequent hospitalization (greater than two times/year), and/or requiring continuous intensive management. Higher ratings may also be assigned for poor renal function under the criteria for renal dysfunction. 38 C.F.R. § 4.115a. In an April 2009 private evaluation, the Veteran reported testicular pain that was excruciating at times, and worsened by strenuous activity. In a February 2010 VA examination, the examiner described the Veteran's disability as extreme generalized scrotal tenderness that was equal on both sides. At the June 2013 hearing, the Veteran reported flare-ups in the last a couple of months. He wore supportive undergarments and had to restrict his activities due to pain, including swimming, biking, and running. In March 2017, the Veteran underwent kidney conditions, urinary tract, and male reproductive examinations. The Veteran had pain in the left testicular area and the left epididymis was tender to palpation. The Veteran had a voiding dysfunction due to the urethritis. It caused urine leakage but did not require the wearing of absorbent material. The Veteran had nighttime awakenings to void two times per night. There was no evidence of obstructed voiding. In an addendum dated October 24, 2018, the examiner indicated 7 nighttime awakenings to void. At a November 2020 VA urinary tract examination, the examiner diagnosed urethritis. The Veteran reported penile discharge and burning, and increased urinary frequency. The Veteran had a voiding dysfunction with increased in urinary frequency with daytime voiding between 1 and 2 hours and nighttime awakening to void 5 to more times. At a November 2020 VA male reproductive examination, the examiner diagnosed bilateral chronic epididymitis with testalgia and erectile dysfunction. The Veteran had a voiding dysfunction secondary to urethritis, which did not cause urine leakage or require the use of an appliance. There was an increase in urinary frequency with daytime voiding between 1 and 2 hours and nighttime awakening to void 5 to more times. There were no signs or symptoms of obstructed voiding. The physical examination showed a normal penis and severe diffuse bilateral testicular tenderness. The epididymis was tender to palpation bilaterally. The Veteran's representative contended that a change in diagnostic code was needed to address urinary issues and pain. The Board notes that the Veteran had a hyphenated code to address multiple issues. As the Veteran is rated under Diagnostic Code 7518 pertaining to voiding dysfunction, the Board finds the Diagnostic Code assigned appropriate. 11. Entitlement to an initial rating higher than 10 percent for chronic testalgia, epididymitis, and urethritis prior to October 24, 2018 Prior to October 24, 2018, the Board finds a rating higher than 10 percent is not warranted. The evidence showed pain and increased urinary frequency. However, the evidence did not demonstrate a daytime voiding interval between one and two hours or awakening to void three to four times per night. In addition, the Veteran did not experience urinary tract infections. As such, the Board finds a higher rating is not warranted. Accordingly, the preponderance of the evidence is against the claim for rating higher than 10 percent prior to October 24, 2018. Therefore, the claim for a higher rating must be denied. 38 U.S.C. § 5107 (b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 12. Entitlement to an initial rating higher than 40 percent for chronic testalgia, epididymitis, and urethritis as of October 24, 2018 As of October 24, 2018, the Board finds a 40 percent rating, but not higher, is warranted. The evidence of record shows increased urinary frequency of at least five awakenings to void at night. The Board notes that the Veteran is currently receiving the maximum rating available under the assigned rating criteria for urinary frequency. Under voiding dysfunction, a 60 percent rating is available based on urine leakage. While the record indicates some urinary leakage, the leakage did not require any wearing of absorbent materials. Furthermore, there is no evidence that he required the use of an appliance. As such, the Board finds a higher rating is not warranted. Accordingly, the preponderance of the evidence is against the assignment of a rating higher than 40 percent as of October 24, 2018, for chronic testalgia, epididymitis, and urethritis. As the preponderance of the evidence is against the granting of any higher rating, and the claim for a higher rating must be denied. 38 U.S.C. § 5107 (b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 13. Entitlement to TDIU The Veteran is also seeking entitlement to a TDIU by reporting that he is unable to work due to his service-connected disabilities. Total disability will be considered to exist when there is present any impairment of mind or body which is sufficient to make it impossible for the average person to follow a substantially gainful occupation. 38 C.F.R. § 3.340. If the total rating is based on a disability or combination of disabilities for which the Schedule for Rating Disabilities provides a rating of less than 100 percent, it must be determined that the service-connected disabilities are sufficient to produce unemployability without regard to advancing age. 38 C.F.R. § 3.341. In evaluating total disability, full consideration must be given to unusual physical or mental effects in individual cases, to peculiar effects of occupational activities, to defects in physical or mental endowment preventing the usual amount of success in overcoming the handicap of disability and to the effects of combinations of disability. 38 C.F.R. § 4.15. If the schedular rating is less than total, a total disability rating can be assigned based on individual unemployability if the Veteran is unable to secure or follow a substantially gainful occupation as a result of service-connected disability, provided that the Veteran has one service-connected disability rated at 60 percent or higher; or two or more service-connected disabilities, with one disability rated at 40 percent or higher and a combined rating of 70 percent or higher. For the purpose of determining one 60 percent disability, disabilities resulting from a common etiology or a single accident are considered as one disability. 38 C.F.R. §§ 3.340, 3.34l, 4.16(a). The existence or degree of nonservice-connected disabilities will be disregarded if the above-stated percentage requirements are met and the evaluator determines that the Veteran's service-connected disabilities make him incapable of substantial gainful employment. 38 C.F.R. § 4.16(a). The Board notes that the matter of entitlement to TDIU is moot from July 16, 2015, as the Veteran is, effective as of that date, in receipt of a 100 percent schedular rating and special monthly compensation (SMC) at the housebound rate. However, as the 100 percent rating and grant of SMC were not effective prior to July 16, 2015, entitlement to TDIU remains on appeal for the initial period from May 6, 2007. Prior to July 16, 2015, the Veteran was service-connected for Reiter's syndrome, rated 20 percent. Several other service-connected disabilities are secondary to Reiter's syndrome, including Sjogren's syndrome, rated 20 percent; chronic testalgia, epididymitis, and urethritis, rated 10 percent; residuals of a left thumb gamekeeper's tear, rated 10 percent; right knee synovitis, rated 10 percent; left knee condition, rated 10 percent; left hand disability, rated 10 percent; iritis, keratitis, and uveitis, rated noncompensable; and keratoderma blennorrhagica, rated noncompensable. As of May 6, 2007, the combined rating for disabilities resulting from Reiter's syndrome is 60 percent. Thus, the Veteran met the percentage requirements for consideration of the assignment of TDIU. 38 C.F.R. § 4.16(a). The remaining inquiry is whether he is unable to secure or follow substantially gainful occupation due solely to service-connected disabilities. In determining whether a veteran is unemployable for VA purposes, consideration may be given to the veteran's level of education, special training, and previous work experience, but not to age or any impairment caused by nonservice-connected disabilities. 38 C.F.R. §§ 3.341, 4.16, 4.19. On a VA Form 21-8940 submitted in December 2015, the Veteran indicated that he last worked full-time in May 2007, when he was on active duty. He completed four years of college. The Veteran stated that he has been unable to take any employment due to his service-connected disabilities. He was living outside in a tent. A review of the record shows the Veteran has not worked since separation in May 2007. At a March 2008 VA examination, the Veteran had frequent but intermittent knee pain. However, the intermittent arthritis pains impaired mobility. In an April 2009 private evaluation, the Veteran reported that he was renovating his cottage but could only work 3-6 hours a day. He experienced testicular pain that was worsened by strenuous activity. At a February 2010 VA examination, the Veteran had flare-ups with his knee, and he could not exercise largely because of knee pain. A February 2010 VA examiner found the Veteran markedly incapacitated due to joint pain from Reiter's syndrome. At the June 2013 hearing, the Veteran stated that he had trouble concentrating for more than 30 minutes since 2010, and he was no longer able to work in science. His left thumb and hand disability caused reduced strength in grip, weakness, and pain. The knee disability had incapacitating flare-ups that required the use of crutches. He experienced low-grade inflammation and pain most of the time. Based on all the evidence of record of the Veteran's various service-connected disabilities related to Reiter's syndrome, and resolving all reasonable doubt in favor of the Veteran, the Board finds that the Veteran is precluded from securing or following gainful employment due to the combined effects of the service-connected disabilities. The evidence suggests that the service-connected Reiter's syndrome and associated disabilities restrict the Veteran to sedentary work and also severely limit the ability to work at a sedentary job due to difficulty focusing for any length of time. Taken as a whole, the evidence is at least in equipoise regarding whether the Veteran would be able to function in any occupational setting due to his service-connected disabilities, as demonstrated by the evidence. Therefore, the Board finds that a TDIU is warranted effective May 6, 2007, as this is the earliest date on which the evidence demonstrates that the Veteran met the requirements of 4.16(a), and was unable to secure or maintain substantially gainful employment. Accordingly, the Board resolves reasonable doubt in favor of the Veteran and finds that entitlement to TDIU is granted from May 6, 2007. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C. § 5107. 14. Entitlement to special monthly compensation (SMC) under 38 U.S.C. § 1114 (k) for loss of use of the legs The Veteran, through his representative, contends that the Veteran has loss of use of both lower extremities because the October 2016 VA examiner indicated the Veteran had difficulty walking and required the use of crutches. Special monthly compensation under 38 U.S.C. § 1114 (k) is payable for one of a number of conditions, including each anatomical loss or loss of use of one hand, one foot, both buttocks, one or more creative organs. 38 C.F.R. § 3.350 (a). The term "loss of use of a hand or foot" is defined as existing when "no effective function remains other than that which would be equally well served by an amputation stump at the site of election below the elbow or knee with the use of a suitable prosthetic appliance." For example: (a) Extremely unfavorable complete ankylosis of the knee, or complete ankylosis of two major joints of an extremity, or shortening of the lower extremity of 3 1/2 inches or more, will constitute loss of use of the hand or foot involved, and; (b) Complete paralysis of the external popliteal nerve (common peroneal) and consequent footdrop, accompanied by characteristic organic changes including trophic and circulatory disturbances and other concomitants confirmatory of complete paralysis of this nerve, will be taken as loss of use of the foot. 38 C.F.R. § 3.350 (a)(2). At an October 2016 VA knee examination, the Veteran reported flare-ups and constant pain. The Veteran constantly used crutches. The examiner noted the functional impact of the bilateral knee disabilities was limited walking. At a November 2020 VA knee and lower leg examination, the Veteran's bilateral knee disabilities resulted in flare-ups and functional loss. The Veteran reported pain and stiffness. The examiner did not indicate no effective function remaining other than that which would be equally well served by an amputation with prosthesis. In addition, joint stability and strength testing were normal. The functional impact resulted in walking restricted to short distances with frequent breaks and the use of a mobility scooter or crutches. While the Veteran is competent to report symptomatology, including that he has pain and weakness in his legs and that he has difficulty walking, the determination of whether "loss of use" exists is a legal determination. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Here, the Veteran's lay reports are outweighed by the medical evidence of record, which fails to demonstrate that he is unable to ambulate with his lower extremities. While the Veteran constantly uses assistive devices, the probative evidence shows that he has retained the ability to ambulate using assistive devices. Further, the evidence does not indicate that the Veteran's legs approximate that no effective function remains other than that which would be equally well served by an amputation stump at the site of election below the knee with the use of a suitable prosthetic appliance during this period. Thus, loss of use is not demonstrated, and the claim is denied. Bethany L. Buck Veterans Law Judge Board of Veterans' Appeals Attorney for the Board C. Kass, 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.