Citation Nr: 21028949 Decision Date: 05/12/21 Archive Date: 05/12/21 DOCKET NO. 15-33 874 DATE: May 12, 2021 ORDER Entitlement to a higher rating, increased from 0 percent to 10 percent, but no higher, for left knee tendonitis/tendinosis prior to September 21, 2020, is granted. Entitlement to a higher rating, increased from 0 percent to 10 percent, but no higher, for right knee tendonitis/tendinosis prior to September 21, 2020, is granted. Entitlement to a rating in excess of 10 percent for left knee tendonitis/tendinosis on and after September 21, 2020, is denied. Entitlement to a rating in excess of 10 percent for right knee tendonitis/tendinosis on and after September 21, 2020, is denied. Entitlement to an initial rating in excess of 20 percent for left knee instability is denied. Entitlement to an initial rating in excess of 20 percent for right knee instability is denied. Entitlement to an initial rating of 10 percent under Diagnostic Code 7800 (reassigned from 7806) for pseudofolliculitis barbae is granted. Entitlement to service connection for a left shoulder disability is denied. Entitlement to service connection for a right shoulder disability is denied. Entitlement to a 10 percent evaluation for multiple noncompensable service-connected disabilities pursuant to 38 C.F.R. § 3.324 is denied. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is denied. FINDINGS OF FACT 1. The Veteran's left knee tendonitis/tendinosis has manifested in painful motion but not in limitation of flexion to 30 degrees or less or limitation of extension to 10 degrees or greater. 2. The Veteran's right knee tendonitis/tendinosis has manifested in painful motion but not in limitation of flexion to 30 degrees or less or limitation of extension to 10 degrees or greater. 3. The Veteran's left knee instability manifests in no more than moderate instability. 4. The Veteran's right knee instability manifests in no more than moderate instability. 5. The Veteran's pseudofolliculitis barbae does not involve at least five percent of his body or his exposed areas, and it does not require systemic therapy such as corticosteroids or other immunosuppressive drugs; the Veteran's skin condition is characterized by hyperpigmentation and covers an area that exceeds 39 square centimeters. 6. The Veteran did not exhibit a left shoulder disability in service; arthritis did not manifest to a compensable degree within one year after discharge from service; and a left shoulder disability is not otherwise shown to be associated with service. 7. The Veteran did not exhibit a right shoulder disability in service; arthritis did not manifest to a compensable degree within one year after discharge from service; and a right shoulder disability is not otherwise shown to be associated with service. 8. Effective the March 28, 2012, date of claim, the Veteran is receiving compensable ratings for several service-connected disabilities; during the one year period prior to the date of claim, it is not factually ascertainable that the Veteran's service-connected knee disabilities increased in severity such that it became factually ascertainable that these disabilities clearly interfered with normal employability. 9. The Veteran's service-connected disabilities have not been shown to prevent him from securing and following substantially gainful employment. CONCLUSIONS OF LAW 1. The criteria for entitlement to a higher rating, increased from 0 percent to 10 percent, but no higher, for left knee tendonitis/tendinosis prior to September 21, 2020, have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1-4.14, 4.25, 4.27, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5003, 5260, 5261. 2. The criteria for entitlement to a higher rating, increased from 0 percent to 10 percent, but no higher, for right knee tendonitis/tendinosis prior to September 21, 2020, have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1-4.14, 4.25, 4.27, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5003, 5260, 5261. 3. The criteria for entitlement to a rating in excess of 10 percent for left knee tendonitis/tendinosis on and after September 21, 2020, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1-4.14, 4.25, 4.27, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5003, 5260, 5261. 4. The criteria for entitlement to a rating in excess of 10 percent for right knee tendonitis/tendinosis on and after September 21, 2020, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1-4.14, 4.25, 4.27, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5003, 5260, 5261. 5. The criteria for entitlement to an initial rating in excess of 20 percent for left knee instability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1-4.14, 4.25, 4.27, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5257. 6. The criteria for entitlement to an initial rating in excess of 20 percent for right knee instability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1-4.14, 4.25, 4.27, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5257. 7. The criteria for entitlement to an initial rating of 10 percent for pseudofolliculitis barbae have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.27, 4.118, Diagnostic Code 7800. 8. The criteria for entitlement to service connection for a left shoulder disability have not been met. 38 U.S.C. §§ 1110, 1112, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309(a). 9. The criteria for entitlement to service connection for a right shoulder disability have not been met. 38 U.S.C. §§ 1110, 1112, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309(a). 10. The criteria for a 10 percent evaluation based on multiple, noncompensable service-connected disabilities have not been met. 38 C.F.R. §§ 3.324, 3.400. 11. The criteria for entitlement to a TDIU have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.340, 3.341, 4.15, 4.16, 4.18, 4.25, 4.26. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from February 1989 to February 1993. This matter comes before the Board on appeal from October 2013 and April 2015 Regional Office (RO) rating decisions. In May 2019, the Veteran testified at a hearing before the undersigned Veterans Law Judge. Increased Ratings Disability ratings are determined by comparing a veteran's symptoms with criteria listed in VA's Schedule for Rating Disabilities, which is based, as far as practically can be determined, on average impairment in earning capacity. 38 U.S.C. § 1155; 38 C.F.R. § Part 4. When there is a question as to which of two ratings to apply, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating; otherwise the lower rating shall be assigned. 38 C.F.R. § 4.7. "Staged ratings," or different percentage evaluations for separate periods based on the facts found, may also be awarded. Fenderson v. West, 12 Vet. App. 119, 126-7 (1999); Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007). 1. Entitlement to a higher rating, increased from 0 percent to 10 percent, but no higher, for left knee tendonitis/tendinosis prior to September 21, 2020, is granted. 2. Entitlement to a higher rating, increased from 0 percent to 10 percent, but no higher, for right knee tendonitis/tendinosis prior to September 21, 2020, is granted. 3. Entitlement to a rating in excess of 10 percent for left knee tendonitis/tendinosis on and after September 21, 2020, is denied. 4. Entitlement to a rating in excess of 10 percent for right knee tendonitis/tendinosis on and after September 21, 2020, is denied. 5. Entitlement to an initial rating in excess of 20 percent for left knee instability is denied. 6. Entitlement to an initial rating in excess of 20 percent for right knee instability is denied. Evaluation of a service-connected disability involving a joint rated on limitation of motion requires adequate consideration of functional loss due to pain under 38 C.F.R. § 4.40 and functional loss due to weakness, fatigability, incoordination, or pain on movement of a joint under 38 C.F.R. § 4.45. See generally DeLuca v. Brown, 8 Vet. App. 202 (1995). Pain must affect some aspect of "the normal working movements of the body" such as "excursion, strength, speed, coordination, and endurance," in order to constitute functional loss. Mitchell v. Shinseki, 25 Vet. App. 32, 38-43 (2011) (quoting 38 C.F.R. § 4.40). Under Diagnostic Code 5003, when limitation of motion is noncompensable, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion. Even in the absence of limitation of motion, actually painful, unstable, or malaligned joints due to healed injury are entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59; Burton v. Shinseki, 25 Vet. App. 1 (2011). Joints are to be tested for pain on both active and passive motion, in weight-bearing and nonweight-bearing, and, if applicable, with the range of the opposite, undamaged joint. Correia v. McDonald, 28 Vet. App. 158, 168 (2016). Effective September 21, 2020, the Veteran is in receipt of 10 percent ratings for left knee and right knee tendonitis/tendinosis based on limitation of motion. Prior to that date, he is in receipt of 0 percent ratings for these disabilities. These ratings are assigned pursuant to 38 C.F.R. § 4.71a, Diagnostic Code 5260, as limitation of flexion. When rating disabilities of the knee, separate ratings may be assigned for limited knee motion in flexion (under Diagnostic Code 5260) and in extension (under Diagnostic Code 5261), as well as for instability (under Diagnostic Code 5257). VA Gen. Counsel. Prec. 23-97 (July 1, 1997). A separate compensable rating may also be assigned for meniscal pathology under Diagnostic Code 5258 or 5259. Lyles v. Shulkin, 29 Vet. App. 107 (2017). The evaluation of the same disability under various diagnoses, known as pyramiding, is generally to be avoided. 38 C.F.R. § 4.14. The critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the disabilities is duplicative or overlapping with the symptomatology of the other disability. See Esteban v. Brown, 6 Vet. App. 259, 261- 62 (1994). Under Diagnostic Code 5257, a rating of 10 percent is warranted when there is slight recurrent subluxation or lateral instability; a 20 percent rating is warranted when there is moderate recurrent subluxation or lateral instability; and a 30 percent rating is warranted when there is severe recurrent subluxation or lateral instability. Words such as "slight," "moderate," and "severe" are not defined in the Rating Schedule. Rather than applying a mechanical formula, VA must evaluate all evidence, to the end that decisions will be equitable and just. 38 C.F.R. § 4.6. Under Diagnostic Code 5258, a 20 percent rating is warranted for dislocated semilunar cartilage with frequent episodes of locking, pain, and effusion into the joint. Under Diagnostic Code 5259, a 10 percent rating is warranted for removal of semilunar cartilage, symptomatic. Under Diagnostic Code 5260, a 0 percent (noncompensable) rating is assigned for leg flexion limited to 60 degrees. A 10 percent rating is assigned for leg flexion limited to 45 degrees. A 20 percent rating is assigned for leg flexion limited to 30 degrees. A maximum 30 percent rating is assigned for leg flexion limited to 15 degrees. Diagnostic Code 5261 provides a 0 percent rating for leg extension limited to 5 degrees. A 10 percent rating is warranted where extension is limited to 10 degrees. A 20 percent rating is warranted where extension is limited to 15 degrees. A 30 percent rating is warranted where extension limited to 20 degrees. A 40 percent rating is warranted where extension is limited to 30 degrees. A 50 percent rating is warranted where extension is limited to 45 degrees. Turning to the evidence of record, the Veteran testified at his Board hearing that he is unable to squat or bend normally. (See Board hearing transcript, pages 6-7.) He also noted that it is painful to use the clutch and gear shift while working as a truck driver. (See Board hearing transcript, pages 8-9.) He also reported that he has to move his legs around while driving because he experiences stiffness. (See Board hearing transcript, page 9.) He reported that "There's really no full range of activity that I can do. Every once in a while I can bend down and grab something, but on a regular basis? No." (See Board hearing transcript, page 10.) The Veteran underwent VA examinations in connection with these claims in October 2012 and September 2020. The October 2012 VA examination report notes, in relevant part, that the Veteran feels knee discomfort in the morning and when climbing into and out of his truck. He reported pain and stiffness but denied deformity, giving way, instability, weakness, incoordination, decreased speed of joint motion, episodes of dislocation or subluxation, locking episodes, effusion, or other symptoms. There were no signs of inflammation, the condition did not affect the motion of the joint, and there were no flare-ups. There were no constitutional symptoms or incapacitating episodes of arthritis. There were no limitations of standing or walking. The Veteran did not use assistive devices. On examination, there were clicks or snaps. However, there were no bumps consistent with Osgood-Schlatter's disease, crepitation, mass behind the knee, grinding, instability, patellar abnormality, meniscus abnormality, abnormal tendons or bursae, or other knee abnormalities. The October 2012 VA examination report notes that initial range of motion of the left knee was normal, with full flexion (0 to 140 degrees) and full extension (to 0 degrees) without objective evidence of pain with active motion. Initial range of motion of the right knee was flexion from 0 to 136 degrees and with full extension (to 0 degrees) without objective evidence of pain with active motion. There was no additional limitation of range of motion or objective evidence of pain on repetitive motion. The examiner diagnosed transient bilateral knee inflammation with normal exam and x-rays. The knee disabilities had a mild effect on chores, exercise, sports, and recreation. They had no effect on shopping, travelling, feeding, bathing, dressing, toileting, grooming, or driving. In terms of occupation, it was noted that the Veteran is a truck driver and his knees can hurt getting into and out of the truck cab, but his knees do not keep him from performing his work. The September 2020 VA examination report notes left and right knee tendonitis and tendinosis, left and right knee pain syndrome, left and right knee meniscal tear, and left and right knee instability. The Veteran reported daily flare-ups of mild to moderate severity that are precipitated by running or jogging. The duration and alleviating factors were unknown. He reported functional limitation in that he has interference with squatting, bending, crawling, climbing, kneeling, running, jumping, and prolonged positioning. The September 2020 VA examination report notes right knee initial range of motion of flexion to 100 degrees and extension to 0 degrees. The range of motion contributed to less range of motion, less flexibility, and increased pain. There was pain on flexion and extension and with weight-bearing and pain in the entire knee. Left knee initial range of motion was flexion to 95 degrees and extension to 0 degrees. The range of motion contributed to less range of motion, less flexibility, and increased pain. There was pain on flexion and extension and with weight-bearing and pain was located in the patella. There was no additional loss of function or range of motion on repetitive use testing in either knee. The examiner estimated that there would be no additional loss of range of motion on flare-up. The examiner noted that less movement than normal due to ankylosis, adhesions, etc.; weakened movement due to muscle injury or peripheral nerves injury, etc.; instability of station; disturbance of locomotion; interference with sitting; and interference with standing contributed to disability in both the left and the right knees. It was noted that these factors occur daily and increase with increased activities. There was no ankylosis of either knee. There was no history of recurrent subluxation in either knee, but there was moderate lateral instability in both knees. It specifically notes anterior, posterior, medial, and lateral instability of 2+ (5 to 10 millimeters) in both knees. It does not check the box indicating 3+ (10 to 15 millimeters) instability in either knee. The Veteran did not have any tibial or fibular impairment. It was noted that the Veteran currently has bilateral meniscus tears. They were manifested by frequent episodes of joint pain. They were not manifested by frequent episodes of joint locking or effusion or other symptoms. It was noted that these symptoms occur daily and increase with increased activities. There were no other pertinent physical finding, complications, conditions, signs, or symptoms related to either knee. The Veteran regularly uses a cane for support. Review of the Veteran's VA and private medical records reveals no additional evidence of instability, limitation of range of motion, or meniscal conditions that were reported in the examination reports. The Board finds that increased ratings from 0 percent (noncompensable) to 10 percent rating, but no higher, are warranted for each knee during the period prior to September 21, 2020, based on painful motion of both knees as well as for limitation of motion of the right knee. Sowers v. McDonald, 27 Vet. App. 472 (2016). The Board notes that the October 2012 VA examination report reflects that the Veteran reported painful motion at the October 2012 VA examination, and the right knee range of motion was flexion to 136 degrees, which is less than full flexion to 140 degrees. The Board acknowledges that the left knee was not painful on examination. However, as the Board finds that the Veteran's statements concerning left knee pain on movement to be credible, the Board will resolve reasonable doubt in the Veteran's favor and will grant a minimal compensable rating. Diagnostic Code 5260 provides a minimal compensable rating of 10 percent for limitation of flexion of the knee. Thus, separate 10 percent ratings are warranted for painful motion of the left knee and the right knee prior to September 21, 2020. The Board finds, however, that ratings in excess of 10 percent are not warranted at any point during the appeals period. The above evidence reflects that the Veteran has not had limitation of flexion to 30 degrees or less for either knee at any point during the appeals period to warrant a rating of 20 percent under Diagnostic Code 5260. Nor has he had limitation of extension to 10 degrees or more to warrant a separate rating under Diagnostic Code 5261. These determinations include consideration of additional limitation from flare-ups or functional impairment due to pain, weakness, fatigability, incoordination, or pain on movement. The Board notes that, in general, the effective date of an evaluation and award of compensation based on a claim for increase will be the date of receipt of the claim or the date entitlement arose, whichever is the later. 38 U.S.C. § 5110 (a); 38 C.F.R. § 3.400. An exception applies, however, under circumstances where evidence demonstrates that a factually ascertainable increase in disability occurred within the one-year period preceding the date of receipt of a claim for increased compensation. In such an instance, the law provides that the effective date of the award "shall be the earliest date as of which it is ascertainable that an increase in disability had occurred, if application is received within one year from such date." 38 U.S.C. § 5110(b)(2); see also 38 C.F.R. § 3.400(o)(2); Harper v. Brown, 10 Vet. App. 125 (1997). In the case at hand, the Board finds that the 10 percent ratings are not warranted at any point during the one-year period prior to March 28, 2012, which is the date of VA's receipt of the Veteran's increased ratings claims for left knee and right knee tendonitis/tendinosis, as there is no pertinent evidence of record from the one-year period prior to VA's receipt of the claim. Therefore, it is not factually ascertainable that either knee increased in disability during that period. The Board notes that some of the rating criteria under 38 C.F.R. § 4.71a have recently changed, effective February 7, 2021. There has been no substantive change to the criteria of Diagnostic Codes 5260 or 5261. Thus, a higher rating is not warranted under the new rating criteria. The Board will next consider whether increased ratings are warranted based on left and right knee instability. With respect to the Veteran's instability, the Board finds that entitlement to a rating in excess of 20 percent is not warranted for either knee on and after September 21, 2020. While it is not dispositive, the September 2020 VA examination report notes an instability reading of 2+, indicating 5 to 10 millimeters, rather than 3+, indicating 10 to 15 millimeters. The fact that the Veteran's instability does not satisfy the criteria for the highest instability classification on testing indicates to the Board that the Veteran's left and right knee disabilities are not of the maximum instability that is contemplated by the rating criteria of Diagnostic Code 5257. The Board also finds that a separate compensable rating for instability is not warranted at any time during the period prior to September 21, 2020. Specifically, the Board notes that the October 2012 VA examination report expressly notes no instability, and the Veteran's medical treatment records prior to September 21, 2020, do not reflect the presence of instability during that period. As noted above, some of the rating criteria under 38 C.F.R. § 4.71a have recently changed, effective February 7, 2021. Specifically, a 30 percent rating is available for recurrent subluxation or instability when there is unrepaired or failed repair of complete ligament tear causing persistent instability and a medical provider prescribes both an assistive device (e.g., cane(s), crutch(es), walker) and bracing for ambulation. Alternatively, a 30 percent rating is available for patellar instability when there is a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for a brace and either a cane or a walker. In the case at hand, the Veteran has not had knee surgery. Therefore, entitlement to a 30 percent rating is not warranted at any point on or after February 7, 2021. Turning to the remaining diagnostic codes, in the absence of ankylosis, a rating in excess of 10 percent is not warranted for either knee under Diagnostic Code 5256. Under Diagnostic Code 5258, a 20 percent rating is warranted when there is cartilage, semilunar, dislocated, with frequent episodes of "locking," pain, and effusion into the joint. In the case at hand, the Veteran has been shown to have had meniscal tears in both knees. However, while he has been shown to have frequent episodes of pain, the September 2020 VA examination report expressly declined to find that he has frequent episodes of locking or effusion. None of the remaining evidence of record reflects the presence of frequent episodes of locking or effusion. Therefore, entitlement to separate, 20 percent ratings is not warranted as to do so would constitute impermissible pyramiding of benefits. 38 C.F.R. § 4.14. Because the Veteran has not had surgery on either meniscus, the criteria for separate 10 percent ratings under Diagnostic Code 5259, for cartilage, semilunar, removal of, symptomatic, are not met. In the absence of tibia and fibula impairment, entitlement to ratings in excess of 20 percent is not warranted under Diagnostic Code 5262. Finally, because Diagnostic Code 5263 does not provide a higher rating than 10 percent, and because the Veteran does not have genu recurvatum, entitlement to ratings under Diagnostic Code 5263 is not warranted. In short, the Board finds that entitlement to increased ratings of 10 percent, but no higher, is warranted for left and right knee tendonitis/tendinosis prior to September 21, 2020. The Board also finds that entitlement to ratings in excess of 10 percent are not warranted for left and right knee tendonitis/tendinosis on and after September 21, 2020. Finally, the Board finds that entitlement to ratings in excess of 20 percent are not warranted for left and right knee instability on and after September 21, 2020, and entitlement to separate, compensable ratings for instability is not warranted prior to September 21, 2020. To the extent that any benefit being sought with respect to the left and right knee claims has not been granted, the Board has considered the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claims, the claims are not in equipoise. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). Accordingly, the claims must be denied. 7. Entitlement to an initial compensable rating of 10 percent for pseudofolliculitis barbae is granted. The Veteran's pseudofolliculitis barbae has been characterized as "dermatophytosis" under 38 C.F.R. § 4.118, Diagnostic Code 7813. Pursuant to that diagnostic code, the Board may evaluate this disability as "[d]ermatitis or eczema" under Diagnostic Code 7806 or as disfigurement of the head under Diagnostic Code 7800. The criteria for skin disabilities have been revised, effective August 13, 2018. On and after that date, claims pending prior to August 13, 2018, will be considered under both old and new rating criteria, and the criteria that is more favorable to the Veteran will be applied. Prior to August 13, 2018, under Diagnostic Code 7806, a noncompensable rating is assigned for less than 5 percent of the entire body or less than 5 percent of exposed areas affected, and; no more than topical therapy required during the past 12 months. 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. 38 C.F.R. § 4.118, Diagnostic Code 7806. 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, Diagnostic Code 7806. For claims filed prior to August 13, 2018, the Court held that a systemic therapy is one 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. Id. 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). Significantly, with regard to the effective date of the new criteria, VA indicated in the Supplementary Information to the Final Rule that its "intent is that the 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." Additionally, effective August 13, 2018, a new General Rating Formula for the Skin applies to Diagnostic Codes 7806, 7809, 7813 to 7816, 7820 to 7822, and 7824. See 38 C.F.R. § 4.118. Under this formula, a noncompensable rating is assigned for no more than topical therapy required over the past 12-month period and at least one of the following: (1) characteristic lesions involving less than 5 percent of the entire body affected; or (2) characteristic lesions involving less than 5 percent of exposed areas affected. A 10 percent rating is assigned for at least one of the following: (1) characteristic lesions involving at least 5 percent, but less than 20 percent, of the entire body affected; or (2) at least 5 percent, but less than 20 percent, of exposed areas affected; or (3) intermittent 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 for a total duration of less than 6 weeks over the past 12- month period. A 30 percent rating is assigned for at least one of the following: (1) characteristic lesions involving more than 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected; or (2) 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: (1) characteristic lesions involving more than 40 percent of the entire body or more than 40 percent of exposed areas affected; or (2) constant or near-constant systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, 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 Diagnostic Codes 7806, 7809, 7813-7816, 7820-7822, and 7824. Turning to the evidence of record, the October 2012 VA examination report notes that the Veteran's pseudofolliculitis barbae affects less than 5 percent of exposed areas and less than 5 percent of his total body area. It was noted that he gets redness and bumps on his face if he close shaves his beard. The Veteran testified at his May 2019 Board hearing that his pseudofolliculitis barbae has interfered with employment in that he cannot wear a facial respirator, so he is unable to work at jobs on oil rigs or as a regular firefighter because he is unable to have a clean seal of the respirator on his face. He reported that he did some of these jobs a few times when he was working construction. The September 2020 VA examination report notes that the Veteran has not been treated with medication in the past 12 months for any skin condition. In addition, it notes that the Veteran has not had any treatments or procedures. (This criterion refers to treatment other than systemic or topical medications.) It was noted that the Veteran's pseudofolliculitis barbae affects less than 5 percent of exposed areas and less than 5 percent of his total body area. His pseudofolliculitis barbae was "hyperpigmented, raised, erythematous thin whispy [sic] hairs 30cm x 13 cm." Review of the Veteran's VA and private medical records reflects that he has not been treated for pseudofolliculitis barbae during any portion of the appeals period. Both of the VA examination reports reflect that the Veteran's pseudofolliculitis barbae involves less than 5 percent of the entire body or less than 5 percent of the exposed areas. This finding fits squarely within the criteria for a 0 percent rating. In addition, the September 2020 VA examination report notes that the Veteran does not use any treatment, to include topical or systemic theory. The October 2012 VA examination report does not indicate that the Veteran uses any medication for this condition. Therefore, entitlement to a compensable rating for pseudofolliculitis barbae under Diagnostic Code 7806 is not warranted. As the Veteran's skin condition, however, is characterized by hyperpigmentation and covers an area that exceeds 39 square centimeters, the Veteran is entitled to a 10 percent rating under Diagnostic Code 7800. As noted above, the Veteran has reported that he is unable to engage in certain occupations because of his pseudofolliculitis barbae. The Board notes, however, that the Veteran is currently employed as a truck driver, and therefore his pseudofolliculitis barbae is not aggravated by being unable to wear a respirator that makes a tight facial seal. In any event, the Board finds that a flare-up of the symptoms that have been described by the Veteran, redness and itching, are fully contemplated by the applicable rating criteria. Service Connection 8. Entitlement to service connection for a left shoulder disability is denied. 9. Entitlement to service connection for a right shoulder disability is denied. Service connection is warranted where the evidence of record establishes that an injury or disease resulting in disability was incurred in the line of duty in the active military service or, if pre-existing such service, was aggravated thereby. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). To establish a right to compensation for a present disability, a veteran must show (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship, or nexus, between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may also be granted for listed chronic diseases, such as arthritis, if such were shown as chronic in service; manifested to a compensable degree within a presumptive period (usually one year) after separation from service; or were noted in service with continuity of symptomatology since service. 38 U.S.C. §§ 1112, 1113; Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013); 38 C.F.R. §§ 3.303(b), 3.307, 3.309(a). The Veteran contends that he has current disabilities of the left and right shoulders that are related to the gear he had to wear and the duties he had to perform during service. (See Board hearing transcript, page 20.) The Veteran's service treatment records reflect that his upper extremities were clinically normal at the time of his December 1992 RAD, July 1993 quadrennial, and May 2001 Reserve enlistment examinations. He denied any history of, or current, painful or trick shoulder on his July 1993 quadrennial and May 2001 Reserve enlistment medical history reports. (No December 1992 RAD medical history report is of record.) His service treatment records otherwise reflect that he neither complained of nor sought treatment for symptoms that have been associated with a shoulder disability. The Veteran originally claimed entitlement to service connection for his shoulders in March 1993, one month following his separation from service. The April 1993 VA examination report notes that the Veteran "complains of a numb feeling in the upper extremity when he puts a shoulder bag on the shoulder. The numb feeling involving the upper extremities occurs on the opposite side; in other words, when he puts the shoulder bag on the right shoulder, his left shoulder is numb." Following examination, including musculoskeletal and neurological examination of the upper extremities, the examiner did not diagnose a disability of either shoulder. VA medical records reflect that the Veteran sought treatment for right shoulder pain in February 2001. At that time, he reported that he has had intermittent pain in his right shoulder but that the pain was now more constant. A few days later that month, he again sought treatment, with a notation being made that he has had "arthritis in multiple joints since being in the service [and] presents for e[v]aluation of hip and shoulder pain." It was noted that the "Pain continues to bother him intermit[e]ntly." Following examination, an assessment of bicipital tendonitis was given. A September 2005 VA medical record notes that the Veteran has had bilateral shoulder pain, left greater than right, since 1991. He reported that it feels like he has bursitis in his left shoulder. This record also notes multiple musculoskeletal complaints. Following physical examination, an impression of arthralgia was given, but it is unclear whether this assessment applies specifically to either shoulder. He reported at his October 2012 VA examination that his "right shoulder began to hurt in service with putting on pack and equipment. Over[]time this began to hurt him. Now his shoulder gets tired, after construction for years Vet's shoulder has become worse." Physical examination notes full range of motion but that there was objective evidence of pain with active motion on both sides. There was no objective evidence of pain or additional limitation of motion on repetitive motion. An October 2012 radiology report notes that a right shoulder x-ray was normal. There is no indication that left shoulder diagnostic testing was performed. The VA examiner included a copy of a September 2012 emergency department record noting that the Veteran has complained of pain in his left shoulder and inter scapular area for several years, and there had been no injury. It was noted that he works as a truck driver. He does not do loading or unloading and the majority of time he keeps his left arm on the window. Following physical examination, the report notes "musculoskeletal pain of scapular area." No diagnosis is listed for either shoulder. The October 2012 VA spine examination report notes that the Veteran reported his right shoulder condition had its onset immediately after service. A March 2015 VA medical record notes that the Veteran reported that his "bilateral shoulders hurt at times." However, no diagnosis or assessment of a shoulder condition was given. He also sought treatment for shoulder pain in January 2017, but no assessment of a shoulder condition was given. At his May 2019 Board hearing, the Veteran described his current shoulder difficulties. He noted that his shoulders "pop" and are "like a knuckle cracking," and stated that, while performing his work as a truck driver, "I'll use the handles to pull myself up manually but then I still get ... aggravation in the shoulders." (See Board hearing transcript, page 7.) As with the back claim, the Veteran believes that his shoulder disabilities occurred from "[w]ear and tear, and wearing a backpack," "wearing the Alice Pack." He reported that these disabilities came on "[g]radually." He noted that "The weapons harness, the suspenders for it, when you strap it on you've got to put it around your waist and pull all your gear and everything on that." (See Board hearing transcript, page 20.) He reported that both shoulders are affected, but mainly the left. He testified that no doctor has diagnosed any shoulder disability and that he is not receiving any shoulder treatment. (See Board hearing transcript, page 22.) The Veteran underwent VA examination in September 2020. Based on review of the record and interview and examination of the Veteran, the VA examiner diagnosed bilateral rotator cuff tendonitis and bilateral rotator cuff tear. Arthritis was not diagnosed. In terms of relevant history, the Veteran reported that he felt shoulder symptoms "'In 1995-96, after I got out of the Marines, wear and tear from service.'" Based on review of the record and interview and examination of the Veteran, the VA examiner determined that the claimed conditions were less likely than not incurred in or caused by the claimed in-service injury, event, or illness. As rationales the examiner noted the following: "Evidence: No complaints of left shoulder during service. Remand Letter dated 6/15/2020 was reviewed," and "Evidence: No complaints of right shoulder during service. Remand Letter dated 6/15/2020 was reviewed." An addendum opinion was obtained in November 2020. Based on review of the record, the examiner opined that the Veteran's diagnosed rotator cuff tendonitis and rotator cuff tear are less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner noted that there are no service treatment records demonstrating related complaints or treatment during service, and no nexus is reasonable given the evidence of record. Later that month, the examiner who had provided the November 2020 opinion provided an addendum opinion with an expanded rationale. The second November 2020 opinion reiterated that the Veteran's shoulder disabilities were less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner reiterated that there are no service treatment records demonstrating related complaints or treatment during service. His rationale continued by stating that: While the veteran states that his shoulder injury is due to chronic wear and tear that occurred while he was performing his duties during service, there is simply no objective evidence to demonstrate related complaints at any point during service, and therefore given the lack of concrete evidence demonstrating such evidence, it cannot be concluded that there is a relationship between the current condition and the wear-and-tear occurring during service. Similarly, there is also no direct evidence demonstrating specific backpack use or exercise during service which is likely to contribute to the shoulder injury. The Board finds these opinions, in particular the second November 2020 etiology opinion and the September 2020 report of examination, to be highly probative, as they were authored by individuals who possess the necessary education, training, or experience to provide competent medical evidence under 38 C.F.R. § 3.159 (a)(1). See Cox v. Nicholson, 20 Vet. App. 563 (2007). The November 2020 opinion is based on review of the record and the September 2020 VA examination report. It contains a detailed rationale that includes citation to the Veteran's case and pertinent medical principles. The VA examiner essentially found that there is a medical reason to reject the proposition that the Veteran's current shoulder disabilities are related to service. The lack of contemporaneous findings renders the VA examiner's ability to provide an opinion based on probability of a nexus rather than mere possibility unfeasible. For these reasons, the Board finds the September 2020 report of examination and the second November 2020 etiology opinion to be highly probative. The Board notes that no medical professional has opined that there is a link between the Veteran's current left and right shoulder disabilities and his military service. The only remaining contrary opinion comes from the Veteran himself. The Board recognizes that there are instances in which a layperson may be competent to offer testimony on medical matters, such as describing symptoms observable to the naked eye or even diagnosing simple conditions. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). The Board finds, however, that the questions posed by this claim are of such complexity as to require that individuals who provide competent medical evidence on this matter possess a level of expertise that a layperson simply does not possess. Specifically, the Board finds that the Veteran does not possess the appropriate expertise to link current shoulder disabilities to activities that occurred years earlier. Therefore, the Board finds that the criteria for entitlement to service connection for left and right shoulder disabilities are not met on a direct basis. The Board also finds that service connection based on chronic disability is not warranted, in part because the Veteran has not been diagnosed with arthritis or with another chronic disability listed under 3.309(a). The only notation even suggesting arthritis appears in a VA medical record reflecting that the Veteran sought treatment for right shoulder pain in February 2001. At that time, he reported that he has had intermittent pain in his right shoulder but that the pain was now more constant. A few days later that month, he again sought treatment, with a notation being made that he has had "arthritis in multiple joints since being in the service [and] presents for e[v]aluation of hip and shoulder pain." It is unclear whether the Veteran was asserting that he specifically had arthritis of either shoulder. The Board finds, however, that the Veteran does not possess the necessary medical expertise to diagnose arthritis. The Board also notes that the same February 2001 VA medical record notes an assessment of bicipital tendonitis and that no other record has actually diagnosed arthritis of either shoulder. Thus, the Board finds that entitlement to service connection for service connection for left and right shoulder disabilities is not warranted on any claimed basis. The Board has considered the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claims, the claims are not in equipoise. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). Accordingly, the claims must be denied. 38 C.F.R. § 3.324 10. Entitlement to a 10 percent evaluation for multiple noncompensable service-connected disabilities pursuant to 38 C.F.R. § 3.324 is denied. Whenever a Veteran is suffering from two or more separate permanent service-connected disabilities of such character as clearly to interfere with normal employability, even though none of the disabilities may be of compensable degree under the 1945 Schedule for Rating Disabilities, the rating agency is authorized to apply a 10 percent rating, but not in combination with any other rating. 38 C.F.R. § 3.324. As noted above, in general, the effective date of an evaluation and award of compensation based on a claim for increase will be the date of receipt of the claim or the date entitlement arose, whichever is the later. 38 U.S.C. § 5110 (a); 38 C.F.R. § 3.400. In the case at hand, this issue has arisen from a claim that was received by VA on March 28, 2012. The Veteran is in receipt of a compensable rating as of that date. Accordingly, entitlement to a 10 percent evaluation based on multiple, noncompensable service-connected disabilities from March 28, 2012, is denied. As further noted above, however, an exception to the effective date rule applies under circumstances where evidence demonstrates that a factually ascertainable increase in disability occurred within the one-year period preceding the date of receipt of a claim for increased compensation. In such an instance, the law provides that the effective date of the award "shall be the earliest date as of which it is ascertainable that an increase in disability had occurred, if application is received within one year from such date." 38 U.S.C. § 5110(b)(2); see also 38 C.F.R. § 3.400(o)(2); Harper v. Brown, 10 Vet. App. 125 (1997). The Board has thus considered whether a 10 percent rating is warranted during the one-year period prior to the date of claim. During the one-year period prior to the date of claim, the Veteran was in receipt of a 0 percent (noncompensable) rating for "history of patellofemoral pain syndrome, bilateral knees," pursuant to 38 C.F.R. § 4.71a, Diagnostic Code 5099-5014. Service connection was not in effect for any other disability at that time. (In adjudicating this claim, the Board acknowledges that the left and right knee disabilities are listed as a single disability on the codesheet prior to March 28, 2012. Even though the February 1994 rating decision listed these two separate disabilities as a single disability under a single diagnostic code, the Board considers the left and right knee disabilities to be "two ... separate permanent service-connected disabilities" and thus potentially eligible for benefits under 38 C.F.R. § 3.324.) The Board must find, however, that the evidence of record does not demonstrate that a factually ascertainable increase in disability occurred within the one-year period prior to the date of receipt of claim. As noted above, there is no evidence of record dated within the one-year period prior to the March 28, 2012, date of claim that relates to the Veteran's left and right knee disabilities. Furthermore, the evidence reflects that the Veteran has been reporting knee pain, including knee pain that interferes with employment, prior to that period. For example, the February 2001 VA medical record notes that the Veteran was reporting intermittent right knee pain that "is interfering with ability to perform employment activities." Therefore, the Board finds that the evidence of record does not demonstrate that a factually ascertainable increase in disability occurred within the one-year period prior to the date of receipt of claim. The Board has considered the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, the claim is not in equipoise. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). Accordingly, the claim must be denied. TDIU 11. Entitlement to a TDIU is denied. The Board has also considered whether entitlement to a TDIU is warranted. A total disability rating based upon individual unemployability due to service-connected disabilities is assigned when service-connected disabilities result in such impairment of mind or body that the average person would be precluded from following a substantially gainful occupation. 38 C.F.R. §§ 3.340, 4.15. If there is only one service-connected disability, it must be rated at 60 percent or more; if there are two or more service-connected disabilities, at least one must be rated at 40 percent or more and the combined rating must be at least 70 percent. 38 C.F.R. § 4.16(a). A claim for a total compensation rating based upon individual unemployability, "presupposes that the rating for the [service-connected] condition is less than 100%, and only asks for TDIU because of 'subjective' factors that the 'objective' rating does not consider." Vettese v. Brown, 7 Vet. App. 31, 34-35 (1994). In evaluating a veteran's employability, consideration may be given to his or her level of education, special training, and previous work experience in arriving at a conclusion, but not to her age or to impairment caused by nonservice-connected disabilities. 38 C.F.R. §§ 3.341, 4.16, 4.19. As further provided by 38 C.F.R. § 4.16(a), marginal employment shall not be considered substantially gainful employment. For purposes of TDIU, marginal employment generally shall be deemed to exist when a veteran's earned annual income does not exceed the amount established by the U.S. Department of Commerce, Bureau of the Census, as the poverty threshold for one person. The amounts established by the United States Department of Commerce, Bureau of the Census, as the poverty threshold for one person during the appeals period in this case are: $11,720 (2012); $11,888 (2013); $12,071 (2014); $12,082 (2015); $12,228 (2016); $12,488 (2017); $12,784 (2018); $13,011 (2019); and $13,468 (2020). See https://www.census.gov/data/tables/time-series/demo/income-poverty/historical-poverty-thresholds.html. Marginal employment may also be held to exist, on a facts-found basis including, but not limited to, employment in a protected environment such as a family business or sheltered workshop, when earned annual income exceeds the poverty threshold. 38 C.F.R. § 4.16(a). In Cantrell v. Shulkin, 28 Vet. App. 382 (2017), the Court addressed this method of establishing marginal employment which required the Court to review the meaning of employment in a protected work environment. The Court found that the plain language of § 4.16(a) does not expressly define "employment in a protected environment" and that the non-exhaustive list of examples of what may constitute employment in a protected environment i.e., a family business or sheltered workshop, fails to resolve this uncertainty. The Court also determined that it was unable to defer to the Secretary's definition, finding instead that the Secretary had refused to proffer any definition of employment in a protected environment for the Court to analyze. Absent an articulated standard for employment in a protected environment, the Court concluded that it was unable to effectively review the Board's decision. The Board recognizes that protected environment has not been defined by regulation. Merriam-Webster's Collegiate Dictionary offers several definitions of the word "protect," but one that appears to be applicable in this inquiry is "to save from contingent financial loss." See Merriam-Webster's Collegiate Dictionary (online) (2017). "Contingent" can mean "likely but not certain to happen: possible." Id. Thus, within the context of awarding a TDIU, a protected work environment exists when one's employment is not based on merit alone, but rather is established to save the individual from likely financial loss. In other words, a protected environment is an employment environment that would not exist, but for the willingness of the employer to hire and pay the employee for altruistic reasons. In the case at hand, the Veteran has had disabilities that combine to produce an overall rating of at least 70 percent. The record reflects that he works full-time as a truck driver. It is unclear whether the Veteran's earned annual income has exceeded the amount established by the U.S. Department of Commerce, Bureau of the Census, as the poverty threshold for one person, as the Veteran has not cooperated with VA's attempts to obtain this information. Specifically, he did not complete and return the VA Form 21-8940, "Veterans Application for Increased Compensation Based on Unemployability," that VA sent to him in January 2021. Nor did he complete and return the VA Form 21-4192, "Request for Employment Information in Connection with Claim for Disability Benefit," for any employers that would have been identified on the VA Form 21-8940, which was also sent to him in January 2021. Without this information, VA cannot adjudicate the Veteran's claim. The Veteran has a duty on his part to cooperate with VA in developing a claim. See Wood v. Derwinski, 1 Vet. App. 190, 193 (1991) (noting that the duty to assist is not a one-way street). VA's duty must be understood as a duty to assist the Veteran in developing his claim, rather than a duty on the part of VA to develop the entire claim with the Veteran performing a passive role. Turk v. Peake, 21 Vet. App. 565, 568 (2008). In any event, the record reflects that the Veteran is employed full time as a truck driver, and the record suggests that this employment is full time. For example, an August 2020 VA medical record notes that the Veteran "is a long-haul truck driver and is usually on the road every week. Tried to get home at least one day a week, but this is irregular." There is no indication that the Veteran's work as a long-haul truck driver is marginal, as there is no indication that the Veteran's long-haul truck driving, which frequently takes him out-of-state and on the road for days at a time, constitutes a protected environment. There is no indication that the Veteran's employment as a truck driver would not exist but for the willingness of his employer to hire and pay him for altruistic reasons. In short, the Board finds that the criteria for entitlement to a TDIU have not been met. The Board has considered the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, the claim is not in equipoise. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). Accordingly, the claim must be denied. TANYA SMITH Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Elizabeth Jalley, 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.