Citation Nr: 21032313 Decision Date: 05/26/21 Archive Date: 05/26/21 DOCKET NO. 15-36 253 DATE: May 26, 2021 ORDER Service connection for a depressive disorder secondary to service-connected disabilities is granted. A disability evaluation in excess of 10 percent for osteoarthrosis of the medial compartment of the right knee based upon limitation of motion is denied. A compensable disability evaluation for osteoarthrosis of the medial compartment of the right knee based upon subluxation/lateral instability is denied. A disability evaluation in excess of 10 percent for osteoarthrosis of the medial compartment of the left knee based upon limitation of motion prior to October 26, 2016, is denied. A compensable evaluation for osteoarthrosis of the medial compartment of the left knee based upon subluxation/lateral instability prior to October 26, 2016 is denied. A separate 10 percent evaluation, the highest schedular evaluation available for the Veteran's left knee meniscectomy, prior to October 26, 2016, is granted. A disability evaluation in excess of 30 excess percent for a left knee total arthroplasty from December 1, 2017 is denied. An initial compensable disability rating for scars of the left knee associated with osteoarthrosis of the medial compartment of the left knee is denied. REMANDED Entitlement to service connection for a right shoulder disability is remanded. Entitlement to service connection for a left shoulder disability is remanded. Entitlement to an initial disability rating in excess of 20 percent for peripheral neuropathy of the right upper extremity is remanded. Entitlement to an initial disability rating in excess of 20 percent for peripheral neuropathy of the left upper extremity is remanded. Entitlement to an initial disability rating in excess of 10 percent for peripheral neuropathy of the right lower extremity is remanded. Entitlement to an initial disability rating in excess of 10 percent for peripheral neuropathy of the left lower extremity is remanded. FINDINGS OF FACT 1. The Veteran's depressive disorder is aggravated by his service-connected disabilities. 2. Throughout the appeal period, the Veteran was not shown to have right knee extension limited to less than 0 degrees or flexion limited to less than 90 degrees, and no subluxation/lateral instability was demonstrated. 3. Throughout the appeal period, the Veteran was not shown to have left knee extension limited to less than 0 degrees or flexion limited to less than 90 degrees, and no subluxation/lateral instability was demonstrated. 4. Prior to the Veteran having undergone a left knee total arthroplasty on October 26, 2016, his left knee meniscectomy was reported to cause pain, intermittent instability, and moderate-severe osteoarthrosis. 5. For the time period from December 1, 2017, the Veteran's left knee total arthroplasty has not resulted in chronic residuals consisting of severe painful motion or weakness in the affected extremity, with flexion limited to no less than 100 degrees or extension to 0 degrees, and subluxation or lateral instability is not demonstrated. 6. The Veteran's left knee scars are stable and superficial, do not cause functional loss, and do not measure 144 square inches. CONCLUSIONS OF LAW 1. Resolving reasonable doubt in the Veteran's favor, the criteria for service connection for depressive disorder as secondary to service-connected disabilities, by way of aggravation, have been met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2020). 2. The criteria for a rating in excess of 10 percent for osteoarthrosis of the medial compartment of the right knee, based upon limitation of motion, have not been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 4.7, 4.14, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5260, 5261 (2020). 3. The criteria for a compensable evaluation for osteoarthrosis of the medial compartment of the right knee, based upon subluxation/lateral instability, have not been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 4.71a, Diagnostic Code 5257 (2020). 4. The criteria for a rating in excess of 10 percent for osteoarthrosis of the medial compartment of the left knee, based upon limitation of motion, prior to October 26, 2016 have not been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 4.7, 4.14, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5260, 5261 (2020). 5. The criteria for a compensable evaluation for osteoarthrosis of the medial compartment of the left knee based upon subluxation/lateral instability prior to October 26, 2016 have not been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 4.71a, Diagnostic Code 5257 (2020). 6. The criteria for a separate 10 percent evaluation, the highest schedular evaluation available for the Veteran's left knee meniscectomy, prior to October 26, 2016, have been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 4.7, 4.14, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5259 (2020). 7. The criteria for an evaluation in excess of 30 percent for a left knee total arthroplasty from December 1, 2017 have not been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 4.7, 4.14, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5055, 5260, 5261 (2020). 8. The criteria for a compensable evaluation for left knee scars have not been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 4.1, 4.7, 4.118, Diagnostic Code 7801-7805 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from December 1965 to September 1969, during the Vietnam Era. These matters come to the Board of Veterans' Appeals (Board) from a November 2013 rating decision. In August 2018, the Board remanded the claims for further development. Service Connection Psychiatric Disorder, to Include Depression/Depressive Disorder, Other Than Neurocognitive Disorder The Veteran maintains that he has depression caused or aggravated by his service-connected disabilities, to include his service-connected coronary artery disease, diabetes mellitus, bilateral upper and lower extremity neuropathy, right and left knee disorders, tinnitus, and hearing loss, which were in effect at the time his claim of service connection for depression. At the outset, the Board notes that service connection for a neurocognitive disorder due to Parkinson's Disease was granted in a February 2021 rating decision, with a 50 percent disability evaluation being assigned effective April 6, 2020. The Veteran's claim for a depression has been pending since his claim for service connection for depression was received on January 30, 2013. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). As a general matter, service connection for a disability requires evidence of: (1) the existence of a current disability; (2) the existence of the disease or injury in service, and; (3) a relationship or nexus between the current disability and any injury or disease during service. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004); see also Hickson v. West, 12 Vet. App. 247, 253 (1999), citing Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996). Service connection may also be granted for disability which is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310; Allen v. Brown, 7 Vet. App. 439, at 448 (1995) (holding that service connection on a secondary basis requires evidence sufficient to show that the current disability was caused or aggravated by a service-connected disability). To establish secondary service connection, the law states that there must be (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) nexus evidence establishing a connection between a service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). Generally, lay evidence is competent with regard to a disease with "unique and readily identifiable features" that is "capable of lay observation." See Barr v. Nicholson, 21 Vet. App. 303, 308-09 (2007) (concerning varicose veins); see also Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007) (a dislocated shoulder); Charles v. Principi, 16 Vet. App. 370, 374 (2002) (tinnitus); Falzone v. Brown, 8 Vet. App. 398, 405 (1995) (flatfoot); Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a veteran is competent to report on that of which he or she has personal knowledge). Lay evidence can be competent and sufficient evidence of a diagnosis if (1) the layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). In weighing credibility, VA may consider interest, bias, inconsistent statements, bad character, internal inconsistency, facial plausibility, self-interest, consistency with other evidence of record, malingering, desire for monetary gain, and demeanor of the witness. Caluza v. Brown, 7 Vet. App. 498 (1995). When there is an approximate balance in the evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. The Court has held that an appellant need only demonstrate that there is an "approximate balance of positive and negative evidence" in order to prevail. See Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). The Court has also stated, "It is clear that to deny a claim on its merits, the evidence must preponderate against the claim." Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert. In support of his claim, the Veteran submitted a June 2015 Mental Disorders Disability Benefits Questionnaire (DBQ) and medical opinion from H. H.-G., Ph.D., who diagnosed the Veteran as having depressive disorder due to a medical condition with depressive features and indicated, based on an interview of the Veteran and a review of the claims file, that the Veteran's coronary artery disease, diabetes mellitus II, peripheral neuropathy of the bilateral upper and lower extremities, osteoarthritis of the left and right knee, and tinnitus more likely than not aggravated his depressive disorder. The clinician noted that the Veteran reported he used to go hiking and fishing, which he could no longer do due to his knees. In a November 2020 VA examination report, the examiner opined that the claimed condition was less likely than not proximately due to or the result of the Veteran's service-connected conditions. The examiner noted the private June 2015 in which the Veteran was diagnosed with depressive disorder due to another medical condition with depressed features, but explained that upon examination, the Veteran and his spouse both indicated that they did not recall the Veteran being evaluated in 2015 and denied a history of symptoms endorsed in the June 2015 DBQ. The examiner stated that while it was common for depression to co-exist secondary to medical conditions or pain, medical records between 2015 to the present did now show a diagnosis of depression, and evaluations between 2018 to present all indicated absence of mental health symptoms. As the Veteran did not report any symptoms that met the criteria for diagnosis of a depressive disorder, the examiner indicated that a diagnosis could not be rendered. The examiner did not address the question of aggravation. In the present case, the record does not demonstrate nor has the Veteran contended that his psychiatric disorder had its onset in service. As such, service connection on a direct basis is not warranted. As to the issue of service connection on a secondary basis, the Board notes that the VA examiner specifically indicated that the Veteran's service-connected disabilities did not cause his depression. Furthermore, the Veteran's private clinician did not indicate that his depression was proximately due to or caused by his service-connected disabilities. As such service connection for a depressive disorder as proximately due to or caused by a service-connected disability is also not warranted. However, the Board will resolve reasonable doubt in favor of the Veteran and find that he has a depressive disorder which is aggravated by his service-connected disabilities. The Board notes that while the November 2020 VA examiner indicated that the Veteran did not meet the diagnostic criteria for a diagnosis at the time of the November 2020 VA examination and that the record did not support a diagnosis of depressive disorder, the June 2015 private opinion provides great detail as to the state of the Veteran at the time of the examination and also cites to specific history and findings when reaching the conclusion that the Veteran has a depressive disorder per the diagnostic criteria. Therefore, the Board gives the private opinion probative weight. The medical report and opinion also cite to specific findings in the record and notes the disabilities for which service connection was in effect at the time the opinion was rendered and following a thorough review of the record and examination of the Veteran, the private clinician specifically opined that the Veteran's service-connected disabilities more likely than not aggravated his depressive disorder. The Board gives less probative weight to the November 2020 VA opinion. While the examiner indicated that treatment records from 2015 to the present did now show a diagnosis of depression, the Board notes that VA treatment records show a positive depression screen in June 2015. Given the foregoing, and resolving reasonable doubt in favor of the Veteran, service connection for a depressive disorder as aggravated by his service-connected disabilities is warranted. Evaluations Disability evaluations are determined by the application of the Schedule for Rating Disabilities, which assigns ratings based on the average impairment of earning capacity resulting from a service-connected disability. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. It is the defined and consistently applied policy of VA to administer the law under a broad interpretation, consistent, however, with the facts shown in every case. Any reasonable doubt regarding the degree of disability is resolved in favor of the Veteran. See 38 C.F.R. § 4.3. Where the appeal arises from the original assignment of a disability evaluation following an award of service connection, the severity of the disability at issue is to be considered during the entire period from the initial assignment of the disability rating to the present time. See Fenderson v. West, 12 Vet. App. 119 (1999). Where entitlement to compensation has already been established, and an increase in the disability rating is at issue, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Nevertheless, the Board acknowledges that a claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Hart v. Mansfield, 21 Vet. App. 505 (2007). In view of the number of atypical instances it is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified. Findings sufficiently characteristic to identify the disease and the disability therefrom, and above all, coordination of rating with impairment of function will, however, be expected in all instances. 38 C.F.R. § 4.21 (2020). In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of a veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). When the evidence supports the claim or is in relative equipoise, the claim will be granted. See Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990); see also Wise v. Shinseki, 26 Vet. App. 517, 532 (2014). If the preponderance of the evidence weighs against the claim, it must be denied. See id.; Alemany v. Brown, 9 Vet. App. 518, 519 (1996). Left and Right Knee The Veteran maintains that the symptomatology associated with his right knee and left knee warrant evaluations in excess of those which are currently assigned. Limitation of motion of the knee is addressed in 38 C.F.R. § 4.71a, Diagnostic Codes 5260 and 5261. Diagnostic Code 5260 provides for a zero percent rating where flexion of the leg is limited to 60 degrees; 10 percent rating where flexion is limited to 45 degrees; 20 percent rating where flexion is limited to 30 degrees; and 30 percent rating where flexion is limited to 15 degrees. Diagnostic Code 5261 provides for a zero percent rating where extension of the leg is limited to 5 degrees; 10 percent rating where extension is limited to 10 degrees; 20 percent rating where extension is limited to 15 degrees; a 30 percent rating where extension is limited to 20 degrees; a 40 percent rating where extension is limited to 30 degrees; and a 50 percent rating where extension is limited to 45 degrees. 38 C.F.R. § 4.71a, Diagnostic Codes 5260, 5261. The knee is considered a major joint. 38 C.F.R. § 4.45(f). The normal range of motion of the knee is from zero to 140 degrees. 38 C.F.R. § 4.71, Plate II. Diagnostic Code 5257 provides 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 rating when there is severe recurrent subluxation or lateral instability. 38 C.F.R. § 4.71a, Diagnostic Code 5257. The Board notes that regulations regarding the musculoskeletal system changed effective February 7, 2021. While DCs 5260 and 5261 remained the same, DC 5257 changed. The new criteria state that for recurrent subluxation or instability, 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 warrants a 30 percent rating. A 20 percent rating is warranted for (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 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 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 warranted a 30 percent rating. 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: brace, cane, or walker warrants a 20 percent rating. A diagnosed condition involving the patellofemoral complex with recurrent instability (with or without history of surgical repair) that does not require a prescription from a medical provider for a brace, cane, or walker warrants a 10 percent rating. Note (1) states that for patellar instability, the patellofemoral complex consists of the quadriceps tendon, the patella, and the patellar tendon. Note (2) states that a surgical procedure that does not involve repair of one or more patellofemoral components that contribute to the underlying instability shall not qualify as surgical repair for patellar instability (including, but not limited to, arthroscopy to remove loose bodies and joint aspiration). Under Diagnostic Code 5259, a maximum 10 percent disability rating is warranted for symptomatic removal of the semilunar cartilage. The General Counsel considered a hypothetical situation in which a knee disability was evaluated under Diagnostic Code 5259 that was productive of pain, tenderness, friction, osteoarthritis established by x-rays, and a slight loss of motion. For the purposes of the hypothetical, it was assumed that Diagnostic Code 5259 did not involve limitation of motion. The General Counsel further noted in VAOPGCPREC 9-98 that the removal of the semilunar cartilage may involve restriction of movement caused by tears and displacements of the menisci, but that the procedure may result in complications such as reflex sympathetic dystrophy, which can produce loss of motion. Therefore, limitation of motion is a relevant consideration under Diagnostic Code 5259, and the provisions of 38 U.S.C. §§ 4.40, 4.45, and 4.59 must be considered. Under Diagnostic Code 5055, for a total knee replacement with prosthesis, a 100 percent evaluation is assigned for 1 year following implantation of the prosthesis. After that year, a minimum rating of 30 percent disabling is assigned. With intermediate degrees of residual weakness, pain or limitation of motion, the rater is directed to evaluate as analogous to Diagnostic Codes 5256, 5261, or 5262. A 60 percent evaluation is assigned for chronic residuals consisting of severe painful motion or weakness in the affected extremity. See 38 C.F.R. § 4.71a, Diagnostic Code 5055. VA's General Counsel has held that a claimant who has arthritis and instability of the knee may be rated separately under Diagnostic Codes 5003 and 5257. VAOPGCPREC 23-97; 62 Fed. Reg. 63,604 (1997). The General Counsel subsequently clarified that 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. A separate rating for arthritis could also be based on x-ray findings and painful motion under 38 C.F.R. § 4.59. VAOPGCPREC 9-98 (1998); 63 Fed. Reg. 56,704 (1998). The General Counsel further held that separate ratings could also be provided for limitation of knee extension and flexion. VAOPGCPREC 9-2004; 69 Fed. Reg. 59,990 (2004). In VAOPGCPREC 9-98, VA's General Counsel reiterated that, if a veteran has a disability rating under Diagnostic Code 5257 for instability of the knee, and there is also x-ray evidence of arthritis, a separate rating for arthritis could also be based on painful motion under 38 C.F.R. § 4.59. For disabilities evaluated on the basis of limitation of motion, VA is required to apply the provisions of 38 C.F.R. §§ 4.40, 4.45, pertaining to functional impairment. The Court has instructed that in applying these regulations VA should obtain examinations in which the examiner determined whether the disability was manifested by weakened movement, excess fatigability, incoordination, or pain. Such inquiry is not to be limited to muscles or nerves. 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. DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Johnston v. Brown, 10 Vet. App. 80, 84-85 (1997); 38 C.F.R. § 4.59 (2019). Diagnostic Code 5003 provides that degenerative arthritis established by x-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved (DC 5200 etc.). When, however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under Diagnostic Code 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. In the absence of limitation of motion, a 10 percent evaluation is assigned where x-ray evidence shows involvement of two or more major joints or 2 or more minor joint groups. Where there is x-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups, with occasional incapacitating exacerbations, a 20 percent evaluation is assigned. Note (1) to Diagnostic Code 5003 states that the 20 and 10 percent ratings based on x-ray findings, above, will not be combined with ratings based on limitation of motion. Id. In Correia v. McDonald, 28 Vet. App. 158 (2016), the Court held that the final sentence of 38 C.F.R. § 4.59 creates a requirement that certain range of motion testing be conducted whenever possible in cases of joint disabilities. The final sentence provides that the joints involved should be tested for pain on both active and passive motion, in weight-bearing and non-weight-bearing and, if possible, with the range of the opposite undamaged joint. The Court found that, to be adequate, a VA examination of the joints must, wherever possible, include the results of the range of motion testing described in the final sentence of § 4.59. Correia, 28 Vet. App. at 169-170. In this case, the Board finds that the medical evidence of record is sufficient to decide the case and is compliant with prevailing caselaw. In conjunction with his claim, the Veteran was afforded a VA examination in October 2013. At that time, diagnoses of moderate to severe osteoarthrosis of the medial compartment of the knees were rendered. The Veteran reported that his knees had progressed in pain and disability. He rated his left and right knee as daily pain of 6/10 with flares to 9/10 caused by going up and down stairs or walking for prolonged periods of time. His knees ached daily. He reported mild swelling of both knees with overuse. He used rest and elevation as the main treatment and avoided prolonged standing, stairs, and hills. He stated that his left knee was not stable with full weight bearing and that it tended to give out. The examiner noted that the Veteran was scheduled for total left knee replacement but that his surgery had been cancelled and not yet rescheduled. Physical examination of the right knee revealed flexion to 100 degrees with pain at 90 degrees. Extension was to 0 degrees. Left knee flexion was to 100 degrees with pain at 90 degrees. As to extension, there was no objective evidence of painful motion. Motion after three repetitions was flexion to 100 degrees and extension to 0 degrees for both knees. The Veteran's knee problems were noted to cause less movement than normal, excess fatigability, and pain on movement. There was tenderness or pain to palpation for the joint line or soft tissue on the left. Muscle strength was 5/5 for flexion and extension. Joint stability testing revealed normal findings for anterior instability, posterior instability, and medial-lateral instability. There was no patellar subluxation/dislocation. The Veteran was noted to have undergone a meniscectomy in 1967 on his left knee, which resulted in pain, intermittent instability, and moderate-severe osteoarthrosis. The Veteran did not use assistive devices. The examiner stated that based upon his exam and evaluation, it was more likely than not that there would be limitations to functional ability during flare-ups or when the joint was used repeatedly over a period of time either from pain, weakness, fatigability or lack of coordination. He stated that it was not feasible for him to predict in terms of degrees any additional range of motion loss or functional limitation due to pain on use or during flare-ups as any prediction would be mere speculation. Private treatment records associated with the file reveal that the Veteran was given right and left knee injections in 2015 and 2016. In October 2016, the Veteran underwent a left total knee arthroplasty. The Veteran was afforded a VA examination in November 2020. At that time, diagnoses of status post left total knee replacement and osteoarthrosis of the medial compartment of the right knee were rendered. The Veteran reported that he underwent left total knee replacement surgery in 2016. He indicated that he had been having residual symptoms of pain, stiffness, and limited range of motion of the left knee. He also stated that his right knee symptoms had gotten worse over time and developed arthritis. He noted that there was a plan for right total knee replacement but stated that it was not yet scheduled. He stated that he was having pain, stiffness, and limited range of motion of the right knee. The Veteran reported having flare-ups of the right knee that occurred once a month. The right knee flare-ups were moderate and lasted two to three days. The right knee flare-ups were precipitated by prolonged walking, standing, and cold weather. They were alleviated by rest and pain medications. The Veteran stated that due to his knee condition, he could not walk for prolonged periods, climb ladders, or take the stairs. Physical examination revealed flexion from 0 to 110 degrees for the right knee and 0 to 120 degrees for the left knee. There was evidence of pain with flexion and with weight bearing. There was no evidence of localized tenderness or pain on palpation of the joint or associated soft tissue. The Veteran reported that he could not walk for prolonged periods and could not climb ladders or take stairs. Repetitive testing did not result in additional loss of function or range of motion. Pain with repeated use over a period of time limited range of motion from 0 to 100 degrees on the right and 0 to 110 degrees on the left. The examination was not being conducted during a flare-up, but the examiner estimated range of motion from 0 to 90 degrees on the right. Muscle strength for flexion and extension was 5/5 on the left and right. There was no ankylosis. There was no history of recurrent subluxation or lateral instability. Joint stability testing was normal for anterior instability, posterior instability, medial instability, and lateral instability for both the left and right knee. There were no current meniscal conditions on either side. The examiner noted that the Veteran did not have symptoms related to meniscus tear except for a residual scar. He was status-post left total knee replacement and did not have a history of a meniscal condition of the right knee. As to the left total knee replacement, the examiner checked the box indicating that the Veteran had pain and limited motion. There were no findings of intermediate degrees of residual weakness, pain or limitation of motion; or, chronic residuals consisting of severe painful motion or weakness. The Veteran did not use any assistive devices. The examiner found that the Veteran had evidence of pain on passive motion for both knees but no evidence of pain on non-weight bearing testing. Upon review of the evidence of record, as it relates to the right knee, the Veteran was not shown to have flexion to less than 60 degrees at the time of any VA examination or outpatient visits during the time period in question, with flexion to no less than 90 degrees being reported during the course of the appeal. As the Veteran has been shown to have limitation of motion, although noncompensable for rating purposes, the Board finds that a 10 percent disability evaluation, and no more, is warranted under 5260 for painful motion. As to extension, the Veteran has been shown to have extension to 0 degrees. Symptoms of painful motion are evaluated under limitation of flexion and awarding a separate evaluation under extension for the same symptomatology would violate the rules against pyramiding. As such, a compensable disability evaluation is not warranted for extension under 5261. While the Board is sympathetic to the Veteran's reports of pain, objective testing did not reveal that any pain on use or during flare-ups, abnormal movement, fatigability, incoordination, or any other such factors such that motion of the right knee was limited to the extent required for a 20 percent rating for limitation of flexion or extension of the right knee. 38 C.F.R. §§ 4.40, 4.45; DeLuca v. Brown, 8 Vet. App. 202 (1995). To any extent that there were deficiencies in the October 2013 VA examination as it pertains to flare-ups, the Board notes that the November 2020 examination, in which the Veteran reported worsening of his right knee since his previous examination, is adequate, and the Board has weighed any reasonable doubt as to the severity of the Veteran's right knee in his favor. As it relates to instability, the Veteran has not reported instability in his right knee nor has he been found to have instability or subluxation of the right knee, to include on two separate VA examinations, the most recent being in November 2020. The examinations revealed normal anterior stability, posterior stability, lateral stability, and medial-lateral stability testing. There were also no findings of subluxation. As such, a compensable disability evaluation based up subluxation/lateral instability is not warranted. As it relates to flexion of the left knee prior to October 26, 2016, the date of the Veteran's left total knee replacement, the Veteran was not shown to have flexion to less than 90 degrees before experiencing pain. As the Veteran has been shown to have limitation of motion, although noncompensable for rating purposes, a 10 percent disability evaluation, and no more, is warranted under 5260 for painful motion. As to extension, the Veteran was shown to have extension to 0 degrees. Symptoms of painful motion are evaluated under limitation of flexion and awarding a separate evaluation under extension for the same symptomatology would violate the rules against pyramiding. As such, a compensable disability evaluation is not warranted for extension under 5261. While the Board is sympathetic to the Veteran's reports of pain, objective testing did not reveal that any pain on use or during flare-ups, abnormal movement, fatigability, incoordination, or any other such factors such that motion of the left knee was limited to the extent required for a 20 percent rating for limitation of flexion or extension of the left knee. 38 C.F.R. §§ 4.40, 4.45; DeLuca v. Brown, 8 Vet. App. 202 (1995). As it relates to instability, the Veteran was found to have no instability or subluxation of the left knee, with normal anterior stability, posterior stability, lateral stability, and medial-lateral stability testing. There were no findings of any subluxation. As such, a compensable disability evaluation based up subluxation/lateral instability was not warranted prior to October 26, 2016. As it relates to the left knee meniscectomy, the October 2013 VA examiner found that the meniscectomy was reported to have resulted in pain, intermittent instability, and moderate-severe osteoarthrosis. Given the foregoing, a 10 percent disability evaluation, the maximum benefit under 5259 for a symptomatic meniscectomy, is warranted until October 26, 2016, the date of the left knee total arthroplasty. Following the surgery, the Veteran was not found to have any further meniscectomy residuals, with the November 2020 VA examiner specifically indicating that the Veteran had no other residuals other than the scar. As noted above, the Veteran underwent a left knee total arthroplasty on October 26, 2016. This resulted in a 100 percent rating being assigned until December 1, 2017. For the time period from December 1, 2017, a 30 percent evaluation has been assigned for the status post residuals of the left total knee arthroplasty. Treatment records from this time period do not demonstrate that the Veteran has chronic residuals consisting of severe painful motion or weakness in the affected extremity. The Veteran was noted to have extension to 0 degrees and flexion to no less than 100 degrees, which warrant evaluations of no more than 10 percent for flexion and a noncompensable disability evaluation for extension. Moreover, the examiner specifically did not check the boxes indicating findings of intermediate degrees of residual weakness, pain or limitation of motion; or, chronic residuals consisting of severe painful motion or weakness, the latter being the requirement for a 60 percent evaluation. While the Board is sympathetic to the Veteran's reports of pain, objective testing did not reveal that any pain on use or during flare-ups, abnormal movement, fatigability, incoordination, or any other such factors which resulted in the left knee being limited in motion to the extent required for an evaluation in excess of 30 percent for status post left total knee arthroplasty residuals. 38 C.F.R. §§ 4.40, 4.45; DeLuca v. Brown, 8 Vet. App. 202 (1995). As it relates to instability, the Veteran was found to have no instability or subluxation of the left knee, with the November 2020 VA examination revealing normal anterior stability, posterior stability, lateral stability, and medial-lateral stability testing. There were no findings of subluxation. Left Knee Scar The Veteran maintains that the symptomatology associated with his left knee scars are worse than those which are contemplated by his current rating and that an increased evaluation is warranted. The applicable rating criteria include Diagnostic Code 7801, which provides ratings for scars, other than the head, face, or neck, that are deep or that cause limited motion. Scars in an area or areas exceeding 6 square inches (39 sq. cm.) are rated 10 percent disabling. Note (1) to Diagnostic Code 7801 provides that a deep scar is one associated with underlying soft tissue damage. 38 C.F.R. § 4.118, Diagnostic Code 7801. Diagnostic Code 7802 provides ratings for scars, other than the head, face, or neck, that are superficial or that do not cause limited motion. Superficial scars that do not cause limited motion, in an area or areas of 144 square inches (929 sq. cm.) or greater, are rated 10 percent disabling. Note (1) to Diagnostic Code 7802 provides that a superficial scar is one not associated with underlying soft tissue damage. 38 C.F.R. § 4.118, Diagnostic Code 7802. Diagnostic Code 7804 pertains to unstable or painful scars. One or two scars that are unstable or painful warrant a 10 percent rating, while a 20 percent rating is warranted for three or four of such scars. Five or more scars that are unstable or painful are 30 percent disabling. Note (1) to Diagnostic Code 7804 provides that an unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. 38 C.F.R. § 4.118, Diagnostic Code 7804. Diagnostic Code 7805 provides that any other scars (including linear scars) and other disabling effects of scars should be evaluated even if not considered in a rating provided under diagnostic codes 7800-04 under an appropriate diagnostic code. 38 C.F.R. § 4.118, Diagnostic Code 7805. Effective August 13, 2018, changes were made to the rating criteria for skin disabilities (38 C.F.R. § 4.118). See 83 Fed. Reg. 32,592 (July 13, 2018). The old regulation will be considered for periods both before and after the effective date of the regulatory change. However, the revised criteria will be applied if favorable to the claim from the effective date of the regulatory change. See VAOPGCPREC 3-2000, 65 Fed. Reg. 33,422 (2000); Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). To summarize, the revisions to Diagnostic Codes 7801, 7802, and 7805, pertaining to scars: (1) replace the deep/nonlinear/superficial terminology in Diagnostic Code 7801 and 7802 with "underlying soft tissue damage;" (2) streamline the body parts/areas into six zones of the body, defined as each extremity, the anterior trunk and the posterior trunk (Note 1 to DCs 7801 and 7802); and (3) indicate how to assign separate evaluations for each affected zone of the body under § 4.25 (Note 2 to DCs 7801 and 7802). At the time of an October 2013 VA examination, the Veteran was noted to have a well healed left medial knee scar which measured 6 centimeters by 0.5 centimeters, without functional impairment. At the time of a November 2020 VA examination, the Veteran was noted to have a 25 centimeter by 0.5 centimeter scar on the anterior aspect of his left knee due to total knee replacement. There was also a 10 centimeter x 1 centimeter scar on the medial aspect of the left knee. The scars were not painful or unstable and did not have a total square area of greater than 39 square centimeters. The scars did not cause limitation of function and there were no other pertinent physical findings, complications, conditions, or signs or symptoms such as muscle or nerve damage associated with any scar. The scars also did not impact the Veteran's ability to work. As the Veteran's residual scars do not measure at least 929 square centimeters, either separately or combined, the Board finds the Veteran's service-connected residual scarring does not warrant a compensable rating. 38 C.F.R. §§ 4.3, 4.7, 4.118, Diagnostic Code 7802. The Board has considered whether any alternate Diagnostic Codes might entitle the Veteran to a higher rating. 38 C.F.R. § 4.118, Diagnostic Codes 7801 and 7804 provide criteria for evaluations based on deep, unstable or painful scarring and scarring causing limitation of motion of the affected part. As noted above, the Veteran's residual scars were found to be superficial, nontender and asymptomatic with no limitation of motion. Therefore, the Veteran is not entitled to a compensable rating under any other potentially applicable Diagnostic Code. REASONS FOR REMAND The claims of entitlement to service connection for right and left shoulder disabilities are remanded. As it relates to the claims of service connection for left and right shoulder disabilities, the Board notes that post-service treatment records contain diagnoses of shoulder arthritis. The Veteran has indicated that his current shoulder disorders had their onset in service and have continued to the present day. To date, the Veteran has not been afforded a VA shoulder examination. An opinion that considers and addresses the Veteran's reports regarding onset of his shoulder disorders and provides an adequate rationale for all medical opinions provided, must be obtained on remand. See Dalton v. Nicholson, 21 Vet. App. 23, 39-40 (2007) (holding that when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate). The claims of entitlement to an initial disability rating in excess of 20 percent each for peripheral neuropathy of the right and left upper extremity, and in excess of 10 percent each for peripheral neuropathy of the right and left lower extremity, are remanded. As it relates to the claims for increased evaluations for left and right upper and lower extremity peripheral neuropathy, the Board notes that the last comprehensive VA examination afforded the Veteran occurred in October 2013. The Veteran maintains that the symptomatology associated with his neuropathy has increased in severity. Given the foregoing, the Veteran should be afforded a VA examination to determine the current severity of his upper and lower extremity peripheral neuropathy. The matters are REMANDED for the following actions: 1. Undertake appropriate development to obtain all outstanding VA and/or private treatment records related to the Veteran's outstanding claims. If any requested records are not available, the record should be annotated to reflect such and the Veteran notified. 2. The Veteran should be scheduled for a VA examination to determine the nature and etiology of any current left or right shoulder disorder. All indicated tests and studies should be performed and all findings must be reported in detail. The entire record must be made available for review and the examiner should note such review in his/her report. After a complete review of the claims folder, the examiner is requested to offer the following opinions: Is it as likely as not (50 percent probability or greater) that any current right or left shoulder disorder is related to the Veteran's period of service? In providing the above opinions, the examiner should consider and address statements from the Veteran regarding the onset and continuity of symptomatology since service. Dalton v. Nicholson, 21 Vet. App. 23 (2007). Complete detailed rationale is requested for any opinion that is rendered. 3. The Veteran should be afforded an appropriate VA examination to determine the current severity of his service-connected bilateral upper and lower extremity peripheral neuropathy. All indicated tests and studies should be undertaken. The record, including a complete copy of this remand, must be made available for review in connection with the examination. The examiner should identify the nature and severity of all manifestations of the Veteran's peripheral neuropathy of the bilateral upper and lower extremities. The examiner should indicate whether such disabilities more nearly approximate mild, moderate, or severe incomplete paralysis or complete paralysis of the nerves involved. The examiner should also comment upon the functional impairment resulting from the Veteran's peripheral neuropathy of the bilateral upper and lower extremities. 4. After completing the above, and any other development as may be indicated, the Veteran's claims should be readjudicated based on the entirety of the evidence. If the claims remain denied, the Veteran and his representative should be issued a supplemental statement of the case (SSOC). An appropriate period of time should be allowed for response. Thereafter, the case should be returned to the Board for further appellate consideration, if otherwise in order. Stephanie M. Owen Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board T. S. Kelly, 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.