Citation Nr: 21040737 Decision Date: 07/06/21 Archive Date: 07/06/21 DOCKET NO. 16-41 013 DATE: July 6, 2021 ORDER A rating in excess of 40 percent for lumbar spine intervertebral disc syndrome is denied. For the entire rating period on appeal, a 20 percent rating, but no higher, for right lower extremity radiculopathy is granted. For the rating period prior to August 30, 2019, a 10 percent rating, but no higher, for left lower extremity radiculopathy is granted. A rating in excess of 30 percent for residuals of a cervical spine strain with anterior osteophyte degenerative changes is denied. A rating in excess of 10 percent for right knee osteoarthritis is denied. A rating in excess of 10 percent for left knee osteoarthritis is denied. A separate 10 percent rating, but no higher, for right knee instability is granted. A separate 10 percent rating, but no higher, for left knee instability is granted. A rating in excess of 20 percent for right shoulder right shoulder bicipital tenodesis, status post SLAP tear with Mumford procedure repair (right shoulder disability), is denied. A rating in excess of 20 percent for hemorrhoids is denied. A rating of 50 percent, but no higher, for generalized anxiety disorder is granted. A rating of 30 percent, but no higher, for gastroesophageal reflux disease (GERD) is granted. A compensable rating for onychomycosis is denied. FINDINGS OF FACT 1. The Veteran's lumbar spine disability did not more nearly approximate unfavorable ankylosis of the entire thoracolumbar spine or incapacitating episodes having a total duration of at least 6 weeks during the past 12 months requiring bed rest prescribed by a physician. 2. For the entire rating period on appeal, the Veteran's right lower extremity radiculopathy was manifested by, at worst, moderate incomplete paralysis of the sciatic nerve. 3. For the entire rating period on appeal, the Veteran's left lower extremity radiculopathy was manifested by, at worst, mild incomplete paralysis of the sciatic nerve. 4. The Veteran's cervical spine disability is not manifested by unfavorable ankylosis of the entire cervical spine and/or incapacitating episodes that required bed rest prescribed by a physician and treatment by a physician having a total duration of at least four weeks during the past twelve months. 5. The Veteran's right and left knee disabilities have been manifested by painful motion and slight, subjective lateral instability, but not moderate recurrent subluxation or lateral instability, ankylosis, limitation of flexion to 45 degrees, limitation of extension to 10 degrees, dislocated or removed semilunar cartilage, or impairment of the tibia or fibula. 6. The Veteran's right shoulder disability has not more nearly approximated limitation of motion to midway between the side and shoulder level or 25 degrees from the side. 7. The Veteran's hemorrhoid disability is assigned the maximum schedular rating authorized by regulation and his symptoms are encompassed by the applicable rating criteria in this regard. 8. The Veteran's psychiatric disability more nearly approximates occupational and social impairment with reduced reliability and productivity. 9. The Veteran's GERD is manifested by persistently recurrent epigastric distress with dysphagia, pyrosis, reflux, regurgitation, melena, substernal arm or shoulder pain, and sleep disturbance, which is productive of considerable impairment of health. 10. The Veteran's skin disability (onychomycosis) does not affect at least 5 percent, but less than 20 percent of the Veteran's entire body; and the condition is not treated with intermittent systemic therapy such as immunosuppressive drugs for a total duration of less than 6 weeks in a 12-month periods. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 40 percent for lumbar spine intervertebral disc syndrome are not met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. § 4.71a, Diagnostic Code 5243 (2020). 2. For the entire rating period on appeal, the criteria for a 20 percent rating, but no higher, for right lower extremity radiculopathy (sciatic nerve) are met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.3, 4.124a, Diagnostic Code 8520 (2020). 3. For the rating period prior to August 30, 2019, the criteria for a 10 percent rating, but no higher, for left lower extremity radiculopathy (sciatic nerve) are met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.3, 4.124a, Diagnostic Code 8520 (2020). 4. The criteria for a rating in excess of 30 percent for residuals of a cervical spine strain with anterior osteophyte degenerative changes are not met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.7, 4.71a, Diagnostic Codes 5242, 5247 (2020). 5. The criteria for a rating in excess of 10 percent for right knee osteoarthritis are not met. 38 U.S.C. § 1155 (2012); 38 C.F.R. § 4.71a, Diagnostic Codes 5003, 5010, 5260 (2020). 6. The criteria for a rating in excess of 10 percent for left knee osteoarthritis are not met. 38 U.S.C. § 1155 (2012); 38 C.F.R. § 4.71a, Diagnostic Codes 5003, 5010, 5260 (2020). 7. The criteria for a separate 10 percent rating, but no higher, for right knee instability are met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 4.1-4.14, 4.21, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5257 (2020); 85 Fed. Reg. 76460, 76457 (Feb 7, 2021). 8. The criteria for a separate 10 percent rating, but no higher, for left knee instability are met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 4.1-4.14, 4.21, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5257 (2020); 85 Fed. Reg. 76460, 76457 (Feb 7, 2021). 9. The criteria for a rating in excess of 20 percent for the right shoulder disability are not met. 38 U.S.C. § 1155, 5107 (2012); 38 C.F.R. §§ 4.59, 4.71a, Diagnostic Code 5201 (2020). 10. The criteria for a rating in excess of 20 percent for hemorrhoids are not met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.14, 4.114, Diagnostic Code 7336 (2020). 11. The criteria for a rating of 50 percent, but no higher, for generalized anxiety disorder are met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 4.1-4.7, 4.130, Diagnostic Code 9400 (2020). 12. The criteria for a rating of 30 percent, but no higher, for GERD are met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.114, Diagnostic Code 7346 (2020). 13. The criteria for a compensable rating for onychomycosis are not met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.21, 4.118, Diagnostic Codes 7813-7899 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from October 1991 to June 1996. The Veteran also served on active duty in the United States Navy from September 1996 to January 2012. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a June 2014 rating decision by the Department of Veterans Affairs (VA). These issues were previously remanded by the Board for further development in November 2018. The Board notes that in the September 2020 rating decision, the AOJ granted service connection for left lower and right lower extremity radiculopathy at 10 percent disabling effective August 30, 2019. As the claims were granted, the claims are no longer before the Board after the effective date. See Grantham v. Brown, 114 F.3d 1156, 1158-59 (Fed. Cir. 1997). However, as the rating decision was issued in September 2020, the Veteran has one-year from the date of the notification letter to file a notice of disagreement (NOD) if he disagrees with the decision. Disability RatingsLaws and Regulations Disability evaluations are determined by evaluating the extent to which a Veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing his symptomatology with the criteria set forth in the Schedule for Rating Disabilities (Rating Schedule). 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10. If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation; otherwise, the lower evaluation will be assigned. 38 C.F.R. § 4.7. The Veteran's entire history is to be considered when making disability evaluations. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Where entitlement to compensation has already been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Nevertheless, where the evidence contains factual findings that show a change in the severity of symptoms during the course of the rating period on appeal, assignment of staged ratings would be permissible. Hart v. Mansfield, 21 Vet. App. 505 (2007). When evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use and, therefore, not be reflected on range-of-motion testing. 38 C.F.R. § 4.45 requires consideration also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Nonetheless, even when the background factors listed in § 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a (musculoskeletal system) or § 4.73 (muscle injury); a separate or higher rating under § 4.40 or 4.45 itself is not appropriate. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016) ("[I]t is clear that the guidance of § 4.40 is intended to be used in understanding the nature of the veteran's disability, after which a rating is determined based on the § 4.71a [or 4.73] criteria."). It is the intention to recognize actual painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. Lumbar Spine Disability The Veteran's lumbar spine disability has been evaluated as 40 percent disabling throughout the entire rating period on appeal. Disabilities of the spine are rated under the General Rating Formula for Diseases and Injuries of the Spine (General Rating Formula) (for DCs 5235 to 5243, unless 5243 is evaluated under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes (IVDS Formula)). Ratings under the General Rating Formula are made with or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease. The disabilities of the spine that are rated under the General Rating Formula include vertebral fracture or dislocation (DC 5235), sacroiliac injury and weakness (DC 5236), lumbosacral or cervical strain (DC 5237), spinal stenosis (DC 5238), unfavorable or segmental instability (DC 5239), ankylosing spondylitis (DC 5240), spinal fusion (DC 5241), and degenerative arthritis of the spine (DC 5242) (for degenerative arthritis of the spine, see also DC 5003). The General Rating Formula provides a 40 percent rating is assigned forward flexion of the thoracolumbar spine 30 degrees or less; or, unfavorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is assigned for unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent rating is assigned for unfavorable ankylosis of entire spine. The Notes following the General Rating Formula provide further guidance in rating diseases or injuries of the spine. Note (1) provides that any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, should be rated separately under an appropriate diagnostic code. Note (2) provides that, for VA compensation purposes, normal forward flexion of the thoracolumbar spine is zero to 90 degrees, extension is zero to 30 degrees, left and right lateral flexion are zero to 30 degrees, and left and right lateral rotation are zero to 30 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion of the thoracolumbar spine is 240 degrees. The normal ranges of motion for each component of spinal motion provided in this note are the maximum that can be used for calculation of the combined range of motion. DC 5243 provides that IVDS is to be rated either under the General Rating Formula or under the IVDS Formula, whichever method results in the higher rating when all disabilities are combined under 38 C.F.R. § 4.25. The IVDS Formula provides a 10 percent rating for IVDS with incapacitating episodes having a total duration of at least one week but less than 2 weeks during the past 12 months; a 20 percent rating for IVDS with incapacitating episodes having a total duration of at least 2 weeks but less than 4 weeks during the past 12 months; a 40 percent rating for IVDS with incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months; and a 60 percent rating for IVDS with incapacitating episodes having a total duration of at least 6 weeks during the past 12 months. Note (1) to DC 5243 provides that, for purposes of ratings under DC 5243, an incapacitating episode is a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician. Note (2) provides that, if intervertebral disc syndrome is present in more than one spinal segment, provided that the effects in each spinal segment are clearly distinct, each segment is to be rated on the basis of incapacitating episodes or under the General Rating Formula, whichever method results in a higher evaluation for that segment. 38 C.F.R. § 4.71a. Effective February 7, 2021, VA's Schedule, 38 C.F.R. Part 4, was amended with regard to rating musculoskeletal disorders. Fed. Reg. 76453 (November 30, 2020) (codified at 38C.F.R. §4.71a). When a law or regulation changes during the course of a claim or an appeal, the version more favorable to the veteran will apply, to the extent permitted by any stated effective date in the amendment in question. VAOPGCPREC 3-2000; Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). The revised musculoskeletal regulations do not provide for retroactive application; thus, the amendments may be applied as of, but not prior to, February 7, 2021. Hence, VA has made clear that its intent is that the claims pending prior to the effective date will be considered under both old and new rating criteria, and whatever criteria is more favorable to the Veteran will be applied. For applications filed on or after the effective date, only the new criteria will be applied. As the Veteran's claim was pending prior to February 7, 2021, the Board will consider entitlement under the prior regulations as well as the updated regulations from February 7, 2021 forward, applying the most favorable criteria for the Veteran. The changes effective February 7, 2021 under 38 C.F.R. § 4.71a, DC 5242 and 5243 were not to the rating schedule itself but added instruction to classify disabilities associated with IVDS under DC 5243 and all other intervertebral disc disabilities under 5242. As such, DC 5242 now reflects "Degenerative arthritis, degenerative disc disease other than intervertebral disc syndrome (also, see either DC 5003 or 5010)"; DC 5243 now reflects "Intervertebral disc syndrome: Assign this diagnostic code only when there is disc herniation with compression and/or irritation of the adjacent nerve route; assign diagnostic code 5242 for all other disc diagnoses." As such, the changes do not impact the general rating formula and evaluation of the disability under the pre-and post-February 7, 2021 regulations is not required. After a review of all the evidence of record, the Board finds that a disability rating in excess of 40 percent is not warranted for the Veteran's lumbar spine disability. The Veteran was afforded VA spine examinations in May 2014 and August 2019. He has also undergone treatment for his lumbar spine disability through VA. At no time during the appeal period has the Veteran been shown to have unfavorable ankylosis of the entire thoracolumbar spine or IVDS resulting in incapacitating episodes (requiring physician prescribed bed rest). The Board has considered the Veteran's reported impairment of function, such as back pain and difficulty walking, running, bending, sleeping, and performing more strenuous activities such as yardwork. The Board has considered additional limitations of motion due to pain. See e. g., August 2019 VA spine examination report. These factors have been applied in awarding the currently assigned 40 percent rating. As such, the additional limitation of motion or function of the spine due to pain or other symptoms such as weakness, fatigability, weakness, or incoordination (see 38 C.F.R. §§ 4. 40, 4.45, 4.59, DeLuca), do not provide a basis the assignment of an even higher rating. For these reasons, the Board finds that a rating in excess of 40 percent for the Veteran's lumbar spine disability is not warranted. Lower Extremity Radiculopathy The Veteran is currently in receipt of 10 percent ratings for both right and left lower extremity radiculopathy (sciatic nerve) for the appeal period beginning August 30, 2019 (the date of the most recent VA spine examination). Under Diagnostic Code 8520, a 10 percent rating is warranted for mild incomplete paralysis of the sciatic nerve; 20 percent for moderate incomplete paralysis; 40 percent for moderately severe incomplete paralysis; 60 percent for severe incomplete paralysis with marked muscular atrophy; and 80 percent for complete paralysis of the sciatic nerve. 38 C.F.R. §4.124a, Diagnostic Code 8520. 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, whether due to varied level of the nerve lesion or to partial regeneration. 38C.F.R. §4.124a. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. Id. The Board finds that the Veteran has complained of pain and radicular symptoms throughout the rating period on appeal, and even prior to the current appeal period. In a 2011 VA examination report, the Veteran complained of intermittent radiating symptoms to the hips and thigh. During an August 2019 VA examination, the Veteran stated that he experienced symptoms of pain, numbness, and tingling to the bilateral legs, with worsening symptoms in the last 18 months. The 2019 VA examiner specifically indicated that the Veteran had "moderate" incomplete paralysis of the sciatic nerve root on the right, and "mild" incomplete paralysis in the left lower extremity. For these reasons, and resolving reasonable doubt in the Veteran's favor, the Board finds that a rating of 20 percent is warranted for right lower extremity radiculopathy for the entire appeal period. The Board further finds that a 10 percent rating is warranted for the appeal period prior to August 30, 2019. The Board further finds that ratings in excess of 20 percent for the right lower extremity and in excess of 10 percent for the left lower extremity (both prior to and after August 30, 2019) are not warranted. In this regard, the August 2019 VA examiner performed a sensory examination and straight leg raise test, both of which were normal in both lower extremities. Muscle strength was only slightly reduced, and the Veteran did not have muscle atrophy. No other neurological abnormalities were noted. For these reasons, the Board finds that, for the entire rating period on appeal, a 20 percent rating, but no higher, for right lower extremity radiculopathy is warranted. For the rating period prior to August 30, 2019, a 10 percent rating, but no higher, for left lower extremity radiculopathy is also warranted. Cervical Spine Disability The Veteran is currently in receipt of a 30 percent rating for his cervical spine disability for the entire rating period on appeal. Under the General Rating Formula, the following ratings are either currently assigned or available: 100 percent for unfavorable ankylosis of the entire spine; 40 percent for unfavorable ankylosis of the entire cervical spine; 30 percent for forward flexion of the cervical spine 15 degrees or less; or, favorable ankylosis of the entire cervical spine. For VA compensation purposes, unfavorable ankylosis is a condition in which the entire cervical spine, the entire thoracolumbar spine, or the entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching. Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. See 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Note (5). The Formula for Rating IVDS provides a 40 percent disability rating for IVDS with incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months; and a 60 percent disability rating for IVDS with incapacitating episodes having a total duration of at least 6 weeks during the past 12 months. 38 C.F.R. § 4.71a. As noted in the previous section, effective February 7, 2021, VA's Schedule, 38 C.F.R. Part 4, was amended with regard to rating musculoskeletal disorders. Fed. Reg. 76453 (November 30, 2020) (codified at 38C.F.R. §4.71a). The changes effective February 7, 2021 under 38 C.F.R. § 4.71a, DC 5242 and 5243 were not to the rating schedule itself but added instruction to classify disabilities associated with IVDS under DC 5243 and all other intervertebral disc disabilities under 5242. As such, DC 5242 now reflects "Degenerative arthritis, degenerative disc disease other than intervertebral disc syndrome (also, see either DC 5003 or 5010)"; DC 5243 now reflects "Intervertebral disc syndrome: Assign this diagnostic code only when there is disc herniation with compression and/or irritation of the adjacent nerve route; assign diagnostic code 5242 for all other disc diagnoses." As such, the changes do not impact the general rating formula and evaluation of the disability under the pre-and post-February 7, 2021 regulations is not required. Upon review of the record, the Board finds that a rating in excess of 30 percent for the cervical spine disability is not warranted. The medical evidence of record, to include the May 2014 and August 2019 VA cervical spine examination reports and VA treatment records, does not indicate that the Veteran has unfavorable ankylosis of the cervical spine. The evidence of record also does not reflect that the Veteran has IVDS of the cervical spine or that he has been prescribed periods of bed rest for cervical spine IVDS during the appeal period which would meet the criteria for a higher rating in excess of 30 percent. Thus, the Board finds that this alternative rating method likewise provides no basis for any higher rating. Moreover, a review of the evidence of record does not indicate that the Veteran has been diagnosed with upper extremity radiculopathy and/or any other neurologic or other disabilities related to the service-connected cervical spine disability. As such, no separate compensable disability rating is warranted for any additional disability related to the cervical spine. Right and Left Knee Disabilities The Veteran seeks higher ratings in excess of 10 percent for his service-connected right and left knee disabilities, diagnosed as osteoarthritis. The Board observes that the schedular criteria for evaluating disabilities of the musculoskeletal system, including the knee joint, have undergone revision during the pendency of this appeal. Specifically, and as relevant to this case, revisions to Diagnostic Code 5003, 5010, and 5257 were made effective February 7, 2021. See 85 Fed. Reg. 76460, 76457 (Feb 7, 2021). Prior to February 7, 2021, Diagnostic Code 5010, instructed the rater to rate traumatic arthritis as degenerative arthritis under Diagnostic Code 5003. Under the revised criteria, Diagnostic Code 5010 applies only to post-traumatic arthritis, which is to be rated as limitation of motion, dislocation, or other specified instability under the affected joint. If there are 2 or more joints affected, each rating shall be combined in accordance with § 4.25. Under both the earlier and revised rating criteria, degenerative arthritis is rated under Diagnostic Code 5003. Under this code, arthritis established by X-ray findings is rated on the basis of limitation of motion under the appropriate Diagnostic Codes for the specific joint or joints involved. When, however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined and not added, under Diagnostic Code 5003. For purpose of rating disability from arthritis, the knee is considered a major joint. 38 C.F.R. § 4.45 (f). The diagnostic codes that focus on limitation of motion of the knee are Diagnostic Codes 5260 (limitation of flexion) and 5261 (limitation of extension). For rating purposes, normal range of motion in a knee joint is from 0 to 140 degrees. 38 C.F.R. § 4.71, Plate II. The Rating Schedule provides for ratings of 0, 10, 20, or 30 percent where there is limitation of flexion of the leg to 60, 45, 30, or 15 degrees, respectively, and for ratings of 0, 10, 20, 30, 40, or 50 percent for limitation of extension of the leg to 5, 10, 15, 20, 30, or 45 degrees, respectively. 38 C.F.R. § 4.71a, Diagnostic Codes 5260, 5261. VA's General Counsel has held that separate ratings are available for limitation of flexion and limitation of extension under Diagnostic Codes 5260 and 5261. VAOPGCPREC 9-2004 (2004). As it pertains to recurrent subluxation or instability of the knee, and as noted above, revisions to Diagnostic Code 5257 were made effective February 7, 2021. See 85 Fed. Reg. 76457 (Feb 7, 2021). Because these changes took effect during the pendency of the Veteran's appeal, both the former and revised criteria will be considered in evaluating the Veteran's service-connected right knee disability. However, application of the new criteria prior to the effective date of the amended regulation is not allowed. See Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003); Green v. Brown, 10 Vet. App. 111, 116-119 (1997); see also 38 U.S.C. § 5110 (g). Prior to February 7, 2021, instability of the knee was rated under Diagnostic Code 5257, which provided ratings of 10, 20, and 30 percent for recurrent subluxation or lateral instability of the knee, which is slight, moderate, or severe, respectively. 38 C.F.R. § 4.71a, Diagnostic Code 5257. Effective February 7, 2021, Diagnostic Code 5257 provides ratings for both recurrent subluxation or instability of the knee and for patellar instability. As it pertains to recurrent subluxation or instability of the knee, Diagnostic Code 5257 provides a 10 percent rating for a sprain, incomplete ligament tear, or complete ligament tear (repaired, unrepaired, or failed repair) causing persistent instability, without a prescription from a medical provider for an assistive device (e.g., cane(s), crutch(es), walker) or bracing for ambulation. A 20 percent rating is warranted for either (a) sprain, incomplete ligament tear, or repaired complete ligament tear causing persistent instability, and a medical provider prescribes a brace and/or assistive device, or (b) unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribes either an assistive device or bracing for ambulation. A 30 percent rating is warranted for unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribes both an assistive device and bracing for ambulation. As it pertains to patellar instability of the knee, Diagnostic Code 5257 provides a 10 percent rating 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 warranted for a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for one of the following: A brace, cane, or walker. A 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. Note (1): For patellar instability, the patellofemoral complex consists of the quadriceps tendon, the patella, and the patellar tendon. Note (2): A surgical procedure that does not involve repair of one or more patellofemoral components that contribute to the underlying instability shall not qualify as surgical repair for patellar instability (including, but not limited to, arthroscopy to remove loose bodies and joint aspiration). See DC 5257 (Effective February 7, 2021). Diagnostic Code 5258 provides a 20 percent rating may be assigned for dislocated semilunar cartilage with frequent episodes of "locking," pain, and effusion into the joint. Diagnostic Code 5258 provides a 20 percent rating may be assigned for dislocated semilunar cartilage with frequent episodes of "locking," pain, and effusion into the joint. Diagnostic Code 5259 provides for a 10 percent rating for symptomatic removal of the semilunar cartilage. The Veteran's currently assigned 10 percent ratings have been awarded based on painful motion of the knee joints. Because the Veteran's range of knee motion in flexion, to include during repetitive use testing and during flare-ups, has been no worse than 60 degrees (right knee) and to 100 degrees (left knee), ratings in excess of 10 percent are not warranted under DC 5260. See May 2014 VA examination report (noting flexion limited to 60 degrees in the right knee following repetitive use testing and limited to 100 degrees in the left knee); see also august 2019 VA examination (flexion in both knees limited to 100 degrees during flare-ups). Further, as noted in the 2014 and 2019 VA knee examination reports, the Veteran has been able to fully extend both knees; as such, higher or separate compensable ratings under Diagnostic Code 5261 are not warranted. The Board recognizes the Veteran's reports of continued bilateral knee pain, swelling, and stiffness as discussed in the VA examination reports dated in 2014 and 2019. The Board considered this knee pain, as well as any additional limitations of motion due to pain (including difficulty with prolonged sitting, walking, running, kneeling, and bending). However, even considering additional limitation of motion or function of the knee due to pain or other symptoms such as weakness, fatigability, weakness, or incoordination (see 38 C.F.R. §§ 4.40, 4.45, 4.59, DeLuca), the evidence still does not show that the bilateral knee disability more nearly approximates the criteria for a higher ratings. Repetitive-use testing during the VA examinations discussed above showed no significant decreased range of motion in either knee. Moreover, there is no evidence of any knee ankylosis, dislocated semilunar cartilage, or malunion of the tibia and fibula to support higher or separate ratings under DCs 5256, 5258, or 5262. The Board next finds that, based on the evidence of record, the Veteran's bilateral knee disabilities, based on instability, warrant separate 10 percent ratings throughout the period on appeal. Stability testing during the period on appeal has consistently found no instability; however, the 2014 VA examiner indicated that the Veteran's functional impairment in the knees resulted in less movement than normal, pain on movement, swelling, instability of station, disturbance of locomotion, and interference with sitting, standing, and weight-bearing. Diagnostic Code 5257 does not require objective medical evidence of lateral instability for a rating to be assigned. See English v. Wilkie, 30 Vet. App. 347 (2018). Because the Veteran's bilateral knee disability has been shown to result in some instability of station and disturbance of locomotion, the Board finds that separate 10 percent ratings are warranted for slight lateral instability for the rating period on appeal. The Board further finds that the Veteran's bilateral knee instability is not more accurately described as moderate. The medical records do not specifically describe instability of the knee joints and VA examiners and private treatment records have consistently found that the knee joints are normal on all stability tests. The Board finds that knee instability that causes functional impairment but is undetectable on all forms of examination is best characterized as slight in nature. The Board has also considered whether higher ratings are warranted beginning February 7, 2021, and pursuant to the revised criteria for DC 5257. In this case, the Veteran has been shown to have osteoarthritis and has not been diagnosed with a sprain, incomplete ligament tear, or repaired complete ligament tear. Further, the Veteran's bilaterally knee instability does not more nearly approximate "recurrent instability." As noted above, VA and private examiners have consistently found that the knee joints are normal on all stability tests. The Veteran's osteoarthritis associated with his knees has also not required surgical repair. Accordingly, higher ratings for instability of the knee joints is not warranted under both the earlier and revised rating criteria. For these reasons, the Board finds that separate 10 percent ratings are warranted for slight lateral instability of the right and left knee for the rating period on appeal. The Board further finds that the weight of the evidence is against a grant of ratings in excess of 10 percent for painful motion associated with osteoarthritis of the right or left knee. 38 U.S.C.§ 5107 (b); 38 C.F.R. §§ 4.3, 4.7. Right Shoulder Disability The Veteran is currently in receipt of a 20 percent rating for his right shoulder disability for the entire rating period on appeal. Under Diagnostic Code 5200, which pertains to ankylosis of the scapulohumeral articulation, a 20 percent rating is warranted for favorable ankylosis with abduction to 60 degrees, a 30 percent rating is warranted for ankylosis which is intermediate between favorable and unfavorable, and a 40 percent rating is warranted where there is unfavorable ankylosis with abduction limited to 25 degrees from the side. Limitation of motion of the shoulder joint is rated under Diagnostic Code 5201. Under Diagnostic Code 5201 (major side), a 20 percent rating is warranted for limitation of arm motion to shoulder level; a 30 percent rating is warranted for limitation of arm motion to midway between the side and shoulder level; and a maximum 40 percent rating is warranted for limitation of arm motion to 25 degrees from the side. 38 C.F.R. § 4.71a. Under Plate I of 38 C.F.R. § 4.71a, normal range of motion of the shoulder is forward elevation (flexion) and abduction to 180 degrees, and internal and external rotation to 90 degrees. The Board notes that effective February 7, 2021, VA's Schedule, 38 C.F.R. Part 4, was amended with regard to rating musculoskeletal disorders. Fed. Reg. 76453 (November 30, 2020) (codified at 38C.F.R. §4.71a). The changes effective February 7, 2021 under 38 C.F.R. § 4.71a, DC 5201 were not to the rating schedule itself but added instruction to clarify the degree of range of motion for limitation of motion of the arm. Specifically, limitation of the minor arm motion warrants a 20 percent rating when limited at the shoulder level (flexion and/or abduction limited to 90 degrees), or midway between the side and shoulder level (flexion and/or abduction limited to 45 degrees), and a 30 percent rating when limited at 25 degrees from the side (flexion and/or abduction). Diagnostic Code 5202 provides ratings for other impairment of the humerus. Recurrent dislocations of the humerus at the scapulohumeral joint are rated as 20 percent for the minor shoulder. Fibrous union of the humerus is rated as 40 percent for the minor shoulder. Nonunion of humerus (false flail joint) is rated as 50 percent for the minor shoulder. Loss of head of the humerus (flail shoulder) is rated as 70 percent for the minor shoulder. Under DC 5203 for impairment of the clavicle or scapula, a 10 percent rating is assigned for malunion or for nonunion without loose movement. When there is nonunion with loose movement, a 20 percent rating is assigned. A 20 percent rating is also assigned when there is dislocation of the clavicle or scapula. The Board further finds that Diagnostic Code 5200 is inapplicable because there is no evidence of ankylosis of the Veteran's right shoulder as required under Diagnostic Code 5200. Likewise, as the evidence does not show that the Veteran's clavicle and scapula are impaired, the Board finds that Diagnostic Code 5203 is not applicable. The Veteran has not been shown to have recurrent dislocations of the humerus; as such, Diagnostic Code 5202 is also not for application. With respect to Diagnostic Code 5201, the Board finds that a disability rating in excess of 20 percent is not warranted as the Veteran has not shown limitation of right shoulder motion midway between the side and shoulder level. Instead, the Veteran's range of motion during the May 2014 and August 2019 VA examination reports was shown to be, at worst, limited to 95 degrees in abduction and limited to 100 degrees in flexion (during flare-ups). The Board recognizes the Veteran's complaints of functional loss as a result of his shoulder disability, notably his pain. However, the Veteran was still able to demonstrate range of motion that exceeds the criteria for the next higher rating. The Board finds that the 20 percent rating currently assigned contemplates any functional impairment that the Veteran experiences in his right shoulder. In light of the above, the claim for a higher schedular rating for the Veteran's right shoulder disability must be denied. In reaching this decision, the Board finds that the preponderance of the evidence is against the claim, and the claim must be denied. 38 U.S.C. § 5107 (b) (2012); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Hemorrhoids The Veteran's service-connected hemorrhoid disability is rated under the provisions of 38 C.F.R. § 4.114, Diagnostic Code 7336 (2020) which pertains to both internal and external hemorrhoids. A maximum 20 percent rating is warranted for persistent bleeding and secondary anemia, or with fissures. Id. The record reflects that the Veteran is receipt of the maximum schedular rating for internal and external hemorrhoids for the entire rating period on appeal. As noted in an August 2019 VA examination report, the Veteran's hemorrhoids have continued to be manifested by persistent rectal bleeding, itching, and pain. However, the clinical evidence does not reflect evidence of any symptomatology or specialized treatment not contemplated by the schedular criteria of Diagnostic Code 7336. Consideration has been given to other potentially applicable schedular criteria, including Diagnostic Codes 7332 (impairment of sphincter control), 7333 (stricture of rectum and anus), 7334 (rectum prolapse), and 7335 (fistula in ano). However, the Veteran does not appear to have any additional symptoms relative to those diagnostic codes that might warrant a higher rating under any other applicable rating criteria. In view of the above, the Board finds that the Veteran has not met the criteria for a higher schedular rating for any associated hemorrhoid symptomatology. Accordingly, a rating in excess of 20 percent for the service-connected hemorrhoids is not warranted and an increased rating is denied. The preponderance of the evidence is against the claim. Psychiatric Disability The Veteran's generalized anxiety disorder with depression is rated under the General Rating Formula for Mental Disorders. See 38 C.F.R. § 4.130, Diagnostic Code 9400. Ratings are assigned according to the manifestation of particular symptoms. When determining the appropriate disability evaluation to assign, the Board's primary consideration is a veteran's symptoms, but it must also make findings as to how those symptoms impact a veteran's occupational and social impairment. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 118 (Fed. Cir. 2013); Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). Because the use of the term "such as" in the rating criteria demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, the Board need not find the presence of all, most, or even some, of the enumerated symptoms to award a specific rating. Mauerhan, 16 Vet. App. at 442; see also Sellers v. Principi, 372 F.3d 1318, 1326-27 (Fed. Cir. 2004). A 30 percent rating is assigned when a mood disorder causes occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks, chronic sleep impairment and mild memory loss. 38 C.F.R. § 4.130. A 50 percent disability rating requires evidence of the following: Occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. The criteria for a 70 percent rating are: Occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near- continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting; inability to establish and maintain effective relationships.). The criteria for a 100 percent rating are: Total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. 38 C.F.R. § 4.130, Diagnostic Code 9411. In determining the level of impairment under 38 C.F.R. § 4.130, a rating specialist is not restricted to the symptoms provided under the diagnostic code, and should consider all symptoms which affect occupational and social impairment, including those identified in the DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS (DSM-IV or DSM 5). See Mauerhan v. Principi, 16 Vet. App. 436 (2002). If the evidence demonstrates that a claimant suffers symptoms or effects that cause an occupational or social impairment equivalent to those listed in that diagnostic code, the appropriate, equivalent rating is assigned. See Mauerhan, 16 Vet. App. 436. Upon review of all evidence of record, both lay and medical, the Board finds that a higher rating of 50 percent for the Veteran's psychiatric disability is warranted for the entire period on appeal. The Board finds that the Veteran's symptoms have remained relatively consistent throughout the appeal period. The Veteran's disability has been manifested by anxiety, suspiciousness, irritability, chronic sleep impairment, mild memory loss, some social isolation, difficulty in establishing and maintaining effective work and social relationships, and mild depression. See May 2014 and August 2019 VA psychiatric examination reports. Some of these symptoms (including memory loss and difficulty in establishing and maintaining effective work and social relationships) are specifically contemplated in the 50 percent rating criteria. Accordingly, and resolving reasonable doubt in the Veteran's favor, the Board finds that a 50 percent rating for the Veteran's psychiatric disability is warranted for the rating period on appeal. The Board next finds that the Veteran's psychiatric disability has not more nearly approximated occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood as required for the next higher 70 percent rating. The Board recognizes that the Court in Mauerhan, 16 Vet. App. 436, stated that the symptoms listed in VA's general rating formula for mental disorders is not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating; however, the Court further indicated that, without those examples, differentiating between rating evaluations would be extremely ambiguous. Id. at 442. With this in mind, the weight of the evidence demonstrates that the Veteran's overall disability picture is adequately contemplated by the 50 percent rating assigned herein for the rating period granted herein. The Veteran does experience sleep impairment, but this symptom is specifically contemplated under the criteria for a 30 percent rating, a lower rating than his currently assigned 50 percent rating. The Veteran's disturbances of motivation and mood (depression and anxiety) are specifically contemplated in the 50 percent rating criteria, as are his difficulty in establishing and maintaining relationships. Moreover, the Veteran reported that he continues to work full-time as a nurse supervisor, an occupation which the Board finds involves interacting with various individuals. He has also reported that he continues to have a good marriage and has some friends. See August 2019 VA examination report. Further, the weight of the evidence of record, including VA examination reports and treatment records, do not reflect impaired impulse control (such as unprovoked irritability with periods of violence), spatial disorientation, neglect of personal appearance and hygiene, or an inability to establish and maintain effective relationships. The weight of the evidence does not demonstrate deficiency in most areas for the rating period on appeal. For these reasons, the Board finds that a 50 percent rating, but no higher, for the Veteran's service-connected psychiatric disability is warranted for the rating period on appeal. GERD The Veteran maintains that his GERD disability is more severe than what is contemplated by the currently assigned 10 percent evaluation. The Veteran's GERD is rated under Diagnostic Code (DC) 7346 for hiatal hernia. 38 C.F.R. § 4.114, DC 7346. Under DC 7346, symptoms of pain, vomiting, material weight loss and hematemesis or melena with moderate anemia, or other symptom combinations productive of severe impairment of health warrant a 60 percent rating. Persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health, warrants a 30 percent rating. Two or more of the symptoms for the 30 percent rating of less severity warrant a 10 percent rating. 38 C.F.R. § 4.114, DC 7346. The evidence includes VA examination reports conducted in May 2014 and August 2019. These reports indicate VA examination report, which note various symptoms of GERD to include persistent and recurrent epigastric distress, pyrosis, reflux, regurgitation, substernal arm pain, melena, and sleep disturbance. The Veteran requires the use of medication to treat his symptoms. The Veteran's GERD was also noted to impact his occupational productivity and efficiency. Upon review of all the lay and medical evidence of record, the Board finds that the evidence is at least in equipoise as to whether the Veteran's GERD more nearly approximates a 30 percent rating under Diagnostic Code 7346. The Veteran has been found to have numerous symptoms of GERD, to include melena (a symptoms found in the 60 percent rating criteria). Additionally, Veteran's sleep impairment due to GERD would likely result in some considerable impairment of health, as required for an increased 30 percent rating under Diagnostic Code 7346. For these reasons, and resolving reasonable doubt in the Veteran's favor, the Board finds that a 30 percent rating for GERD is warranted for the entire rating period on appeal. The Board next finds that a higher rating of 60 percent is not warranted, as the evidence of record does not support findings consistent with pain, vomiting, material weight loss and hematemesis or melena with moderate anemia; or other symptom combinations productive of severe impairment of health. The evidence does not show that the Veteran have anemia or material weight loss as a result of his GERD disability. Accordingly, a rating in excess of 30 percent for GERD is not warranted at any time during the appeal period. Onychomycosis The Veteran's skin condition is rated under DC 7899-7813. Hyphenated diagnostic codes are used when a rating under one code requires use of an additional diagnostic code to identify the basis for the evaluation assigned. 38 C.F.R. § 4.27. Under DC 7813, a noncompensable rating is warranted for dermatophytosis, to include tinea pedis, involving less than 5 percent of the entire body or less than 5 percent of the exposed areas affected, and no more than topical therapy required during the past-12-month period. A 10 percent rating is warranted for involvement of at least 5 percent, but less than 20 percent, of the entire body, or at least 5 percent, but less than 20 percent, of exposed areas affected, or; intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs were required for a total duration of less than six weeks during the past 12-month period. A 30 percent rating is warranted for involvement of 20 to 40 percent of the entire body or 20 to 40 percent of the exposed areas affected, or; when systemic therapy such as with corticosteroids or other immunosuppressive drugs were required for a total duration of six weeks or more, but not constantly, during the past 12-month period. A maximum (60 percent) rating is warranted for involvement of more than 40 percent of the entire body or more than 40 percent of exposed areas affected, or; when constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs was required during the past 12-month period. 38 C.F.R. § 4.118, DC 7813. The Board notes that applicable regulations for rating skin disabilities have changed for claims pending on August 13, 2018, and that such regulations should be followed if they are more favorable to the veteran. The new regulations set bright line rules for what constitutes a "topical" versus a "systemic" treatment and define a "systemic" treatment as "therapy administered through any route (orally, injection, suppository, intranasally) other than the skin." Under the old regulations, in Johnson v. Shulkin, 862 F.3d 1351 (Fed. Cir. 2017), the United States Court of Appeals for the Federal Circuit (Federal Circuit) distinguished between "systemic" therapy versus "topical" therapy, holding that systemic therapy means treatment affecting the whole body, whereas topical therapy means treatment pertaining to a particular surface area that affects only the area to which it is applied. In considering whether a treatment is systemic, the Board must also consider whether the treatment affects the body as a whole and whether the given treatment is like or similar to a corticosteroid or other immunosuppressive drug. Burton v. Wilkie, 30 Vet. App. 286 (2018). Considering the collective medical evidence of record, the Board finds that at no point pertinent to the claim for increase has the Veteran's skin condition warranted a compensable rating. Specifically, the May 2014 and August 2019 VA skin examinations of record do not indicate that five percent or more of the Veteran's total body or the exposed area was affected by his skin condition. During the 2014 VA examination, the examiner noted that the Veteran used Lotrimin ointment 6 weeks or more in the past 12 months, but not constantly. The Veteran's treatment was topical and was applied to the affected area (toenails) and did not affect the body as a whole. As mentioned, in Johnson v. Shulkin, the Federal Circuit distinguished between "systemic" therapy versus "topical" therapy, holding that systemic therapy means treatment affecting the whole body, whereas topical therapy means treatment pertaining to a particular surface area that affects only the area to which it is applied. 862 F.3d 1351 (Fed. Cir. 2017). The Board finds that the Veteran's occasional use of topical ointments only to the toenails does not absorb into the skin enough to be considered systemic therapy. The Board has considered all potentially applicable provisions for skin disorders, whether or not they have been raised by the Veteran. In this case, the Board finds no provision upon which to assign the Veteran a compensable disability rating for his condition. The Board also notes that DC 7806 provides for rating as disfigurement of the head, face, or neck (DC 7800) or scars (DC's 7801, 7803, 7804, or 7805), depending upon the predominant disability. The evidence does not indicate that the Veteran has any scarring or disfigurement as a result of his skin condition. Accordingly, the claim for a compensable rating for onychomycosis is denied. Because the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application, and the appeal must be denied as to this issue. See 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. Other Considerations The Board has also considered whether an inferred claim for a total disability rating based on individual unemployability (TDIU) under Rice v. Shinseki, 22 Vet. App. 447 (2009) has been raised. However, the evidence of record shows that the Veteran is working full-time. See August 2019 VA psychiatric examination report. As such, no further discussion is required. The Veteran has not raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 371 (2017). Idongesit T. Umo Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board R. Casadei, 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.