Citation Nr: 21031512 Decision Date: 05/24/21 Archive Date: 05/24/21 DOCKET NO. 17-05 254 DATE: May 24, 2021 ORDER An initial disability rating in excess of 10 percent for left ankle collateral ligament sprain with calcaneal spurs is denied. An initial disability rating in excess of 10 percent for left knee strain with shin splint is denied. An initial disability rating in excess of 10 percent for right knee strain with shin splint is denied. From February 7, 2021, a separate noncompensable disability rating for left shin splint, apart from left knee strain, is granted. From February 7, 2021, a separate noncompensable disability rating for right shin splint, apart from right knee strain, is granted. FINDINGS OF FACT 1. The Veteran's left ankle collateral ligament sprain with calcaneal spurs manifested by no more than moderate limited motion of the ankle. 2. The Veteran's left knee strain with shin splint did not manifest as limited flexion of 30 degrees or less or limited extension of 15 degrees or more. 3. The Veteran's right knee strain with shin splint did not manifest as limited flexion of 30 degrees or less or limited extension of 15 degrees or more. 4. As of February 7, 2021, the Veteran is entitled to a separate noncompensable disability rating for his right shin splint, apart from his left knee strain, which required treatment for less than 12 consecutive months and did not manifest as unresponsive to surgery and either shoe orthotics or other conservative treatment. 5. As of February 7, 2021, the Veteran is entitled to a separate noncompensable disability rating for his left shin splint, apart from his right knee strain, which required treatment for less than 12 consecutive months and did not manifest as unresponsive to surgery and either shoe orthotics or other conservative treatment. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 10 percent for left ankle collateral ligament sprain with calcaneal spurs have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5271 (in effect prior to February 7, 2021). 2. The criteria for a rating in excess of 10 percent for left knee strain with shin splint have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.14, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5260, 5261. 3. The criteria for a rating in excess of 10 percent for right knee strain with shin splint have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.14, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5260, 5261. 4. As of February 7, 2021, the criteria for a compensable rating for left shin splint have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.14, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5262 (effective February 7, 2021). 5. As of February 7, 2021, the criteria for a compensable rating for right shin splint have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.14, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5262 (effective February 7, 2021). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Marine Corps from December 2005 until his honorable discharge in January 2016. This case comes before the Board of Veterans' Appeals (Board) on appeal from a May 2016 decision by a Regional Office of the United States Department of Veterans Affairs (VA). In February 2020, the Veteran testified at a Board hearing before the undersigned Veterans Law Judge. In April 2020, the Board remanded the case to the VA Regional Office for further development. Specifically, the Board directed the VA Regional Office to obtain new VA examinations addressing the severity of the Veteran's service-connected disabilities, which the RO accomplished. The case now returns to the Board. Evidentiary Standards In deciding claims, it is the Board's responsibility to evaluate the entire record on appeal. VA is required to give due consideration to all pertinent medical and lay evidence when rating disabilities. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 C.F.R. § 4.3. To deny a claim on its merits, the preponderance of the evidence must be against the claim. See Alemany v. Brown, 9 Vet. App. 518, 519 (1996). An initial rating is one assigned at the time service-connection is granted. When an initial rating decision is on appeal, evidence contemporaneous with the claim and with the initial rating decision granting service connection would be most probative of the degree of disability existing at the time and should be the evidence used to decide whether an original rating was erroneous. Fenderson v. West, 12 Vet. App. 119, 126 (1999). Separate ratings can be assigned for separate periods of time based on the facts founda practice known as "staged" ratings. Id. A staged rating is a rating that looks backwards and retroactively assigns specific ratings to discrete periods. See Reizenstein v. Shinseki, 583 F.3d 1331, 1337 (Fed. Cir. 2009). This practice 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); see also 38 C.F.R. § 4.1. The effective date for a staged rating is when it is factually ascertainable that a particular rating is warranted. Hart v. Mansfield, 21 Vet. App. 505, 509 (2007). In cases where staged ratings are appropriate, it is necessary to consider all "the evidence of record from the time of the veteran's application." Fenderson, 12 Vet. App. at 127. The law requires the Board address its reasons for rejecting evidence favorable to the Veteran. Timberlake v. Gober, 14 Vet. App. 122, 12829 (2000). The Board must review the entire record but does not have to discuss each piece of evidence. Gonzales v. West, 218 F.3d 1378, 1381 (Fed. Cir. 2000). The analysis below focuses on the most salient and relevant evidence within the period on appeal and on what this evidence shows, or fails to show, on the claims. Increased Ratings Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities found in 38 C.F.R. Part 4. The Schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Diagnostic codes (DC) are assigned to individual disabilities. Diagnostic codes provide rating criteria specific to a particular disability. If two diagnostic codes are applicable to the same disability, the diagnostic code that allows for the higher disability rating applies. 38 C.F.R. § 4.7. When a question arises as to which of two ratings apply under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating. Id. 1. An initial disability rating in excess of 10 percent for left ankle collateral ligament sprain with calcaneal spurs is denied. Rating Criteria Left Ankle The Veteran's left ankle collateral ligament sprain with calcaneal spurs (left ankle disability) is rated under 38 C.F.R. § 4.71a, DC 5271 ("Ankle, limited motion"), which, prior to February 7, 2021, provided: Rating (%) Ankle, limited motion of: Marked 20 Moderate 10 The criteria in DC 5271, however, contained no specific objective "limited motion" measurements, and neither DC 5271 nor section 4.71a defined "moderate" or "marked" limitation of motion. Absent an express definition, it is presumed that VA regulations employ words using their ordinary dictionary meanings at the time the regulations were promulgated. See Nielson v. Shinseki, 607 F.3d 802, 80506 (Fed. Cir. 2010). "Moderate," as an adjective, is defined as "not violent, severe, or intense"; "limited in scope or effect." Moderate, Merriam-Webster Dictionary Online, https://www.merriam-webster.com/dictionary/moderate, Definitions 3 and 5 (last visited May 7, 2021). "Marked," as an adjective, is defined as "having a distinctive or emphasized character." Marked, Merriam-Webster Dictionary Online, https://www.merriam-webster.com/dictionary/marked, Definition 2 (last visited May 7, 2021). Using the above definitions as guidance, the Board must arrive at an equitable and just decision based on an evaluation of all relevant evidence. 38 C.F.R. §§ 4.2, 4.6. The Board keeps in mind that the terms "moderate" and "marked" are used in relation to the ankle's "limitation of motion" under DC 5271, which may encompass various symptoms. It should also be noted that use of terminology such as "moderate" and "marked" by VA examiners or other physicians, although an element of evidence to be considered by the Board, is not dispositive of an issue. In addition, objective evidence is not required to assign a disability rating under DC 5271 prior to February 7, 2021. Cf. English v. Wilkie, 30 Vet. App. 347, 353 (2018); Petitti v. McDonald, 27 Vet. App. 415, 424 (2015). VA amended DC 5271 as of February 7, 2021. See Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 76,460 (Nov. 30, 2020), as amended 85 Fed. Reg. 85,523 (Dec. 29, 2020), as amended 86 Fed. Reg. 8,142 (Feb. 4, 2021). Because the Veteran's appeal was pending prior to these amendments, the Board is required to analyze his claim under both versions of 38 C.F.R. § 4.71a, DC 5271, and which ever criteria is more favorable to the Veteran will be applied as of February 7, 2021. See Ervin v. Shinseki, 24 Vet. App. 318 (2011) (discussing retroactivity and effects of changes in law or regulation during the pendency of an appeal), opinion corrected, 25 Vet. App. 178 (2012). As of February 7, 2021, 38 C.F.R. § 4.71a, DC 5271 now provides: Rating (%) Ankle, limited motion of: Marked (less than 5 degrees dorsiflexion or less than 10 degrees plantar flexion) 20 Moderate (less than 15 degrees dorsiflexion or less than 30 degrees plantar flexion) 10 Notably, the terms "moderate" and "marked" are now accompanied by objective criteria relating to limitation of motion. As such, DC 5271 now requires objective evidence of such limitation for either rating but does not exclude subjective evidence from consideration. The normal range of motion for the ankle is 0 to 20 degrees for dorsiflexion and 0 to 45 degrees for plantar flexion. 38 C.F.R. § 4.71, Plate II. In addition, when VA evaluates musculoskeletal disabilities, it must determine whether or not the factors listed in 38 C.F.R. §§ 4.40, 4.45, and 4.59 are properly accounted for within the applicable diagnostic criteria. Under section 4.40, VA must consider whether there is evidence of functional loss due to pain on movement and diminished excursion, strength, speed, coordination, and endurance, to include during flare-ups or after repetitive use. 38 C.F.R. § 4.40; Mitchell v. Shinseki, 25 Vet. App. 32, 43 (2001). Pain on movement, standing alone, is not sufficient to warrant a higher rating under section 4.40. Id. (reaffirming that pain must affect some aspect of "the normal working movements of the body . . . in order to constitute functional loss"). Section 4.45 expands upon the concept of functional loss, noting six factors that VA must consider when evaluating a disability, namely: (1) less or (2) more movement than is normal; (3) weakened movement; (4) excess fatigability; (5) incoordination; and (6) pain on movement (as well as swelling, deformity, and atrophy) that affects stability, standing, and weight-bearing, to include during flare-ups or after repetitive use. 38 C.F.R. § 4.45. Noticeably, the aspects of functional loss listed in section 4.40 closely parallel the factors listed in section 4.45. Section 4.45 applies to muscles, nerves, as well as the entire musculoskeletal system. DeLuca v. Brown, 8 Vet. App. 202, 207 (1995). Under section 4.59, a veteran may be awarded the minimum compensable evaluation available under a given musculoskeletal diagnostic code, even if application of that code would not support a compensable evaluation, where there is evidence of "actually painful, unstable, or malaligned joints." 38 C.F.R. § 4.59; Petitti v. McDonald, 27 Vet. App. 415, 427 (2015). Section 4.59 does not require medical evidence; it may be satisfied with lay and other non-medical evidence. Id. at 428. Thus, pain alone is compensable under section 4.59 for joint disabilities in general. Burton v. Shinseki, 25 Vet. App. 1, 5 (2011). Analysis The Board finds the Veteran's left ankle disability did not manifest as marked limitation of motion, to include less than 5 degrees dorsiflexion or less than 10 degrees plantar flexion, throughout the appeal period. The Board has considered whether the new version of DC 5271 would be beneficial to the Veteran as of February 7, 2021, but finds it would not as the Veteran's left ankle never demonstrated less than 5 degrees dorsiflexion or less than 10 degrees plantar flexion. Therefore, the Board will apply the version of DC 5271 in effect prior to February 7, 2021, for the entire period on appeal. The Veteran has been afforded three VA examinations in connection with his left ankle disability during the appeal period. During a March 2014 VA examination, the examiner documented the Veteran's left ankle dorsiflexion was 0 to 22 degrees and plantar flexion was 0 to 20 degrees. Pain was noted during each range of motion testing and on weight bearing. There was no additional functional loss following repetitive-use testing. The was no observed loss of muscle strength, atrophy, or ankylosis. The examiner documented the Veteran experienced left shin splint that affected his ankle's range of motion, but he offered no further explanation as to how. Although the Veteran reported flare-ups, the examiner did not offer an opinion about additional loss of range of motion due to flare-ups or following repetitive use over time. The Board finds the examination is still credible and probative in other respects. Monzingo v. Shinseki, 26 Vet. App. 97, 107 (2012) ("[E]ven if a medical opinion is inadequate to decide a claim, it does not necessarily follow that the opinion is entitled to absolutely no probative weight."). During a June 2016 VA examination, the examiner documented the Veteran's left ankle dorsiflexion was 0 to 20 degrees and plantar flexion was 0 to 45 degrees. The examiner did not observe pain on weight bearing, nor did he observe loss of muscle strength, atrophy, instability, or ankylosis. There was no additional functional loss following repetitive-use testing. The Veteran did not report experiencing flare-ups. The Veteran's left ankle disability limited his ability to lift, carry, push, and pull objects in excess of thirty pounds, and to walk/run more than thirty minutes. During a November 2020 VA-contracted examination, the Veteran reported his left ankle disability had worsened due to "the way it rolls out." The examiner documented the Veteran's left ankle dorsiflexion was 0 to 20 degrees and plantar flexion was 0 to 20 degrees. Pain was not observed by the examiner during range of motion testing, weight bearing, non-weight bearing, or on passive range-of-motion testing. There was no evidence of localized tenderness or pain on palpation of the joint or associated soft tissue. There was no additional functional loss following repetitive-use testing. The Veteran reported flare-ups, which the examiner opined would result in left ankle dorsiflexion of 0 to 15 degrees and plantar flexion of 0 to 15 degrees due to pain and weakness. There was no observed loss of muscle strength, atrophy, instability, or ankylosis. The examiner also concluded that the Veteran suffered from a left calcaneal heel spur, which was a progression of his left ankle disability. The Veteran reported occasional use of an ankle brace. Absent evidence to the contrary, the Board finds the above-mentioned medical professionals were competent to exam and diagnose the Veteran and to provide medical judgments related to the Veteran's adjustment disorder. Cox v. Nicholson, 20 Vet. App. 563, 569 (2007) (the competency of medical professionals is presumed absent evidence to the contrary). The Board finds the medical professionals' respective examinations, medical findings, and medical opinions are credible and probative unless otherwise indicated. The medical professionals conducted thorough examinations, relied on accurate facts, considered the Veteran's relevant medical records, medical history, and lay statements, and provided well-reasoned medical judgments. The Board has also reviewed the Veteran's medical records associated with his claims file. His medical records generally document his treatment for his left ankle. The Board has considered his lay statements as well as his testimony during his February 2020 Board hearing. The Board finds the Veteran's left ankle disability manifested as symptomatology most consistent with one characterized by moderate limitation of motion. The Veteran's dorsiflexion remained full and without limitation during the appeal period. While the Veteran's plantar flexion progressively worsened during the appeal period, but the ankle still maintained an ability to function despite his limited plantar flexion. The Veteran testified that he felt his left ankle was unstable, and the Board finds his testimony credible and probative. He has now reported use of a brace on occasion. This symptom, however, is not "marked," as it is not frequent or prolonged in duration, as demonstrated by his "occasional" use of a brace. The Board finds it is best characterized as "moderate" in these respects. Moreover, the Veteran's left ankle disability did not manifest as symptoms of atrophy or ankylosis. The Veteran has generally reported limited functioning with walking and running in excess of thirty minutes, and limited functioning as to lifting, carrying, pushing, and pulling. These functional limitations, however, do not markedly affect his daily activities. The Board finds they are best characterized as moderate affects on his limitation of left ankle motion. Overall, the Board concludes the severity, frequency, and duration of the Veteran's symptoms associated with his left ankle disability did not result in an ankle disability characterized by markedly limited motion during the appeal period. Instead, his symptomatology is best characterized as moderate limitation of left ankle motion. The Board has considered the factors found in 38 C.F.R. §§ 4.40, 4.45, and 4.59, and concludes the Veteran's left ankle pain, weakness, fatiguability and/or incoordination throughout the appeal period, during flare-ups on following repetitive use, are properly encompassed by his 10 percent disability rating under DC 5271. The Board has also considered whether any other diagnostic code is appliable to the Veteran's left ankle disability. In the absence of evidence of ankylosis (DC 5270 and DC 5272), malunion of the os calcis or astragalus (DC 5273), and astragalectomy (DC 5724), no other diagnostic code is applicable. The Board notes the Veteran's diagnosed left shin splint is addressed further within this decision. Accordingly, the preponderance of the evidence is against finding that a disability rating in excess of 10 percent is warranted for the appeal period. 2. An initial disability rating in excess of 10 percent for left knee strain with shin splint is denied. 3. An initial disability rating in excess of 10 percent for right knee strain with shin splint is denied. The Board addresses the Veteran's left and right knee strains with bilateral shin splints together as the same law and regulations apply to these disabilities. Rating Criteria Knee Two diagnostic codes relate to the knee's ability to bend (flex and extend): 38 C.F.R. § 4.71a, DC 5260 (limited flexion) and DC 5261 (limited extension). Diagnostic Code 5260 provides: Rating (%) Leg, limitation of flexion of: Flexion limited to 15° 30 Flexion limited to 30° 20 Flexion limited to 45° 10 Flexion limited to 60° 0 Diagnostic Code 5261 provides: Rating (%) Leg, limitation of extension of: Extension limited to 45° 50 Extension limited to 30° 40 Extension limited to 20° 30 Extension limited to 15° 20 Extension limited to 10° 10 Extension limited to 5° 0 The normal range of motion of the knee is from 0 degrees extension to 140 degrees flexion. 38 C.F.R. § 4.71, Plate II. Separate ratings can be assigned for knee disabilities when none of the symptomatology overlaps and the separate rating is based on additional disabling symptomatology. See VAOPGCPREC 23-97, 62 Fed. Reg. 63,603 (1997); VAOPGCPREC 9-98, 63 Fed. Reg. 56,703 (1998); VAOPGCPREC 9-2004; 69 Fed. Reg. 59,988 (2004); Lyles v. Shulkin, 29 Vet. App. 107 (2017).VAOPGCPREC 9-2004. VA General Counsel precedential opinions are binding on the Board. 38 U.S.C. § 7104(c); 38 C.F.R. § 14.507. The Board is also required to consider whether the factors found within 38 C.F.R. §§ 4.40, 4.45, and 4.59, as discussed above, are appropriately accounted for within the criteria used to rate the Veteran's bilateral knee disabilities. Analysis Left Knee The Veteran has been afforded two VA examinations to assess his left knee disability. In March 2016, a VA examiner documented that the Veteran's left knee flexion was 0 to 145 degrees and extension was 145 to 0 degrees. The examiner did not observe pain on range-of-motion testing or on weight bearing. The examiner did not find additional loss of range of motion following repetitive-use testing. The examiner did not find loss of muscle strength, atrophy, instability, or ankylosis. The Veteran reported flare-ups during physical activity. Over time, he experienced pain and stiffness in his knee. The examiner did not offer an opinion about additional loss of range of motion due to flare-ups or following repetitive use over time. Nevertheless, the Board finds the examination is still credible and probative in other respects discussed. Monzingo v. Shinseki, 26 Vet. App. 97, 107 (2012) ("[E]ven if a medical opinion is inadequate to decide a claim, it does not necessarily follow that the opinion is entitled to absolutely no probative weight."). During a November 2020 VA-contracted examination, the examiner documented the Veteran's right knee flexion was 0 to 115 degrees and extension was 115 to 0 degrees. The examiner did not observe pain on range-of-motion testing or on weight bearing. The examiner did not find additional loss of range of motion following repetitive-use testing. The examiner did not find loss of muscle strength, atrophy, instability, or ankylosis. The Veteran reported experiencing mild flare-ups five times a week lasting 20 minutes. He described the pain as "shooting" and rated it an 8 out 10. He said his knee locked up and the kneecap felt like it would pop it. The Veteran reported occasional use of a knee brace. The examiner opined that following repetitive use over time, the Veteran's range of motion would not be affected due to pain, weakness, fatigability or incoordination. During a flare-up, however, the examiner opined the Veteran would experience flexion of 0 to 110 degrees and extension of 110 to 0 degrees due to weakness, pain, and incoordination. Absent evidence to the contrary, the Board finds the above-mentioned medical professionals were competent to exam and diagnose the Veteran and to provide medical judgments related to the Veteran's adjustment disorder. Cox, 20 Vet. App. at 569. The Board finds the medical professionals' respective examinations, medical findings, and medical opinions are credible and probative unless otherwise indicated. The medical professionals conducted thorough examinations, relied on accurate facts, considered the Veteran's relevant medical records, medical history, and lay statements, and provided well-reasoned medical judgments. The Board has also reviewed the Veteran's medical records associated with his claims file. His medical records generally document his treatment for his left knee strain. The Board has considered his lay statements as well as his testimony during his February 2020 Board hearing. Throughout the appeal period the Veteran's left knee flexion never exhibited limited motion less than 110 degrees. Notably, limitation of 30 degrees is necessary to obtain a 20 percent disability rating. 38 C.F.R. § 4.71a, DC 5260. In addition, throughout the appeal period, the Veteran's left knee extension was always normal. Notably, limited extension to 15 degrees is necessary to obtain a 20 percent disability rating. 38 C.F.R. § 4.71a, DC 5261. The VA Regional Office assigned a minimum 10 percent disability rating under DC 5260 based on the Veteran's associated pain under 38 C.F.R. § 4.59 and taking into consideration the factors under 38 C.F.R. §§ 4.40 and 4.45. The Board finds the Veteran's descriptions of the severity, duration, and frequency of pain, weakness, fatigue, and incoordination associated with his left knee disability are properly captured by his assigned 10 percent disability rating under DC 5260. The Veteran maintains extensive functional ability in his left knee, in both flexion and extension. The examiner's documented findings and opinions are the most probative evidence on this issue. Therefore, the Board finds a rating in excess of 10 percent is not warranted under DC 5260 for his left knee disability. The Board points out that the Veteran is not entitled to two individual ratings under DC 5260 and DC 5261 for his left knee pain because the symptom is not separate and distinct as applied to each diagnostic code. That is, the Veteran does not have distinct pain on flexion that is separate from his pain on extension. Rather, his pain is one entity. Thus, the VA Regional Office's choice to rate his pain under only DC 5260 is valid. 38 C.F.R. § 4.14 (prohibiting duplicate compensation for the same manifestation (i.e., symptom) of disability under different diagnoses, known as "pyramiding"); see generally Boggs v. Peake, 520 F.3d 1330, 1337 (Fed. Cir. 2008) ("[A] veteran cannot be compensated more than once for the same disability."). Furthermore, the Board recognizes that during the appeal period the Veteran experienced a left shin splint. Prior to February 7, 2021, there was not a separate diagnostic code for shin splints and the disability was generally rated under 38 C.F.R. § 4.71a, DC 5262 (impairment of tibia and fibula). In this particular case, however, the Veteran's left shin splint manifested as pain that was not separate and distinct from his left knee pain. See generally March 2016 VA Examination; November 2020 VA-Contracted Examination. There is no medical evidence, or competent lay evidence, that the Veteran's left shin splint pain and left knee pain are attributable to different disabilities. Rather, the symptoms are one entity, stemming from the Veteran's left knee. As such, the rule against pyramiding applies, and a separate rating under DC 5262 is not warranted. 38 C.F.R. § 4.14. The Board has also considered all potentially applicable provisions of 38 C.F.R. Parts 3 and 4, irrespective of whether they have been raised by the Veteran, his representative, or by the record. Except as to the Veteran's shin splints, which will be discussed further within this decision, the Board finds no evidence of left knee ankylosis, meniscus dislocation or removal, impairment of the tibia and fibula, or genu recurvatum to support higher or separate ratings under Diagnostic Codes 5256, 5257, 5258, 5259, or 5263. To the extent that the record reflects symptoms of painful motion, stiffness, and difficulty with walking, standing, or squatting and related activities, such symptoms are contemplated by the rating assigned herein for the left knee under DC 5260, including due to painful motion. Right Knee The Veteran has been afforded two VA examinations to assess his right knee disability. In March 2016, a VA examiner documented that the Veteran's right knee flexion was 0 to 142 degrees and extension was 142 to 0 degrees. The examiner did not observe pain on range-of-motion testing or on weight bearing. The examiner did not find additional loss of range of motion following repetitive-use testing. The examiner did not find loss of muscle strength, atrophy, instability, or ankylosis. The Veteran reported flare-ups during physical activity, and he said he was unable to move his right knee after kneeling down. Over time, he experienced pain and stiffness in his knee. The examiner did not offer an opinion about additional loss of range of motion due to flare-ups or following repetitive use over time. Nevertheless, the Board finds the examination is still credible and probative in other respects discussed. Monzingo v. Shinseki, 26 Vet. App. 97, 107 (2012) ("[E]ven if a medical opinion is inadequate to decide a claim, it does not necessarily follow that the opinion is entitled to absolutely no probative weight."). During a November 2020 VA-contracted examination, the examiner documented the Veteran's right knee flexion was 0 to 120 degrees and extension was 120 to 0 degrees. The examiner did not observe pain on range-of-motion testing or on weight bearing. The examiner did not find additional loss of range of motion following repetitive-use testing. The examiner did not find loss of muscle strength, atrophy, instability, or ankylosis. The Veteran reported experiencing mild flare-ups five times a week lasting 20 minutes. He described the pain as "shooting" and rated it an 8 out 10. He said his knee locked up and the kneecap felt like it would pop it. The Veteran reported occasional use of a knee brace. The examiner opined that following repetitive use over time, the Veteran's range of motion would not be further limited due to pain, weakness, fatigability or incoordination. During a flare-up, however, the examiner opined the Veteran would experience flexion of 0 to 115 degrees and extension of 115 to 0 degrees due to incoordination. Absent evidence to the contrary, the Board finds the above-mentioned medical professionals were competent to exam and diagnose the Veteran and to provide medical judgments related to the Veteran's adjustment disorder. Cox, 20 Vet. App. at 569. The Board finds the medical professionals' respective examinations, medical findings, and medical opinions are credible and probative unless otherwise indicated. The medical professionals conducted thorough examinations, relied on accurate facts, considered the Veteran's relevant medical records, medical history, and lay statements, and provided well-reasoned medical judgments. The Board has also reviewed the Veteran's medical records associated with his claims file. His medical records generally document his treatment for his right knee strain. The Board has considered his lay statements as well as his testimony during his February 2020 Board hearing. Throughout the appeal period the Veteran's right knee flexion never exhibited limitation less than 115 degrees. Notably, limitation of 30 degrees is necessary to obtain a 20 percent disability rating. 38 C.F.R. § 4.71a, DC 5260. In addition, throughout the appeal period, the Veteran's right knee extension was always normal. Notably, limitation of 15 degrees is necessary to obtain a 20 percent disability rating. 38 C.F.R. § 4.71a, DC 5261. The VA Regional Office assigned a minimum 10 percent disability rating under DC 5260 based on the Veteran's associated pain under 38 C.F.R. § 4.59 and taking into consideration the factors under 38 C.F.R. §§ 4.40 and 4.45. The Board find the Veteran's descriptions of the severity, duration, and frequency of pain, weakness, fatigue, and incoordination associated with his right knee disability are properly captured by his assigned 10 percent disability rating under DC 5260. The Veteran maintains extensive functional ability in his right knee, in both flexion and extension. The examiner's documented findings and opinions are the most probative evidence on this issue. Therefore, the Board finds a rating in excess of 10 percent is not warranted under DC 5260. The Board points out that the Veteran is not entitled to two individual ratings under DC 5260 and DC 5261 for his right knee pain because the symptom is not separate and distinct. That is, the Veteran does not have distinct pain on flexion that is separate from his pain on extension. Rather, his pain is one entity. Thus, the VA Regional Office's choice to rate his pain under only DC 5260 is valid. 38 C.F.R. § 4.14 (prohibiting duplicate compensation for the same manifestation (i.e., symptom) of disability under different diagnoses, known as "pyramiding"); see generally Boggs v. Peake, 520 F.3d 1330, 1337 (Fed. Cir. 2008) ("[A] veteran cannot be compensated more than once for the same disability."). Furthermore, the Board recognizes that during the appeal period the Veteran experienced right shin splint. As explained, prior to February 7, 2021, there was not a separate diagnostic code for shin splints. Here, the Veteran's right shin splint manifested as pain that was not separate and distinct from his left knee pain. See generally March 2016 VA Examination; November 2020 VA-Contracted Examination. There is no medical evidence, or competent lay evidence, that the Veteran's right shin splint pain and right knee pain are attributable to different disabilities. Rather, the symptoms are one entity, stemming from the Veteran's right knee. As such, the rule against pyramiding applies, and a separate rating under DC 5262 is not warranted. 38 C.F.R. § 4.14. The Board has also considered all potentially applicable provisions of 38 C.F.R. Parts 3 and 4, irrespective of whether they have been raised by the Veteran, his representative, or by the record. Except as to the Veteran's shin splints, which will be discussed further later within this decision, the Board finds no evidence of right knee ankylosis, meniscus dislocation or removal, impairment of the tibia and fibula, or genu recurvatum to support higher or separate ratings under Diagnostic Codes 5256, 5257, 5258, 5259, or 5263. To the extent that the record reflects symptoms of painful motion, stiffness, and difficulty with walking, standing, or squatting and related activities, such symptoms are contemplated by the ratings assigned herein for the right knee under DC 5260 and 5261, including due to painful motion. In sum, the Veteran's right and left knee disabilities did not manifest as limited flexion of 30 degree or less and did not manifest as limited extension of 15 degrees or more throughout the appeal period. The Veteran's bilateral knee pain, weakness, fatigue, and incoordination are all properly accounted for with his currently assigned ratings. Accordingly, ratings in excess of 10 percent for right and left knee strains (with bilateral shin splints) are not warranted. 4. From February 7, 2021, a separate noncompensable disability rating for left shin splint, apart from left knee strain, is granted. 5. From February 7, 2021, a separate noncompensable disability rating for right shin splint, apart from right knee strain, is granted. During the Veteran's November 2020 VA-contracted examination, the examiner diagnosed the Veteran with right and left shin splints. Again, prior to February 7, 2021, 38 C.F.R. Part 4 did not provide a specific diagnostic code to rate shin splints. As of February 7, 2021, 38 C.F.R. § 4.71a, DC 5262 specifically recognizes shin splints as a separate compensable disability. Rating Criteria Shin Splint The Veteran's bilateral shin splints are rated under 38 C.F.R. § 4.71a, DC 5262 ("Tibia and fibula, impairment of"). As of February 7, 2021, DC 5262 provides: Rating (%) Tibia and fibula, impairment of: Nonunion of, with loose motion, requiring brace 40 Malunion of: Evaluate under diagnostic codes 5256, 5257, 5260, or 5261 for the knee, or 5270 or 5271 for the ankle, whichever results in the highest evaluation. Medial tibial stress syndrome (MTSS), or shin splints: Requiring treatment for no less than 12 consecutive months, and unresponsive to surgery and either shoe orthotics or other conservative treatment, both lower extremities 30 Requiring treatment for no less than 12 consecutive months, and unresponsive to surgery and either shoe orthotics or other conservative treatment, one lower extremity 20 Requiring treatment for no less than 12 consecutive months, and unresponsive to either shoe orthotics or other conservative treatment, one or both lower extremities 10 Treatment less than 12 consecutive months, one or both lower extremities 0 As stated, the Veteran has a diagnosis of right and left shin splints. As these disabilities are now specifically recognized as distinct compensable disabilities, the Veteran is entitled to a noncompensable disability rating for his right and left shin splints from February 7, 2021. (Continued on the next page) The Veteran's medical records do not indicate that he received treatment for either his right or left shin splints for at least twelve consecutive months. Nor has the Veteran reported receiving such treatment. Likewise, there is no medical or lay evidence that the Veteran's right or left shin splints were unresponsive to either shoe orthotics or other conservative treatment. Therefore, he is not entitled to a 10 percent disability rating under the schedular criteria of DC 5262 as of February 7, 2021. The Veteran is also not entitled to a minimum compensable rating under DC 5262 for his associated pain in relation to his bilateral shin splints under 38 C.F.R. § 4.59. As already discussed, the Veteran's pain associated with his bilateral shin splints is not separate and distinct from his bilateral knee pain. There is no medical evidence or competent lay evidence drawing such a distinction. Thus, the Board can only assign the Veteran a noncompensable disability rating for his right and left shin splints as of February 7, 2021. M. Tenner Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. F. Sawka, Associate Counsel The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.