Citation Nr: 21029578 Decision Date: 05/14/21 Archive Date: 05/14/21 DOCKET NO. 16-40 342 DATE: May 14, 2021 ORDER Entitlement to service connection for a right arm disability is denied. Entitlement to service connection for bilateral hearing loss is denied. Entitlement to an initial compensable rating for the Veteran's service-connected scar on scrotum with partial tear is denied. Entitlement to an initial compensable rating for the Veteran's service-connected left leg road rash scars is denied. Entitlement to an initial disability rating in excess of 20 percent for the Veteran's service-connected right shoulder strain is denied. Entitlement to an initial disability rating in excess of 10 percent for the Veteran's service-connected right wrist strain is denied. Entitlement to an initial disability rating in excess of 10 percent prior to October 22, 2019 for the Veteran's service-connected lumbar strain is denied. Since October 22, 2019, entitlement to an initial disability rating of 20 percent, but no higher, for the Veteran's service-connected lumbar strain is granted. Entitlement to an initial disability rating in excess of 10 percent for the Veteran's service-connected left knee strain is denied. Entitlement to an initial disability rating in excess of 10 percent for the Veteran's service-connected right ankle lateral collateral ligament sprain is denied. Entitlement to an initial disability rating in excess of 10 percent prior to January 2, 2020, a compensable rating from January 2, 2020 to November 8, 2020, and in excess of 10 percent thereafter, for the Veteran's service-connected lateral epicondylitis, status post non-displaced fracture of the radial head of the right elbow, based on limitation of flexion is denied. Entitlement to an initial disability rating in excess of 20 percent from January 2, 2020 to November 8, 2020, and entitlement to compensable rating from November 9, 2020 for the Veteran's service-connected lateral epicondylitis, status post non-displaced fracture of the radial head of the right elbow, based on limitation of pronation is denied. REMANDED Entitlement to service connection for a left shoulder disability is remanded. FINDINGS OF FACT 1. The evidence fails to demonstrate that the Veteran has experienced a right arm disability during the appellate period that is separate and distinct from his service-connected right elbow disability. 2. The Veteran has not experienced bilateral hearing loss for VA compensation purposes within the appellate period. 3. The Veteran's service-connected scar on the scrotum is not painful or unstable, is less than 39 square centimeters in area, and does not result in functional impairment or limitation. 4. The Veteran's service-connected left leg road rash scars are not painful or unstable; they reach a maximum total area of 42 squared centimeters but are superficial; and they do not result in functional impairment or limitation. 5. The Veteran's right shoulder disability has been primarily manifested by recurrent dislocation at the scapulohumeral joint, with infrequent episodes and guarding of movement only at shoulder level (flexion and/or abduction at 90 degrees). The Veteran's right shoulder disability has not resulted in right shoulder ankylosis; compensable limitation of motion; impairment of the clavicle or scapula; or loss of head (flail shoulder), nonunion (false flail joint), fibrous union, or malunion of the right humerus. 6. The Veteran is in receipt of the highest schedular rating for limitation of motion of the right wrist for the entire appellate period, and the Veteran has never experienced any form of ankylosis in the right wrist during the appellate period. 7. Prior to October 22, 2019, the Veteran's service-connected lumbar spine disability did not result in spine ankylosis; flexion limited to less than 60 degrees; combined range of motion of the thoracolumbar spine of 120 degrees or less; or muscle spasm or guarding severe enough to result in abnormal gait or abnormal spinal contour. 8. Since October 22, 2019, the Veteran's service-connected lumbar spine disability did not result in forward flexion of the thoracolumbar spine of 30 degrees or less, or any type of ankylosis affecting the spine. The Regional Office's (RO) ratings regarding lower extremity radiculopathy since February 6, 2019 are correct and supported by the evidence of record. 9. Throughout the appellate period, the Veteran's left knee disability has been primarily manifested by pain, but flexion has not been limited to less than 130 degrees and extension has been normal at 0 degrees. The Veteran's left knee condition has not resulted in meniscal disability, ankylosis, credible evidence of instability, arthritis, genu recurvatum, or impairment of the tibia or fibula. 10. Throughout the appellate period, the Veteran's service-connected right ankle disability was manifested by pain productive of no worse than moderate limitation of ankle motion. 11. Prior to January 2, 2020, the Veteran's right elbow disability did not result in limitation of flexion to support a higher 20 percent rating or compensable limitation of pronation. From January 2, 2020 to November 8, 2020, the Veteran's right elbow disability did not result in limitation of flexion sufficient to support a compensable rating, and the Veteran's limitation of pronation was consistent with motion lost beyond last quarter of arc, where the hand does not approach full pronation. Since November 9, 2020, the Veteran's right elbow disability did not result in limitation of flexion to support a higher 20 percent rating or compensable limitation of pronation. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for a right arm disability have not been met. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. 2. The criteria for entitlement to service connection for bilateral hearing loss have not been met. 38 U.S.C. § 1110; 38 C.F.R. §§ 3.303, 3.385. 3. The criteria for entitlement to an initial compensable rating for the Veteran's service-connected scar on scrotum with partial tear have not been met. 38 U.S.C. § 1155; 38 C.F.R. § 4.118, Diagnostic Codes 7800-7805. 4. The criteria for entitlement to an initial compensable rating for the Veteran's service-connected left leg road rash scars have not been met. 38 U.S.C. § 1155; 38 C.F.R. § 4.118, Diagnostic Codes 7800-7805. 5. The criteria for entitlement to an initial disability rating in excess of 20 percent for the Veteran's service-connected right shoulder strain have not been met. 38 U.S.C. § 1155; 38 C.F.R. § 4.71a, Diagnostic Codes 5200-5203. 6. The criteria for entitlement to an initial disability rating in excess of 10 percent for the Veteran's service-connected right wrist strain have not been met. 38 U.S.C. § 1155; 38 C.F.R. § 4.71a, Diagnostic Code 5214-5215. 7. The criteria for entitlement to an initial disability rating in excess of 10 percent prior to October 22, 2019 for the Veteran's service-connected lumbar strain have not been met. 38 U.S.C. § 1155; 38 C.F.R. § 4.71a, Diagnostic Code 5237. 8. Effective October 22, 2019, the criteria for a 20 percent rating, but no higher, for the Veteran's service-connected lumbar strain have been met. 38 U.S.C. § 1155; 38 C.F.R. § 4.71a, Diagnostic Code 5242. The ratings in effect for the Veteran's lower extremity neurological symptoms are appropriate. 38 U.S.C. § 1155; 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Note (1); 38 C.F.R. § 4.124, Diagnostic Code 8520. 9. The criteria for entitlement to an initial disability rating in excess of 10 percent for the Veteran's service-connected left knee strain have not been met. 38 U.S.C. § 1155; 38 C.F.R. § 4.71a, Diagnostic Codes 5256-5263. 10. The criteria for entitlement to an initial disability rating in excess of 10 percent for the Veteran's service-connected right ankle lateral collateral ligament sprain have not been met. 38 U.S.C. § 1155; 38 C.F.R. § 4.71a, Diagnostic Codes 5270-5274. 11. The criteria for entitlement to an initial disability rating in excess of 10 percent prior to January 2, 2020, a compensable rating from January 2, 2020 to November 8, 2020, and in excess of 10 percent thereafter, for the Veteran's service-connected lateral epicondylitis, status post non-displaced fracture of the radial head of the right elbow, based on limitation of flexion have not been met. 38 U.S.C. § 1155; 38 C.F.R. § 4.71a, Diagnostic Codes 5205-5213. 12. Entitlement to an initial disability rating in excess of 20 percent from January 2, 2020 to November 8, 2020, and entitlement to compensable rating from November 9, 2020 for the Veteran's service-connected lateral epicondylitis, status post non-displaced fracture of the radial head of the right elbow, based on limitation of pronation is denied. 38 U.S.C. § 1155; 38 C.F.R. § 4.71a, Diagnostic Codes 5205-5213. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from November 2009 to November 2013. These matters come before the Board of Veterans' Appeals (Board) on appeal from a May 2014 rating decision issued by a RO of the United States Department of Veterans Affairs (VA). The Veteran presented testimony before the undersigned Veterans Law Judge at a February 2019 Board hearing. A copy of the hearing transcript has been associated with the electronic claims file. These matters were previously before the Board in May 2019, at which time they were remanded for further evidentiary development. A review of the record shows that there has been substantial compliance with the remand directives, and neither the Veteran nor his representative have alleged otherwise. See Stegall v. West, 11 Vet. App. 268, 271 (1998). The Board may proceed with its appellate consideration. The claims seeking service connection for a right knee disability and an increased initial disability rating for a left index finger laceration with residuals were fully resolved in the November 2020 rating decision and are no longer on appeal. Grantham v. Brown, 114 F.3d 1156 (Fed. Cir. 1997). As to the matters adjudicated below, neither the Veteran nor his representative has raised any issues with the duty to notify, the duty to assist, or the conduct of his Board hearing as to the duties discussed in Bryant v. Shinseki, 23 Vet. App. 488, 496-97 (2010). See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board . . . to search the record and address procedural arguments when the veteran fails to raise them before the Board."); See also Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016). Thus, the Board need not discuss any potential issues in this regard. The Veteran has been substantially gainfully employed for the duration of the appellate period, and there is no indication that this employment was marginal or performed in a protected work environment. As such a claim of entitlement to a total disability rating based on individual unemployability has not been raised by the evidence of record. See Rice v. Shinseki, 22 Vet. App. 447 (2009). Hearing Testimony The Veteran presented testimony at a February 2019 Board hearing. Regarding his claim seeking service connection for a right arm disability, he stated that he suffered a broken arm during service. He did not distinguish this claimed condition from his already service-connected right elbow disability. He also testified to experiencing left shoulder pain during service, but he did not testify to the presence of current symptoms. The Veteran provided testimony about his in-service motorcycle accident. Regarding his increased rating claims, the Veteran testified that his low back complaints were the most predominant. He described pain and limitations of getting up and down and sitting/standing for prolonged periods. He also reported numbness in his legs. He also described knee pain, and difficulty climbing ladders, getting in/out of his truck, lifting his children, squatting, and kneeling. The Veteran's testimony, as described above, is addressed for the relevant claims, below. Service Connection 1. Entitlement to service connection for a right arm disability is denied. The Veteran seeks entitlement to service connection for a right arm disability, aside from his already service-connected lateral epicondylitis, status post non-displaced fracture of the radial head of the right elbow. At the April 2014 shoulder, arm, and elbow VA examinations, the Veteran reported loss of motion in the right arm. Following an in-person assessment, the VA examiner did not diagnose the Veteran with a separate right arm disability distinct from his already service-connected right elbow disability. In January 2019, the Veteran submitted a private medical opinion from a chiropractor which stated he had orthopedic symptomatology of the arms that was related to active duty service. The diagnosis in this statement was general and non-distinct. The private chiropractor did not indicate whether the Veteran experienced a right arm disability separate from the Veteran's already service-connected right elbow disability. Given the vague and generic nature of this medical opinion, it is not probative in this determination. Similarly, the Veteran's VA treatment records, as well as the private chiropractic records, are negative for a right arm disability distinct from the Veteran's service-connected right elbow disability. At the January 2020 VA examinations of the shoulder, arms, forearms, and elbow, there was no right arm disability diagnosed that was separate from the Veteran's service-connected right elbow disability. Following a November 2020 elbow VA examination, the VA examiner did not appreciate a right arm disability separate and distinct from the Veteran's service-connected right elbow disability. The Board has fully reviewed the electronic claims file and finds no probative evidence establishing that the Veteran has experienced a right arm disability separate and distinct from his already service-connected lateral epicondylitis, status post non-displaced fracture of the radial head of the right elbow. In the absence of a current disability showing a separate right arm disability, the Veteran's claim seeking service connection for a right arm disability must be denied. 2. Entitlement to service connection for bilateral hearing loss is denied. The Veteran alleges that he experiences a current bilateral hearing loss disability as a result of military noise exposure. A foundational requirement for entitlement to service connection for bilateral hearing loss is that the Veteran experiences a current disability within the appellate period, as defined by VA regulations. Pursuant to 38 C.F.R. § 3.385, hearing loss is considered a disability for VA compensation purposes when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, 4000 Hertz (Hz) is 40 decibels or greater; or when the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, or 4000 Hz are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. Review of the electronic claims file establishes that the Veteran has never experienced bilateral hearing loss under the definition set forth in 38 C.F.R. § 3.385 during the pendency of the claim. At an in-service audiogram conducted in February 2013, slightly prior to the period on appeal, the Veteran did not exhibit pure tone thresholds that satisfied the definition of a current disability under 38 C.F.R. § 3.385. The results were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 5 0 10 15 5 LEFT 5 5 0 15 10 At a VA examination conducted in April 2014, audiogram testing was performed, and pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 15 0 10 5 10 LEFT 10 5 10 10 10 Pure tone test results were deemed valid for rating purposes. Speech discrimination testing was conducted using the Maryland CNC word list, and revealed that the Veteran had a speech recognition ability of 96 percent in both ears. The VA examiner stated that the use of speech discrimination scores was appropriate for the Veteran. The above results do not demonstrate bilateral hearing loss for VA compensation purposes under 38 C.F.R. § 3.385. At the February 2019 Board hearing, the Veteran agreed to attend an additional VA examination based on his allegation of worsening hearing. At a VA examination conducted in December 2019, audiogram testing was performed, and pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 10 10 15 15 15 LEFT 5 10 10 15 10 Pure tone test results were deemed valid for rating purposes. Speech discrimination testing was conducted using the Maryland CNC word list, and revealed that the Veteran had a speech recognition ability of 100 percent in both ears. The VA examiner stated that the use of speech discrimination scores was appropriate for the Veteran. The above results do not demonstrate bilateral hearing loss for VA compensation purposes under 38 C.F.R. § 3.385. At a final VA examination conducted in January 2020, audiogram testing was performed, and pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 5 20 15 20 20 LEFT 5 15 15 15 10 Pure tone test results were deemed valid for rating purposes. Speech discrimination testing was conducted using the Maryland CNC word list, and revealed that the Veteran had a speech recognition ability of 100 percent in the right ear and 96 percent in the left ear. The VA examiner stated that the use of speech discrimination scores was appropriate for the Veteran. The above results do not demonstrate bilateral hearing loss for VA compensation purposes under 38 C.F.R. § 3.385. The electronic claims file does not contain any further audiological testing during the appellate period. To the extent that the Veteran has subjectively expressed diminished hearing acuity, he is competent to report symptoms perceived within the realm of his personal experience. Layno v. Brown, 6 Vet. App. 465, 469 (1994). However, even to the extent the Veteran would be competent to report diminished hearing acuity during the appellate period, he would not be competent to diagnose bilateral hearing loss for VA compensation purposes, as such a determination would require both objective audiometric and/or speech recognition testing, which the Veteran could not perform on himself. The Board has considered the United States Court of Appeals for the Federal Circuit's decision in Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018), which held that symptoms alone, without any underlying pathology, may rise to the level of a current disability if they result in a functional impairment of earning capacity. However, where VA has limited compensation to disabilities that conform to particular regulatory requirements, Saunders is not for application. C.f. Martinez-Bodon v. Wilkie, 32 Vet. App. 393 (2020). Based on the foregoing, the issue of entitlement to service connection for bilateral hearing loss is denied because the Veteran has not experienced a bilateral hearing loss disability for VA compensation purposes at any time during the appellate period. 38 C.F.R. § 3.385; see Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). While bilateral hearing loss is a "chronic disease" under 38 C.F.R. §§ 3.307, 3.309(a), a presumptive service connection analysis cannot be conducted in the absence of a current bilateral hearing loss disability for VA compensation purposes during the appellate period. Increased Rating Disability ratings are determined by application of the criteria set forth in VA's Schedule for Rating Disabilities, which is based on average impairment of earning capacity. 38 U.S.C. § 1155; 38 C.F.R. Part 4. The Veteran's entire history is to be considered when making disability evaluations. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). "Staged" ratings are appropriate for any rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007); Fenderson v. West, 12 Vet. App. 119 (1999). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. Any reasonable doubt regarding a degree of disability will be resolved in favor of the veteran. 38 C.F.R. § 4.3. When evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use and, therefore, not be reflected on range-of-motion testing. 38 C.F.R. § 4.45 requires consideration also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Nonetheless, even when the background factors listed in § 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a (musculoskeletal system) or § 4.73 (muscle injury); a separate or higher rating under § 4.40 or 4.45 itself is not appropriate. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016) ("[I]t is clear that the guidance of § 4.40 is intended to be used in understanding the nature of the veteran's disability, after which a rating is determined based on the § 4.71a [or 4.73] criteria."). Moreover, the provisions of 38 C.F.R. § 4.59, which relate to painful motion, are not limited to arthritis, and must be considered when raised by the claimant or when reasonably raised by the record. Burton v. Shinseki, 25 Vet. App. 1 (2011). Pyramiding, that is the evaluation of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when evaluating a veteran's service-connected disability. 38 C.F.R. § 4.14. However, it is possible for a veteran to have separate and distinct manifestations from the same injury which would permit rating under several diagnostic codes; the critical element in permitting the assignment of several evaluations under various diagnostic codes is that none of the symptomatology for any one of the conditions is duplicative or overlapping with the symptomatology of the other condition. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). During the pendency of the appeal, the rating criteria for evaluating musculoskeletal disabilities under 38 C.F.R. § 4.71a were amended, effective February 7, 2021. 85 Fed. Reg. 230 (Nov. 30, 2020). These amendments revised select diagnostic codes "to ensure that this portion of the rating schedule uses current medical terminology and provides detailed and updated criteria for the evaluation of musculoskeletal disabilities." Id. If a law or regulation changes during the course of a claim or an appeal, the version more favorable to the Veteran will apply, to the extent permitted by any stated effective date in the amendment in question. 38 U.S.C. § 5110(g). If the revised version of the regulation is more favorable, the implementation of that regulation under 38 U.S.C. § 5110(g) can be no earlier than the effective date of that change. If the former version is more favorable, VA can apply the earlier version of the regulation for the period prior to, and from, the effective date of the change. 38 U.S.C. § 5110. For the applicable claims affected by the February 2021 musculoskeletal changes, the Board will consider the Veteran's claims under the old criteria prior to February 7, 2021 and both the old and new rating criteria from February 7, 2021. The criteria that is more favorable to the Veteran will be applied. The Board shall address the regulatory changes relevant to each claim in the appropriate section, infra. 3. Entitlement to an initial noncompensable rating for the Veteran's service-connected scar on scrotum with partial tear is denied. 4. Entitlement to an initial compensable rating for the Veteran's service-connected left leg road rash scars is denied. In the May 2014 rating decision, the Veteran was awarded service connection for painful scars, rated as 20 percent disabling, effective November 16, 2013. In pertinent part, the RO also granted service connection for left leg road rash scars and a scar on the scrotum, each rated as noncompensable, effective November 16, 2013. On appeal, the Veteran seeks initial ratings for his service-connected left leg road rash and scrotum scars. During the pendency of this appeal, the rating criteria for evaluating scar conditions were revised, effective August 13, 2018. See 83 Fed. Reg. 32592 (July 13, 2018); 38 C.F.R. § 4.118, Diagnostic Codes 7801, 7802, 7805. Applicable to these claims only, the Veteran's symptoms will be evaluated under both the old and new rating criteria, and the version that is more beneficial to the Veteran will be applied. See 83 Fed. Reg. 32592, 32593 (July 13, 2018) ("[F]or this final rule, VA's 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."). Under the rating criteria in effect prior to the August 13, 2018 changes, a minimum compensable rating (10 percent) for scars not of the head, face, or neck was warranted if (1) the scar was deep and nonlinear and of at least 39 square centimeters in area; (2) the scar was superficial and nonlinear and of at least 929 square centimeters; or (3) there were one or two scars that were unstable or painful. Under the new rating criteria, effective August 13, 2018, a minimum compensable rating (10 percent) for scars not of the head, face, or neck is warranted if (1) the scar is associated with underlying soft tissue damage and of at least 39 square centimeters in area; (2) the scar is not associated with underlying soft tissue damage and of at least 929 square centimeters in area; or (3) there are one or two scars that are unstable or painful. 38 C.F.R. § 4.118, Diagnostic Codes 7801, 7802, 7804. An "unstable" scar is one where, for any reason, there is frequent loss of covering of skin over the scar. See 38 C.F.R. § 4.118, Diagnostic Code 7804, Note (1). The Veteran attended a VA examination in April 2014 to assess the scars impacting his scrotum and left leg. He had no active road rash on the left leg. The VA examiner stated that the Veteran had a scar on the scrotum and two scars on the left leg, and the scars were not reported as painful or unstable. The Veteran had an oval shaped (nonlinear) and superficial scar on the medial distal thigh/knee of the left leg measuring 5 by 3 centimeters and another superficial round (nonlinear) scar on the lateral left leg measuring 2 by 2 centimeters. The Veteran's scrotal scar was linear and superficial, and measured 3 centimeters in length. The Veteran attended a VA examination in January 2020 to assess his service-connected scars. The VA examiner stated that none of the Veteran's trunk/extremity scars were painful or unstable. The VA examiner noted a scar on the medial aspect of the left knee, measuring 6 by 7 centimeters, with a total area of 42 square centimeters. The VA examiner noted a scar on the right scrotum measuring 2.5 by 0.2 centimeters, with a total area of 0.5 square centimeters. None of the scars had underlying tissue damage. The Veteran's private and VA treatment records, as well as his Board hearing testimony, do not contain relevant information for rating the Veteran's scar disabilities. Regarding the Veteran's scrotal scar, it was not painful or unstable, and it did not measure a total area of 39 square centimeters or greater. Thus, under either the prior or current rating criteria, the Veteran would be ineligible for a compensable disability rating for his service-connected scrotal scar under all applicable diagnostic codes. Regarding the Veteran's left leg road rash scars, they measured a total area greater than 39 square centimeters but not equal to or greater than 929 square centimeters, and they were superficial (i.e., not associated with underlying soft tissue damage). The scars were not painful or unstable. Given these facts, under either the prior or current rating criteria, the Veteran would be ineligible for a compensable disability rating for his service-connected left leg road rash scars under all applicable diagnostic codes. The criteria for initial compensable ratings for the Veteran's scrotal scar and left leg road rash scars have not been met, under either the prior or current rating criteria. The Veteran's claims for an initial increased rating must be denied. The Board has considered the applicability of the benefit of the doubt doctrine and finds it inapplicable because the preponderance of the evidence weighs against the claims. 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). 5. Entitlement to an initial disability rating in excess of 20 percent for the Veteran's service-connected right shoulder strain is denied. The Veteran is currently assigned a 20 percent rating for his service-connected right shoulder strain under Diagnostic Code 5202, 38 C.F.R. § 4.71a. The Veteran seeks a higher initial rating on appeal. The rating criteria for evaluating disabilities of the shoulder, including Diagnostic Code 5202, distinguish between the major (dominant) extremity and the minor (non-dominant) extremity. The injured hand of an ambidextrous individual will be considered the dominant hand for rating purposes. See 38 C.F.R. § 4.69. The Veteran is right hand dominant. Under Diagnostic Code 5202, prior to the musculoskeletal regulatory changes, a 20 percent rating was warranted for malunion of the major humerus with moderate deformity, or for infrequent episodes of recurrent dislocation of the scapulohumeral joint of the major extremity with guarding of movement only at the shoulder level. A 30 percent rating was warranted for malunion of the major humerus with marked deformity or frequent episodes of recurrent dislocation with guarding of all arm movements. A 50 percent rating was warranted for fibrous union of the major humerus. A 60 percent rating required nonunion (a false flail joint) of the major humerus. An 80 percent rating required loss of the head of the major humerus (flail shoulder). 38 C.F.R. § 4.71a. The rating criteria for the shoulder were slightly affected by the February 2021 regulatory changes. Diagnostic Code 5201 was amended to clarify that limitation of motion included flexion and abduction, and specific range of motion measurements were added to the rating criteria. Diagnostic Code 5202 was amended to define "movement only at shoulder level" as being flexion and/or abduction at 90 degrees. The Veteran attended a VA examination in April 2014 to assess the severity of his right shoulder disability. The Veteran denied flare-ups and specific functional loss/impairment of the joint or extremity. Range of motion was normal in the right shoulder for both flexion and abduction. Repetitive use testing was conducted, and following three repetitions, there was no additional limitation of motion in the right shoulder. The VA examiner noted pain with range of motion testing and when used in weightbearing and non-weightbearing, but it did not result in limitation of motion. Regarding muscle strength, the VA examiner noted normal strength with right shoulder flexion and abduction (5/5), but also stated there was a reduction in muscle strength. There was no ankylosis in the right shoulder. The Veteran did not have a rotator cuff condition in the right shoulder. The VA examiner noted a history of right shoulder instability/dislocation, with mechanical symptoms such as clicking, catching, etc. The VA examiner noted infrequent episodes of dislocation of the scapulohumeral joint with guarding of movement only at shoulder level. Despite mild tenderness in the acromioclavicular (AC) joint, the VA examiner determined that the Veteran did not experience an AC joint condition or any other impairment of the clavicle or scapula. Cross-body adduction testing was negative. Regarding impairments of the humerus, the Veteran did not have loss of head (flail shoulder), nonunion (false flail shoulder), fibrous union, or malunion of the humerus. There was no right shoulder degenerative arthritis. The Veteran was afforded an additional VA examination of the right shoulder in January 2020. The Veteran reported mild flare-ups once per week, lasting a day, precipitated by heavy lifting, or overhead reaching. The flare-ups were alleviated by rest and sling. The Veteran did not report any specific functional loss/impairment of the joint or extremity. Right shoulder range of motion testing showed flexion limited to 120 degrees and abduction limited to 110 degrees. Pain was noted with rotation testing, but not with flexion or abduction. There was mild tenderness to palpation in the bicipital groove. There was no objective evidence of crepitus. Repetitive use testing was performed, and following three repetitions, no additional limitation of motion was noted. The VA examiner estimated there would be no additional limitation of motion following repeated use over time or during flare-ups, despite pain. Muscle strength testing was normal in the right shoulder. There was no right shoulder ankylosis. Right shoulder rotator cuff condition was suspected due to positive Hawkins' impingement, empty-can, external rotation/infraspinatus strength, and lift-off subscapularis tests. Right shoulder instability or dislocation was not suspected. Right shoulder clavicle, scapular, AC, or sternoclavicular joint conditions were not suspected. Regarding impairments of the humerus, the Veteran did not have loss of head (flail shoulder), nonunion (false flail shoulder), fibrous union, or malunion of the humerus. There was no evidence of arthritis. The Board has reviewed the Veteran's private and VA treatment records and they show symptomatology and clinical findings similar to those documented at the April 2014 and January 2020 VA examinations. At a December 2017 VA orthopedic visit, the Veteran reported chronic right shoulder pain. Upon physical examination he had no muscle wasting, normal muscle strength, and full range of motion. He was noted to have mild AC arthritis. Considering the results of the April 2014 and January 2020 VA examinations, as well as the Veteran's treatment records, the Veteran has never experienced right humerus impairment manifested by loss of head (flail shoulder), nonunion (false flail joint), fibrous union, or malunion. The Veteran experienced infrequent episodes of recurrent dislocation of the scapulohumeral joint with guarding of movement only at shoulder level (flexion and/or abduction at 90 degrees), but did not experience frequent episodes of dislocation causing guarding of all arm movements during the appellate period. The evidence of record most closely approximates a 20 percent rating under Diagnostic Code 5202 (under either the old or current version) during the appellate period. The Board has considered the applicability of other diagnostic codes; however, the evidence does not establish that the Veteran experienced ankylosis in the right shoulder; thus, Diagnostic Code 5200 is not for application. Further, the evidence, even considering flare-ups and repeated use over time, never showed right shoulder motion limited to shoulder level or lower (flexion and/or abduction limited to 90 degrees or less); thus, Diagnostic Code 5201 is not for application under either the old or current version of the code. Likewise, the evidence has not shown impairment of the clavicle or scapula, so Diagnostic Code 5203 is not for application. While the December 2017 VA orthopedist noted mild AC arthritis, a separate rating based on arthritis is not warranted, as the Veteran's rating under Diagnostic Code 5202 already compensates the Veteran for pain resulting in guarding of movement (i.e., hesitation or restriction of normal movement). To award a separate rating for painful arthritis would violate VA's prohibition against pyramiding. 38 C.F.R. § 4.14. The evidence preponderates against a disability rating in excess of 20 percent under Diagnostic Code 5202 for a right shoulder disability. As the evidence preponderates against the claim, the benefit of the doubt doctrine is not for application. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3; Gilbert, 1 Vet. App. at 53. The Veteran's appeal seeking an initial disability rating in excess of 20 percent for his service-connected right shoulder strain is denied. 6. Entitlement to an initial disability rating in excess of 10 percent for the Veteran's service-connected right wrist strain is denied. The Veteran is currently assigned a 10 percent rating for his service-connected right wrist strain under Diagnostic Code 5215, 38 C.F.R. § 4.71a. The Veteran seeks a higher initial rating on appeal. The Board notes that the rating criteria for the wrist were not affected by the February 2021 regulatory changes. A 10 percent rating is the highest rating available under Diagnostic Code 5215. The Veteran is right hand dominant. Consideration of Diagnostic Code 5214 is appropriate, and to achieve a higher rating, the evidence would have to reflect that the Veteran's right wrist disability manifested as favorable ankylosis in 20 to 30 degrees of dorsiflexion or unfavorable ankylosis. The Veteran was afforded a VA examination assessing the right wrist in April 2014. The Veteran denied flare-ups. Range of motion testing showed palmar flexion limited to 70 degrees or greater (no objective evidence of painful motion); dorsiflexion limited to 70 degrees or greater (no objective evidence of painful motion); and right wrist ulnar and radial deviation limited to 45 degrees and 20 degrees, respectively, with objective evidence of painful motion beginning at the endpoint for both tests. Repetitive use testing was conducted, and following three repetitions, there was no additional limitation of motion. The Veteran exhibited tenderness at the anterior aspect of the wrist. Muscle strength testing was normal, and there was no ankylosis in the wrist joint. The Veteran attended an additional VA examination of the right wrist in January 2020. He reported mild flare-ups occurring weekly, lasting a day, and precipitated by overuse, writing, or typing. The flare-ups were alleviated by rest. The Veteran did not report specific functional loss/impairment of the joint/extremity. Range of motion testing showed palmar flexion to 70 degrees, dorsiflexion to 60 degrees, ulnar deviation to 45 degrees, and radial deviation to 20 degrees. Pain was noted during palmar flexion and dorsiflexion. There was no pain on passive range of motion testing or with weightbearing or non-weightbearing. There was mild tenderness in the dorsal radial region. There was no additional limitation of motion following repetitive use, and based on record evidence the VA examiner estimated there would be no further limitation of motion following repeated use or during a flare-up, despite pain. Muscle strength testing was normal and there was no ankylosis. The Veteran was afforded a final VA examination in March 2020. While this VA examination was focused on the left wrist, it contained information regarding the Veteran's right wrist as well. Range of motion testing showed palmar flexion limited to 80 degrees, dorsiflexion limited to 70 degrees, ulnar deviation limited to 45 degrees, and radial deviation limited to 20 degrees. No pain was noted on examination, there was no evidence of pain with weightbearing, and there was no objective evidence of crepitus. Repetitive use testing was performed and did not result in additional limitation of motion. The VA examiner estimated no additional limitation of motion following repeated use over time. Muscle strength testing was normal and there was no ankylosis. As noted above, the Veteran is already receiving the highest schedular rating under Diagnostic Code 5215 for his right wrist disability for the entire appellate period. The Board has reviewed the Veteran's private and VA treatment records, as well as the VA examinations identified above, and at no point during the appellate period has the Veteran's service-connected right wrist disability been manifested by any form of ankylosis. As such, the Veteran cannot achieve a higher disability rating under Diagnostic Code 5214. As the preponderance of the evidence weighs against the claim, the benefit of the doubt doctrine is not for application. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3; Gilbert, 1 Vet. App. at 53. The Veteran's appeal seeking an initial disability rating in excess of 10 percent for his service-connected right wrist strain is denied. 7. Entitlement to an initial disability rating in excess of 10 percent prior to October 22, 2019 for the Veteran's service-connected lumbar strain is denied. 8. Since October 22, 2019, entitlement to an initial disability rating of 20 percent, but no higher, for the Veteran's service-connected lumbar strain is granted. In the May 2014 rating decision, the Veteran was assigned an initial 10 percent disability rating under Diagnostic Code 5237, 38 C.F.R. § 4.71a, for his lumbar spine disability. In the November 2020 rating decision, the RO assigned a staged rating and raised the Veteran's disability rating to 20 percent, effective January 2, 2020. In this rating decision, the RO also changed the Veteran's Diagnostic Code 5237 to 5243, which rates for intervertebral disc syndrome (IVDS). Given that the Veteran has never satisfied the regulatory requirements of IVDS; the evidence does not show disc herniation with compression and/or irritation of the adjacent nerve root as required for Diagnostic Code 5243 under the February 2021 regulatory changes; and the VA treatment records confirm degenerative changes in the lumbar spine, the Board finds it most appropriate to change the Veteran's Diagnostic Code to 5242, effective January 2, 2020. See December 2017 VA treatment record/radiograph; see also Butts v. Brown, 5 Vet. App. 532, 538 (1993). The Board finds no prejudice to the Veteran in changing this assigned Diagnostic Code. Initially, the Board notes that the January 2020 and July 2020 VA examiners check marked that the Veteran had IVDS. However, neither examiner found that the Veteran's lumbar spine disability was manifested by incapacitating episodes of acute signs and symptoms requiring bed rest prescribed by a physician for any duration during the preceding 12 months. Indeed, the medical evidence does not indicate that the Veteran was ever prescribed bed rest by a physician due to incapacitating episodes of low back symptoms during the appellate period. As such, the General Rating Formula for Rating IVDS Based on Incapacitating Episodes is not for application during the appellate period. The Veteran's service-connected lumbar spine disability is rated using the General Rating Formula for Diseases and Injuries of the Spine. This General Formula provides the following ratings, as appropriate: A 20 percent rating is warranted when there is forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis; A 40 percent rating is warranted when there is forward flexion of the thoracolumbar spine 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine; A 50 percent rating is warranted for unfavorable ankylosis of the entire thoracolumbar spine; and A 100 percent rating is warranted for unfavorable ankylosis of the entire spine. Note (1) under the General Formula directs VA to evaluate any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, separately, under an appropriate diagnostic code. The February 2021 regulatory changes did not substantively change the criteria in the General Formula. Instead, they altered the requirements for assignment of Diagnostic Codes 5242 and 5243, and added a new Diagnostic Code 5244 for "traumatic paralysis, complete." Diagnostic Code 5242 was revised to "degenerative arthritis, degenerative disc disease other than intervertebral disc syndrome" and Diagnostic Code 5243 was revised to "Intervertebral disc syndrome: Assign this diagnostic code only when there is disc herniation with compression and/or irritation of the adjacent nerve root; assign diagnostic code 5242 for all other disc diagnoses." The Veteran's lumbar disability was assessed at an April 2014 VA examination. The Veteran reported that pain was localized to the mid-back region, with no shooting pain. He did not report flare-ups. Range of motion testing showed forward flexion of 90 degrees or greater (pain beginning at endpoint); extension of 30 degrees or greater (pain beginning at 20 degrees); right lateral flexion of 30 degrees or greater (pain beginning at endpoint); left lateral flexion of 30 degrees or greater (pain beginning at endpoint); right lateral rotation of 30 degrees or greater (no objective evidence of painful motion); and left lateral rotation of 30 degrees or greater (no objective evidence of painful motion). Repetitive use testing was performed, and following three repetitions, there was no additional limitation of motion. Physical examination revealed tenderness to palpation in the mid-back region. There was no guarding or muscle spasm in the back. Muscle strength testing was normal with no atrophy. Reflex and sensory examinations were normal. Straight leg raising tests were negative. There was no radiculopathy or other neurologic abnormalities. There was no evidence of arthritis. VA treatment records from December 2014 include a radiograph showing no degenerative changes, however a radiograph from December 2017 showed very mild degenerative changes at the thoracic lumbar junction. The Veteran attended a VA examination of the lumbar spine in January 2020. He reported back discomfort and left lower extremity radicular symptoms, but no bladder or bowel incontinence. He reported mild flare-ups occurring once per week and lasting 1-2 days, precipitated by overuse and heavy lifting. The symptoms were alleviated by chiropractic adjustment, massage, and rest. He did not report any specific functional loss/impairment of the thoracolumbar spine. Range of motion testing showed forward flexion limited to 55 degrees; extension limited to 15 degrees; left and right lateral flexion each limited to 20 degrees; and left and right lateral rotation each limited to 30 degrees. Pain was noted during forward flexion and right lateral rotation testing, and it is assumed that pain began at the endpoints. There was pain with weightbearing, but no pain with non-weightbearing or during passive range of motion testing. There was mild tenderness in the upper lumbar spine. Repetitive use testing did not result in additional limitation of motion following three repetitions. The VA examiner estimated that repeated use over time and during flare-ups would not result in additional limitation of motion, despite pain. Muscle spasm and/or guarding was present, but it did not result in abnormal gait or abnormal spinal contour. Muscle strength testing was normal. Reflex examination was normal. Sensory examination was normal on the right side. On the left side, sensations were normal in the upper anterior thigh, but decreased in the thigh/knee, lower leg/ankle, and foot/toes. Straight leg raising tests were negative. Radiculopathy testing showed no symptoms in the right lower extremity, but mild constant pain, mild paresthesias/dysesthesias, and mild numbness in the left lower extremity. The VA examiner diagnosed mild left lower extremity sciatic nerve radiculopathy. There were no other neurological abnormalities. There was no ankylosis of the lumbar spine. In March 2020, the Veteran underwent a VA examination assessing the peripheral nerves. The Veteran did not report symptoms of constant pain, intermittent pain, paresthesias/dysesthesias, or numbness in either lower extremity. Muscle strength, reflex, and sensory testing was normal in the lower extremities. No trophic changes were observed, and the Veteran's gait was normal. The VA examiner found the lower extremity nerves to be clinically normal. In June 2020, the Veteran submitted private chiropractic records documenting tenderness, pain, tightness, and poor mobility in the back, with intermittent moderate tingling in the right anterior leg and left posterior thigh, left anterior knee, and left anterior leg. The chiropractor did not diagnose the Veteran with a clinically significant neurological disability. The range of motion testing recorded in the private treatment records are confusing and difficult to interpret. It appears that the Veteran had forward flexion of the lumbar spine limited to 60 degrees at both the October 22, 2019 and March 2, 2020 visits. Deep tendon reflexes were normal at both visits. The Veteran attended a VA lumbar examination in July 2020. He reported discomfort and intermittent bilateral lower extremity radicular symptoms, but no bladder/bowel incontinence. He reported mild flare-ups occurring once per week, lasting 1 to 2 days, precipitated by heavy lifting, twisting, and reaching, and alleviated by rest and chiropractic adjustment. He did not report specific functional loss/impairment of the thoracolumbar spine. Range of motion testing showed forward flexion limited to 55 degrees, extension limited to 25 degrees, and right lateral flexion, left lateral flexion, right lateral rotation, and left lateral rotation, each limited to 30 degrees. Pain was noted during forward flexion, extension, and right lateral rotation testing, and it is assumed it began at the endpoint. There was no pain on passive range of motion testing or during weightbearing or non-weightbearing. Repetitive use testing was conducted and did not result in additional limitation of motion following three repetitions. The VA examiner estimated that there would be no additional limitation of motion following repeated use over time or during flare-ups, despite pain. There was no guarding or muscle spasm in the lumbar spine. Muscle strength and reflex testing was normal. Sensory exam was normal on the left side, but decreased on the right side at the upper anterior thigh, thigh/knee, lower leg/ankle, and foot/toes. Straight leg raising tests were negative. The Veteran reported no radiculopathy symptoms in the left lower extremity, but reported mild right lower extremity constant pain, and moderate right lower extremity paresthesias/dysesthesias and numbness. The Veteran was diagnosed with right lower extremity sciatic radiculopathy. No other neurological abnormalities were identified. There was no ankylosis of the lumbar spine. In December 2020, the RO obtained an addendum VA medical opinion addressing the conflicting evidence regarding the Veteran's lower extremity radiculopathy. Following a review of the January 2020, March 2020, and July 2020 VA examinations, the VA examiner confirmed a diagnosis of bilateral lower extremity radiculopathy. In December 2020, the RO issued a rating decision granting a 10 percent rating for left lower extremity radiculopathy, effective February 6, 2019, the date of the Veteran's Board hearing, and granting service connection for right lower extremity radiculopathy, with a 10 percent rating from February 6, 2019 to July 29, 2020, and a 20 percent thereafter. For the period prior to October 22, 2019, the evidence has never demonstrated ankylosis in the lumbar/entire spine; flexion limited to less than 60 degrees; combined range of motion of the thoracolumbar spine of 120 degrees or less; or muscle spasm or guarding severe enough to result in abnormal gait or abnormal spinal contour. At the April 2014 VA examination, the Veteran's forward flexion was limited to 90 degrees, his combined range of motion of the thoracolumbar spine was 240 degrees, he had no ankylosis in the spine, and no muscle spasm or guarding resulting in abnormal gait or abnormal spinal contour. VA and private treatment records do not contain any information to support a higher rating during this time period. For instance, VA treatment records consistently documented normal gait. Accordingly, the Veteran is not entitled to a disability rating in excess of 10 percent for his service-connected lumbar spine disability prior to October 22, 2019. Effective October 22, 2019, the Veteran's private chiropractic records show forward flexion of 60 degrees, which is sufficient to raise the Veteran's rating to 20 percent earlier than the currently assigned date of January 2, 2020. Since October 22, 2019, the evidence has not demonstrated forward flexion of the thoracolumbar spine of 30 degrees or less, or any type of ankylosis affecting the spine. At the January 2020 and July 2020 VA examination, ankylosis of the spine was not noted and forward flexion was not limited to less than 55 degrees. The Veteran's VA and private treatment records also fail to show ankylosis of the spine or forward flexion of the thoracolumbar spine of 30 degrees or less. Accordingly, the Veteran is not entitled to a disability rating in excess of 20 percent since October 22, 2019 for his service-connected lumbar spine disability. The Board now turns to the appropriate rating for the Veteran's related neurological symptoms. As noted above, the Veteran has been awarded a 10 percent rating for left leg radiculopathy since February 6, 2019, and a 10 percent rating for right leg radiculopathy since February 6, 2019, raised to 20 percent, effective July 30, 2020. Neither the Veteran nor his representative has challenged the ratings or effective dates assigned for these disabilities. Prior to February 6, 2019, the Board finds no probative evidence establishing neurological abnormalities in either leg, and a rating for such is denied. The Veteran's lower extremity radiculopathy is rated under Diagnostic Code 8520. Diagnostic Code 8520 provides a 10 percent rating for mild incomplete paralysis of the sciatic nerve; a 20 percent rating for moderate incomplete paralysis of the sciatic nerve; a 40 percent rating for moderately severe incomplete paralysis of the sciatic nerve; a 60 percent rating for severe incomplete paralysis of the sciatic nerve with marked muscular atrophy; or an 80 percent rating for complete paralysis of the sciatic nerve (where the foot dangles and drops, no active movement possible of muscles below the knee, flexion of the knee weakened or (very rarely) lost). In addition, in rating peripheral nerve injuries and their residuals, attention should be given to the site and character of the injury, the relative impairment and motor function, trophic changes, or sensory disturbances. 38 C.F.R. § 4.120. The words "mild," "moderate," "moderately severe," and "severe" as used in Diagnostic Code 8520 are not defined in the VA Schedule for Rating Disabilities. However, mild is generally defined as "not severe." Merriam-Webster's Dictionary (merriam-webster.com/dictionary, accessed May 3, 2021). Moderate is generally defined as "tending toward the mean or average amount." Id. Severe is generally defined as "of a great degree." Id. The use of such terminology by VA examiners, although an element of evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision that is "equitable and just." 38 C.F.R. §§ 4.2, 4.6. After a complete review of the evidence, the Board finds that the Veteran's 10 percent rating for left leg radiculopathy since February 6, 2019 is appropriate. At the January 2020 VA examination, the Veteran experienced minor sensation deficits, but muscle testing and reflex examinations were normal. He reported mild pain, paresthesias/dysesthesias, and numbness. The March 2020 VA peripheral nerve exam showed normal findings in the left lower extremity. At the July 2020 VA examination, muscle testing, sensation, and reflex examinations were normal, and the Veteran reported no radiculopathy symptoms on the left side. Reviewing the above evidence, the Board finds that the Veteran's left lower extremity radiculopathy has most closely approximated mild incomplete paralysis of the sciatic nerve commensurate with the currently assigned 10 percent rating. To this end, an initial rating in excess of 10 percent for the Veteran's service-connected left leg radiculopathy is denied. Regarding the right lower extremity, the January 2020 VA examination showed normal muscle testing, sensation, and reflex findings, and no signs of right leg radiculopathy. Similarly at the March 2020 VA peripheral nerves examination, no neurological signs were observed in the right extremity. However, at the July 2020 VA examination, reflex and muscle testing was normal, but sensation was decreased on the right side. The Veteran experienced mild constant pain but moderate paresthesias/dysesthesias and numbness in the right lower extremity. Given these findings, the evidence supports a 10 percent rating at maximum for mild right leg radiculopathy prior to the July 2020 VA examination. At this examination, the findings were most consistent with moderate incomplete paralysis of the sciatic nerve, and it was appropriate for the RO to assign a 20 percent rating, but no higher, as of the date of the examination, July 30, 2020. Accordingly, the Veteran's appeal seeking an initial disability rating in excess of 10 percent prior to July 30, 2020, and in excess of 20 percent thereafter, for the Veteran's service-connected right leg radiculopathy is denied. The evidence does not show any other neurological abnormalities such as bladder/bowel incontinence during the appellate period. In adjudicating the above claims involving the Veteran's rating for his service-connected lumbar spine disability and related lower extremity neurological symptoms, the Board has considered the Veteran's February 2019 hearing testimony. However, it was general in nature and the symptoms described are already contemplated by the ratings currently assigned or granted in this decision. 9. Entitlement to an initial disability rating in excess of 10 percent for the Veteran's service-connected left knee strain is denied. The Veteran is currently receiving a 10 percent rating for his service-connected left knee disability under Diagnostic Code 5260, 38 C.F.R. § 4.71a. He seeks a higher initial rating on appeal. Initially, the Board notes that the Veteran has never experienced degenerative/traumatic arthritis, ankylosis, a meniscal disability, tibia/fibula impairment, or genu recurvatum in the left knee. Thus, Diagnostic Codes 5003, 5010, 5256, 5258, 5259, 5262 and 5263 are not for application. The February 2021 regulatory changes did not impact Diagnostic Code 5260 or 5261, which rate based on limitation of flexion and extension, respectively. Under Diagnostic Code 5260, a 10 percent rating is warranted for flexion limited to 45 degrees; a 20 percent rating is warranted for flexion limited to 30 degrees; and a 30 percent rating is warranted for flexion limited to 15 degrees. Under Diagnostic Code 5261, a 10 percent rating is warranted for extension limited to 10 degrees; a 20 percent rating is warranted for extension limited to 15 degrees; a 30 percent rating is warranted for extension limited to 20 degrees; a 40 percent rating is warranted for extension limited to 30 degrees; and a 50 percent rating is warranted for extension limited to 45 degrees. Prior to the February 2021 regulatory changes, recurrent subluxation and lateral instability of the knee warranted a 10, 20, or 30 percent rating if slight, moderate, or severe, respectively. 38 C.F.R. § 4.71a, Diagnostic Code 5257. "Slight," as relevant to a physical condition, is defined as "small of its kind or in amount." Merriam-Webster's Dictionary (merriam-webster.com/dictionary, accessed May 3, 2021). It is similar to "mild," which is defined as "not severe" or temperate; with "Temperate" being defined as "keeping or held within limits" and "not extreme or excessive." "Moderate" is defined as "tending toward the mean or average amount," "not violent, severe, or intense," and "limited in scope or effect." Id. "Severe" is defined as "very painful or harmful" or "of a great degree." Id. Within the context of the old version of Diagnostic Code 5257, which established a successive, tiered rating structure, "severe" represented the highest or most extreme level of disability. As of February 7, 2021, Diagnostic Code 5257 contains two sections for rating other impairment of the knee. 38 C.F.R. § 4.71a, Diagnostic Code 5257. The first is for recurrent subluxation or instability. The second is for patellar instability. Regarding recurrent subluxation and instability, a compensable rating requires persistent instability. Id.; see also 38 C.F.R. § 4.31. "Persistent" is defined as "continuing or inclined to persist in a course" with "continuing" defined as "constant" and "persist" defined as "to continue to exist." Merriam-Webster's Dictionary (merriam-webster.com/dictionary, accessed May 3, 2021). Under these criteria, a 30 percent rating is assigned with unrepaired or failed repair of complete ligament tear which causes persistent instability and a medical provider prescribes both an assistive device (e.g., cane(s), crutch(es), walker) and bracing for ambulation. A 20 percent rating is assigned with either (a) Sprain, incomplete ligament tear, or repaired complete ligament tear causing persistent instability, and a medical provider prescribes a brace and/or assistive device for ambulation, or (b) Unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribes either an assistive device or bracing for ambulation. A 10 percent rating is assigned for sprain, incomplete ligament tear, or complete ligament tear (repaired, unrepaired, or failed repair) causing persistent instability without a prescription from a medical provider for an assistive device or bracing for ambulation. Regarding patellar instability, 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 warrants a 30 percent rating, which is the highest allowable rating for patellar instability. A diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for a brace, cane, or walker warrants a 20 percent rating. A diagnosed condition involving the patellofemoral complex with recurrent instability (with or without history of surgical repair) that does not require a prescription from a medical provider for a brace, cane, or walker warrants a 10 percent rating. The patellofemoral complex consists of the quadriceps tendon, the patella, and the patellar tendon. 38 C.F.R. § 4.71a, Diagnostic Code 5257, Note (1). A surgical procedure that does not involve repair of one or more patellofemoral components that contribute to the underlying instability shall not qualify as surgical repair for patellar instability (including, but not limited to, arthroscopy to remove loose bodies and joint aspiration). Id., Note (2). The Veteran was afforded a VA examination of the left knee in April 2014. He reported that he experienced pain with prolonged standing and intermittent incidents of his knees giving out. He did not report flare-ups. Range of motion testing showed left knee flexion of 140 degrees or greater, with painful motion beginning at the endpoint, and no left knee extension (0 degrees). Repetitive use testing was completed and did not result in additional limitation of motion. Muscle strength testing was normal. Joint stability testing, including anterior instability, posterior instability, and medial-lateral instability, were normal. There was no evidence of patella subluxation/dislocation or meniscal disability. The Veteran attended a second VA examination of the left knee in January 2020. The Veteran reported left knee discomfort and the use of a brace. He reported mild flare-ups occurring biweekly, lasting 2 days, and precipitated by prolonged walking and standing. His symptoms were alleviated by rest and use of a knee brace. The Veteran did not report any specific functional loss/impairment of the joint/extremity. Range of motion testing showed flexion limited to 130 degrees and no extension (0 degrees). There was no pain noted on examination, to include during active/passive range of motion testing or with weightbearing or non-weightbearing. There was no evidence of crepitus. Repetitive use testing was conducted and resulted in no additional limitation of motion following three repetitions. The VA examiner found that pain, weakness, fatigability, and incoordination would not result in additional limitation of motion with flare-ups or repeated use over time. Muscle strength testing was normal; there was no ankylosis; and joint stability testing, including anterior, posterior, medial, and lateral instability testing, was normal in the left knee. There was no evidence of patellar subluxation/dislocation or meniscal disability. The Veteran was afforded a final VA examination of the left knee in November 2020. He did not report flare ups. Range of motion in the left knee was normal, from 0 to 140 degrees, with pain noted during flexion. There was no pain with weightbearing or non-weightbearing. There was no pain during passive range of motion testing. There was objective evidence of crepitus. Repetitive use testing did not reveal additional limitation of motion following three repetitions. Muscle strength testing was normal, there was no ankylosis, and joint stability testing, including anterior, posterior, lateral, and medial instability tests, were normal. There was no evidence of patellar subluxation/dislocation or meniscal disability. The Board has fully reviewed the relevant VA examinations, VA treatment records, private treatment records, and lay evidence, and it does not establish that the Veteran ever experienced left knee extension limited to 10 degrees or greater. At the April 2014, January 2020, and November 2020 VA examinations, left knee extension was 0 degrees. VA and private treatment records do not demonstrate compensable limitation of extension. As such, Diagnostic Code 5261 is not for application. Regarding left knee flexion, the Veteran has never exhibited flexion limited to 30 degrees or less to achieve a higher 20 or 30 percent rating under Diagnostic Code 5260. In the May 2014 rating decision, the Veteran was assigned a 10 percent rating under Diagnostic Code 5260 based solely on painful motion, despite no compensable limitation of flexion. Contra Thompson, 815 F.3d at 786. During the appellate period, the Veteran's left knee flexion has been limited to 130 degrees, at most, even considering flare-ups and repeated use over time. The Veteran is not entitled to higher disability rating based on limitation of flexion during the appellate period. At the May 2014 VA examination, the Veteran reported his knee giving out, and at the January 2020 VA examination, the Veteran reported using a knee brace. These contentions raise the prospect of whether the Veteran is entitled to a separate rating based on left knee instability during the appellate period. The Board has fully reviewed and weighed the evidence, and for the reasons below, the Board finds that a separate rating for left knee instability is not in order. The evidence does not probatively establish that the Veteran is entitled to a rating for left knee instability under the old rating criteria for knee instability during the appellate period. The Veteran is competent to report that he experiences a sensation of his left knee giving way as this is within the realm of his personal perception. See Layno, 6 Vet App. at 469; see also English v. Wilkie, 30 Vet. App. 347 (2018)(suggesting that lay evidence of knee instability is generally competent). However, the Veteran's lay reports regarding his claimed left knee instability and required brace use are not credible when considered with the other evidence in the appellate record. For example, the April 2014, January 2020, and November 2020 VA examiners found no clinical evidence of left knee instability. A review of the Veteran's private and VA treatment records document reports of chronic knee pain, however, there is no evidence that the Veteran ever reported left knee instability to his treatment providers, or that any of these providers prescribed or told the Veteran that his condition required the use of knee bracing. In fact, the Veteran's private chiropractic records contain a detailed list of the Veteran's subjective orthopedic complaints, and they do not include any reports of left knee instability or weakness. Given the extent of the subjective orthopedic symptoms reported, it is reasonable to assume the Veteran would have reported left knee instability, if it was present. The absence of this expected evidence weighs against the Veteran's assertions. See Kahana v. Shinseki, 24 Vet. App. 428, 440 (2011) (Lance, J., concurring) (holding that silence in a medical record can be weighed against lay testimony if the alleged injury, disease, or related symptoms would ordinarily have been recorded in the medical record being evaluated by the fact finder (citing Fed. R. Evid. 803 (7))); see AZ v. Shinseki, 731 F.3d 1303 (Fed. Cir. 2013) (recognizing the widely held view that the absence of an entry in a record may be considered evidence that the fact did not occur if it appears that the fact would have been recorded if present). The Board finds the Veteran's lay reports of instability to be inconsistent with the other evidence of record. See Madden v. Gober, 125 F.3d 1477, 1481 (1997) (finding the Board entitled to discount the credibility of evidence in light of its own inherent characteristics and its relationship to other items of evidence). Regarding application of the new rating criteria for knee instability, the Board finds that a rating is not warranted for recurrent subluxation or instability due to the lack of evidence showing persistent instability. A single noncredible lay report of instability does not reach the duration and frequency necessary to be considered a peristent finding. Regarding patellar instability, the Board finds no evidence showing that the Veteran has been prescribed a brace, cane, or walker; thus precluding a 20 or 30 percent rating. While the Veteran has been diagnosed with patellofemoral pain syndrome, much like the analysis for instability under the rating criteria in effect prior to the regulatory change, the Veteran's lay reports of instability do not comport with the other evidence of record, and thus, even in the absence of a prescribed ambulating assistance device, the evidence does not support a separate rating for recurrent instability. In adjudicating the Veteran's claim seeking a higher initial disability rating for his left knee disability, the Board has considered the Veteran's hearing testimony. However, this testimony was general in nature and the symptoms described, including physical deficits and limitation of motion due to knee pain, is already contemplated by his current 10 percent rating. In sum, the evidence does not support the award of a rating in excess of 10 percent for the Veteran's service-connected left knee disability. As the preponderance of the evidence weighs against the claim, the benefit of the doubt doctrine is not applicable. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3; Gilbert, 1 Vet. App. at 53. Accordingly, the Veteran's appeal seeking an initial disability rating in excess of 10 percent for his service-connected left knee strain is denied. 10. Entitlement to an initial disability rating in excess of 10 percent for the Veteran's service-connected right ankle lateral collateral ligament sprain is denied. The Veteran is currently receiving a 10 percent rating for his service-connected right ankle disability under Diagnostic Code 5271, 38 C.F.R. § 4.71a. He seeks a higher initial disability rating on appeal. Under Diagnostic Code 5271, prior to the musculoskeletal regulatory changes, a 10 percent rating was warranted for moderate ankle limitation of motion, and a 20 percent rating was warranted for marked ankle limitation of motion. The February 2021 regulatory changes clarified these criteria, by defining the term "marked" as less than 5 degrees dorsiflexion or less than 10 degrees plantar flexion, and defining the term "moderate" as less than 15 degrees dorsiflexion or less than 30 degrees plantar flexion. The Board finds the regulatory changes to be immaterial because prior to their effect, the Veterans Benefits Administration had already issued guidance in the M21-1 Adjudication Procedures Manual defining marked and moderate in Diagnostic Code 5271 as including the ranges of motion now explicitly set forth in the regulation. The M21-1 is not binding on the Board and, to rely on the M21-1, the Board must conduct an independent analysis before determining whether the provisions may be relied upon as a factor to support its decision. Overton v. Wilkie, 30 Vet. App. 257 (2018). For the period prior to the regulatory changes, the Board finds that the M21-1 may be relied upon as a factor based on the proposed revisions to Diagnostic Code 5271 issued in February 2003 and August 2017. See 68 Fed. Reg. 6998 (Feb. 11, 2003); 82 Fed. Reg. 35719 (Aug. 1, 2017). In February 2003, VA hired an outside consultant, who convened a panel of non-VA specialists, to review the portion of the rating schedule dealing with the musculoskeletal system to formulate recommendations. VA proposed to adopt many of the recommendations, including defining "moderate" and "marked" similarly to what is in the current version of the regulation, to ensure consistent evaluations. See 68 Fed. Reg. at 7018. In August 2017, VA proposed to redefine "moderate" and "marked" exactly as listed in the M21-1 and the proposal noted that "as VA currently uses these standards to define marked and moderate, this change is intended as a clarification of current policy and would ensure consistent application of these criteria among rating personnel." See 82 Fed. Reg. at 35723. The changes described in the August 2017 proposed rule were adopted in the final rule that went into effect on February 7, 2021. See 85 Fed. Reg. 76453 (Nov. 30, 2020). As such, the Board finds the M21-1 guidance on the definition of "moderate" and "marked" prior to the regulation changes to be persuasive, and thus defines those terms accordingly, and consistent with the updated regulatory changes. The Veteran was afforded a VA examination in April 2014 to assess the severity of his right ankle disability. The Veteran reported that his ankle hurt at times when running. He reported flare-ups with excessive running and standing on hard and uneven surfaces. The Veteran did not report function loss/impairment in the joint/extremity. Range of motion was normal for the right ankle (20 degrees dorsiflexion and 45 degrees plantar flexion). See 38 C.F.R. § 4.71, Plate II. Repetitive use testing was performed, and following three repetitions, there was no additional limitation of motion. Pain was not present during active, passive, or repetitive use testing. There was no pain with weightbearing or non-weightbearing. There was no localized tenderness or pain on palpation of the joint. Muscle strength testing was normal and there was no ankylosis or joint instability/dislocation. The Veteran did not have shin splints, stress fractures, Achilles tendonitis, an Achilles tendon rupture, malunion of the calcaneus (os calcis) or talus (astragalus), or an astragalectomy. The Veteran was afforded an additional VA examination of the right ankle in January 2020. The Veteran reported mild flare-ups occurring weekly and lasting one day. The flare-ups were precipitated by prolonged walking/standing. The flare-ups were alleviated by rest and bracing. Range of motion testing was normal (dorsiflexion to 20 degrees and plantar flexion to 45 degrees) and there was no pain on examination (passive or active range of motion or weightbearing or non-weightbearing). There was mild tenderness on the deltoid ligament and the Achilles tendon. Repetitive use testing was conducted, and following three repetitions, there was no additional limitation of motion. The examiner stated that pain, weakness, fatigability, or incoordination would not significantly limit functional ability, including additional limitation of motion, with repeated use over time or during flare-ups. Muscle strength testing was normal and there was no ankylosis. Joint stability testing revealed a positive talar tilt test. The Veteran did not have shin splints, stress fractures, an Achilles tendon rupture, malunion of the calcaneus (os calcis) or talus (astragalus), or an astragalectomy; but he exhibited mild tenderness to the right Achilles tendon. The Board has reviewed the Veteran's private and VA treatment records, and aside from infrequent reports of right ankle pain, they do not show any clinical findings more severe than those documented at the April 2014 and January 2020 VA examinations. At no point during the appellate period has the Veteran's right ankle disability been manifested by ankylosis of the ankle; ankylosis of the subastragalar or tarsal joint; malunion of the os calcis or astragalus; or an astragalectomy. As such, Diagnostic Codes 5270, 5272, 5273, and 5274 are not for application. Regarding Diagnostic Code 5271, the evidence does not show that the Veteran's right ankle ever resulted in marked limitation of motion. In fact, at both VA examinations, the Veteran exhibited normal range of motion in the left ankle (dorsiflexion to 20 degrees and plantar flexion to 45 degrees). There was no indication of additional limitation of motion during flare-ups or after repeated use. While the January 2020 VA examiner noted joint instability in the right ankle and a tender Achilles tendon, it did not result in limitation of motion severe enough to warrant a higher 20 percent rating under Diagnostic Code 5271. The Veteran's disability picture is consistent with his currently assigned 10 percent rating under Diagnostic Code 5271 for the entire appellate period. None of medical or lay evidence established that the Veteran's right ankle disability resulted in marked impairment demonstrated by less than 5 degrees dorsiflexion or less than 10 degrees plantar flexion in the right ankle during the appellate period. As the preponderance of the evidence weighs against the claim, the benefit of the doubt doctrine is not for application. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3; Gilbert, 1 Vet. App. at 53. Accordingly, the Veteran's appeal seeking an initial disability rating in excess of 10 percent for his service-connected right ankle lateral collateral ligament sprain is denied. 11. Entitlement to an initial disability rating in excess of 10 percent prior to January 2, 2020, a compensable rating from January 2, 2020 to November 8, 2020, and in excess of 10 percent thereafter, for the Veteran's service-connected lateral epicondylitis, status post non-displaced fracture of the radial head of the right elbow, based on limitation of flexion is denied. 12. Entitlement to an initial disability rating in excess of 20 percent from January 2, 2020 to November 8, 2020, and entitlement to compensable rating from November 9, 2020 for the Veteran's service-connected lateral epicondylitis, status post non-displaced fracture of the radial head of the right elbow, based on limitation of pronation is denied. In the May 2014 rating decision, the Veteran was awarded service connection for a right elbow disability and assigned an initial noncompensable disability rating utilizing Diagnostic Code 5206, 38 C.F.R. § 4.71a. He appealed, and in November 2020, the RO issued a rating decision granting a higher 10 percent rating prior to January 2, 2020, and from November 9, 2020. The November 2020 rating decision kept the Veteran's right elbow rating as noncompensable from January 2, 2020 to November 8, 2020. The November 2020 rating decision also granted service connection for right elbow impairment of proration utilizing Diagnostic Code 5213, and assigned a 20 percent rating from January 2, 2020 to November 8, 2020, and a noncompensable rating thereafter. The Veteran seeks higher initial ratings on appeal. The February 2021 regulatory changes did not impact the codes for rating elbow injuries/diseases. Disabilities of the elbow generally are rated under Diagnostic Codes 5205-5213. Initially, the Board notes that the Veteran's right elbow has never been manifested by arthritis, ankylosis; extension limited to 45 degrees or greater; forearm flexion limited to 100 degrees and extension to 45 degrees; impairment of the flail joint; or impairment of the radius or ulna, to include flail false joint, nonunion, or malunion. Accordingly, Diagnostic Codes 5003, 5205, 5207, 5208, 5209, 5210, 5211, and 5212 are not for application. Diagnostic Code 5206 rates based on forearm limitation of flexion. Given that the Veteran is right handed, a noncompensable rating is assigned for elbow flexion limited to 110 degrees, a 10 percent rating is warranted for elbow flexion limited to 100 degrees; a 20 percent rating is warranted for elbow flexion limited to 90 degrees; a 30 percent rating is warranted for elbow flexion limited to 70 degrees; a 40 percent rating is warranted for elbow flexion limited to 55 degrees, and a maximum 50 percent rating is warranted for elbow flexion limited to 45 degrees. Diagnostic Code 5213 rates based on impairment of supination and pronation. As applicable to the current matter, limitation of pronation characterized by motion lost beyond last quarter of the arc, where the hand does not approach full pronation, in the major extremity warrants a 20 percent evaluation. Pronation lost beyond the last the middle of the arc in the major extremity warrants a 30 percent evaluation. 38 C.F.R. § 4.71a, Diagnostic Code 5213. The Veteran has never experienced loss of bone fusion or supination limited to 30 degrees or less in the right elbow. Thus, the Veteran cannot achieve higher or separate ratings under Diagnostic Code 5213 using these bases during the appellate period. The Veteran's right elbow disability was assessed at an April 2014 VA examination. The Veteran reported that his right elbow felt tender and strained, at times. He did not report flare-ups. Range of motion testing showed right elbow flexion of 145 degrees or greater, with no objective evidence of pain, and no limitation of extension. Right elbow pronation was 80 degrees or greater, and right elbow supination was 85 degrees or greater, both without objective evidence of painful motion. Repetitive use testing was performed, and following three repetitions, there was no additional limitation of motion. Physical examination revealed tenderness at the right lateral epicondyle. Muscle strength testing was normal and there was no ankylosis. The Veteran did not have a flail joint, joint fracture and/or impairment of supination or pronation. The Veteran did not have degenerative arthritis. The Veteran attended a second VA examination in January 2020 assessing his service-connected right elbow disability. The Veteran reported mild flare-ups occurring every other week, lasting a day, and precipitated by overuse of the elbow or use of hand tools. Symptoms were alleviated by rest. The Veteran did not report specific functional loss/impairment in the joint/extremity. Range of motion showed flexion limited to 110 degrees, extension limited to 10 degrees, forearm supination limited to 85 degrees, and forearm pronation limited to 50 degrees. Pain was only noted on forearm pronation, and it is assumed that it began at the endpoint. There was no pain on passive motion, weightbearing, or non-weightbearing, and there was no crepitus. Repetitive use testing was performed and did not result in additional limitation of motion following three repetitions. The VA examiner estimated that repeated use over time and flare-ups would not result in additional limitation of motion, despite pain. Muscle strength testing was normal and there was no ankylosis. The Veteran did not have a flail joint, joint fracture, ununited fracture, malaligned fracture, or any impairment of supination or pronation. There was no arthritis. The Veteran attended a final VA examination in November 2020 to assess his right elbow disability. The Veteran reported chronic pain and denied flare-ups. He reported pain in the right elbow with lifting. Range of motion testing showed flexion limited to 145 degrees, extension limited to 10 degrees, forearm supination limited to 85 degrees, and forearm pronation limited to 80 degrees. Pain was noted on extension testing. There was moderate tenderness/pain in the lateral epicondyle. Repetitive use testing was conducted and did not result in additional limitation of motion after three repetitions. The exam was consistent with functional loss following repeated use over time. Muscle strength testing was normal with right elbow flexion, but slightly diminished with right elbow extension. There was no ankylosis. There was no flail joint, joint fracture, ununited fracture, malaligned fracture, or impairment of supination or pronation. There was no arthritis. The Veteran's private and VA treatment records, as well as his Board hearing testimony, do not provide any meaningful information relevant to rating the Veteran's service-connected right elbow disability under the rating schedule. For the period prior to January 2, 2020, the Veteran never experienced right elbow flexion limited to 90 degrees or less, or limitation of pronation resulting in motion lost beyond last quarter arc or lost beyond middle arc. When the RO granted the higher 10 percent rating under Diagnostic Code 5206 in the November 2020 rating decision, they relied solely on the April 2014 VA examination's finding of right elbow tenderness. The results of the April 2014 VA examination did not show compensable limitation of flexion or limitation of pronation. The Board finds no probative record evidence to support the RO's grant of a 10 percent rating, but the Board shall not disturb this favorable finding. The evidence does not support a higher rating under Diagnostic Code 5206 due to limitation of flexion during this time period, and the Board finds no error in the RO's denial of a separate rating based on Diagnostic Code 5213 during this period. Beginning from January 2, 2020 through November 8, 2020, the Veteran was assigned a noncompensable rating based on limitation of flexion in the right elbow, and a 20 percent rating based on limitation of pronation. These ratings were based on the results of the January 2020 VA examination, which showed flexion limited to 110 degrees, but without pain. This range of motion finding is commensurate with a noncompensable rating under Diagnostic Code 5206, and the evidence does not support a higher rating during this time period. Regarding impairment of pronation, the evidence showed pronation limited to 50 degrees, with motion lost beyond last quarter arc, where the hand did not approach full pronation. There was no evidence of pronation limited to the extent that motion was lost beyond the middle of the arc. The evidence does not support a higher rating under Diagnostic Code 5213 during this time period. Beginning November 9, 2020, the Veteran was assigned a 10 percent rating based on limitation of flexion in the right elbow, and a noncompensable rating for limitation of pronation, based on the results of the November 2020 VA examination. At this examination, right elbow flexion was limited 145 degrees, with moderate tenderness in the lateral epicondyle. These findings are commensurate with a noncompensable rating under Diagnostic Code 5206. The Board shall not disturb the RO's favorable finding of a 10 percent rating; however the evidence does not support a higher rating during this time period. Regarding limitation of pronation, the November 2020 VA examination showed pronation limited to 80 degrees, which is normal. There was no evidence of motion lost beyond last quarter arc or lost beyond middle arc to support a higher rating under Diagnostic Code 5213 during this time period. In adjudicating this claim, the Board recognizes that the RO granted a 10 percent rating for limitation of flexion, lowered it to noncompensable for a period, and then raised it again to 10 percent. Likewise, the RO granted a 20 percent rating for impairment of pronation for a period, but then lowered it to noncompensable. The RO did this utilizing the staged rating process, a practice that accounts "for the possible dynamic nature of a disability while the claim works its way through the adjudication process." O'Connell v. Nicholson, 21 Vet. App. 89, 93 (2007). As the Veteran's claims were never reduced during the appellate period below what was originally granted in the May 2014 rating decision, which was a single noncompensable rating for the Veteran's service-connected right elbow disability, the laws and procedural protections for rating reductions are not for application. Id. In sum, the evidence preponderates against ratings higher than those currently in effect for the Veteran's service-connected right elbow disability. As the evidence weighs against the Veteran's claims, the benefit of the doubt doctrine is not for application. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3; Gilbert, 1 Vet. App. at 53. Consequently, the Veteran's appeal seeking an initial disability rating in excess of 10 percent prior to January 2, 2020, a compensable rating from January 2, 2020 to November 8, 2020, and in excess of 10 percent thereafter, for his service-connected right elbow disability based on limitation of flexion is denied. Likewise, the appeal seeking an initial disability rating greater than 20 percent from January 2, 2020 to November 8, 2020, and an initial compensable rating thereafter, for the Veteran's service-connected right elbow disability based on limitation of pronation is denied. REASONS FOR REMAND 1. Entitlement to service connection for a left shoulder disability is remanded. At the April 2014 VA shoulder/arm examination, the Veteran was not diagnosed with a left shoulder disability and range of motion was normal in the left shoulder. A private medical opinion from a chiropractor was received in January 2019 which stated that the Veteran had orthopedic symptomatology of the shoulders related to his active duty service. This medical opinion was conclusory and unsupported by an explanatory rationale. Thus, it has no probative value and cannot resolve the Veteran's appeal. VA treatment records from December 2017 document complaints of left shoulder pain, and contain magnetic resonance imaging showing anterior glenolabral articular disruption with an anterior labral tear, some chondral fissuring, and minimal glenohumeral and AC joint arthritis. See also December 2017 radiograph showing subchondral irregularity of the distal clavicle. In November 2020, the RO obtained a VA medical opinion addressing whether the Veteran's left shoulder disability was incurred during service, or was otherwise secondary to his service-connected right shoulder disability pursuant to 38 C.F.R. § 3.310. The VA examiner issued a negative opinion on direct service connection. The VA examiner acknowledged the Veteran's in-service motorcycle accident and stated that he took the brunt of the fall to his right side, to include his right shoulder, elbow, and knee. The VA examiner stated that the Veteran complained of bilateral shoulder pain at service separation, but the exam was normal. It was not until a magnetic resonance image in 2017 that the Veteran exhibited left shoulder pathology. The VA examiner stated the 4-year gap between separation and the first objective radiologic evidence of left shoulder disability, weighed against medical nexus. The Board has reviewed the record, and finds this medical opinion to be based on an inaccurate factual premise. See Reonal v. Brown, 5 Vet. App. 458, 461 (1993) ("An opinion based upon an inaccurate factual premise has no probative value."). Contrary to the VA examiner's statements, the September 2013 exit examination documented more than the Veteran's lay reports of bilateral shoulder pain. The clinical evaluation of the left shoulder was not normal, as the VA examiner alleged. Instead, it clearly documented limited range of motion in the bilateral shoulders and pain with resistance. Given this evidentiary issue, the Board finds that a new VA medical opinion is warranted. Regarding secondary service connection, the November 2020 VA examiner also denied a nexus. The VA examiner stated that the Veteran's left shoulder injury was of a greater magnitude and severity than what would be observed had it simply been the result of wear and tear due to favoring the left shoulder over the service-connected and injured right shoulder. While the Board finds this opinion to be adequate and supported by a plausible explanation, the VA examiner did not provide an opinion on secondary aggravation as required by 38 C.F.R. § 3.310(b). See El-Amin v. Shinseki, 26 Vet. App. 136, 140 (2013) (a secondary service connection medical opinion is insufficient when it fails to adequately address the question of aggravation); see also Ward v. Wilkie, 31 Vet. App. 233, 239 (2019) (holding that aggravation under 38 C.F.R. § 3.310(b) does not require that there be "permanent worsening" of the nonservice-connected disability. Instead, secondary service connection is warranted for "any incremental increase in disabilityany additional impairment of earning capacityin nonservice-connected disabilities resulting from service-connected conditions, above the degree of disability existing before the increaseregardless of its permanence."). Lastly, the RO is requested to obtain any outstanding VA treatment records from July 2020 to the present, if such evidence exists. See38 C.F.R. § 3.159(c)(2) and (3). The matter is REMANDED for the following action: 1. Obtain the Veteran's VA treatment records for the period from July 2020 to the present, if such evidence exists. 2. Then, obtain an addendum opinion from an appropriate VA examiner addressing the nature of the Veteran's current left shoulder disability. Following a complete review of the electronic claims file, including a copy of this REMAND, the VA examiner is requested to address the following inquiries: (a.) Is it at least as likely as not (50 percent probability or greater) that the Veteran's current left shoulder disability was incurred in or is otherwise etiologically related to the Veteran's active duty service, to include his August 2013 motorcycle injury? In forming an opinion, the VA examiner is requested to address the clinical findings at the September 2013 service separation examination which documented limited range of motion in the left shoulder and pain with resistance. (b.) Is it at least as likely as not (50 percent probability or greater) that the Veteran's left shoulder underwent any incremental increase in disability, regardless of its permanence, due to the Veteran's service-connected right shoulder disability? The term "incremental increase in disability" means additional impairment of earning capacity. Objective measurement, or numerical quantification, is not required to ascertain an increase in disability. Moreover, any "incremental increase in disability" need not be permanent. [Continued on Next Page] The VA examiner must provide a complete rationale for any opinion expressed that is based on the examiner's clinical experience and medical expertise; established medical principles; and citation to the evidence of record, as appropriate. Cynthia M. Bruce Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Galante 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.