Citation Nr: 21031464
Decision Date: 05/22/21	Archive Date: 05/22/21

DOCKET NO. 20-14 303
DATE: May 22, 2021

ORDER

Service connection for a hormone imbalance, to include diabetes mellitus, type 1, infertility, and hair loss, is denied.

A compensable rating for keloid chest scars is denied.

A disability rating in excess of 10 percent for a right knee strain is denied.

A disability rating in excess of 30 percent for posttraumatic stress disorder (PTSD) is denied.

A disability rating in excess of 10 percent for a right wrist strain status post-ganglionectomy, is denied.

A compensable rating for diverticulitis is denied.

REMANDED

Entitlement to service connection for a right knee disorder, to include an anterior cruciate ligament (ACL) tear, medial meniscus tear, and patellar fracture, as secondary to the service-connected right knee strain is remanded.

Entitlement to service connection for a left knee disorder is remanded.

Entitlement to service connection for a right knee scar is remanded.

Entitlement to service connection for a left thumb disorder is remanded.

Entitlement to service connection for a skin disorder is remanded.

FINDINGS OF FACT

1. The Veteran has a current disability of diabetes mellitus, type 1.

2. The Veteran's hair loss is a developmental defect and not a disability for VA compensation purposes.

3. The Veteran's diabetes mellitus, type 1, was not chronic in service, was not manifest within one year of separation from service, and has not been symptomatic continuously since service.

4. The Veteran's diabetes mellitus, type 1, and infertility are not related to any incident of service to include vaccinations and medications administered by the Army.

5. For the entire appeal period, the Veteran has two chest keloid scars that are not painful or unstable, and do not affect the head, face, or neck, are not deep or associated with underlying soft tissue damage, are not of a size to warrant a compensable rating, and do not result in any additional disabling effects.

6. For the entire appeal period, the Veteran's right knee strain is manifested by limitation of flexion to 125 degrees and full extension, even in contemplation of functional loss due to symptoms such as pain, fatigue, weakness, lack of endurance, or incoordination, or as a result of repetitive motion and/or flare-ups, without ankylosis, lateral instability or recurrent subluxation, removal or dislocation of semilunar cartilage, impairment of the tibia or fibula, or genu recurvatum.

7. For the entire appeal period, the Veteran's PTSD is productive of occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks.

8. For the entire appeal period, the Veteran's right wrist disability is manifested by pain and limitation of motion, without ankylosis or loss of use of the hand.

9. For the entire appeal period, the Veteran's diverticulitis has been asymptomatic and is not shown to have been manifested by symptoms or impairment consistent with moderate ulcerative colitis, more than mild irritable colon syndrome, or more than mild peritoneal adhesions.

CONCLUSIONS OF LAW

1. The criteria for service connection for a hormone imbalance are not met. 38 U.S.C. §§ 1110, 1112, 1117, 5107 (2020); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.317 (2020).

2. The criteria for a compensable rating for keloid chest scars are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.118, Diagnostic Code (DC) 7805.

3. The criteria for a disability rating in excess of 10 percent for a right knee strain are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.27, 4.40, 4.45, 4.59, 4.71a, DC 5260.

4. The criteria for a disability rating in excess of 30 percent for PTSD are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.126, 4.130, DC 9411.

5. The criteria for a disability rating in excess of 10 percent for a right wrist strain status post-ganglionectomy, are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.27, 4.40, 4.45, 4.59, 4.71a, DC 5215.

6. The criteria for a compensable rating for diverticulitis are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.21, 4.31, 4.114, DCs 7327, 7301, 7319, 7323.

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran served on active duty from January 2001 to August 2005. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a January 2019 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO).

Additionally, the Veteran argued for a higher rating for the service-connected tinnitus, believing such was on appeal. However, the Veteran has not filed an appeal as to the assigned rating for tinnitus.

Finally, the Veteran described effects of a skin disorder when discussing his appeal for a compensable rating for his chest scars. He has also referenced the fact that he wanted his underlying skin condition considered in the rating. However, the Veteran's appeal for a compensable rating for his chest scars does not include service connection for any skin disorder. Nonetheless, the Veteran indicated in his claim for an increased rating, that he wished an "increase for skin condition," and he proceeded to describe the effects of his skin condition and note that he wanted compensation for the underlying skin condition in addition to the keloid chest scars. Consequently, the issue of entitlement to service connection for a skin disorder has been added to the appeal. See Bailey v. Wilkie, 33 Vet. App. 188 (2021).

SERVICE CONNECTION

1. Entitlement to service connection for a hormone imbalance.

The Veteran contends that he has a hormone imbalance disorder that is due to his service. Specifically, he contends that an anthrax vaccine may have potentially caused a hormone imbalance, which has resulted in diabetes mellitus, type 1, hair loss, skin issues, and fertility problems. For the reasons that follow, the Board finds the Veteran does not have an undiagnosed illness or medically unexplained multisymptom chronic illness (MUCMI), that the Veteran's hair loss is not a disability for VA purposes, and that his infertility and diabetes mellitus are not shown to be causally or etiologically related to an event, injury, or disease during service, and thus, do not warrant service connection on a presumptive or direct basis. The skin issues are addressed in the Remand section below. Consequently, the Board concludes service connection is not warranted for a hormone imbalance, variously described as diabetes, hair loss, and infertility.

a. Presumptive Service Connection under 38 U.S.C. § 1117

The Veteran's service records show he served in South West Asia during the Persian Gulf War, with deployments in Kuwait and Iraq. Therefore, the Board finds that he is a Persian Gulf War Veteran.

Service connection may be warranted for a Persian Gulf Veteran who exhibits objective indications of a qualifying chronic disability that became manifest during active military, naval or air service in the Southwest Asia theater of operations during the Persian Gulf War, or that became manifest to a degree of 10 percent or more not later than December 31, 2021. 38 C.F.R. § 3.317(a)(1).

For purposes of 38 C.F.R. § 3.317, there are three types of qualifying chronic disabilities: (1) an undiagnosed illness; (2) a medically unexplained chronic multi symptom illness; and (3) a diagnosed illness that the Secretary determines in regulations prescribed under 38 U.S.C. § 1117(d) warrants a presumption of service connection. Neither diabetes mellitus, type 1, nor the hair loss or infertility are diagnosed illnesses for which a presumption of service connection has been created under 38 U.S.C. § 1117(d). 38 C.F.R. § 3.317(a)(2)(i)(B), (c)-(d). 

Presumptive service connection under 38 U.S.C. § 1117(d) is not warranted for diabetes mellitus, type 1. First, the Veteran's diabetes mellitus, type 1, has been clinically diagnosed and, therefore, is not an "undiagnosed illness." 38 C.F.R. § 3.317(a)(1)(ii). Moreover, diabetes is specifically excluded from those conditions which may be considered a MUCMI. 38 C.F.R. § 3.317(a)(2)(ii). 

Presumptive service connection is also not warranted the Veteran's complaints of hair loss and infertility because these have not resulted in disability that is 10 percent or more. 38 C.F.R. § 3.317(a)(1)(i). 

To determine whether the undiagnosed illness is manifested to a degree of 10 percent or more the condition must be rated by analogy to a disease or injury in which the functions affected, anatomical location or symptomatology are similar. See 38 C.F.R. § 3.317(a)(5); see also Stankevich v. Nicholson, 19 Vet. App. 470 (2006).

Focusing first on the allegations of hair loss, there is no evidence that shows such have manifested to a compensable degree at any point following service. Specifically, the hair loss would be appropriately rated as analogous to alopecia, which warrants a noncompensable rating if hair loss is limited to the scalp and face, and a maximum 10 percent rating is warranted for loss of all body hair. 38 C.F.R. § 4.118, DC 7831. Here, the Veteran has only reported that he has lost some hair on the top of his head, which would not warrant a compensable rating.

Similarly, loss of fertility could be rated by analogy to penis deformity under DC 7522 or testis atrophy under DC 7523. 38 C.F.R. § 4.115b. However, in the instant case, the medical evidence of record reflects that the Veteran has not lost his erectile power, deformity of the penis, nor does it show that he has any testicular atrophy. Thus, the Veteran's alleged disability would not be compensable under the Rating Schedule. Presumptive service connection is therefore not available. 38 C.F.R. § 3.317. 

The Board observes that the requirement of a disability manifest to 10 percent or more does not encompass the rating for special monthly compensation (SMC) for loss of use of a creative organ. 38 U.S.C. §§ 1114(k); 1117. The SMC rating is made "independent" of ratings from 10 to 100 percent assigned under the Rating Schedule. 38 U.S.C. § 1114(k). Accordingly, consideration of that award cannot satisfy the requirement that the disability be manifest "to a degree of 10 percent or more" for presumptive service connection. 38 U.S.C. § 1117(a)(1)(B). 

Accordingly, as the Veteran's diabetes is not an undiagnosed illness or a MUCMI, and the reported symptoms of hair loss and sterility have not been shown to be manifest to a compensable degree, the Board concludes that presumptive service connection for an undiagnosed illness manifested by a hormone imbalance is not warranted. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102.

b. Presumptive Service Connection for Chronic Diseases

Additionally, diabetes mellitus is considered a chronic disease under 38 C.F.R. § 3.309. In this regard, where a veteran served for at least 90 days during a period of war or after December 31, 1946, and manifests diabetes mellitus to a degree of 10 percent within one year, from the date of termination of such service, such disease shall be presumed to have been incurred or aggravated in service, even though there is no evidence of such disease during the period of service. 38 U.S.C. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309. Alternatively, when a disease at 38 C.F.R. § 3.309(a) is not shown to be chronic during service or the one-year presumptive period, service connection may also be established by showing continuity of symptomatology after service. See 38 C.F.R. § 3.303(b). 

In the instant case however, the Veteran was diagnosed with diabetes mellitus, type 1, in March 2014, nine years after separation from service, and thus not within the presumptive period. See March 2014 VA Treatment Records. Further, there is no showing in the record or alleged by the Veteran that there were symptoms of diabetes in service, within the presumptive period, or continuously since service. In this regard, the record is silent for diabetes or diabetes-related clinical findings prior to the diagnosis. Therefore, service-connection for a hormone imbalance disorder manifested by diabetes mellitus, type 1, on a presumptive basis as a chronic disease is not warranted. See 38 C.F.R. §§ 3.303(b), 3.307.

Notwithstanding the foregoing, a veteran is not precluded from establishing service connection with proof of direct causation. Combee v. Brown, 34 F.3d 1039, 1042 (Fed. Cir. 1994). In this regard, the Veteran reported his hair loss manifested in service, and he believes the vaccinations and drugs he was given in service caused his hormone imbalance. The Board turns to consider direct service connection.

c. Direct Service Connection

Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). 

i. Current Disability

The Board finds that the Veteran has a current disability of diabetes mellitus, type 1, and will assume for the purposes of this decision that he has a disability resulting in infertility. The Board finds further that the Veteran's hair loss is a developmental defect. The Board concludes that service connection is not warranted for the Veteran's hair loss.

The Veteran's treatment records demonstrate amply that he has a current disability of diabetes mellitus, type 1. This element of service connection is satisfied. Shedden, 381 F.3d at 1166-67. 

The Board will also assume for the purposes of this decision that he has infertility. The Veteran indicated that he and his wife had to use in-vitro fertilization in order to conceive a child through a private provider. The Veteran has not provided any records pertaining to this procedure or his claimed fertility issues. The Veteran is competent to report that he and his wife had to go through in vitro fertilization to have a child. However, the scope and nature of the underlying medical condition (and whether it affects the Veteran and not his wife), involves a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). As resolving the medical question is not necessary to the outcome of this issue, the Board will assume there is a disability. Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991) (holding that the Board is not required to remand a claim for additional development when it would impose unnecessary burdens on VA with no additional benefit flowing to the veteran). The Board will address this further below.

Turning to the manifestations of hair loss, as above, the Veteran is competent to report experiencing hair loss and its onset date. However, not every defect, infirmity, or disorder is a compensable disability. Terry v. Principi, 340 F.3d 1378, 1383 (Fed. Cir. 2003). Under applicable regulation, the term "disability" means impairment in earning capacity resulting from diseases and injuries and their residual conditions. 38 C.F.R. § 4.1; see also Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018) (the term "disability" as used in 38 U.S.C. § 1110" refers to the functional impairment of earning capacity, not the underlying cause of said disability," and held that "pain alone can serve as a functional impairment and therefore qualify as a disability"). 

The Veterans Benefits Administration (VBA) Adjudication Manual M21-1 contains a prohibition on awarding service connection for hair loss as androgenetic alopecia or male pattern baldness. M21-1 III.iv.4.L.4.a. The manual contains a brief rationale that "VA classifies these conditions as congenital or developmental abnormalities."

Generally, congenital defects are not diseases for VA compensation purposes. 38 C.F.R. § 3.303(c). In the absence of a superimposed disease or injury, service connection may not be allowed for congenital defects, as these are not diseases or injuries within the meaning of applicable legislation relating to service connection. VA regulations specifically prohibit service connection for a congenital defect unless such a defect was subjected to a superimposed disease or injury that created additional disability. See VAOPGCPREC 82-90; 55 Fed. Reg. 45,711 (July 18, 1990). Thus, in the absence of some event or trauma, hair loss is a constitutional or development abnormality for which compensation benefits may not be authorized. 38 C.F.R. § 3.303(c), 4.9. Here, as noted above, the record is silent for any hair loss in service or trauma which created an additional disability. Accordingly, the VBA does not consider the Veteran's hair loss to be a disability for VA compensation purposes. 

Although administrative materials such as circulars and the manual are not binding on the Board, the Board is obligated to independently review relevant manual provisions. Overton v. Wilkie, 30 Vet. App. 257, 264 (2018). In evaluating the M21-1, the Board looks to the precedent opinions of VA's General Counsel on similar issues. The General Counsel has issued several precedential opinions regarding whether specific medical conditions are "diseases" for disability compensation purposes, most recently in VAOPGCPREC 1-2017. In that opinion, the General Counsel stated that a "disease" contemplates an impairment or deviation from normal functioning of a body part or system, identified by characteristic signs or symptoms. VAOPGCPREC 1-2017, para. 9. The General Counsel looked to medical authorities' statements that the only identifiable sign of obesity is its defining characteristic, excess accumulation of body fat, which is not necessarily an impairment. Applying this logic to the M21-1, hair loss also has a single identifiable sign without an impairment or deviation from normal functioning of a body part or system. Like obesity, the subject of VAOPGCPREC 1-2017, hair loss is not directly listed as a disability in the VA ratings schedule. Scarring alopecia and alopecia areata are listed, with hair loss limited to the scalp and face as one level of disability within the ratings for alopecia areata. 38 C.F.R. § 4.118, Diagnostic Codes 7830, 7831. Moreover, review of the file does not reflect any reports of functional impairment or loss in earnings capacity due to this disorder, rather it led to the Veteran shaving his head. 

Considering the foregoing, the Board is persuaded that the Veteran's hair loss is a congenital or developmental abnormality and not a disability for compensation purposes. As a result, the Board finds that the Veteran does not have a current disability characterized by hair loss. See McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). The Board concludes that service connection for hair loss, within the claim for service connection for a hormone imbalance, is not warranted. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. The Board turns to the in-service incurrence element of service connection for diabetes mellitus, type 1, and infertility.

ii. In-Service Incurrence

The Veteran asserts that vaccinations, shots, and medications caused the reported manifestations of a hormone disorder. The Veteran's service treatment records (STRs) reflect immunizations for tetanus and diphtheria in February 2001, hepatitis A in August 2001, anthrax, hepatitis B, and typhoid in May 2004, and influenza in December 2004. The Veteran also received a variety of medications over the course of his service. The Board finds these in-service events occurred. 

The Veteran's STRs do not reflect the presence of symptoms or diagnoses of a hormone imbalance, either diabetes or infertility, during service. Further, the post-service treatment records are silent for any hormone imbalance disorder treatment or diagnosis. In this regard, an October 2011 medical record notes that the Veteran took HGH [human growth hormone] to help with his knee pain and intestinal issues, notably specifying that such hormone was taken for treatment of the knee and intestinal disorders, and was not a hormone disorder generally. Otherwise, the record includes a diagnosis of and treatment for diabetes mellitus, type 1, starting in March 2014. The Veteran has asserted that he and his wife had to undergo IVF treatment to conceive a child. A March 2014 VA Form 686c, Declaration of Status of Dependents, indicates the child was born in October 2013, well after the Veteran's service. Nevertheless, the in-service vaccinations, shots, and medications did occur. The Board turns to consider the final aspect of service connection. 

iii. Nexus

Specifically, there is no indication in the medical evidence of record that any of the reported manifestations of a hormone imbalance disorder are related to his active duty service. While the Veteran is competent to report having experienced hair loss, infertility, and diabetes, for many years, he is not competent to provide a diagnosis in this case or determine that these symptoms were manifestations of an undiagnosed hormone imbalance disorder as the Veteran has not demonstrated the necessary medical expertise. The issue is medically complex, as it requires knowledge of the interaction between multiple organ systems in the body and interpretation of complicated diagnostic medical testing. Jandreau, supra.

The Veteran has not submitted any evidence, lay or medical, that indicates an association between the Veteran's diabetes mellitus, type 1, or infertility may be related, or any incident therein. The Veteran asserts without foundation that his current disorders are related to service. The Board acknowledges that a VA examination for a hormone imbalance disorder has not been performed, nor was an etiological opinion obtained. Notably, in a March 2020 correspondence, the Veteran's representative argued that a VA examination should be provided to see if a disability existed. However, as the evidence does not indicate an association between the Veteran's service and any later reported manifestations of a hormone imbalance disorder, the Veteran's bare contentions are not enough to trigger VA's duty to assist to provide an opinion regarding this issue. Waters v. Shinseki, 601 F.3d 1274, 1278-79 (Fed. Cir. 2010) (explaining that something more than a veteran's conclusory, generalized statement is needed to trigger VA's duty to assist by providing a medical nexus examination).

In light of the foregoing, the Board finds the preponderance of the evidence is against a finding that the Veteran's diabetes mellitus, type 1, or infertility are related to any incident of service, to include his immunizations or medications. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. Service connection is not warranted a direct basis. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. There being no remaining avenue of entitlement to service connection for a hormone imbalance, variously described as diabetes mellitus, type 1, infertility, and hair loss, the appeal must be denied.

INCREASED RATING

The Veteran contends that the symptoms of his chest scars, right knee disability, wrist disability, PTSD, and diverticulitis, are more severe than is reflected by the currently assigned disability ratings. However, after a review of the record, the Board finds that his symptomatology and severity of his service-connected disabilities are wholly contemplated by the currently assigned disability ratings.

Disability ratings are determined by applying a schedule of ratings that is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R., Part 4. Each disability must be viewed in relation to its history and the limitation of activity imposed by the disabling condition should be emphasized. 38 C.F.R. § 4.1. Examination reports are to be interpreted in light of the whole recorded history, and each disability must be considered from the point of view of the veteran working or seeking work. 38 C.F.R. § 4.2. All reasonable doubt will be resolved in the claimant's favor. 38 C.F.R. § 4.3. Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. 38 C.F.R. § 4.7.

Separate ratings can be assigned for separate periods based on the facts found - a practice known as "staged" ratings. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Staged ratings are appropriate whenever the factual findings show distinct periods where the service-connected disability exhibits symptoms that would warrant different ratings. Id.

When evaluating a musculoskeletal disability, VA must consider functional loss due to pain, weakness, excess fatigability, or incoordination. See DeLuca v. Brown, 8 Vet. App. 202, 206 (1995); 38 C.F.R. §§ 4.40, 4.45. These determinations are, if feasible, to be expressed in terms of the degree of additional range-of-motion loss due to any weakened movement, excess fatigability, incoordination, flare-ups, or pain. The examiner should also determine the point, if any, at which such factors cause functional impairment. See Sharp v. Shulkin, 29 Vet. App. 26, 33 (2017); Mitchell v. Shinseki, 25 Vet. App. 32, 43-44 (2011); see also 38 C.F.R. § 4.59.

The period on appeal for the Veteran's increased rating claims begins September 28, 2018, the date VA received his claim for increased ratings, plus the one-year look-back period. See Gaston v. Shinseki, 605 F.3d 979, 982 (Fed. Cir. 2010).

1. Entitlement to a compensable rating for keloid chest scars.

The Veteran contends that his keloid chest scars warrant a compensable rating. Specifically, he reports that his scars are a constant discomfort, and that he has been prescribed many creams and scrubs which do not help. He also reported that his scars open, bleed, and are painful. 

The Veteran is in receipt of a noncompensable rating for his two keloid chest scars pursuant to DC 7805, for other scars rated based on functional impairment.

Turning to the propriety of the assigned rating, the Board notes that prior to the pendency of the appeal but during the look back period, VA published a final rule amending its regulations on skin disabilities, effective August 13, 2018. The amendment, in pertinent part, amended diagnostic codes 7801 and 7802. See 83 Fed. Reg. 32,592 (July 13, 2018). There are no changes to DCs 7800, 7804, 7805, and 7828 under the August 13, 2018 amended version of the skin criteria.

Scars are rated under 38 C.F.R. § 4.118, DCs 7800 through 7805. Initially, DC 7800 does not apply, as such pertains to burn scars of the head, face, or neck; scars of the head, face, or neck due to other causes; or other disfigurement of the head, face, or neck.

As to DC 7801, it has been amended under the new regulations. Prior to August 13, 2018, the pre-amended DC 7801 provided disability ratings for burn scar(s) or scar(s) due to other causes, not of the head, face, or neck, that are deep and nonlinear. In contrast to the previous DC, the amended DC 7801 contemplates burn scar(s) or scar(s) due to other causes, not of the head, face, or neck, that are associated with underlying soft tissue damage. 38 C.F.R. § 4.118. Here, neither the amended or previous version of DC 7801 are applicable as the Veteran's scars are not deep, nonlinear, or associated with underlying soft tissue damage. In this regard, the record does not reflect, and the Veteran has not reported, that there is any underlying tissue damage associated with the scars.

As to DC 7802, it has been amended under the new regulations. Under the previous version of DC 7802, a maximum 10-percent rating is warranted for burn scars or scars due to other causes, not of the head, face, or neck, that are superficial and nonlinear, affecting an area or areas of 144 square inches (929 sq. cm.) or greater. Note (1) to DC 7802 defines a "superficial" scar as one not associated with underlying soft tissue damage. See 38 C.F.R. § 4.118. Under the amended version of DC 7802, a maximum 10-percent rating is warranted for burn scars or scars due to other causes, not of the head, face, or neck, that are not associated with soft tissue damage, affecting an area or areas of 144 square inches (929 sq. cm.) or greater. Here, neither the amended nor previous version of DC 7802 are applicable as the Veteran's scars do not affect an area of 929 sq. cm. The Veteran's scars measure only 1 cm by .1 cm and 3.5 cm by .5 cm (1.76 cm squared), as noted in the December 2018 examination. As such, DC 7802 would not provide a compensable rating.

As noted above, DC 7804 has not been amended. DC 7804 applies to scars that are unstable and painful. Note (1) states that an unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. Here, the December 2018 VA examiner noted that the Veteran's scar is not painful or unstable and the medical evidence of record does not reflect any complaints of such symptoms. Notably, the Veteran reported his scars are painful, they open and bleed, they cause discomfort, and the creams and scrubs do not work. However, the Veteran has consistently conflated the symptoms attributable to his scars and those attributable to his skin disorders. In the correspondences detailing his scar symptoms, the Veteran explicitly reported that his underlying skin condition is the problem. As such, and as explained above, the Board has included the issue of entitlement to service connection for a skin condition to incorporate the disability for which the Veteran is actually seeking compensation. 

Given such, DC 7804 would not provide a compensable rating. In reaching this decision, the Board finds the medical evidence of record, including the December 2018 examination, wherein a VA examiner performed an in-person evaluation of the Veteran, more probative than his reports. Notably, the Veteran's reports are directly contradicted by the medical evidence of record. Further, the "creams and scrubs" he described are associated with his ongoing treatment for skin disorders.

The Veteran is currently assigned a noncompensable rating under DC 7805 for his keloid scars. As stated above, DC 7805 has not changed under the amended regulations. Under DC 7805, any other scars, including linear scars, are to be rated based on any disabling effects and the appropriate diagnostic code for such effects. Here, in the December 2018 VA examination report, the VA examiner noted that there are two scars on his anterior trunk, which are keloid in nature. The scars measured 1 cm by .1 cm and 3.5 cm by .5 cm. They were not painful or unstable, nor was it noted to limit motion or result in any functional impairment. Thus, under DC 7805, the Veteran would not be entitled to a compensable rating because the Veteran's scar does not have any disabling effects. In reaching this decision, the Board has again found the medical evidence of record more probative than the Veteran's reports, which as noted above, are contradicted by the record.

In light of the foregoing, the Board find the preponderance of the evidence is against assigning a compensable rating for his two chest keloid scars. Consequently, the benefit of the doubt rule does not apply. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. The Board concludes that the criteria for a compensable rating for two chest keloid scars have not been met.

2. Entitlement to a disability rating in excess of 10 percent for a right knee strain.

The Veteran contends that a rating in excess of 10 percent is warranted for his right knee strain as he reported that he is unable to bend it when it flares, he has difficulty moving it from pain, and it occasionally buckles. However, after a review of the record, the Board finds that all his symptoms are contemplated by the currently assigned rating, and a higher or separate rating for the service-connected right knee strain is not warranted.

The Veteran's right knee disability has been rated as 10 percent disabling for the entire appeal period pursuant to DC 5260 for painful movement with otherwise noncompensable range of motion (ROM). 38 C.F.R. §§ 4.59, 4.71a.

Normal range of knee motion is 140 degrees of flexion and zero degrees of extension. 38 C.F.R. § 4.71, Plate II.

Limitation of motion of the knee is contemplated in 38 C.F.R. § 4.71a, DCs 5260 and 5261. DC 5260 provides for a zero percent rating where flexion of the leg is only limited to 60 degrees. For a 10 percent rating, flexion must be limited to 45 degrees. A 20 percent rating is warranted where flexion is limited to 30 degrees. A 30 percent rating may be assigned where flexion is limited to 15 degrees.

DC 5261 provides for a zero percent rating where extension of the leg is limited to five degrees. A 10 percent rating requires extension limited to 10 degrees. A 20 percent rating is warranted where extension is limited to 15 degrees. A 30 percent rating may be assigned where extension is limited to 20 degrees. For a 40 percent rating, extension must be limited to 30 degrees. Finally, where extension is limited to 45 degrees a 50 percent rating may be assigned.

VA's General Counsel has stated that separate ratings under DC 5260 (limitation of flexion of the leg) and DC 5261 (limitation of extension of the leg) may be assigned for disability of the same joint. VAOPGCPREC 9-04 (September 17, 2004), published at 69 Fed. Reg. 59,990 2004).

The Veteran underwent a VA examination for his knees during the appeal period in November 2018. At that time, he was noted to have a diagnosis of a right knee strain, also with a diagnosis of arthritis noted later, and he reported pain ranging from 2 out of 10 to 9 out of 10. He also reported his knees would buckle 2 or 3 times per month. He reported experiencing crepitus, and that his knee disability was aggravated by prolonged sitting, standing, walking, and climbing stairs. He also reported he had an ACL tear, a medial meniscus tear, and a patellar fracture repair surgery in 2007. While such disorders are currently on appeal and are remanded herein, the limitation caused by the separate disorders was not explicitly distinguished from the limitation caused by the right knee strain. Therefore, in analyzing the findings from this examination, and from the record as a whole, the Board will resolve such doubt in the Veteran's favor and attribute all such impairment found to the service-connected disability. See Mittleider v. West, 11 Vet. App. 181, 182 (1998) (per curiam). 

Upon evaluation, the Veteran's right knee showed limitation of flexion to 125 degrees, with pain on flexion, but full ROM for extension and no pain noted. While the examiner did not the presence of crepitus, there was no pain with weightbearing, no localized tenderness, and no additional loss after repetitive use. Importantly, the examiner indicated that the examination was conducted after repeated use over time and during a flare-up; and there was no additional loss of ROM or functional impairment. There were no additional contributing factors of disability, ankylosis was not present, there was no recurrent patellar dislocation or shin involvement, and there were no noted meniscal conditions. Upon clinical testing, there was no recurrent subluxation, instability, or effusion. Specifically, stability testing was performed, but no joint instability was present, including from the Lachman test, the posterior drawer test, a medial instability test, and a lateral instability test. 

The treatment evidence of record also supports such impairment found on the examination. In this regard, the Veteran has consistently reported pain in his right knee, with some limitation of motion. However, he has never reported ankylosis or severe flare-ups which preclude movement. Rather, in December 2018, he reported that he likes to run, but that it aggravates his knees, noting that he runs a couple miles a day. At that time, he also reported that he feels like his knees will buckle a couple of times a month, noting an incident from prior to the period on appeal in 2010 when his knees buckled, and he fell down some stairs. Such reports in the treatment records show he has impairment in his mobility due to pain from his knee, however he is still able to run daily.

Accordingly, based on the foregoing, the Board finds that a rating in excess of 10 percent for the Veteran's right knee disability is not warranted. In this regard, the Veteran has shown limitation of flexion, at worst, to 125 degrees with pain, but such does not result in additional functional loss more nearly approximating limitation of flexion to 30 degrees, even in contemplation of functional loss due to symptoms such as pain, fatigue, weakness, lack of endurance, or incoordination, or as a result of repetitive motion and/or flare-ups, which is required for a higher rating under DC 5260. Further, the Veteran is in receipt of the minimal compensable rating due to the provisions of 38 C.F.R. § 4.59. Thus, a rating in excess of 10 percent for the Veteran's right knee disability pursuant to DC 5260 is not warranted.

Moreover, a higher or separate rating is not warranted pursuant to DC 5261 as the Veteran's right knee extension has not been shown to be limited to 5 degrees, even in contemplation of functional loss due to symptoms such as pain, fatigue, weakness, lack of endurance, or incoordination, or as a result of repetitive motion and/or flare-ups. Rather, he tested for full extension, without pain noted.

The Veteran has also reported subjective instability, reporting his knees feel like they will buckle. Thus, the Board has considered whether a separate rating for instability is warranted. See Lyles v. Shulkin, 29 Vet. App. 107 (2017).

In this regard, 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); see also Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). 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. Kuzma, 341 F.3d 1327. Therefore, the Board will consider the Veteran's claim 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.

Prior to the regulatory change, DC 5257 provided for assignment of a 10 percent rating when there is slight recurrent subluxation or lateral instability, a 20 percent rating when there is moderate recurrent subluxation or lateral instability, and a 30 percent evaluation for severe recurrent subluxation or lateral instability.

As of February 7, 2021, under the amended criteria, DC 5257 provides separate ratings for recurrent subluxation or instability, and patellar instability. Specifically, for recurrent subluxation or instability, a 30 percent rating is warranted for unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribes both an assistive device (e.g., cane(s), crutch(es), walker) and bracing for ambulation. A 20 percent rating is warranted for either; (a) a sprain, incomplete ligament tear, or repaired complete ligament tear causing persistent instability, and a medical provider prescribes a brace and/or assistive device (e.g., cane(s), crutch(es), walker) for ambulation; or, (b) unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribes either an assistive device (e.g., cane(s), crutch(es), walker) or bracing for ambulation. A 10 percent rating is warranted for a 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 (e.g., cane(s), crutch(es), walker) or bracing for ambulation.

For patellar instability, a 30 percent rating is warranted for 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. A 20 percent rating is warranted for a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for one of the following: A brace, cane, or walker. A 10 percent rating is warranted for 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.

In this regard, VA's General Counsel has stated that when a knee disorder is rated under 38 C.F.R. § 4.71a, DC 5257 and an appellant also has limitation of knee motion which at least meets the criteria for a noncompensable evaluation under 38 C.F.R. § 4.71a, DC 5260 or 5261, separate evaluations may be assigned for arthritis with limitation of motion and for instability. However, General Counsel (GC) stated that, if an appellant does not meet the criteria for a noncompensable rating under either DC 5260 or DC 5261, there is no additional disability for which a separate rating for arthritis may be assigned. VAOPGCPREC 23-97 (July 1, 1997), published at 62 Fed. Reg. 63,604 (1997). If a rating is assigned under the provisions for other knee impairment (38 C.F.R. § 4.71a, DC 5257) a separate 10 percent rating may be assigned where some limitation of motion, albeit noncompensable, has been demonstrated. See VAOPGCPREC 9-98, 63 Fed. Reg. 56,704 (1998). Specifically, for a knee disability rated under DC 5257 to warrant a separate rating for arthritis based on X-ray findings and limitation of motion, limitation of motion under DC 5260 or DC 5261 need not be compensable, but must at least meet the criteria for a zero-percent rating. Id. The GC opinion relates to the interplay between instability and limitation of motion, and as the amended ratings criteria do not preclude the award of separate rating for such, the opinion is still applicable to the amended criteria.

Nonetheless, while the Veteran complained of instability and buckling throughout the period on appeal, such was not found on examinations conducted during the appeal period. In this regard, while he is competent describe feelings of instability and buckling, he is not competent to relate such symptoms to a diagnosis of lateral instability, recurrent subluxation, or patellar instability. In this regard, there is no indication that he possesses the requisite knowledge to administer or interpret specialized testing that would reveal instability. See Jandreau, supra; Woehlaert v. Nicholson, 21 Vet. App. 456 (2007) (although the claimant is competent in certain situations to provide a diagnosis of a simple condition such as a broken leg or varicose veins, the claimant is not competent to provide evidence as to more complex medical questions). In this regard, the VA examiner, who have the training to conduct and interpret ligament testing, found that there was no instability in the right knee, after conducting numerous clinical tests. Consequently, the Board finds that a higher or separate rating under the old or revised DC 5257 is not warranted.

Finally, as the evidence does not show ankylosis, dislocation or removal of semilunar cartilage, impairment of the tibia or fibula, or genu recurvatum, higher or separate ratings under DCs 5256, 5258, 5259, 5262, and 5263, respectively, are not warranted. Notably, the Veteran's remanded claims include possible involvement of the semilunar cartilage, and could potentially warrant a rating if service connected. However, the evidence currently of record does not include any involvement of the semilunar cartilage.

Thus, the Board finds that the preponderance of the evidence is against a rating in excess of 10 percent for the Veteran's right knee disability. Therefore, the benefit of the doubt doctrine is not applicable, and the Veteran's claim for a higher rating must be denied. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7.

3. Entitlement to a disability rating in excess of 30 percent PTSD.

The Veteran contends that his PTSD symptoms cause a greater functional impact than is reflected by the currently assigned rating. In this regard, he reported worsening problems with being easily irritated, anxiety while driving, difficulty dealing with stress from work, trouble sleeping, difficulty with crowds, some obsessive behaviors, being confrontational, and not being social. Consequently, he claims that an increased rating for PTSD is warranted. However, after a review of the record, the Board finds that his symptoms, and resulting occupational and social impairment, are contemplated by the currently assigned disability ratings.

The Veteran's service-connected PTSD is evaluated as 30 percent disabling under the criteria of DC 9411, which provides that such disability is evaluated pursuant to the General Rating Formula for Mental Disorders. See 38 C.F.R. § 4.130.

Under such DC, a 30 percent rating is warranted for occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). Id.

A 50 percent rating is warranted when there is occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment, impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. Id.

A 70 percent rating is warranted where there is occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work like setting); inability to establish and maintain effective relationships. Id.

A 100 percent rating is warranted when there is total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication, persistent delusions or hallucinations, grossly inappropriate behavior, persistent danger of hurting self or others, intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene), disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Id.

The evaluation under 38 C.F.R. § 4.130 is "symptom-driven," meaning that "symptomatology should be the fact-finder's primary focus when deciding entitlement to a given disability rating" under that regulation. See Vazquez-Claudio v. Shinseki, 713 F.3d 112, 116-117 (Fed. Cir. 2013). The symptoms listed are not exhaustive, but rather "serve as examples of the type and degree of symptoms, or their effects, that would justify a particular rating." Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). In the context of determining whether a higher disability evaluation is warranted, the analysis requires considering "not only the presence of certain symptoms, but also that those symptoms have caused occupational and social impairment in most of the referenced areas" - i.e., "the regulation...requires an ultimate factual conclusion as to the Veteran's level of impairment in most areas." Vazquez-Claudio, 713 F.3d at 117-118; 38 C.F.R. § 4.130, DC 9411.

Further, when evaluating a mental disorder, the Board must consider the "frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran's capacity for adjustment during periods of remission," and must also "assign an evaluation based on all the evidence of record that bears on occupational and social impairment rather than solely on the examiner's assessment of the level of disability at the moment of the examination." 38 C.F.R. § 4.126(a).

Turning to the evidence of record, the Veteran underwent a VA examination during the period on appeal in November 2018. At that time, the examiner endorsed an occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, equivalent to the currently assigned 30 percent rating. The Veteran reported he was married from 2001 to 2010, and he was remarried for 8 years, noting they have a good marriage. He also reported having a great relationship with his daughter, and that he used to see his parents frequently, but not since moving from California. Similarly, he has some friends in California he keeps in touch with, and he has 3 siblings with an "alright" relationship. He enjoys working out and watching sports, as well as family activities like going to the park, the zoo, or other excursions.

The Veteran worked for a railroad for 13 years in California, developing and teaching mechanical training, but he has not worked since move to Illinois, rather becoming the primary caregiver for his daughter. He reported experiencing persistent anxiety, particularly when driving, noting he does not like being confined in traffic or in crowds. He also reported his sleep has improved, but as a result of sleeping more he has more nightmares. He still struggles with anger and irritability, but his medications have helped. He denied suicidal ideation or intent, and he denied current alcohol consumption, with none for a few years, and no illicit drug use for years.

The examiner noted explicit symptoms espoused in the ratings criteria of anxiety, panic attacks weekly or less often, chronic sleep impairment, and disturbances in motivation and mood. Further, on examination, the Veteran was well groomed, casually dressed, cooperative and friendly with good eye contact. He had normal speech rate, volume, and tone, he had good judgment and fair insight, and he was oriented to person, place, and time. His mood was reported as anxious, but he had an appropriate affect and logical thought processes. Finally, and again, he denied suicidal and homicidal ideation, and he denied auditory and visual hallucinations or delusions. 

In his correspondences with VA, the Veteran focused a great deal on his functional impairment while driving, due to his activities in service driving in convoys. However, he also submitted a symptom list in April 2020, in which he described experiencing symptoms of anger, anxiety, chronic sleep problems, being a danger to hurting himself or others, delusions, drug abuse, emotional numbing, flashbacks, hallucinations, heavy use of alcohol, inability to make and keep friends, inappropriate behaviour, intrusive thoughts, isolation, lack of emotions, neglect of family, no friends, being overly concerned with personal hygiene, panic attacks, periods of violence, problems with communication, problems at work, problems getting along with people, substance abuse, suicidal thoughts and feeling, suspiciousness, and being unable to share his feelings. Similarly, in a separate April 2020 correspondence, he reported quitting his job in California due to suicidal thoughts from high anxiety and stress from work, and they needed to move because California was too expensive.

The Veteran has also followed with VA for psychiatric treatment since he moved to Illinois, and thus for the entire appeal period. In this regard, his level of impairment and symptoms more closely reflect the VA examination findings. In this regard, in May 2018, he reported social anxiety, anxiety while driving, road rage, and anxiety in public. He stated that he has become verbally aggressive in the past, but denied physical aggression. He also reported sleep disturbance, and nightmares. In June 2018, he reported that they moved to Chicago in December 2017 because his wife wanted to be closer to her family, so he took retirement from his position with the railroad after working there for 13 years. He separately reported they planned on being there for 2 years, but perhaps longer if he finds a job. Later, in August 2018 treatment records, the Veteran focused on anger and anxiety issues he experiences while in crowded driving conditions. Importantly, the Veteran uniformly denied any suicidal or homicidal thoughts, or delusions or hallucinations, and he was without depressive symptoms.

Based on the foregoing, the Board finds that for the entire appeal period, the Veteran's PTSD resulted in, at most, occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, thus warranting no more than the currently assigned 30 percent rating for such period.

Initially, the Veteran has described in his correspondences numerous symptoms which have not been found on examination, and are not supported by the medical treatment evidence of record. Rather, the medical treatment evidence and examination report contradict his reported symptoms. Specifically, the Veteran reported that he had to leave his job due to stress and suicidal thoughts; however, the record reflects that he moved to Chicago because his wife wanted to be closer to her family. There is no evidence in the record that the Veteran was not successful in his employment or that it caused such severe symptoms. Notably, suicidal ideation alone may cause occupational and social impairment with deficiencies in most areas. See Bankhead v. Shulkin, 29 Vet. App. 10 (2017). In this case, the Veteran consistently denied suicidal ideation for the entire appeal period, notwithstanding the two reports for compensation purposes in April 2020. The Veteran has otherwise affirmatively denied having suicidal ideation or thoughts. Moreover, the presence of a single symptom is not dispositive of the particular disability level. Bankhead, 29 Vet. App. at 22. The Veteran's suicidal ideation is rare in the record before the Board and has not been tied to any specific impairment in occupational or social functioning. The Board finds that the presence of this symptom has not resulted in occupational and social functioning with deficiencies in most areas.

Likewise, the Veteran endorsed the presence of hallucinations and delusions. However, the record again includes numerous times where the Veteran affirmatively denied experiencing such symptoms. Again, the presence of a single symptom is not dispositive of the particular disability level. Bankhead, at 22. The Veteran's reported hallucinations and delusions are rare in the record before the Board and have not been tied to any specific impairment in occupational or social functioning. 

Again, the Veteran indicated that he has no friends, an inability to make friends, he neglects his family, and he is socially isolated, among others. However, such statements are contradicted by the medical evidence of record again, specifically with him noting he has a good relationship with his wife and great one with his daughter. He also reported having friends in California, and that he remains in contact with his family in California.

Accordingly, the Board finds the statements given during his treatment, and during the examination, detailing the presence and severity of his symptoms, are more probative than his correspondences which included numerous additional symptoms never reported previously. See Harvey v. Brown, 6 Vet. App. 390, 394 (1994) (Board decision properly assigned more probative value to a private hospital record that included lay history that was made for treatment purposes than to subsequent statements made for compensation purposes); Pond v. West, 12 Vet. App. 341 (1999) (although the Board must take into consideration the Veteran's statements, it may consider whether self-interest may be a factor in making such statements). Thus, the Board relies on the symptoms and impairment found in the medical evidence of record in reaching its decision.

In this regard, such evidence does not include any symptoms commensurate with a 70 or 100 percent rating. Moreover, he has been noted to have one symptom which is commensurate with a 50 percent rating, disturbances in motivation and mood. Reading the record as a whole however, the Veteran has routinely reported significant anxiety while driving, and particularly during crowded traffic conditions. He also reported that he experiences a panic attack multiple times a week. Thus, resolving all doubt in his favor, the Board finds that his panic attacks, likely occurring while driving, would occur more than once per week. Thus, such symptomatology is commensurate with a 50 percent rating as well. However, the frequency and severity of these two symptoms considered under a 50 percent rating, as well the other symptoms considered under a 30 percent rating, do not rise to a level to warrant a higher 50 percent rating. 

In this regard, despite some statements to the contrary, the Veteran appears to have a good family relationship, he is able to make and maintain friendships, and while he has social anxiety, he also reported he enjoys going out to do things with his family. Further, he had successful employment for 13 years, which he voluntarily retired from to move with his wife to Chicago.

Thus, while the Veteran's PTSD does cause social and occupational impairment; the record reflects that his PTSD symptoms are wholly contemplated by his current 30 percent rating. Therefore, a higher rating for PTSD is not warranted.

In reaching its determination, the Board acknowledges the Veteran's sincerely held belief that the severity of his PTSD symptoms warrants a higher disability rating. In this regard, the Board must consider the entire evidence of record when analyzing the criteria laid out in the rating schedule. While the Board recognizes that the Veteran is competent to describe his symptomatology, he is not competent to provide an opinion regarding the severity of his symptomatology in accordance with the rating criteria. Woehlaert, supra. Ultimately, the Board finds the medical evidence in which professionals with specialized expertise examined the Veteran, acknowledged his reported symptoms, and described the manifestations of such disabilities in light of the rating criteria to be more persuasive than his own reports regarding the severity of his disabilities.

Therefore, as the Veteran's PTSD was not manifested by symptoms of a nature, severity, frequency, or duration contemplated by a 50, 70, or 100 percent rating and does not result in more severe manifestations that more nearly approximate occupational and social impairment with reduced reliability and productivity, occupational and social impairment with deficiencies in most areas, or total occupational and social impairment, a rating in excess of 30 percent is not warranted.

4. Entitlement to a disability rating in excess of 10 percent for a right wrist disorder.

The Veteran also contends that his right wrist disability is more severe than the currently assigned rating reflects. Specifically, he contends the pain in his wrist causes difficulty when lifting any weights. However, after a review of the record, the Board finds that his current symptomatology is wholly considered by the assigned rating.

The Veteran's right wrist disability has been rated for otherwise noncompensable painful limitation of motion in accordance with 38 C.F.R. § 4.59, pursuant to DC 5215. Under DC 5215, the sole and maximum evaluation of 10 percent is assigned for limitation of (major or minor) wrist motion, where dorsiflexion is less than 15 degrees, or palmar flexion is limited in line with the forearm. In this regard, in order to warrant a rating in excess of 10 percent, ankylosis of the wrist must be shown. Specifically, DC 5214 provides that where there is ankylosis of the wrist that is favorable in 20 degrees to 30 degrees of dorsiflexion, a 30 percent rating for the major extremity and a 20 percent rating for the minor extremity is warranted. Where there is ankylosis of the wrist in any other position, except favorable, a 40 percent rating for the major extremity and a 30 percent rating for the minor extremity is warranted. Where there is ankylosis of the wrist that is unfavorable, in any degree of palmar flexion, or with ulnar or radial deviation, a 50 percent rating for the major extremity and a 40 percent rating for the minor extremity is warranted. 38 C.F.R. § 4.71a.

In connection with his claim, the Veteran was afforded a VA examination in November 2018. At such time, the Veteran was noted to have a right wrist strain post-surgery to remove a ganglionectomy. He reported that he had right wrist pain that ranged from 3 out of 10 to 10 out of 10. Physical examination revealed a ROM with dorsiflexion to 65 degrees, palmar flexion to 25 degrees, ulnar deviation to 40 degrees and radial deviation to 20 degrees. The examiner noted that there were no additional limitations by pain, fatigue, weakness, or lack of endurance following repetitions. Further, the examination was conducted after repeated use over time and during a flare-up, but there was no additional loss of use. Finally, there was no muscle strength loss or ankylosis.

After a careful review of the record, the Board finds that a rating in excess of 10 percent for the Veteran's wrist disability is not warranted pursuant to DC 5215. In this regard, the Board notes that he has been assigned the sole and maximum evaluation under DC 5215 in contemplation of pain and limitation of motion. Thus, a rating higher than 10 percent is not available under DC 5215. Further, while the Veteran has limitation of motion of his right wrist, it is not shown to be ankylosed as he is still capable of movement in each direction of movement even during flare-ups. Therefore, a higher or separate rating under DC 5214 based on ankylosis is not warranted.

In light of the foregoing, the Board find the preponderance of the evidence is against assigning higher or separate ratings for the right wrist disability. Consequently, the benefit of the doubt rule does not apply, and the Veteran's claim for a higher rating must be denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. 

5. Entitlement to a compensable rating for diverticulitis.

The Veteran also contends that is diverticulitis warrants a compensable rating, reporting that he must take extra fiber to avoid symptoms. However, after a review of the record, the Board finds the Veteran's diverticulitis has been asymptomatic for the entire appeal period, and thus a compensable rating is not warranted.

Under DC 7327, diverticulitis is rated as irritable colon syndrome, peritoneal adhesions, or colitis, ulcerative, depending upon the predominant disability picture. A single evaluation will be assigned under the DC which reflects the predominant disability picture, with elevation to the next higher evaluation where the severity of the overall disability picture warrants such elevation. 38 C.F.R. § 4.114.

Under DC 7301, mild peritoneal adhesions warrant a noncompensable rating. Moderate peritoneal adhesions warrant a 10 percent rating and are manifested by pulling pain on attempting work or aggravation by movements of the body, or occasional episodes of colic pain, nausea, constipation (perhaps alternating with diarrhea) or abdominal distension. Moderately severe peritoneal adhesions warrant a 30 percent rating and are manifested by partial obstruction with delayed motility of barium meal and less frequent and less prolonged pain. Severe adhesions, manifested by definite partial obstruction, shown by X-ray, with frequent and prolonged episodes of severe colic distension, nausea, or vomiting, following severe peritonitis, ruptured appendix, perforated ulcer, or operation with drainage, warrant a maximum schedular rating of 50 percent rating. The Note states that ratings for adhesions will be considered when there is history of operative or other traumatic or infectious (intraabdominal) process, and at least two of the following: disturbance of motility, actual partial obstruction, reflex disturbances, presence of pain. 38 C.F.R. § 4.114, DC 7301. 

Under DC 7319, mild irritable colon syndrome manifested by disturbances of bowel function with occasional episodes of abdominal distress warrants a noncompensable rating. Moderate irritable colon syndrome manifested by frequent episodes of bowel disturbance with abdominal distress warrants a 10 percent rating. Severe irritable colon syndrome manifested by diarrhea, or alternating diarrhea and constipation with more or less constant abdominal distress warrants a maximum schedular rating of 30 percent. 38 C.F.R. § 4.114, DC 7319.

Under DC 7323, moderate ulcerative colitis with infrequent exacerbations warrants a 10 percent rating. Moderately severe ulcerative colitis with frequent exacerbations warrants a 30 percent rating. Severe ulcerative colitis with numerous attacks per year and malnutrition, and with health only fair during remissions, warrants a 60 percent rating. Pronounced ulcerative colitis resulting in marked malnutrition, anemia, and general debility, or with serious complication as liver abscess warrants a 100 percent rating. 38 C.F.R. § 4.114, DC 7323.

The Veteran underwent a VA examination for diverticulitis in November 2018. At that time, the Veteran reported his last "flare" of diverticulitis was 10 years earlier, and he has not had any surgical treatment. The examiner noted that continuous medication is not required for control, but the Veteran takes a daily fiber supplement of psyllium. The Veteran reports that if he misses for a few days, he will have left lower quadrant pain. Upon examination, the Veteran had no signs or symptoms attributable to any non-surgical non-infectious intestinal conditions, no episodes of bowel disturbance with abdominal distress or exacerbations or attacks of the intestinal condition, no weight loss attributable to intestinal condition, no malnutrition, and no tumors. The examiner further stated there was no functional impact of the service-connected diverticulitis.

Turning to the period prior to the period on appeal, the Veteran was first diagnosed with diverticulitis while in service in 2005 after having some blood in his stool and left lower quadrant pain. However, such was found to be resolving in June 2005. Thereafter, the Veteran had acute abdominal pain in June 2006, but there was no diverticulitis found on a CT. Similarly, a March 2007 CT showed a normal bowel, with no evidence of diverticulosis or diverticulitis. A later October 2011 record noted that diverticulitis was asymptomatic at that time. Thereafter, the Veteran's treatment records are silent for diverticulitis symptoms, but show he continued to take psyllium supplements.

Based on the foregoing, the Board finds that the Veteran's symptoms do not more closely reflect moderate peritoneal adhesions, manifested by pulling pain on attempting work or aggravation by movements of the body, or occasional episodes of colic pain, nausea, constipation (perhaps alternating with diarrhea) or abdominal distension. In this regard, the Veteran has not been found to have any peritoneal adhesions, nor has he reported such manifestations detailed in the DC. Thus, a 10 percent rating under DC 7301 is not warranted.

Nor do his symptoms more closely reflect moderate ulcerative colitis with infrequent exacerbations. Here, the Veteran's disability has been asymptomatic for the entire appeal period and thus would not have any exacerbations. Thus, a 10 percent rating under DC 7323 is not warranted.

Nor do his symptoms more closely reflect moderate irritable colon syndrome manifested by frequent episodes of bowel disturbance with abdominal distress. In this regard, the Veteran symptoms are appropriately rated as analogous to irritable colon syndrome, as his primary symptom caused by diverticulitis has been abdominal distress and pain. However, as his disability has been asymptomatic, he has not shown frequent episodes of bowel disturbance or abdominal distress. Thus, a 10 percent rating under DC 7319 is not warranted.

In reaching this decision, the Board has considered the Veteran's argument that his symptoms would be worse if he didn't take as much psyllium as he does. In this regard, pursuant to Jones v. Shinseki, 26 Vet. App. 56, 63 (2012), the Board has considered the Veteran's use of psyllium throughout the appeal period. See McCarroll v. McDonald, 28 Vet. App. 267, 271 (2016) (en banc) (finding if the DC under which the Veteran is evaluated "does not specifically contemplate the effects of medication, the Board is required pursuant to Jones to discount the ameliorative effects of medication" when assigning an evaluation). However, there is no evidence that the Veteran would warrant a higher rating without consideration of the ameliorative effects of his medication. Notably, the Veteran was taking his medication prior to the appeal period for his previous symptomatology, and he has done so since his first and only diagnosed flare of diverticulitis, and thus any effort to discount the effects of such medication would be speculative. Furthermore, the Board has resolved all doubt in the Veteran's favor, and considered the most severe symptomatology found on examination to the ratings criteria. However, the Veteran's report that he would experience left lower quadrant pain after multiple days of missing his psyllium is not reflected in the record, which shows a flare of diverticulitis in 2005 only. In this regard, the Veteran reported a "flare" of diverticulitis treated 10 years prior to the November 2018 VA examination, however, the record reflects no such treatment and that his diverticulitis had been asymptomatic since 2011. Here, as the Veteran has consistently taken such psyllium since he separated from service, there is not enough evidence to state that without it he would have frequent episodes of bowel disturbance. Nonetheless, in reaching this decision, the ameliorative effects of the Veteran's dietary supplement have been, as far as possible, discounted.

In light of the foregoing, the Board find the preponderance of the evidence is against assigning higher or separate ratings for diverticulitis. Consequently, the benefit of the doubt rule does not apply, and the Veteran's claim for a higher rating must be denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102.

OTHER CONSIDERATIONS

The Board recognizes the Veteran's sincerely held belief that his symptomatology is more severe than as reflected by the currently assigned ratings, and notes he is competent to describe his symptoms and their effects on his daily life and occupation. See Jandreau, supra; Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). However, the Board finds the medical evidence in which professionals with medical expertise examined the Veteran, completed necessary testing, acknowledged his reported symptoms, and described the manifestations of such disabilities in light of the rating criteria to be more persuasive than his reports regarding the severity of such conditions. 

The Board has also considered whether staged ratings under Hart, supra, are appropriate for the Veteran's service-connected disabilities; however, the Board finds that his symptomatology has been stable throughout the period on appeal. Therefore, assigning staged ratings is not warranted.  

In reaching this decision, the Board has considered the benefit of the doubt doctrine; however, the preponderance of the evidence is against the Veteran's claims for higher ratings, and as such, that doctrine is not applicable in the instant appeal. Consequently, the claims must be denied. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7.

REASONS FOR REMAND

1. Entitlement to service connection for a right knee disorder, to include an ACL tear, medial meniscus tear, and patellar fracture.

2. Entitlement to service connection for a left knee disorder.

The Veteran contends that he had a right knee ACL tear, medial meniscus tear, and patellar fracture which are due to service. He also contends he has a left knee disorder that was either directly caused by umping in and out of trucks in service, or was caused or aggravated by his service-connected right knee disorder, due to overcompensation. After a review of the record, the Board finds that a remand is necessary in order to attempt to obtain relevant private treatment records, and to obtain an opinion regarding the etiology of such disorders.

In this regard, the Veteran contends that the right knee injuries were actually incurred in the same in-service event for which service connection for a right knee strain was granted. However, he contends that an MRI was not administered by VA. Rather, he underwent a private MRI, which found the disorders, and he underwent an operation to fix such through a private provider.

The STRs reflect that he had a twisting injury to the right knee in 2004, which caused continuing intermittent anterior right knee discomfort and pain. He reported in a March 2005 note that he was told in Iraq when the injury happened that he had a meniscal tear. However, pertinent to the left knee, the STRs are silent for any complaint, treatment, or diagnosis referable to a left knee disorder.

Following service, the Veteran underwent a VA examination in September 2005. At that time, he reported the in-service injury and a history of knee pain. He also noted he did not have an MRI but, again, he stated that he was told he may have a meniscal tear. A concurrent x-ray of the right knee showed narrowing of the medial compartment with no other significant findings. He had no complaints referable to the left knee, and it was normal upon examination. 

Treatment records thereafter reflect that he had a meniscal injury in the past, with continuing pain, apparently based on the Veteran's reported history. In October 2007, the Veteran reported an MRI was supposed to be done at VA, but it had not been done, so he opted to have MRI done with an outside provider, and he was told he had a torn medial meniscus in the right knee and a bone spur. A treatment record in August 2008 noted that he had a history of a right knee torn medial meniscus, chondromalacia, and partial ACL tear, and in November 2007 he underwent partial medial meniscectomy and a chondroplasty of intercondylar femoral notch and patella at Coast Surgery Center in Torrance, with a Dr. Turek. A later April 2009 VA treatment record noted that the Veteran had recently underwent left knee surgery with Dr. Turek at Torrance Memorial.

The treatment records from Torrance Memorial, Coast Surgery Center, and from Dr. Turek are not associated with the record, nor has VA attempted to obtain such records. The records would contain relevant information to the Veteran's claims for service connection for his bilateral knee disorders, and thus on remand the Veteran should be asked to furnish, or to furnish an authorization to enable VA to obtain, any additional private treatment records from providers who treated him for right or left knee disorders, specifically those referenced herein. In this regard, VA should obtain all relevant VA and private treatment records which could potentially be helpful in resolving the claims. Murphy v. Derwinski, 1 Vet. App. 78 (1990); Bell v. Derwinski, 2 Vet. App. 611 (1992).

Additionally, the record includes a January 2019 opinion addressing the etiology of the claimed right knee disorders. The VA clinician opined the right knee ACL tear, medial meniscus tear, and patellar fracture occurred in 2007, two years after discharge, and they were not caused by the left knee sprain, as they are separate conditions from an injury which occurred post discharge. However, the Veteran has not claimed the right knee disorders were due to the left knee. Rather, the opposite is true, that he believes the left knee was due to the right knee. It seems this opinion was given in error, as an opinion is necessary to determine the relationship between the currently service-connected right knee strain, and both the claimed left knee disorder, as well as the claimed right knee ACL tear, medial meniscus tear, and patellar fracture. Thus, a remand is necessary in order to obtain an appropriate etiological opinion for both the claimed knee disorders.

3. Entitlement to service connection for a right knee scar.

The Veteran contends service connection for a right knee scar is warranted as it was a result of the 2007 knee surgeries. Importantly, the adjudication of this service connection claim for a surgical scar relies on whether service connection is granted for the underlying disability. Consequently, adjudication of such issue is intertwined with the right knee disorder, and must be deferred until the completion of the requested development for the right knee disorder.

4. Entitlement to service connection for a left thumb disorder.

The Veteran also contends that he has a current left thumb disorder that began in service, and was caused by repetitive motion from his work duties. After a review of the record, a remand is necessary in order to schedule the Veteran for a VA examination for the left thumb.

In this regard, his STRs are silent for any left thumb complaint, injury, treatment, or diagnosis. They do contain evidence of a right thumb injury, however. Nonetheless, the Veteran contends that the repetitive movement required of his duties in service as a vehicle mechanic.

The Veteran has a current diagnosis of left thumb basilar joint arthritis, and he had a fusion conducted of the carpometacarpal joints in September 2019. Further, he has competently described experiencing pain in his thumb while in service, and December 2018 VA treatment records, among others, note that he reported he first injured his thumb roughly 15 years prior while playing football. Notably, that timeline would put his injury during his active service. Accordingly, the Board finds that the low threshold of the McLendon standard has been met in this instance, and the Veteran should be afforded a VA examination to determine the nature and etiology of his left thumb disorder. See McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006).

5. Entitlement to service connection for a skin disorder.

As noted above, the Veteran indicated in his September 2018 claim for compensation that he wanted an "increase for skin condition." He later proceeded to describe the effects of his skin condition, as noted in the section above pertinent to the keloid chest scars, stating they open and bleed, and he gets rashes. He also consistently stated that he wanted compensation for the underlying skin condition. After a review of the record, a remand is necessary in order to schedule the Veteran for a VA examination to determine the nature and etiology of his skin disorders.

In this regard, his STRs note the presence of recurrent staph infections and recurrent folliculitis. Further, the Veteran's post-service treatment records include treatment for chest rashes and breakouts in December 2016, noting he does not have a diagnosed skin disorder, but it is something he picked up in Iraq. In November 2014, he was noted to have skin eruptions, and dermatitis with pruritic bumps on his face. A March 2007 treatment record noted recurrent skin lesions with suspect hydradenitis.

Accordingly, the Board finds that the low threshold of the McLendon standard has been met in this instance, and the Veteran should be afforded a VA examination to determine the nature and etiology of his skin disorder. See McLendon, supra.

The matters are REMANDED for the following action:

1. The Veteran should be given an opportunity to identify or submit any outstanding private treatment records relevant to the claims on appeal, to include those from private physicians at Torrance Memorial and Coast Surgery Center, and from Dr. Turek. After obtaining any necessary authorization from the Veteran, all outstanding records should be obtained. Specifically, make at least two attempts to obtain records from any identified sources. If any records are unavailable, inform the Veteran and allow him an opportunity to submit any copies in his possession.

2. After obtaining any identified private medical records, forward the record to an appropriate VA clinician for a medical opinion pertaining to the etiology of the claimed left and right knee disorders. The record and a copy of this Remand must be made available to, and reviewed by, the clinician. The need for an examination of the Veteran is left to the discretion of the clinician selected to write the opinion.

(A) The clinician should identify all current left knee and right knee disorder(s).

(B) For each currently diagnosed left knee disorder, the clinician should provide an opinion as to whether it is at least as likely as not (i.e., a 50 percent or greater probability) that such disorder is related to the Veteran's military service, to include from jumping in and out of trucks.

(C) If arthritis is diagnosed, the clinician should offer an opinion as to whether it manifested within one year of the Veteran's separation from active service in August 2005 and, if so, describe the manifestations.

(D) For each currently diagnosed left knee disorder, the clinician should offer an opinion whether such is at least as likely as not caused by the service-connected right knee strain, or aggravated beyond its natural progression by the service-connected right knee strain. 

(E) For the claimed right knee ACL tear, medial meniscal tear, and patellar fracture, the clinician should offer an opinion as to whether such is at least as likely as not (i.e., a 50 percent or greater probability) that such disorder is related to the Veteran's military service, to include the in-service twisting injury.

(F) If the claimed right knee ACL tear, medial meniscal tear, and patellar fracture, are not found to be directly related to the Veteran's military service, the clinician should offer an opinion as to whether such is at least as likely as not caused by the service-connected right knee strain, or aggravated beyond its natural progression by the service-connected right knee strain

A rationale should be provided for any opinion offered.

3. Schedule the Veteran an appropriate VA examination to determine the nature and etiology of his left thumb and skin disorders. The examiner should review the record and note such review in the examination report. The examination should include a review of the Veteran's history and current complaints as well as a comprehensive evaluation and any tests deemed necessary.

(A) The examiner should identify all current left thumb and skin disorder(s) (other than the keloid scarring of the chest and right knee surgical scars).

(B) For each currently diagnosed left thumb disorder, the examiner should provide an opinion as to whether it is at least as likely as not (i.e., a 50 percent or greater probability) that such disorder is related to the Veteran's military service.

(C) If arthritis is diagnosed, the examiner should offer an opinion as to whether it manifested within one year of the Veteran's separation from active service in August 2005 and, if so, describe the manifestations.

(D) For each currently diagnosed skin disorder, the examiner should provide an opinion as to whether it is at least as likely as not (i.e., a 50 percent or greater probability) that such disorder is related to the Veteran's military service, to include his in-service skin treatment and complaints.

A rationale should be provided for any opinion offered.

 

J. B. FREEMAN

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	Jonathan M. Estes

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.