Citation Nr: 21033740 Decision Date: 06/03/21 Archive Date: 06/03/21 DOCKET NO. 15-37 559 DATE: June 3, 2021 ORDER Entitlement to service connection for a dental disorder, including temporomandibular joint (TMJ) and bruxism, is denied. Entitlement to service connection for a left hip disorder is denied. Entitlement to service connection for a right hip disorder is denied. Prior to October 2, 2015, entitlement to a disability rating in excess of 10 percent for residuals, lumbar strain with Schmorl's nodes L2, L3, and L4 with slight narrowing L5-S1 ("lumbar spine disorder") is denied. From October 2, 2015, entitlement to a disability rating in excess of 40 percent for lumbar spine disorder is denied. Prior to October 2, 2015, entitlement to a rating in excess of 10 percent for left knee patellofemoral syndrome is denied. From October 2, 2015, entitlement to a rating in excess of 20 percent for left knee patellofemoral syndrome is denied. Prior to October 2, 2015, entitlement to a rating in excess of 10 percent for right knee patellofemoral syndrome is denied. From October 2, 2015, entitlement to a rating in excess of 20 percent for right knee patellofemoral syndrome is denied. Prior to October 2, 2015, entitlement to a rating in excess of 10 percent for residuals of a right ankle strain is denied. From October 2, 2015, entitlement to a rating in excess of 20 percent for residuals of a right ankle strain is denied. Entitlement to a rating in excess of 10 percent for reflex sympathetic dystrophy of the left foot and ankle is denied. FINDINGS OF FACT 1. The Veteran does not have a dental disorder, including TMJ and bruxism. 2. The Veteran does not have a current left hip disorder. 3. The Veteran does not have a current right hip disorder. 4. Prior to October 2, 2015, lumbar spine disorder did not manifest as forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. 5. From October 2, 2015, the Veteran's lumbar spine disorder does not manifest as unfavorable ankylosis of the entire thoracolumbar spine. 6. Prior to October 2, 2015, left knee patellofemoral syndrome, did not manifest as compensable limitations of flexion or extension, recurrent subluxation or lateral instability, dislocated or symptomatic post-removal semilunar cartilage, genu recurvatum, or malunion of tibia or fibula, and is not shown to have been ankylosed. 7. From October 2, 2015, left knee patellofemoral syndrome, did not manifest as flexion limited to 15 degrees, a compensable limitation of extension, recurrent subluxation or lateral instability, dislocated or symptomatic post-removal semilunar cartilage, genu recurvatum, or malunion of tibia or fibula, and is not shown to have been ankylosed. 8. Prior to October 2, 2015, right knee patellofemoral syndrome, did not manifest as compensable limitations of flexion or extension, recurrent subluxation or lateral instability, dislocated or symptomatic post-removal semilunar cartilage, genu recurvatum, or malunion of tibia or fibula, and is not shown to have been ankylosed. 9. From October 2, 2015, right knee patellofemoral syndrome, did not manifest as flexion limited to 15 degrees, a compensable limitation of extension, recurrent subluxation or lateral instability, dislocated or symptomatic post-removal semilunar cartilage, genu recurvatum, or malunion of tibia or fibula, and is not shown to have been ankylosed. 10. Prior to October 2, 2015, residuals of a right ankle strain results in moderate limited right ankle motion; marked limitation of motion, ankylosis, malunion, or astragalectomy have not been shown. 11. From October 2, 2015, residuals of a right ankle strain results in marked right ankle limitation of motion; ankylosis, malunion, or astragalectomy have not been shown. 12. At worst, the Veteran's service-connected reflex sympathetic dystrophy of the left foot and ankle neither manifests as moderate incomplete paralysis of the left sciatic nerve nor moderate incomplete paralysis of the left musculocutaneous (superficial peroneal) nerve. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for a dental disorder, including TMJ and bruxism, have not been met. 38 U.S.C. §§ 1110, 1131 (2012); 38 C.F.R. §§ 3.303, 3.310 (2020). 2. The criteria for entitlement to service connection for a left hip disorder have not been met. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. §§ 3.303, 3.310. 3. The criteria for entitlement to service connection for a right hip disorder have not been met. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. §§ 3.303, 3.310. 4. Prior to October 2, 2015, the criteria for a rating in excess of 10 percent for lumbar spine disorder have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.7, 4.40, 4.45, 4.71a, Diagnostic 5237. 5. From October 2, 2015, the criteria for a rating in excess of 40 percent for lumbar spine disorder have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.7, 4.40, 4.45, 4.71a, Diagnostic 5237. 6. Prior to October 2, 2015, the criteria for a rating in excess of 10 percent for left knee patellofemoral syndrome have not been met. 38 U.S.C. § 1155; 38 C.F.R. § 4.71a, Diagnostic Codes 5003, 5010, 5056-63. 7. From October 2, 2015, the criteria for a rating in excess of 20 percent for left knee patellofemoral syndrome have not been met. 38 U.S.C. § 1155; 38 C.F.R. § 4.71a, Diagnostic Codes 5003, 5010, 5056-63. 8. Prior to October 2, 2015, the criteria for a rating in excess of 10 percent for right knee patellofemoral syndrome have not been met. 38 U.S.C. § 1155; 38 C.F.R. § 4.71a, Diagnostic Codes 5003, 5010, 5056-63. 9. From October 2, 2015, the criteria for a rating in excess of 20 percent for right knee patellofemoral syndrome have not been met. 38 U.S.C. § 1155; 38 C.F.R. § 4.71a, Diagnostic Codes 5003, 5010, 5056-63. 10. Prior to October 2, 2015, the criteria for a rating in excess of 10 percent for residuals of a right ankle strain have not been met. 38 U.S.C. § 1155; 38 C.F.R. § 4.71a, Diagnostic Codes 5003, 5010, 5270-74. 11. From October 2, 2015, the criteria for a rating in excess of 20 percent for residuals of a right ankle strain have not been met. 38 U.S.C. § 1155; 38 C.F.R. § 4.71a, Diagnostic Codes 5003, 5010, 5270-74. 12. The criteria for a rating in excess of 10 percent for reflex sympathetic dystrophy of the left foot and ankle have not been met. 38 U.S.C. § § 1155, 5107; 38 C.F.R. § § 3.102, 3.159, 4.59, 4.124a, Diagnostic Code 8622. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active duty in the U.S. Marine Corps from January 2000 to October 2002. These matters come before the Board of Veterans' Appeals (Board) from an October 2014 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). In November 2018, the Board remanded the issues for further development of the evidence including additional VA examinations. The Board finds that there has been substantial compliance with its November 2018 remand directives. Stegall v. West, 11 Vet. App. 268, 271 (1998). Threshold Consideration Initially, the Board notes that the Veteran failed to report for October 2019 scheduled VA thoracolumbar spine, bilateral knee, right ankle, reflex sympathetic dystrophy, bilateral hip. and dental conditions examinations and has failed to provide any good reason for failing to report for any of these examinations. Applicants for benefits, such as the Veteran, are obligated to cooperate and assist VA in developing evidence. See Wamhoff v. Brown, 8 Vet. App. 517, 522 (1996). As such, the Board proceeds with adjudication of these service connection claims and increased rating claims based upon the existing evidence of record and additional VA examinations are not in order. The Board observes that the Veteran's Social Security Administration (SSA) medical records disclose that the Veteran's SSA disability claim includes records concerning chronic regional pain syndrome, back injury, left ankle injury, and right ankle injury. As of September 9, 2014, the SSA case analyses report denial of the Veteran's disability claim. Upon review of the medical records, those that apply to the instant issues on appeal are duplicative of the extensive body of evidence discussed below. Service Connection The Veteran asserts that a dental disorder, including TMJ and bruxism; right hip disorder; and a left hip disorder, were incurred in, aggravated by, or otherwise attributable to, active duty service. The Veteran also contends that a dental disorder was proximately caused by, or aggravated by, his service-connected mental health disability and that right and left hip disorders were proximately caused by, or aggravated, by service-connected orthopedic disabilities, In order to establish service connection on a direct basis, the record must contain competent evidence of: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F. 3d 1163, 1167 (Fed. Cir. 2004). In the absence of proof of a present disability there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Competent medical evidence is evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may also include statements conveying sound medical principles found in medical treatises. It also includes statements contained in authoritative writings, such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159(a)(1). Competent lay evidence is any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159(a)(2). This may include some medical matters, such as describing symptoms or relating a contemporaneous medical diagnosis. Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007); Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011). If the evidence is competent, the Board must then determine if the evidence is credible. Barr v. Nicholson, 21 Vet. App. 303, 308 (2007). After determining the competency and credibility of evidence, the Board must then weigh its probative value. In this regard, the Board may properly consider internal inconsistency, facial plausibility, and consistency with other evidence submitted on behalf of the claimant. Caluza v. Brown, 7 Vet. App. 498, 511 (1995). Disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. 38 C.F.R. § 3.310. Secondary service connection is permitted based on aggravation; compensation is payable for the degree of aggravation of a non-service-connected disability caused by a service-connected disability. Allen v. Brown, 7 Vet. App. 439 (1995). Dental disorder, including TMJ and bruxism In its November 2018 remand, the Board directed the RO to arrange for a VA dental conditions examination. The Board directed the RO to task the clinician to clarify whether the Veteran has current TMJ and to determine whether a 2006 examiner's notation concerning this disability was a misdiagnosis and is now asymptomatic. If the clinician found that current TMJ exists, the clinician should render an etiological opinion. Concerning TMJ and bruxism (if such a current disability or residuals were found), the clinician should determine where these entities were aggravated beyond their natural progress by the Veteran's service-connected psychiatric disability, including the physiological effects of stress and anxiety. Dental and oral conditions for which service-connected compensation benefits are available are set delineated in 38 C.F.R. § 4.150, Diagnostic Codes 9900-9918. This inclusive list consists of: chronic osteomyelitis or osteoradionecrosis of the maxilla or mandible; complete loss of the mandible between angles; loss of mandible, including ramus, unilaterally or bilaterally; nonunion of the mandible, confirmed by diagnostic imaging studies; malunion of the mandible; temporomandibular disorder (TMJ/TMD); loss of one or both sides of condyloid process; loss of coronoid process; loss of hard palate; loss of teeth due to loss of substance of body of maxilla or mandible without loss of continuity; loss of more than half of the maxilla; loss of less than half of the maxilla; malunion or nonunion of the maxilla; benign hard or soft tissue neoplasm; or malignant hard or soft tissue neoplasm. Dental service treatment records (STRs) show that the Veteran received care consisting of flossing, supra-lingual scaling, and rinsing to remove tobacco stains. A dental clinician noted that the Veteran had localized gingivitis. These records do not show complaints of, treatment for, or impressions of either TMJ or bruxism. Upon review of the Veteran's medical STRs, the Veteran experienced difficulty swallowing due to a neck abscess in August 2000. The noting clinician did not indicate involvement of the jaws or teeth. In his September 2002 report of medical history, the Veteran indicated that he had not had and did not have severe tooth or gum trouble; ear, nose, or throat trouble; and/or swollen or painful joints. The Veteran's October 2002 separation report of medical assessment discloses that the Veteran did not have any dental problems. The report includes no guidance as to the presence of either TMJ or bruxism. In a March 2006, a VA dental clinician noted that the Veteran presented with complaints of 6/10 pain "from his left TMJ w/limited vertical opening." This clinician further opined that the Veteran was under significant stress and receiving treatment for anxiety and stress. Treatment consisted of soft diet regimen, a soft night guard, analgesics, and warm compresses. This clinician did not report complaints of, or dental evidence of, bruxism. SSA documentation neither includes allegations of a dental disorder impairment nor any associated treatment. The RO received the Veteran's claim for service connection in January 2014. In August 2014, the Veteran was afforded a VA TMJ examination. A clinician reviewed the claims file; considered the Veteran's accounts; and conducted an appropriate evaluation. The clinician indicated that left TMJ had been diagnosed in March 2006 but had resolved. There was no evidence of current TMJ. The clinician did not provide a diagnosis of bruxism. The Veteran reported that TMJ is proximately due to his adjustment disorder with depressed mood. The Veteran indicated that he experienced no limitations eating, talking, or moving his jaws on a daily basis. Te clinician opined that the claimed condition is less likely than not proximately due to or the result of the Veteran's service-connected disability (adjustment disorder with depressed mood). As a rationale for this negative nexus opinion, the clinician underscored that current medical literature does not support that adjustment disorder with depressed mood causes TMJ. Moreover, upon the instant evaluation the Veteran's temporomandibular joint is normal. In his March 2015 substantive appeal (VA Form 9), the Veteran wrote that his TMJ is secondary due to daily stress and anxiety. The Veteran also reported that he constantly grinds his teeth when he sleeps. The Veteran contends that a dental disorder, including TMJ and bruxism were incurred in, aggravated by, or otherwise attributable to, active duty service. Moreover, the Veteran contends that this dental disorder was proximately caused by, or aggravated beyond its natural progression by, service-connected adjustment disorder with depressed mood. Indeed, the Veteran is competent to report that which is discernable, such as jaw pain. Jandreau, 492 F. 3d 1372. However, as a lay person, the Veteran lacks the specialized training and dental or medical prowess to render an opinion as to causation or etiology of a dental disorder. 38 C.F.R. § 3.159(a)(1). Thus, this lay evidence does not constitute competent dental or medical evidence and warrants minimal probative weight. Neither the Veteran nor his representative has submitted competent medical of dental evidence to support their contentions. Here, the Board notes that the Veteran still ultimately bears some burden of production. 38 U.S.C. § 5107(a); Cromer v. Nicholson, 455 F. 3d 1346 (Fed. Cir. 2006). The Board assigns significant probative weight to August 2014 VA clinician's report. This competent clinician reviewed the claims file; considered the Veteran's lay accounts; and conducted an appropriate evaluation. Noting that the Veteran had had one bout of left TMJ in March 2006, this professional found that the one bout had fully resolved. Upon examination, the Veteran did not have TMJ. Moreover, the clinician reported that current medical literature does not support that adjustment disorder with depressed mood causes TMJ. And, lastly, this clinician did not provide a current diagnosis of bruxism. In the absence of proof of a present disability there can be no valid claim. See Brammer, supra. The weight of extant evidence is against a finding that the Veteran has a current dental disorder, including TMJ and bruxism. Without a current dental disability, service connection cannot be established on either a direct or secondary basis. See Shedden, 492 F. 3d 1372; Allen, 7 Vet. App. 439. The preponderance of evidence is against granting service connection for a dental disorder, including TMJ and bruxism. As such, the benefit of doubt doctrine is not for application in this case. See 38 U.S.C. § § 5107. Left hip disorder Right hip disorder Inasmuch as the evidence applies to the contended left hip and right hip disabilities, it is incorporated herein. The Veteran's October 2002 separation report of medical assessment discloses that the Veteran did not have arthritis, bursitis, or rheumatism; swollen or painful joints; or any broken bones. And, the Veteran's SF-600 includes no guidance as to right hip disorder or left hip disorder. While SSA medical records allege an impairment of arthritis and chronic regional pain syndrome, the records contain no guidance as to any currently diagnosed right hip disorder or left hip disorder. The RO received the Veteran's claims for service connection in January 2014. In August 2014, the Veteran was afforded a VA hip conditions examination. The clinician found that the Veteran did not have current a left or a right hip disorder. The Veteran was capable of bilateral hip flexion to 90 degrees; however, the clinician opined that these abnormal ranges of motion do not conform to normal indices for a person of the Veteran's age or body habitus. The clinician indicated that the Veteran might not be an accurate historian as he was able to ambulate, sit, and bend (with his helper dog) normally. Even though there was evidence of no current right of left hip disorder, the clinician opined that medical literature does not support proximate causation between the lumbar spine and hip disorders. In his March 2015 VA Form 9, the Veteran wrote that his right and left hip conditions are due to chronic ankle sprains and reflex sympathetic dystrophy (RSD). The Veteran also stated that he walks in a funny manner because his entire body is out of alignment, adding that he overcompensates for lateral pain and falls. Neither the Veteran nor his representative have produced any competent evidence to support this theory of causation. See 38 U.S.C. § 5107(a); see also Cromer, 455 F. 3d 1346 The Veteran contends that a right hip disorder and a left hip disorder were incurred in, aggravated by, or otherwise attributable to, active duty service. Moreover, the Veteran advances this these hip disorders were proximately caused by, or aggravated beyond its natural progression by, service-connected orthopedic disabilities. Indeed, the Veteran is competent to report that which is discernable, such as hip instability. Jandreau, 492 F. 3d 1372. However, as a lay person, the Veteran lacks the specialized training and orthopedic prowess to render an opinion as to causation or etiology of a right or left hip disorder. 38 C.F.R. § 3.159(a)(1). Consequently, this lay evidence does not constitute competent medical evidence and warrants diminished probative weight. The Board assigns significant probative weight to August 2014 VA clinician's report. This competent clinical expert reviewed the claims file; considered the Veteran's lay accounts; and conducted an appropriate evaluation. Upon examination, the Veteran did not have a current right hip or left hip disability. Moreover, the clinician reported that current medical literature does not support that a lumbar disorder can proximately cause hip disorders. In the absence of proof of a present disability there can be no valid claim. See Brammer, 3 Vet. App. 223. The weight of extant evidence is against a finding that the Veteran has a current right hip disorder or a current left hip disorder. Without a current a right hip or left hip disability, service connection cannot be established on either a direct or secondary basis. Id. The preponderance of evidence is against granting service connection for right hip disorder and left hip disorder. As such, the benefit of doubt doctrine is not for application in this case. See 38 U.S.C. § § 5107 Increased Ratings The Veteran asserts that the ratings assigned to his service-connected disabilities, as articulated above, do not contemplate the severity of his symptoms. Ratings for service-connected disabilities are determined by comparing the Veteran's symptoms with criteria listed in VA's Schedule for Rating Disabilities, which is based, as far as practically can be determined, on average impairment in earning capacity. Separate Diagnostic Codes identify the various disabilities. 38 C.F.R. Part 4. When rating a service-connected disability, the entire history must be borne in mind. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. 38 C.F.R. § 4.7. The Board will consider entitlement to staged ratings to compensate for times since filing the claim when the disability may have been more severe than at other times during the course of the claim on appeal. Hart v. Mansfield, 21 Vet. App. 505 (2007). Pyramiding, the rating of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when rating a veteran's service-connected disabilities. 38 C.F.R. § 4.14. It is possible for a Veteran to have separate and distinct manifestations from the same injury which would permit rating under several Diagnostic Codes; however, the critical element in permitting the assignment of several ratings under various Diagnostic Codes is that none of the symptomatology for any one of the conditions is duplicative or overlapping with the symptomatology of the other condition. Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). Disability of the musculoskeletal system is primarily the inability, due to damage or infection in the parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. It is essential that the examination on which ratings are based adequately portray the anatomical damage and the functional loss with respect to all these elements. In evaluating disabilities of the musculoskeletal system, it is necessary to consider, along with the schedular criteria, functional loss due to flare-ups of pain, fatigability, incoordination, pain on movement, and weakness. Deluca v. Brown, 8 Vet. App. 202 (1995). Functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective enervation, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. §§ 4.10, 4.40, 4.45. The Court has held that VA must analyze the evidence of pain, weakened movement, excess fatigability, or incoordination and determine the level of associated functional loss under 38 C.F.R. § 4.40, which requires VA to regard as "seriously disabled" any part of the musculoskeletal system that becomes painful on use. See DeLuca, 8 Vet. App. 202. The intent of the rating schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. Painful motion is an important factor of joint disability, which is entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. However, the evaluation of painful motion as limited motion only applies when the limitation of motion is noncompensable under the applicable Diagnostic Code. Where pain alone results in functional impairment, even if there is no identified underlying diagnosis, it can constitute a disability. However, subjective pain and numbness in and of itself will not establish a current disability. Consideration should be given to the impact, or lack thereof, from pain, focusing on evidence of functional limitation caused by pain. See Saunders v. Wilkie, 886 F. 3d 1356 (Fed. Cir. 2018). Musculoskeletal VA examinations, to be adequate, must address particular issues when are where that are practicable and medically possible to include active and passive motion; weight bearing and non-weight bearing; range of motion of an opposing joint; and findings as to loss of motion during flare-ups. See Correia v. McDonald, 28 Vet. App. (2016); Sharp v. Shulkin, 29 Vet. App. 26 (2017). Lumbar spine disorder The RO has rated this disability under 38 C.F.R. § 4.71a, Diagnostic Code 5237, which compensates for lumbosacral strain, and applies the General Rating Formula for Diseases and Injuries of the Spine. Under that rating criteria, a 10 percent rating is assigned for forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height. 38 C.F.R. § 4.71a, Diagnostic Code 5237. A 20 percent rating is assigned for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. Id. A 40 percent rating is assigned for forward flexion of the thoracolumbar spine 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is assigned for unfavorable ankylosis of the entire thoracolumbar spine. Finally, a 100 percent rating is assigned for unfavorable ankylosis of the entire spine. Id. Note (1) under the General Rating Formula for Diseases and Injuries of the Spine stipulates that any associated objective neurological abnormalities including but not limited to, bowel and bladder impairment should be evaluated separately under an appropriate Diagnostic Code. An alternative method of evaluating spine disabilities is pursuant to Diagnostic Code 5243, which compensates based on incapacitating episodes due to intervertebral disc syndrome (IVDS). These ratings are not to be combined, and only the rating which results in a higher evaluation is to be granted. 38 C.F.R. § 4.71a, Diagnostic Code 5243. However, in this matter, the Veteran has not shown such pathology, and therefore a rating under Diagnostic Code 5243 is not for consideration. When considering disability of the musculoskeletal system, arthritis is considered. An evaluation of traumatic arthritis, Diagnostic Code 5010, is rated under the criteria for Diagnostic Code 5003, which in turn evaluates disabilities based on the degree of limitation of motion under the appropriate Diagnostic Codes. 38 C.F.R. § 4.71a. If the disability is noncompensable under the appropriate Diagnostic Code for the joint involved, a 10 percent rating will be for application for such major joint or group of minor joints affected by limitation of motion. 38 C.F.R. § 4.71a. The rating criteria pertaining to Diagnostic Code 5010 was revised effective February 7, 2021. Posttraumatic arthritis is rated as limitation of motion, dislocation, or other specified instability under an affected joint. If there are two or more joints affected, each rating shall be combined in accordance with 38 C.F.R. § 4.25. Evidence and Analysis Prior to October 2, 2015 Upon an October 2002 pre-discharge examination, a clinician indicated that the Veteran described symptoms of pain and "cramping up" when he performed everyday activities. The Veteran reported that his "back condition" radiated upwards and the symptoms were constant and of variable intensity. The clinician indicated that the Veteran's sensations were grossly intact; however, his posture and gait shifted to the right. The Veteran had forward flexion to 85 degrees with pain; extension to 20 degrees with pain; right lateral flexion to 25 degrees with pain; left lateral flexion to 25 degrees without pain; right rotation to 30 degrees with pain; and left rotation to 30 degrees with pain. The clinician reported that pain, fatigue, weakness, lack of endurance, and incoordination additionally limited range of motion. X-ray imaging revealed mild levoscoliosis of the thoracic spine and small Schmorl's nodes of the inferior aspect of L2, superior and inferior aspects of L3 and L4, with slight narrowing of the L5-S1 disc space and hairline spondylolysis of right pars interarticularis. The clinician diagnosed chronic lumbar strain with Schmorl's nodes L2, L3, and L4 with slight narrowing L5-S1 and levoscoliosis of the thoracic spine. In a February 2003 VA progress note, a clinician indicated that the Veteran's lumbosacral film showed some loss of normal curvature, suggesting some muscle spasm. The clinician referred the Veteran for low back educational programming, exercises, and physical therapy (PT). In a January 2005 lay statement, the Veteran's friend noted that the Veteran now limped and slouched, which had not been the case prior to service. This friend also reported that the Veteran did not have the ability to sit in one place for any extended period time. The Veteran also submitted a lay statement in January 2005. He reported that his back and left ankle/leg pain impeded his ability to do daily activity of any kind. The Veteran indicated that he experienced pain upon waking and "severe, excruciating" pain at night which hindered sleep. In a June 2006 lay statement, the Veteran reported that he experienced sharp pains in his lower back after sitting, standing, or walking for more than 10 minutes. He noted 5/10 pain daily. In August 2006, the Veteran reported that he experienced constant pain. In November 2011, the Veteran underwent a VA thoracolumbar spine conditions examination. A clinician reviewed the claims file; considered the Veteran's lay accounts and conducted an appropriate evaluation. The Veteran did not report flare-ups. The Veteran had forward flexion to 90 degrees or greater, with pain at 70 degrees; extension to 30 degrees or greater, without pain; right lateral flexion to 30 degrees or greater, with endpoint pain; left lateral flexion to 30 degrees or greater, without pain; right lateral rotation to 30 degrees or greater, without pain; and left lateral rotation to 30 degrees or greater, with endpoint pain. The Veteran was capable of repetitive use testing (of at least three repetitions) without additional loss in range of motion. The clinician indicated that pain on movement elicited functional loss after repetitive use. The clinician indicated localized tenderness at the right lateral back; however, there was no evidence of guarding, muscle spasm, or muscle atrophy. The Veteran had normal muscle strength, sensation, and reflexes. There was no evidence of radiculopathy, other neurological abnormalities, or IVDS. The Veteran did not report that he used an assistive device. The clinician noted that there was neither evidence of arthritis nor vertebral fracture. The clinician reported that the Veteran reported that this disability functionally impacted his ability to work. Specifically, the Veteran reported that he had to use an elevator instead of stairways at school and pain made it difficult to concentrate. In remarks, the clinician indicated that the Veteran complained of numbness in his feet; however, this report of numbness was not consistent with radiculopathy. November 2011 private treatment records from S. Hospital disclosed that the Veteran had histories of morbid obesity; obstructive sleep apnea; depression/anxiety; fibromyalgia; and gastrointestinal reflux disease (GERD). These records also disclosed that the Veteran underwent a right knee meniscal procedure. In August 2014, the Veteran underwent a VA thoracolumbar spine conditions examination. The Veteran did not report flare-ups. The Veteran commanded forward flexion to 90 degrees or greater, with pain at 70 degrees; extension to 30 degrees or greater, with endpoint pain; right lateral flexion to 30 degrees or greater, with endpoint pain; left lateral flexion to 30 degrees or greater, without pain; right lateral rotation to 30 degrees or greater, without pain; and left lateral rotation to 30 degrees or greater, with endpoint pain. The Veteran was capable of repetitive use testing (of at least three repetitions) without additional loss in range of motion. The clinician indicated that pain on movement elicited functional loss after repetitive use. There was no evidence of localized tenderness or pain to palpation of the joints; no evidence of abnormal gait or abnormal spinal contour; and no evidence of muscle spasm. The Veteran had normal muscle strength, normal reflexes, and normal sensation. There was no evidence of muscle atrophy, radiculopathy, IVDS, ankylosis, or other neurological abnormalities. The Veteran did not report that he used an assistive device. The clinician indicated that the Veteran did not have a thoracic vertebral fracture. The Veteran reported that this disability functionally impacted his ability to work. Specifically, the Veteran reported that he had to use an elevator instead of stairways at school and pain made it difficult to concentrate. Once again, the clinician indicated that the Veteran complained of numbness in his feet; however, this report of numbness was not consistent with radiculopathy. The clinician indicated that pain, weakness, fatigability, or incoordination did not significantly limit functional ability when the joint was used repeatedly over a period. Consequently, there was no decreased range of motion or pain with repetitive use. In his March 2015 VA Form 9, the Veteran wrote that he was unable to bend backwards or forwards due to muscle spasms. He also reported that his back occasionally locked-up, immobilizing him for days. At times, back pain was so intense that he thought that he would vomit. The Veteran believes that his service-connected lumbar spine disorder warranted a rating in excess of 10 percent prior to October 2, 2015. The Veteran is competent to report discernable symptoms such as lumbar region pain. 38 C.F.R. § 3.159(a)(2). Nevertheless, the evidence of record fails to show that this Veteran possesses the highly specialized knowledge in orthopedic medicine to render a complex opinion as to the clinical severity of a lumbar spine disorder. 38 C.F.R. § 3.159(a)(1). Under Diagnostic Code 5237 for an increased rating, there would need to be a showing of forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A summary of the pertinent evidence is delineated above. No examination during the evaluation period found forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. The Board has considered whether a higher disability evaluation is warranted on the basis of functional loss due to pain or due to weakness, fatigability, incoordination, or pain on movement of a joint under 38 C.F.R. §§ 4.40 and 4.45; see also DeLuca 8 Vet. App. 202. Functional loss contemplates the inability of the body to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance, and must be manifested by adequate evidence of disabling pathology, especially when it is due to pain. 38 C.F.R. § 4.40. Painful motion is an important factor of disability; and joints that are actually painful, unstable, or malaligned, due to healed injury, should be entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. Here, the minimal compensable rating for the thoracolumbar spine is already assigned, and analysis must turn to whether functional loss warranting a higher than 10 percent rating is reasonably shown. The November 2011 and August 2014 clinicians indicated that pain on movement elicited functional loss after repetitive use. But these clinicians, in whose opinions the Board assigns significant probative weight, could not ascertain with any certainty what such additional limitation constituted in terms of degrees. (Both of these clinicians also reported that the Veteran was capable of repetitive use testing, of at least three repetitions, without additional loss in range of motion.) Consequently, an increased rating based on functional limitation due these factors is not warranted. While the Veteran experienced thoracolumbar spine pain, pain alone is not sufficient to warrant a higher rating, as pain may cause a functional loss, but of itself does not constitute functional loss. See Saunders, 886 F. 3d 1356. Rather, pain must affect some aspect of "the normal working movements of the body" such as "excursion, strength, speed, coordination, and endurance," to constitute functional loss warranting an increased rating. Id.; see 38 C.F.R. § 4.40. The Board has no reason to question that the Veteran's lumbar spine disorder results in the functional limitations that he has endorsed. Nevertheless, such limitations are contemplated by the criteria for the assigned 10 percent rating. The rating schedule was created as a guide to evaluating disabilities resulting from all types of diseases and injuries encountered, and the percentage ratings that are assigned represent as far as can practicably be determined the average impairment in earning capacity resulting from such diseases and injuries and their residual conditions in civil occupations. 38 C.F.R. § 4.1. Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability. Considering the foregoing, the Board finds that the preponderance of the evidence is against granting a rating in excess of 10 percent prior to October 2, 2015 for the Veteran's service-connected lumbar spine disorder. From October 2, 2015 On October 2, 2015, the Veteran underwent a VA thoracolumbar spine conditions examination. A VA clinician followed VA exam protocols. The Veteran endorsed flare-ups, which he characterized as "sharp pain" about one-to-two times a month. The Veteran reported functional impairment or loss consisting of difficulty bending, putting on socks and shoes, and an inability to play with his children on the floor. The Veteran commanded forward flexion to 45 degrees; extension to 20 degrees; right lateral flexion to 15 degrees or greater; left lateral flexion to 15 degrees; right lateral rotation to 20 degrees; and left lateral rotation to 20 degrees. Range of motion elicited pain at all end points. While the clinician indicated that range of motion itself did not contribute to functional loss, he indicated that pain was present upon rest/non-movement. There was no pain with weight bearing. The clinician reported mild tenderness throughout the lumbar musculature of the right side. The Veteran was capable of repetitive use testing (of at least three repetitions) without additional loss in range of motion. The clinician indicated that evaluation did not occur immediately after repeated use in time. Pain significantly limited functional ability with repeated use over time. The clinician characterized such loss as forward flexion to 20 degrees; extension to 5 degrees; right lateral flexion to 5 degrees; left lateral flexion to 5 degrees; right lateral rotation to 5 degrees; and left lateral rotation to 5 degrees. The clinician indicated that evaluation did not occur immediately after repetitive use in time or during a flare-up. Pain significantly limited functional ability during flare-ups. The clinician characterized such loss as forward flexion to 20 degrees; extension to 5 degrees; right lateral flexion to 5 degrees; left lateral flexion to 5 degrees; right lateral rotation to 5 degrees; and left lateral rotation to 5 degrees. There was no evidence of guarding, muscle spasm, muscle atrophy, or ankylosis. The Veteran commanded normal muscle strength, hypoactive reflexes; and normal sensory responses (with the sole exception of "decreased" at the left foot/toes L5). The clinician reported that there was no evidence of radiculopathy, IVDS, or other neurological abnormalities. The Veteran reported that he did not use an assistive device. There was no evidence of thoracic vertebral fracture. The clinician reported that the Veteran conveyed that this disability functionally impacted his ability to work. Specifically, the Veteran conveyed that he experienced difficulty bending to pick things up; that he must use an elevator rather than stairs; and that he experienced difficulty with prolonged sitting or standing. As already discussed, Veteran failed to report for an October 2019 scheduled VA thoracolumbar spine examinations and failed to provide any good reason for failing to report. The Veteran believes that his service-connected lumbar spine disorder warrants a rating in excess of 40 percent from October 2, 2015. The Veteran is certainly competent to report discernable symptoms. The Board has considered this lay evidence carefully. 38 C.F.R. § 3.159(a)(2). Under Diagnostic Code 5237 for an increased rating, there would need to be a showing of unfavorable ankylosis of the entire thoracolumbar spine. A summary of the pertinent evidence is delineated above. The October 2, 2015 clinician did not indicate that the Veteran's lumbar spine disorder manifests as unfavorable ankylosis of the entire thoracolumbar spine. In fact, the clinician indicated that there was no evidence of ankylosis whatsoever. The Board has considered whether a higher disability evaluation is warranted on the basis of functional loss due to pain or due to weakness, fatigability, incoordination, or pain on movement of a joint under 38 C.F.R. §§ 4.40 and 4.45; see also DeLuca 8 Vet. App. 202. Functional loss contemplates the inability of the body to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance, and must be manifested by adequate evidence of disabling pathology, especially when it is due to pain. 38 C.F.R. § 4.40. Painful motion is an important factor of disability; and joints that are actually painful, unstable, or malaligned, due to healed injury, should be entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. Here, more than the minimal compensable rating for the thoracolumbar spine is already assigned. Under Diagnostic Code 5327, at worst, the Veteran's lumbar spine disorder manifests as forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees. This degree of disability falls squarely with a 20 percent rating. Nevertheless, the October 2, 2015 clinician indicated that pain significantly limited functional ability with repeated use over time and with flare-ups. In both instances, the clinician indicated losses in degrees of motion (forward flexion to 20 degrees; extension to 5 degrees; right lateral flexion to 5 degrees; left lateral flexion to 5 degrees; right lateral rotation to 5 degrees; and left lateral rotation to 5 degrees). Indeed, such losses in degrees upon repeated use and flare-ups, as discussed above, militates in favor of finding that that the Veteran warrants an addition 20 percent rating under the provisions of 38 C.F.R. §§ 4.40 and 4.45. Consequently, the Board finds that the preponderance of evidence warrants an aggregated 40 percent rating, but no higher, for the Veteran's lumbar spine disorder from October 2, 2015. Left knee patellofemoral syndrome Right knee patellofemoral syndrome The RO has rated these disabilities under 38 C.F.R. § 4.71a, Diagnostic Code 5260. Disabilities of the knee and leg are generally rated under 38 C.F.R. § 4.71a, Diagnostic Codes 5256 through 5263. Prior to February 7, 2021, under Diagnostic Code 5257 for recurrent subluxation or lateral instability, a 10 percent rating is warranted for slight recurrent subluxation or lateral instability of the knee; a 20 percent rating is warranted for medical evidence showing that the recurrent subluxation or lateral instability can be characterized as moderate; and a 30 percent rating is warranted for recurrent subluxation or lateral instability which medical evidence discloses can be characterized as severe. The rating criteria pertaining to Diagnostic Code 5257 were revised effective February 7, 2021. A 10 percent rating is assigned 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; a 20 percent rating is assigned 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; and a 30 percent rating is assigned 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. Under Diagnostic Code 5260 for limitation of flexion, a noncompensable rating is assigned for flexion limited to 60 degrees; a 10 percent rating is assigned for flexion limited to 45 degrees; a 20 percent rating is assigned for flexion limited to 30 degrees; and a 30 percent rating is assigned for flexion is limited to 15 degrees. Under Diagnostic Code 5261 for limitation of extension, a noncompensable rating is assigned for extension limited to 5 degrees; a 10 percent rating is assigned for extension limited to 10 degrees; a 20 percent rating is assigned for extension limited to 20 degrees; a 30 percent rating is assigned for extension is limited to 20 degrees; a 40 percent rating is assigned for extension is limited to 30 degrees; and a 50 percent rating is assigned for extension is limited to 15 degrees. Separate compensable ratings may be assigned for limitation of flexion and for limitation of extension, without violating the rule against pyramiding. See 38 C.F.R. § 4.14. Diagnostic Code 5256 pertains to ratings for ankylosis of a knee. Diagnostic Code 5262 applies to ratings for impairment of the tibia and fibula. Diagnostic Code 5258 applies to a dislocated semilunar cartilage. Diagnostic Code 5259 applies to removal of the semilunar cartilage. Diagnostic Code 5263 applies to rating genu recurvatum. The rating criteria pertaining to Diagnostic Code 5262 were revised effective February 7, 2021. However, as those Codes are not applicable in this matter, and the February 7, 2021 effective revision does not require further discussion. In Lyles v. Shulkin, 29 Vet. App. 107 (2017), the Court held that under 38 C.F.R. § 4.71, a separate evaluation may be assigned for meniscal problems under Diagnostic Codes 5258 or 5259, even when ratings are in effect under Diagnostic Codes 5257 and 5261. The Board must also consider functional impairment with respect to the baseline range of motion (ROM) noted during clinical evaluation. English v. Wilkie, 30 Vet. App. 347 (2018) (the Board must adequately explain how it considered functional loss due to pain, including during flare-ups). Evidence and Analysis Prior to October 2, 2015 Upon the October 2002 pre-discharge examination, the clinician indicated that the Veteran had no history of specific injuries to the knees. The Veteran reported that his knee symptoms began in 2002 and he reported locking and throbbing pain when his foot gave out. The clinician reported that there was no evidence of erythema, swelling, effusion, or increased warmth bilaterally. There was tenderness to the bilateral knee joint lines. Crepitus was also present. Bilateral knee flexion was to 105 degrees with pain and extension was to zero degrees. Pain additionally limited bilateral range of motion. X-ray imaging was normal bilaterally. The clinician provided a diagnosis of bilateral patellofemoral syndrome. In a February 2003 VA progress note, a VA clinician indicated that the Veteran experienced chronic bilateral knee pain. Upon a January 2005 VA joints examination, a clinician noted that the Veteran had a history of bilateral patellofemoral syndrome. The Veteran reported that his knees lock and intermittently give out. The Veteran indicated that he took narcotics to treat knee pain. The Veteran reported frequent flare-ups that lasted for hours. The Veteran indicated that this bilateral knee disability impacted his ability to perform activities of daily life. As noted above, the Veteran's friend reported in her January 2005 lay statement that the Veteran now limped and slouched. Likewise, the Veteran's lay statement in this month expressed leg pain that impeded his ability to do daily activity of any kind. In a March 2005 VA treatment record, a clinician noted that the Veteran reported that his bilateral knees locked, which caused him to fall and stumble. In his June 2006 lay statement, the Veteran reported that his right knee was more painful than his left knee. Both knees made popping noises and occasionally gave out. In his August 2006 lay statement, the Veteran elaborated upon his bilateral knee symptoms and their impact. 2006 VA rehabilitation medicine treatment records disclosed that the Veteran sought consultations for bilateral knee pain. Treatment included physical therapy (PT) and the use of mild compression knee-high stockings. Clinicians also prescribed analgesics. Upon a December 2007 VA joints examination, a clinician noted the Veteran's reports of constant bilateral knee pain. The Veteran also indicated that he experienced flare-ups approximately thrice a week. The Veteran had left knee flexion to 80 degrees with pain and left knee extension to negative 20 degrees with pain. The Veteran had right knee flexion to 110 degrees with pain and right knee extension to negative 20 degrees with pain. The clinician indicated that there was no evidence of tenderness with either varus or valgus strain. The clinician also reported that the Veteran did not display weakness upon repetitive range of motion testing and the Veteran had "good" motor, circulatory, and sensory results in the bilateral lower extremities. A batch of private treatment records from Dr. G. disclose that the Veteran sought treatment for knee soreness in 2010 and 2011. Dr. G. followed the Veteran's clinical status and prescribed narcotics, nerve blockers, and analgesics. In an August 2011 report, a clinician at S. Hospital indicated that the Veteran sought treatment for right knee pain. The Veteran reported that this pain coincided with a "twisting injury" 6 months earlier. Magnetic resonance imaging (MRI) revealed a focal area of cartilage loss on the lateral femoral condyle. The Veteran had right knee flexion to 135 degrees. This clinician's treatment included an injection of Marcaine, Kenalog, and dexamethasone, which the Veteran tolerated. As noted above, November 2011 private treatment records from S. Hospital disclosed that the Veteran underwent arthroscopic repair of a right meniscal injury and synovectomy. In November 2011, the Veteran underwent a VA knee examination. The clinician followed VA exam protocols. The Veteran reported flare-ups when he hyperextended his right knee. The Veteran Had right knee flexion to 95 degrees with pain at 60 degrees and right knee extension to zero degrees without pain. The Veteran had left knee flexion to 110 degrees without pain and left knee extension to zero degrees without pain. The Veteran was able to perform repetitive-use testing (of at least three repetitions), without additional loss in range of motion bilaterally. The clinician reported functional loss after repetitive use, namely less movement than normal bilaterally and pain on movement in the right knee. There was evidence of tenderness to palpation of the right knee joint line or associated tissues. The Veteran retained normal knee strength (5/5) bilaterally. The clinician indicated that there was no evidence of patellar subluxation bilaterally; no evidence of shin splints; no evidence of stress fracture; and no evidence of chronic exertional compartment syndrome or other tibial and/or fibular impairment. The clinician did indicate that the Veteran had a right knee meniscus tear, which did not require a meniscectomy. The Veteran reported that he used knee braces occasionally. X-ray imaging did not disclose the presence of either arthritis or patellar subluxation bilaterally. The clinician reported that the Veteran indicated that his bilateral knee disability functionally impacted his ability to work in that he had to take an elevator rather than the stairs and knee pain made it hard to concentrate. In January 2014, the Veteran underwent another VA knee examination. The Veteran did not endorse flare-ups. The Veteran had right knee flexion to 80 degrees without pain and right knee extension to zero degrees without pain. The Veteran had left knee flexion to 80 degrees without pain and left knee extension to zero degrees without pain. The Veteran was able to perform repetitive-use testing (of at least three repetitions), without additional loss in ranges of motion bilaterally. There was evidence of tenderness to palpation of the bilateral knee joint line or associated tissues. The Veteran retained normal knee strength (5/5) bilaterally and normal joint stability bilaterally. The clinician indicated that there was no evidence of patellar subluxation bilaterally; no evidence of shin splints; no evidence of stress fractures; and no evidence of chronic exertional compartment syndrome or other tibial and/or fibular impairment. This clinician opined that the Veteran did not have any meniscal conditions. The Veteran reported that he did not use any assistive devices. X-ray imaging did not disclose the presence of either arthritis or patellar subluxation bilaterally. The clinician noted that the Veteran endorsed functional impact on his ability to work because of an inability to walk or stand on uneven surfaces. In remarks, this clinician opined that it was her opinion that pain, weakness, fatigability, or incoordination did not significantly limit the Veteran's functional ability upon repetitive use. In August 2014, the Veteran underwent another VA knee examination. The Veteran did not report flare-ups. The Veteran had right knee flexion to 80 degrees with endpoint pain and right knee extension to zero degrees without pain. The Veteran had left knee flexion to 100 degrees without pain and left knee extension to zero degrees without pain. The Veteran was able to perform repetitive-use testing (of at least three repetitions), without additional loss in ranges of motion bilaterally. There was evidence of tenderness to palpation of the bilateral knee joint line or associated tissues. The Veteran retained normal knee strength (5/5) bilaterally and normal joint stability bilaterally. The clinician indicated that there was no evidence of patellar subluxation bilaterally; no evidence of shin splints; no evidence of stress fracture; and no evidence of chronic exertional compartment syndrome or other tibial and/or fibular impairment. This clinician reported that the Veteran did not have any meniscal conditions. The Veteran reported that he did not use any assistive devices. X-ray imaging did not disclose the presence of either arthritis or patellar subluxation bilaterally. The clinician noted that October 2011 x-ray studies disclosed normal bilateral knees. This clinician reported that the Veteran endorsed functional impact on his ability to work, namely an inability to walk or stand on uneven surfaces. As was the case in January 2014, the clinician indicated that pain, weakness, fatigability, or incoordination did not significantly limit the Veteran's functional ability upon repetitive use. In March 2015, the Veteran underwent another VA knee examination. The Veteran did not endorse flare-ups. The Veteran did endorse functional impairment, namely standing limited to 10 minutes. The Veteran had right knee flexion to 70 degrees with endpoint pain and right knee extension to zero degrees without pain. The Veteran had left knee flexion to 85 degrees without pain and left knee extension to zero degrees without pain. Bilaterally, the clinician indicated that range of motion did not contribute to functional losses. There was evidence of right knee pain with weight bearing; however, there was no evidence of left knee pain with weight bearing. There was evidence of tenderness to palpation of the bilateral knee medial joint line. Bilaterally, there was no evidence of crepitus. The Veteran was able to perform repetitive-use testing (of at least three repetitions), without additional loss in range of motion bilaterally. The clinician opined that examination occurred immediately after repetitive use over time. Pain, weakness, fatigability, or incoordination did not significantly limit the Veteran's functional ability upon repetitive use bilaterally. The Veteran retained normal knee strength (5/5) bilaterally and normal joint stability bilaterally. The clinician indicated that there was no evidence of patellar subluxation bilaterally; no evidence of ankylosis; no evidence of shin splints; no evidence of stress fracture; and no evidence of chronic exertional compartment syndrome or other tibial and/or fibular impairment. The clinician indicated that the Veteran had had a right meniscal tear for which the Veteran underwent arthroscopic repair and syndectomy. The residuals of this procedure consisted of pain and weakness. The Veteran reported that he used bilateral knee braces when his knees gave way. X-ray imaging did not disclose the presence of either arthritis or patellar subluxation bilaterally. The clinician indicated that the Veteran reported that both standing and walking could only be sustained for 10 minutes. The Veteran believes that his service-connected left and right knee patellofemoral syndrome each warrant a rating in excess of 10 percent prior to October 2, 2015. The Veteran is certainly competent to report discernable symptoms. The Board has considered this lay evidence carefully. 38 C.F.R. § 3.159(a)(2). As noted above, the evidence does not disclose that the Veteran possesses the medical expertise to render an opinion as to the severity of bilateral knee disorders. 38 C.F.R. § 3.159(a)(1). Consequently, this lay evidence does not constitute competent medical evidence. The Board has summarized the pertinent evidence. The Board finds that the competent clinical evidence of record is entitled to considerable probative weight. Prior to October 2, 2015, each of the Veteran's knee disorders was rated at 10 percent under Diagnostic Code 5260. As already noted, Diagnostic Code 5260 provides for a 10 percent rating for flexion limited to 45 degrees; a 20 percent rating for flexion limited to 30 degrees; and a 30 percent rating for flexion limited to 15 degrees. At worst, the medical evidence shows that right knee flexion was limited to 70 degrees, whereas left knee flexion, at worst, was limited to 80 degrees. Such limitations are noncompensable under Diagnostic Code 5260. Turning to Diagnostic Code 5261, a 10 percent rating is assigned for extension limited to 10 degrees and a 20 percent rating is assigned for extension limited to 20 degrees. At worst the medical evidence shows that right knee extension was limited to zero degrees and left knee extension was limited to zero degrees. Such limitations are noncompensable under Diagnostic Code 5261. As the evidence fails to disclose evidence of any form of arthritis, Diagnostic Codes 5003 and 5010 are not applicable. Likewise, no examination or treatment records found evidence of ankylosis, subluxation or instability, genu recurvatum, tibia or fibula impairment, or dislocated or symptomatic post-removal semilunar cartilage. The Veteran reported "giving way," but clinicians did not observe joint laxity or instability such that the giving way is likely difficulty supporting weight due to pain. The Veteran reported intermittent use of braces but they were not prescribed by a physician. Also, there was one mention of a meniscal tear not noted in subsequent examinations and no examinations showed locking or effusion into the joints. Consequently, separate compensable ratings under Diagnostic Codes 5256, 5257, 5258, 5259, 5260, 5261, 5262, or 5263 are not for application. The Board has considered whether a higher disability evaluation is warranted on the basis of functional loss due to pain or due to weakness, fatigability, incoordination, or pain on movement of a joint under 38 C.F.R. §§ 4.40 and 4.45; see also DeLuca, 8 Vet. App. 202. The January 2014 VA clinician reported functional loss after repetitive use, namely less movement than normal bilaterally. Additionally, other clinicians noted painful motion of the bilateral knees. Consequently, having eliminated other possibilities, the Veteran' left knee patellofemoral syndrome and right knee patellofemoral syndrome each warranted 10 percent under the provisions of 38 C.F.R. §§ 4.40, 4.45 and 4.59. Therefore, the Board finds that the preponderance of evidence is against the claims for ratings in excess of 10 percent for left knee patellofemoral syndrome and right knee patellofemoral syndrome prior to October 2, 2015. From October 2, 2015 On October 2, 2015, the Veteran underwent another VA knee examination. The Veteran reported flare-ups, noting sharp pain, and throbbing with prolonged standing or walking. The Veteran also reported functional loss as he only was able to stand for 10 minutes. The Veteran had right knee flexion to 95 degrees and right knee extension to zero degrees. The Veteran had left knee flexion to 100 degrees without pain and left knee extension to zero degrees. Bilaterally, the clinician indicated that range of motion contributes to functional loss; bilaterally, there was pain on weight bearing; bilaterally; there was pain on rest/non-movement; and, bilaterally, there was tenderness throughout the joint line. The Veteran was able to perform repetitive-use testing (of at least three repetitions), with additional loss in range of motion (right knee flexion to 80 degrees and left knee flexion to zero degrees). The clinician reported that the Veteran's examination did not occur immediately after repetitive use in time. Pain significantly limits the Veteran's functional ability upon repetitive use over time bilaterally. The clinician qualified this into bilateral flexion to 30 degrees. Examination did not occur during a flare-up. Pain significantly limits the Veteran's functional ability during flare-ups bilaterally. The clinician also qualified this into bilateral flexion to 30 degrees. Bilaterally, the clinician indicated additional contributing factors of disturbance of locomotion, interference with sitting, and interference with standing. The Veteran retained 5/5 (normal) right knee strength. There was no evidence of muscle atrophy, ankylosis, or joint instability. Likewise, the clinician indicated that there was no evidence of patellar subluxation bilaterally; no evidence of ankylosis; no evidence of shin splints; no evidence of stress fracture; and no evidence of chronic exertional compartment syndrome or other tibial and/or fibular impairment. The clinician indicated that the Veteran had had a right meniscal tear for which the Veteran underwent arthroscopic repair and syndectomy. The residuals of this procedure consisted of pain and weakness. The Veteran reported that a service dog assists him constantly and he regularly uses bilateral knee braces. X-ray imaging disclosed neither arthritis nor any other significant diagnostic findings. The clinician indicated that the Veteran endorsed functional impact on his ability work, namely standing and walking for more than 10 minutes; traversing stairways; and driving in low-riding motor vehicles. As already discussed, Veteran failed to report for an October 2019 scheduled VA knee examination and failed to provide any good reason for failing to report. The Veteran believes that his service-connected left and right knee patellofemoral syndrome each warrant a rating in excess of 20 percent prior from October 2, 2015. The Veteran is certainly competent to report discernable symptoms. The Board has considered this lay evidence carefully. 38 C.F.R. § 3.159(a)(2). As noted above, the evidence does not disclose that the Veteran possesses the medical expertise to render an opinion as to the severity of a bilateral knee disorders. 38 C.F.R. § 3.159(a)(1). Consequently, this lay evidence does not constitute competent medical evidence. The Board has summarized the pertinent evidence. The Board finds the clinical evidence of record is entitled to considerable probative weight. From October 2, 2015, each of the knee disorders is rated at 20 percent under Diagnostic Code 5260. As noted above, this Diagnostic Code provides a 20 percent rating for flexion limited to 30 degrees; and a 30 percent rating is assigned for flexion is limited to 15 degrees. At worst, the medical evidence shows that right knee flexion was limited to 95 degrees, whereas left knee flexion, at worst, was limited to 100 degrees. Such limitations are noncompensable under Diagnostic Code 5260. However, the RO reported both knees are limited to 30 degrees in flexion, which the clinician actually reported as the loss in degrees in bilateral flexion upon repetitive use over time and during flare-ups. With limitations in flexion of 30 degrees, each knee warrants a 20 percent rating under Diagnostic Code 5260. Turning to Diagnostic Code 5261, at worst the medical evidence shows that right knee extension was limited to zero degrees and left knee extension was limited to zero degrees. Such limitations are noncompensable under Diagnostic Code 5261. As the evidence fails to disclose evidence of any form of arthritis, Diagnostic Codes 5003 and 5010 were not applicable. Likewise, no examination or treatment records found evidence of ankylosis, subluxation or instability, genu recurvatum, tibia or fibula impairment, or dislocated or symptomatic post-removal semilunar cartilage. The Veteran reported "giving way," but clinicians did not observe joint laxity or instability such that the giving way is likely difficulty supporting weight due to pain. The Veteran reported intermittent use of braces but they were not prescribed by a physician. Also, there was one mention of a meniscal tear not noted in subsequent examinations and no examinations showed locking or effusion into the joints. Consequently, separate compensable ratings under Diagnostic Codes 5256, 5257, 5258, 5259, 5260, 5261, 5262, or 5263 are not for application. The Board has considered whether a higher disability evaluation is warranted on the basis of functional loss due to pain or due to weakness, fatigability, incoordination, or pain on movement of a joint under 38 C.F.R. §§ 4.40 and 4.45; see also DeLuca, 8 Vet. App. 202 (1995). Here, the minimal compensable rating for the both knees is already assigned, and the analysis must hinge on whether functional loss warranting a higher than 20 percent rating is reasonably shown. The October 2, 2015 clinician did indicate that pain significantly limits the Veteran's functional ability upon repetitive use over time bilaterally. However, the clinician did not indicate such limitations attributable to weakness, fatigability, or incoordination. As noted above, the RO tacitly recognized the limitations upon repetitive use over time and flare-ups in recognizing that both knees are limited to 30 degrees in flexion. Even though the knee can be evaluated under separate Diagnostic Codes, an evaluation of the same symptomatology ("bilateral flexion limited to 30 degrees") would constitute prohibited pyramiding of compensation. 38 C.F.R. § 4.14; see also Esteban, 6 Vet. App. 259. The Board acknowledges the Veteran's bilateral patellofemoral knee syndrome presents functional limitations (standing and walking for more than 10 minutes; traversing stairways; driving in low-riding motor vehicles). The 20 percent rating for each knee already contemplates such limitations. The Board also finds that the right knee symptoms and impairment shown do not include that which the schedular rating criteria do are not adequately address. In sum, the Board finds that the preponderance of the evidence is against the claim for ratings higher than 20 percent prior from October 2, 2015 for left patellofemoral syndrome and right patellofemoral syndrome. Residuals of right ankle strain Disabilities of the ankle are generally rated under 38 C.F.R. § 4.71a, Diagnostic Codes 5270 through 5274. The RO has rated the Veteran's residuals of a right ankle strain under Diagnostic Code 5271. Included within 38 C.F.R. § 4.71a are multiple Diagnostic Codes that evaluate impairment resulting from service-connected ankle disorders, including Diagnostic Code 5270 (ankylosis of the ankle); Diagnostic Code 5272 (ankylosis of subastragalar or tarsal joint); Diagnostic Code 5273 (malunion of os calcis or astragalus); and Diagnostic Code 5274 (astragalectomy). However, the Veteran's right ankle disorder is not shown to have not been manifested by ankylosis, malunion of os calcis or astragalus, or astragalectomy. Therefore, these Diagnostic Codes are not for application. Diagnostic Code 5271 (limited motion of ankle) provides a 10 percent rating for moderate limited ankle motion and a 20 percent rating for marked limited ankle motion. The rating criteria pertaining to Diagnostic Code 5271 was revised effective February 7, 2021. A moderate ankle limitation of motion (less than 15 degrees dorsiflexion or less than 30 degrees plantar flexion) is assigned a 10 percent rating and a marked ankle limitation of motion (less than 5 degrees dorsiflexion or less than 10 degrees plantar flexion) is assigned a 20 percent rating. Normal ranges of ankle motions are 0 to 20 degrees for dorsiflexion and 0 to 45 degrees for plantar flexion. 38 C.F.R. § 4.71, Plate II. Evidence and Analysis Prior to October 2, 2015 The October 2002 pre-discharge examination clinician indicated that the Veteran had plantar flexion to 40 degrees with endpoint pain and right ankle dorsiflexion to 15 degrees with endpoint pain. The clinician reported that pain additionally limited range of motion; however, fatigue, weakness, lack of endurance, or incoordination did not limit range of motion. The January 2005 VA joints examination clinician noted the Veteran's report that he did not sustain any injury to his right ankle; however, the Veteran reported pain over his right Achilles tendon. The Veteran did not report flare-ups. The clinician indicated that the right ankle did not interfere with walking, occupational pursuits, or daily activities. The Veteran had right ankle plantar flexion to 45 degrees and right ankle dorsiflexion to 20 degrees. The Veteran retained normal (5/5) strength and normal sensation over the right foot. Repetitive use testing resulted in no additional limitation in range of motion. The clinician indicated that there was no current diagnosis apposite the Veteran's right ankle endorsed symptoms. In a January 2005 statement, the Veteran's friend noted that the Veteran limped and slouched. Similarly, the Veteran's lay statement reported that this right ankle issue, along with other contended disabilities, impeded his ability to do daily activity of any kind. In his June 2006 lay statement, the Veteran wrote that his right ankle problem was more of an ache. The December 2007 VA joints examination clinician indicated that the Veteran reported right ankle pain of a constant nature (8/10). The Veteran also endorsed right ankle weakness, swelling, instability, locking, fatigability, and lack of endurance, with a component of cold numbness. The Veteran reported right ankle pain flare-ups and use of a brace and cane. The Veteran had right ankle plantar flexion to 40 degrees with pain and right ankle dorsiflexion to 10 degrees with pain. Repetitive use testing resulted in no additional limitation in range of motion; however, the testing elicited pain, staggered movements, and weakness. There was no evidence of varus or valgus angulation of the os calcis in relationship to the long axis of the tibia and fibula. This clinician provided a diagnosis of right ankle strain. In October 2011, the Veteran underwent an abbreviated VA right ankle evaluation. The Veteran reported flare-ups, notably "a hard time walking long distances." The Veteran reported that he used a right ankle brace occasionally. X-ray imaging did not disclose right ankle arthritis. There was no evidence of ankylosis. The clinician indicated that the Veteran conveyed that his right ankle strain functionally impacted his ability to work. Here, the Veteran again indicated that he had to take an elevator and pain made it difficult to concentrate. VA treatment records disclose that the Veteran underwent right ankle PT and exercise educational programming in 2011 and 2012. In a March 2012 VA treatment record, a clinician noted that the Veteran reported that he developed right ankle pain to overcompensate. In May 2012, the Veteran underwent a VA right ankle examination. The Veteran reported flare-ups, notably "a hard time walking long distances." The Veteran had right ankle plantar flexion to 45 degrees without pain and right ankle dorsiflexion to 20 degrees without pain. The Veteran was able to perform repetitive-use testing (of at least three repetitions), without additional loss in range of motion. There was tenderness at the right ankle joint and/or soft tissues. The Veteran retained normal knee strength (5/5). There was no evidence of right ankle instability, ankylosis, shin splint, stress fracture, Achilles tendonitis, Achilles tendon rupture, malunion of os calcis or astragalus, or astragalectomy. The Veteran reported that he occasionally used a right ankle brace. X-ray imaging did not disclose right ankle arthritis. Here, the Veteran again indicated that he had to take an elevator and pain made it difficult to concentrate. In January 2014, the Veteran underwent another VA right ankle examination. The Veteran did not report flare-ups. The Veteran had right ankle plantar flexion to 45 degrees without pain and right ankle dorsiflexion to 5 degrees without pain. The Veteran was able to perform repetitive-use testing (of at least three repetitions), without additional loss in range of motion. The clinician indicated that the Veteran had additional loss in range of motion after repetitive use, namely less movement than normal. There was tenderness at the right ankle joint and/or soft tissues. The Veteran retained normal knee strength (5/5). The was no evidence of right ankle instability, ankylosis, shin splint, stress fracture, Achilles tendonitis, Achilles tendon rupture, malunion of os calcis or astragalus, or astragalectomy. This clinician indicated that the right ankle strain did not impact the Veteran's ability to work. And, the clinician opined that with repeated use and flare-ups, pain, fatigue, weakness, lack of endurance, fatigability, or incoordination did not significantly limit functional ability (which the lack of decreased range of motion upon repetitive use testing supported). In his March 2015 VA Form 9, the Veteran conveyed that his right ankle gave out. The Veteran believes that his residuals of a right ankle strain are more severe than that contemplated by a 10 percent rating. The Veteran is competent to report discernable symptoms. As noted above, to receive a higher disability rating there would need to be a showing of marked limited ankle motion under both versions of Diagnostic Code 5271. Such is not disclosed in the evidence of record. At worst, right ankle dorsiflexion was to zero to 5 degrees and right ankle plantar flexion was zero to 45 degrees. However, the Board observes that other than the outlying right ankle dorsiflexion finding in January 2014, right ankle dorsiflexion was, at worst, to 10 degrees. As noted above, normal ranges of ankle motions are 0 to 20 degrees for dorsiflexion and 0 to 45 degrees for plantar flexion. The Board finds that the limitation of motion, pain requiring limitation in walking endurance; lack of driving; and locking and pressure is best assessed as moderate and indicative of a 10 percent disability rating. See 38 C.F.R. § 4.71a, Diagnostic Code 5271. The Board has considered whether a higher disability evaluation is warranted on the basis of functional loss due to pain or due to weakness, fatigability, incoordination, or pain on movement of a joint under 38 C.F.R. §§ 4.40 and 4.45; see also DeLuca, 8 Vet. App. 202. Here, the minimal compensable rating for the right ankle is already assigned, and the analysis must hinge on whether functional loss warranting a higher than 10 percent rating is reasonably shown. The most recent January 2015 VA clinician indicated that pain, weakness, and incoordination did not cause functional loss with repetitive use over a period of time and during flare-ups; and, consequently, these absent symptoms did not result in any additional limitation of range of motion. Consequently, an increased rating based on functional limitations due to these factors is not warranted. While the Veteran has been shown to experience right knee pain, pain alone is not sufficient to warrant a higher rating, as pain may cause a functional loss, but of itself does not constitute functional loss. Saunders, 886 F. 3d 1356. Rather, pain must affect some aspect of "the normal working movements of the body" such as "excursion, strength, speed, coordination, and endurance," to constitute functional loss warranting an increased rating. Id. at 43; see 38 C.F.R. § 4.40. Considering the foregoing, the Board finds that the preponderance of the evidence is against the claim for a rating higher than 10 percent for residuals of a right knee strain prior to October 2, 2015. From October 2, 2015 On October 2, 2015, the Veteran underwent a VA right ankle examination. The Veteran endorsed flare-ups, namely sharp pain with prolonged walking. The Veteran also reported functional loss consisting of diminished range of motion and locking with repetitive use. The Veteran had right ankle plantar flexion to 45 degrees and dorsiflexion to 5 degrees. The clinician indicated that range of motion did not contribute to functional loss. There was pain with weight beating and mild tenderness with palpation across the right talus. There was no evidence of crepitus. The Veteran was able to perform repetitive-use testing (of at least three repetitions), without additional loss in range of motion. Examination did not take place immediately after repeated use over time. With repetitive use, pain significantly limited functional ability. The clinician characterized this as right ankle plantar flexion to 20 degrees and right ankle dorsiflexion to 2 degrees. Notably, the clinician noted the repetitive use testing results were not consistent with the Veteran's lay endorsements of additional loss in range of motion and locking. The clinician made the same precise findings as to flare-ups, to includes losses in degrees of range of motion. The Veteran retained normal knee strength (5/5). The was no evidence of right ankle instability, ankylosis, shin splints, stress fractures, Achilles tendonitis, Achilles tendon rupture, malunion of os calcis or astragalus, or astragalectomy. This clinician indicated that the Veteran reported that his residuals of right ankle strain impacted his ability to perform any occupational task. The Veteran reported that he had difficulty standing, experienced locking, and pain upon feet/ankle rotation (The Veteran's reporting concerned his bilateral ankles). The Veteran believes that his residuals of a right ankle strain are more severe than that contemplated by a 20 percent rating. The Veteran is competent to report discernable symptoms. Under Diagnostic Code 5271, a marked ankle limitation of motion (less than 5 degrees dorsiflexion or less than 10 degrees plantar flexion) is assigned a 20 percent rating. At worst, the Veteran's right ankle dorsiflexion was to 5 degrees and his right ankle plantar flexion was 45 degrees. Unlike the prior period under consideration, this dorsiflexion finding is not an outlier (in fact it represents the only range of motion finding as to right ankle dorsiflexion from October 1, 2015). A 20 percent rating is the highest schedular rating for limitation of motion of the ankle. To receive a higher disability there would need to be a showing of right ankle ankylosis, which none of the clinical evidence of record reveals. The Board has considered whether a higher disability rating is warranted on the basis of functional loss due to pain or due to weakness, fatigability, incoordination, or pain on movement of a joint. 38 C.F.R. §§ 4.40 and 4.45; see also DeLuca, 8 Vet. App. 202. Indeed, the Veteran conveyed functional loss consisting of diminished range of motion and locking with repetitive use; however, the clinician indicated something altogether different. The clinician indicated that with repetitive use and flare-ups, pain significantly limited functional ability. The Board assigns substantial probative weight to this clinical professional. Here, the Board underscores the none of the clinical evidence of record discloses right ankle "locking" or ankylosis. To the degree that the Veteran shows functional loss, the Board finds that the 20 percent rating assigned to this disability contemplates such limitations. The Board finds that any limitation of motion, pain requiring limitation in walking and standing and turning endurance is best assessed as marked right ankle limitation of motion indicative of a 20 percent disability rating. See 38 C.F.R. § 4.71a, Diagnostic Code 5271. The Board also finds that the residuals of right ankle strain do not include that which the schedular rating criteria do are not adequately address. Considering the foregoing, the Board finds that the preponderance of evidence is against the claim for a rating higher than 20 percent for residuals of a right ankle strain from October 2, 2015. Reflex sympathetic dystrophy (RSD) of the left foot and ankle The RO has rated this disability under 38 C.F.R. § 4.124a, Diagnostic Code 8622. Under Diagnostic Code 8622 a 10 percent rating is warranted when for moderate incomplete paralysis, 20 percent for severe incomplete paralysis, and 30 percent for complete paralysis. 38 C.F.R. § 4.124a, Diagnostic Code 8622. A note preceding the Schedule of Ratings for Diseases of the Peripheral Nerves provides that the term "incomplete paralysis" indicates a degree of lost or impaired function substantially less than the type picture for complete paralysis given with each nerve. The note further states that when the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. Words such as "severe," "moderate," and "mild" are not defined in the Rating Schedule. Rather than applying a mechanical formula, VA must evaluate all evidence, to the end that decisions will be equitable and just. 3 8 C.F.R. § 4.6. Although the use of similar terminology by medical professionals should be considered, it is not dispositive of an issue. Instead, all evidence must be evaluated in arriving at a decision regarding a request for a higher disability rating. 38 U.S.C. § 7104; 38 C.F.R. §§ 4.2, 4.6. Evidence and Analysis The October 2002 pre-discharge examination clinician indicated that the Veteran had received an assessment of superficial peroneal neuropraxia. Amitriptyline had not alleviated the Veteran's left foot giving out and endorsed throbbing pain. The Veteran endorsed a decreased in light touch and pinprick sensation just above the left ankle distally throughout the left foot. The January 2005 joints examination clinician indicated that the Veteran experienced hypersensitivity due to his left ankle and foot neuropraxia. This clinician also reported that the Veteran took a narcotic to assuage his discomfort. 2004 and 2005 VA progress notes disclose that the Veteran sought neurological and podiatric consultations. Clinicians guided the Veteran through fittings for left shoe orthotic devices. Additionally, clinicians assessed the efficacy of the Veteran's roster of pain killers and antidepressants (clinically employed in off-label manner to treat superficial peroneal neuropraxia). As discussed throughout this decision, the Veteran's friend and the Veteran articulated that the Veteran limped, slouched, and experienced pain. And, in his January 2006 lay statement, the Veteran reported that his RSD induced burning, itching, and tingling. The Veteran endorsed sharp, dull, and/or burning pain in his left ankle and left foot (especially in the left heel). As noted, 2006 VA rehabilitation medicine treatment records reveal that the Veteran received courses of PT, to include the use of mild compression knee-high stockings. The December 2007 VA joints examination clinician indicated that the Veteran endorsed left ankle numbness, which the Veteran conveyed, induced difficulties ambulating. The January 2014 VA ankle examination clinician indicated that the Veteran conveyed that RSD caused left foot tingling, cold sensitivity, and hypersensitivity. In August 2014, the Veteran underwent a VA peripheral nerve examination. The clinician indicated that the Veteran was right-hand dominant. Upon assessment, the clinician reported mild left lower extremity constant pain, mild left lower extremity intermittent pain, mild left lower extremity paresthesias and/or dysesthesias, and mild lower extremity numbness. The Veteran maintained normal strength (5/5), normal reflexes, normal sensory ability, and there was no evidence of trophic change. Of all nerve groups, the clinician reported that the Veteran only evinced mild incomplete paralysis of the left musculocutaneous (superficial peroneal) nerve. The Veteran reported that he did not use an assistive device. The clinician indicated that RSD did not functionally impact the Veteran's ability to work. 2014 VA progress notes reveal that the Veteran sought podiatric services to control his RSD. The clinic refined the Veteran's left foot orthotic device to ensure that the Veteran would ambulate comfortably as the Veteran indicated that he could not tolerate hard devices in his shoes. In his March 2015 VA Form 9, the Veteran reported that he suffered from severe RSD pain every single day. The Veteran further reported that he was given a nerve block at a private facility. Lastly, the Veteran wrote that his consumption of pain medication has expanded "exponentially." In a March 2015 lay statement, the Veteran wrote that a private clinician informed him that RSD could "set into" his knee after his knee surgery (right knee). The Veteran also expressed dismay at the way that his RSD has been handled, underscoring that VA clinicians had failed to mention RSD in all of the Veteran's knee examination reports. Again, the Veteran emphasized his severe pain. In October 2015, the Veteran underwent another VA peripheral nerve examination. The Veteran reported the he experienced daily nerve pain throughout his entire left leg and right knee. The symptoms have worsened. The Veteran endorsed temperature fluctuations in his feetat times, cold and at other times, hot "as if they [were] on fire". The clinician indicated endorsement of severe bilateral lower extremity constant pain, mild right lower extremity intermittent pain, severe left lower extremity intermittent pain, moderate right lower extremity paresthesias and/or dysesthesias, severe left lower extremity paresthesias and/or dysesthesias, moderate right lower extremity numbness, and severe left lower extremity numbness. The clinician indicated that Veteran maintained normal reflexes, with the exception of bilateral knees and bilateral ankles which were hypoactive (1 plus). The Veteran maintained normal sensitivity, with the exception of left foot/toes (L5) evaluated as decreased. There were no trophic changes and the Veteran's gait was normal. The clinician indicated mild incomplete paralysis of the left sciatic nerve; otherwise, the Veteran maintained a wholly normal peripheral nerve group evaluation. The Veteran reported that he constantly relied upon the assistance of a service dog and braces. This clinician noted that the Veteran conveyed functional impact on his ability to work. Specifically, the Veteran reported that his leg (presumably left leg) gave out all the time which causes him to fall. The Veteran also reported difficulty standing and walking, and a "locking" Achilles heel (presumably left foot). The Veteran believes that his service-connected RSD of the left foot and ankle is far more severe than that contemplated by a 10 percent rating. The Veteran is competent to report discernable symptoms, such as RSD pain. The Board has discussed the relevant, competent clinical evidence of record, in which the Board assigns significant probative weight. The Veteran's RSD of the left foot and ankle has been rated at 10 percent for almost two decades under Diagnostic Code 8622. As discussed above, a higher rating under Diagnostic Code 8622 necessitates the clinical disclosure of severe incomplete paralysis of the effected peripheral nerve. While the clinical evidence discloses peripheral nerve symptoms of diverse severity, this evidence discloses that, at worst, service-connected RSD of the left foot and ankle, as of the October 2, 2015 VA peripheral nerve examination, was productive of mild incomplete paralysis of the left sciatic nerve and at an earlier point (August 2014) productive of mild incomplete paralysis of the left musculocutaneous (superficial peroneal) nerve. In assessing the "total disability picture" of the Veteran's RSD of the left foot and ankle, the Board is cognizant of the changes in endorsed symptomatology. From August 2014 to October 1, 2015, mild left lower extremity constant pain, mild left lower extremity intermittent pain, mild left lower extremity paresthesias and/or dysesthesias, and mild lower extremity numbness devolved into severe bilateral lower extremity constant pain, mild right lower extremity intermittent pain, severe left lower extremity intermittent pain, moderate right lower extremity paresthesias and/or dysesthesias, severe left lower extremity paresthesias and/or dysesthesias, moderate right lower extremity numbness, and severe left lower extremity numbness. Nevertheless, the peripheral nerve itselfthe impacted generator of these symptomsremained fixed in a state of mild incomplete paralysis. Regrettably, the Veteran failed to appear for a scheduled October 2019 RSD examination which the Board directed in its November 2018 remand. Indeed, the Board sought clinical guidance so that there would be a complete record upon which to decide this claim. Consequently, the Board finds that weight of evidence fails to show that the Veteran's RSD of the left foot and ankle manifests as moderate incomplete paralysis of either the left sciatic nerve or moderate incomplete paralysis of the left musculocutaneous (superficial peroneal) nerve. Therefore, a rating in excess of 10 percent for RSD of the left foot and ankle must be denied. The Veteran was awarded a total disability rating based on individual unemployability (TDIU) and a 100 percent schedular rating effective March 16, 2015. The Veteran met the statutory criteria for a TDIU in November 2013 when the rating for PTSD was increased to 70 percent. The Veteran reported that he had worked in security up to 2007 but became a full time student and earned a bachelor's degree prior to this date prior to November 2013. Although the Veteran's orthopedic disabilities limited his mobility and although his PTSD caused difficulty working in groups, the Board finds that the weight of evidence is that he was not incapable of some form of substantially gainful employment prior to March 2016 when he first raised the issue of unemployability. In view of his education, administrative work, particularly by telework, would have been possible prior to March 16, 2015. J.W. FRANCIS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board B. J. Komins, 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.