Citation Nr: 21042777 Decision Date: 07/13/21 Archive Date: 07/13/21 DOCKET NO. 16-08 619 DATE: July 13, 2021 ORDER Entitlement to an increased evaluation in excess of 30 percent for service-connected left knee patellofemoral syndrome is denied. Prior to December 6, 2019, entitlement to an increased evaluation in excess of 10 percent for service-connected left knee instability is denied. From December 6, 2019, entitlement to an evaluation of 20 percent for service-connected left knee instability is granted. From September 11, 2011, entitlement to a 30 percent rating for service-connected cystic acne is granted. REMANDED Entitlement to service connection for right knee condition, to include as secondary to service-connected left knee patellofemoral syndrome is remanded. Entitlement to service connection for lumbar degenerative disc disease with spondylolisthesis, to include as secondary to service-connected left knee patellofemoral syndrome is remanded. FINDINGS OF FACT 1. Throughout the period on appeal, the Veteran's left knee patellofemoral syndrome is manifested at worst by flexion to 60 degrees, extension to 20 degrees, and painful range of motion. 2. Prior to December 6, 2019, the Veteran's left knee instability is manifested by slight lateral instability. 3. From December 6, 2019, the Veteran's left knee instability is manifested by moderate lateral instability. 4. From September 11, 2011, the Veteran's acne is deep and has affected more than 40 percent of the Veteran's face and neck, requiring treatment with Accutane and Isotretinoin. CONCLUSIONS OF LAW 1. The criteria for entitlement to an increased evaluation in excess of 30 percent for service-connected left knee patellofemoral syndrome have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5261. 2. Prior to December 6, 2019, the criteria for entitlement to an increased evaluation in excess of 10 percent for service-connected left knee instability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5257. 3. From December 6, 2019, the criteria for entitlement to a 20 percent evaluation for service-connected left knee instability have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5257. 4. From September 11, 2011, the criteria for entitlement to a rating of 30 percent for service-connected cystic acne have been met. 38 U.S.C. §§ 1110; 5107; 38 C.F.R. §§ 4.118, DC 7800, 7804, 7828. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from June 2000 to September 2011. This matter comes before the Board of Veterans' Appeals (Board) on appeal from July 2013 and July 2017 rating decisions. The Veteran was afforded a hearing before the undersigned Veterans Law Judge in March 2019. In September 2019, the Board remanded the issues for further development. That development was completed, and the case has since been returned to the Board for appellate review. Increased Rating Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (rating schedule), found in 38 C.F.R. Part 4. The Board attempts to determine the extent to which a veteran's service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, and the assigned rating is based, as far as practicable, upon the average impairment of earning capacity in civil occupations. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.10. When a reasonable doubt arises regarding the degree of disability, such doubt will be resolved in favor of the claimant. 38 C.F.R. § 4.3. If there is a question as to which evaluation to apply to a veteran's disability, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. A Veteran's entire history is to be considered when making disability evaluations. See 38 C.F.R. 4.1, 4.2; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Where the issue involves the assignment of a disability rating following the initial award of service connection for that disability, as is the case here, the entire history of the disability must be considered, and separate ratings can be assigned for separate periods of time based on the facts found, a practice known as "staged" ratings. Fenderson v. West, 12 Vet. App. 119, 126 (1999). 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; 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 criteria."). Under 38 C.F.R. § 4.59, painful motion is a factor to be considered with any form of arthritis; however, 38 C.F.R. § 4.59 is not limited to disabilities involving arthritis. See Burton v. Shinseki, 25 Vet. App. 1 (2011). In Correia v. McDonald, 28 Vet. App 158 (2016), the Court held that the final sentence of 38 C.F.R. § 4.59 requires that the examiner record the results of range of motion testing "for pain on both active and passive motion [and] in weight-bearing and non-weight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint." In Sharp v. Shulkin, 29 Vet. App. 26 (2017), the Court held that VA examiners must obtain information about the severity, frequency, duration, precipitating and alleviating factors, and extent of functional impairment of flares from the veterans themselves, when a flare-up is not observable at the time of examination. In making all determinations, the Board must fully consider the lay assertions of record. A Veteran is competent to report on that of which he or she has personal knowledge. Layno v. Brown, 6 Vet. App. 465, 469 (1994). When considering whether lay evidence is competent, the Board must determine on a case by case basis whether a veteran's particular disability is the type of disability for which lay evidence may be competent. See Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011); see also Jandreau v. Nicholson, 492 F.3d 1372, 1376 -77 (Fed. Cir. 2007). The Board must assess the credibility and weight of all the evidence, including the medical evidence, to determine its probative value, accounting for evidence that it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. See Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992); Hatlestad v. Derwinski, 1 Vet. App. 164 (1991). Equal weight is not necessarily accorded to each piece of evidence contained in the record; not every item of evidence necessarily has the same probative value. 1. Entitlement to an increased evaluation in excess of 30 percent for service-connected left knee patellofemoral syndrome The Veteran contends that the currently assigned 30 percent rating for the left knee patellofemoral syndrome under Diagnostic Code 5261 does not accurately reflect the severity of the condition. The Veteran's left knee patellofemoral syndrome (PFS) is rated under 38 C.F.R. § 4.71a, Diagnostic Code 5261, for limitation of extension of the leg. Under Diagnostic Code 5261, a noncompensable rating is warranted for extension limited to 5 degrees. A 10 percent rating is warranted for extension limited to 10 degrees. A 20 percent rating is warranted for extension limited to 15 degrees. A 30 percent rating is warranted for extension limited to 20 degrees. A 40 percent rating is warranted for extension limited to 30 degrees. A 50 percent rating is warranted for extension limited to 45 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5261. The Board finds that the preponderance of the evidence is against a rating in excess of 30 percent for PFS. The Board acknowledges the Veteran's lay reports of symptoms and that there was functional loss due to pain, instability, and weakened movement. However, even considering the Veteran's lay reports of symptoms and noted functional loss, the degree of additional limitation reflected by the statements that the knee is painful, swells, locks, or buckles daily would not result in limitation of motion more nearly approximating extension limited to 30 degrees. Upon VA examination in December 2015, the Veteran's flexion was to 60 degrees and extension was to 20 degrees. Pain was noted upon flexion and extension, causing functional loss. Range of motion was the same upon repetitive use. There is no ankylosis. The Veteran did not have joint instability. In April 2016, the Veteran complained her left kneecap dislocates to the side and occasionally buckles. See April 2016 VA Treatment Record. She has increased pain with lateral movement of the knee, with stairs, and with prolonged standing. Id. A July 2016 VA treatment note reflects the Veteran's left knee has decreased strength, decreased range of motion, decreased functional mobility, and pain. The Veteran was afforded a VA examination in November 2016. Initial flexion was to 120 degrees and extension was to 5 degrees with pain noted. There was no additional functional loss or range of motion after three repetitions. There was no ankylosis. The left knee had slight lateral instability. The examination shows no joint instability. VA treatment records show the Veteran experiences ongoing pain and wears a brace. See August 2018 VA Treatment Records. The Veteran was afforded a VA examination in December 2019. The Veteran reported her left knee shifts to the left, causing swelling. The Veteran is unable to wear her knee brace when the knee swells. She reports flare-ups occur daily and are severe. She states she can only sit for about an hour otherwise her legs will go numb. If she stands for too long, her left leg will give out. Initial flexion is to 140 degrees, and extension is to 0 degrees with pain noted upon examination in flexion and extension. There is no additional loss of range of motion upon repetitive use testing or during flare-ups. There is no ankylosis. The Veteran has moderate lateral instability, as well as joint instability. The evidence of record does not reflect the Veteran has extension limited to 30 degrees. In regard to flare-ups, the VA examiner maintained that after review of the Veteran's records including the order request, DBQ, physical exam, reported history and subjective complaints, relevant evidence of record and using her medical knowledge and expertise, she had no basis to offer additional losses of function or motion during a flareup. The Board finds this conclusion consistent with the lay and medical evidence of record. Importantly, at the December 2019 VA examination the Veteran reported "Right now, my left knee is shifting to the left. So my IT band pulls my left knee and it causes swelling. Right now I can't wear knee brace due to swelling." The Veteran, however, was able to still demonstrate extension to 0 degrees. Also, as previously noted in the Board's September 2019 Remand, the Board acknowledges that the Veteran asserted in a November 2018 NOD that the RO did not address claims of left iliotibial band syndrome or left knee arthritis. However, the Board notes that the January 2016 rating decision that increased the left knee disability evaluation to 30 percent acknowledged that the left knee patellofemoral syndrome was also claimed as iliotibial band friction. Additionally, the RO assigned a separate rating for left knee instability. The Board has also considered the other Diagnostic Codes pertaining to the knee and leg. Other disability ratings may be assigned only if the symptomatology for a disability is not duplicative or overlapping with the symptomatology of any other disability. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994); Lyles v. Shulkin, 29 Vet. App. 107 (2017) (holding that 38 C.F.R. § 4.14 prohibits paying compensation twice for the same symptoms or functional impairment). The Board finds that a separate compensable rating for limitation of flexion is not warranted. Diagnostic Code 5260, a noncompensable rating is warranted for flexion limited to 60 degrees. A 10 percent rating is warranted for flexion limited to 45 degrees. A 20 percent rating is warranted for flexion limited to 30 degrees. A 30 percent rating is warranted for flexion limited to 15 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5260. The December 2015 VA examination shows the Veteran's flexion was to 60 degrees. The November 2016 VA examination reflects flexion was to 120 degrees. Flexion was to 140 degrees during the December 2019 VA examination. These findings do not warrant a compensable evaluation under Diagnostic Code 5260. While the Veteran experienced painful motion upon flexion, the Veteran is compensated for painful motion under Diagnostic Code 5261 and to do so under Diagnostic Code 5260 would constitute pyramiding. See 38 C.F.R. § 4.14; Esteban v. Brown, 6 Vet. App. 259, 261 (1994) (providing that the critical element is that none of the symptomatology for any condition is duplicative of or overlapping with the symptomatology of the other condition). Therefore, a separate evaluation is not warranted under Diagnostic Code 5260 for left knee patellofemoral syndrome. The Veteran is currently service connected for left knee instability under Diagnostic Code 5257 and is seeking an increased rating. See discussion below. The Board has also considered whether entitlement to a higher evaluation or separate evaluation is warranted under any other applicable diagnostic code. Initially, the Board notes that the required manifestations for evaluation under Diagnostic Codes 5256 (knee, ankylosis), 5262 (tibia and fibula, impairment of), and 5263 (genu recurvatum) are not applicable, as the presence of ankylosis, mal- or nonunion of the tibia and/or fibula, or genu recurvatum have not been demonstrated. There has been no finding of knee ankylosis. In addition, the evidence does not show impairment of the tibia or fibula. Lacking any positive radiological evidence or a medical opinion for malunion or nonunion of the tibia and fibula, no higher rating is warranted under Diagnostic Code 5262. Similarly, there is no evidence of genu recurvatum. Additionally, the evidence does not show the Veteran has dislocated or removal of semilunar cartilage to warrant a rating under Diagnostic Codes 5258 or 5259. Moreover, the Veteran may not be assigned separate ratings under Diagnostic Codes 5258 or 5259 for the same symptoms (painful motion) as to do so would violate the prohibition against pyramiding. See 38 C.F.R. § 4.14; Esteban v. Brown, 6 Vet. App. 259, 261 (1994) (providing that the critical element is that none of the symptomatology for any condition is duplicative of or overlapping with the symptomatology of the other condition). The Board recognizes that at times the Veteran has described her symptoms as severe. The Veteran's lay evidence, however, is outweighed by the competent and credible medical evidence that evaluates the true extent of the impairment based on objective data coupled with the lay complaints. In this regard, the Board notes that the medical examiners have the training and expertise necessary to administer the appropriate tests for a determination of the type and degree of the impairment associated with the Veteran's complaints, and to provide the requisite information for an evaluation of the disability under the rating schedule. For these reasons, greater evidentiary weight is placed on the medical findings in regard to the type and degree of the Veteran's impairment. In conclusion, the Board finds that the preponderance of the evidence is against the Veteran's claim for a rating in excess of 30 percent for left knee patellofemoral syndrome. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. 2. Entitlement to an increased evaluation in excess of 10 percent for service-connected left knee instability The Veteran contends that the currently assigned 10 percent rating for left knee instability does not accurately reflect the severity of the condition. The Veteran's left knee instability (instability) is rated under 38 C.F.R. § 4.71a, Diagnostic Code 5257, for other impairment of the knee. Under Diagnostic Code 5257, a 10 percent rating is warranted for slight recurrent subluxation or lateral instability. A 20 percent rating is warranted for moderate recurrent subluxation or lateral instability. A 30 percent rating is warranted for severe recurrent subluxation or lateral instability. 38 C.F.R. § 4.71a, Diagnostic Code 5257. According to MERRIAM WEBSTER'S COLLEGIATE DICTIONARY 999 (11th Ed. 2007), "slight" means small in amount. "Moderate" means limited in scope or effect. "Severe" means very painful or harmful or of a great degree. Objective medical evidence is not required to establish lateral knee instability under Diagnostic Code 5257, so objective medical evidence cannot be categorically found more probative than lay evidence with respect to this Diagnostic Code. See English v. Wilkie, 30 Vet. App. 347, 352-53 (2018). Prior to December 6, 2019 The Board finds that the preponderance of the evidence is against a rating in excess of 10 percent for left knee instability prior to December 6, 2019. The Board has carefully considered the Veteran's reports about instability. English, 30 Vet. App. 347, 352-53. However, overall, the lay and medical evidence indicates that the instability symptoms have varied and do not suggest the presence of symptoms more nearly approximating moderate severity. As noted above, upon VA examination in December 2015, the Veteran did not have joint instability. The November 2016 VA examination showed the left knee had slight lateral instability. The Veteran is competent to report on symptoms and her perception of the severity of the symptoms but this lay evidence is outweighed by the competent and credible medical evidence that evaluates the true extent of the impairment based on objective data coupled with the lay complaints. In this regard, the Board notes that the medical examiners have the training and expertise necessary to administer the appropriate tests for a determination of the type and degree of the impairment associated with the Veteran's complaints, and to provide the requisite information for an evaluation of the disability under the rating schedule. For these reasons, greater evidentiary weight is placed on the medical findings in regard to the type and degree of the Veteran's impairment. The Board has also considered the other Diagnostic Codes pertaining to the knee and leg. As discussed above, the Board finds that a separate compensable rating for limitation of flexion is not warranted. While the Veteran experienced painful motion with instability, the Veteran is compensated for painful motion under Diagnostic Code 5261 and to do so under Diagnostic Code 5257 would constitute pyramiding. See 38 C.F.R. § 4.14; Esteban v. Brown, 6 Vet. App. 259, 261 (1994) (providing that the critical element is that none of the symptomatology for any condition is duplicative of or overlapping with the symptomatology of the other condition). Therefore, a separate evaluation is not warranted under Diagnostic Code 5260 for left knee instability. The Veteran is currently service connected for left knee patellofemoral syndrome under Diagnostic Code 5261 and, as discussed previously, an increased evaluation is not warranted. Moreover, as discussed previously, entitlement to a separate evaluation under Diagnostic Codes 5256, 5258, 5259, 5262, and 5263 is not warranted. In conclusion, the Board finds that the preponderance of the evidence is against the Veteran's claim for a rating in excess of 10 percent for left knee instability prior to December 6, 2019. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. From December 6, 2019 The Board finds that the evidence warrants a 20 percent rating, but no higher, for left knee instability. The Board has carefully considered the Veteran's reports about instability. English, 30 Vet. App. 347, 352-53. Overall, the lay and medical evidence indicates that the instability symptoms have varied suggesting the presence of symptoms more nearly approximating moderate severity. At the December 2019 VA examination, the Veteran reported her left knee shifts to the left, causing swelling. The examiner noted the Veteran has moderate lateral instability, as well as joint instability. The evidence does not suggest the Veteran experienced symptoms of severe instability. Again, the Veteran is competent to report on symptoms and her perception of the severity of the symptoms but this lay evidence is outweighed by the competent and credible medical evidence that evaluates the true extent of the impairment based on objective data coupled with the lay complaints. In this regard, the Board notes that the medical examiners have the training and expertise necessary to administer the appropriate tests for a determination of the type and degree of the impairment associated with the Veteran's complaints, and to provide the requisite information for an evaluation of the disability under the rating schedule. For these reasons, greater evidentiary weight is placed on the medical findings in regard to the type and degree of the Veteran's impairment. In conclusion, the Board finds that the evidence warrants a rating of 20 percent for left knee instability. A higher rating is not warranted under the new criteria for Rating the Musculoskeletal System effective February 7, 2021. 3. Entitlement to a compensable rating from September 11, 2011; a rating in excess of 10 percent from February 19, 2015; a rating in excess of 30 percent from March 24, 2015; and a compensable rating from June 23, 2015 for service-connected acne The Veteran contends that the current assigned ratings for her service-connected acne do not accurately reflect the severity of her disability. The Veteran has been assigned staged ratings under 38 C.F.R. § 4.118, Diagnostic Code 7828. VA amended the criteria for rating skin disabilities effective from August 13, 2018. Claims, such as this, 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. Diagnostic Code 7828 was not affected by the revision. Under that code, a zero percent rating is assigned for superficial acne (comedones, papules, pustules, superficial cysts) of any extent. A 10 percent rating is assigned for deep acne (deep inflamed nodules and pus-filled cysts) affecting less than 40 percent of the face and neck or deep acne other than on the face and neck. A maximum 30 percent rating is assigned under DC 7828 for deep acne (deep inflamed nodules and pus-filled cysts) affecting 40 percent or more of the face and neck. Id. In October 2011, the Veteran complained of mild acne, with a superficial lesion. See October 2011 Private Treatment Records. It is located on her face, chest, back, and neck. Id. A January 2012 private treatment record notes the Veteran's acne consists of erythematous papules, pustules, comedones, and scars with post inflammatory pigmentation. In March 2012, the Veteran had acne located on her face and was undergoing an Accutane regiment. See March 2012 Private Treatment Records. Her acne consists of erythematous papules, pustules, comedones, and scars with post inflammatory pigmentation. Id. In November 2012 correspondence, the Veteran stated that she was currently finishing an Accutane regiment to correct her acne. The Veteran complained of developing cystic type lesions along the lower face and upper neck. See June 2013 VA treatment record. An August 2013 private treatment note reflects the Veteran was taking isotretinoin for her acne. A private treatment note from August 1, 2013 reflects the Veteran's acne has deep cystic and nodular acne papules on the jawline, cheeks, chin, upper back, and shoulders. There is comedonal lesions on the face. From September 2013 to November 2013, the Veteran's acne has few cystic and inflammatory acneiform papules scattered across the forehead, cheeks, chin, and upper back. See Private Treatment Records. In November 2013, the Veteran related that she has been on various medications for her cystic acne of the face, neck, chest, and back. See November 2013 Statement in Support of Claim. She states that more than 40 percent of the areas were affected which left numerous holes and scars. Id. She noted she is on isotretinoin for her acne which is the strongest medicine for acne. In December 2014, the Veteran had two 4-millimeter brown dome-shaped papules on the right neck as well as some cystic and inflammatory papules periorally. A February 2015 private treatment note reflects the Veteran has few cystic lesions on the cheeks and jawline. There are deep inflamed nodules and pus-filled cysts affecting less than 40 percent of the Veteran's face and neck. There is superficial scarring without underlying soft tissue damage on the face. A March 24, 2015 VA treatment note reflects the Veteran completed a five-month course of isotretinoin in February 2014. Her acne began to reoccur several months prior to the treatment note. A March 2015 private treatment note reflects the Veteran has few cystic lesions on the cheeks and jawline. There are deep inflamed nodules and pus-filled cysts affecting more than 40 percent of the Veteran's face and neck. There is superficial scarring without underlying soft tissue damage on the face. A January 2016 private treatment record notes the Veteran has few inflammatory papules and comedonal lesions on the forehead, cheeks, and chin. She has some mild hyperpigmentation on the areas of the forehead, cheeks, and chin, with skin texture abnormality. There is pitted scarring, slightly shiny atropic in appearance across most of the cheeks, chin, and forehead which is greater than six square inches. In August 2016, a VA dermatology record reflects the Veteran's face has icepick scars around the mouth and jawline, open and closed comedones around the jawline and mouth, and one inflammatory papule on the nose. The Veteran was afforded a VA examination in December 2019. The examiner noted the Veteran has a palpable cyst on the facial skin. The Veteran's cystic acne is less than five percent of total body area and less than five percent of total exposed area. The examiner stated the Veteran's deep acne affects less than 40 percent of the face and neck. The evidence reflects the Veteran's acne is manifested by deep cystic and nodular acne papules on the jawline, cheeks, chin, neck, upper back, and shoulders. The Veteran's acne has affected more than 40 percent of the Veteran's face and neck, requiring treatment with Accutane and Isotretinoin. Accutane and Isotretinoin are medications used to treat severe cystic acne. Therefore, the Board finds that the Veteran is entitled to a 30 percent rating for the entire appeal period. As the Board has awarded the highest schedular rating under Diagnostic Code 7828, there is no basis to award a higher rating. The Board also considered whether a higher rating is warranted under the DC for disfigurement. Under DC 7800, disfigurement of the head, face, or neck may be based, in part, upon the following eight specified characteristics of disfigurement: (1) a scar five or more inches (13 or more centimeters) in length; (2) a scar of at least one-fourth of an inch (0.6 centimeters) wide at its widest part; (3) surface contour of the scar elevated or depressed on palpation; (4) a scar adherent to underlying tissue; (5) skin hypo- or hyper-pigmented in an area exceeding six square inches (39 square centimeters); (6) abnormal skin texture (irregular, atrophic, shiny, scaly, etc.) in an area exceeding six square inches (39 square centimeters); (7) underlying soft tissue missing in an area exceeding six square inches (39 square centimeters); and/or (8) skin indurated and inflexible in an area exceeding six square inches (39 square centimeters). 38 C.F.R. § 4.118, DC 7800, Note (1). A 10 percent evaluation is warranted where there is evidence of one characteristic of disfigurement of the head, face, or neck. A 30 percent rating is warranted for visible or palpable tissue loss and either gross distortion or asymmetry of one feature of a paired set of features (i.e., the nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips or, in the alternative, two or three of the characteristics of disfigurement. A 50 percent rating is warranted when there is visible or palpable tissue loss and either gross distortion or asymmetry of two features or paired sets of features, or; with four or five characteristics of disfigurement. An 80 percent rating is warranted when there is visible or palpable tissue loss and either gross distortion or asymmetry of three or more features or paired sets of features, or; with six or more characteristics of disfigurement. Id. DC 7804 provides ratings for unstable or painful scars. 38 C.F.R. § 4.118, DC 7804. The February 2015 private treatment record found the Veteran had superficial scarring without underlying soft tissue damage on the face. The January 2016 private treatment record shows the Veteran has skin texture abnormality in an area exceeding six square inches. The characteristics of disfigurement do not result in a higher rating. The service-connected disability is cystic acne. The disability at issue is specifically contemplated in DC 7828 and residual scarring is contemplated by DCs 7800-7805. For reasons discussed above, the Board finds that a rating of 30 percent under DC 7828 is warranted for the entire appeal period. See Copeland v. McDonald, 27 Vet. App. 333, 337 (2015) (("[W]hen a condition is specifically listed in the Schedule, it may not be rated by analogy"); 38 C.F.R. §§ 4.20, 4.118, DCs 7800-7805, 7828. REASONS FOR REMAND 1. Entitlement to service connection for right knee condition, to include as secondary to service-connected left knee patellofemoral syndrome is remanded. The Veteran contends that the right knee condition is caused by her service-connected left knee patellofemoral syndrome. A December 2015 VA examination noted the Veteran has right knee osteoarthritis. In September 2019, the Board remanded the issue to obtain an addendum opinion addressing the Veteran's secondary theory of entitlement. The Veteran was afforded a VA knees examination in December 2019. The examiner found the Veteran's right knee x-ray results are normal and there were no abnormal findings. The examiner opined the Veteran's right knee condition was not proximately due to or the result of left knee patellofemoral syndrome or left knee instability because the examiner was unable to confirm a current chronic diagnosis with current available records or via examination. The examiner subsequently opined the Veteran's right knee condition is at least as likely as not proximately due to or the result of the Veteran's service-connected left knee patellofemoral syndrome. The rationale was that the current severity of the service-connected lumbar degeneration with spondylolisthesis warrants by proximity, association of the left knee patellofemoral syndrome claimed as IT band friction. The disorder began subsequent to the service-connected condition and is the direct result of the antecedent condition. The medical literature supports this stating "progression of knee osteoarthritis is associated with the progression of lumbar spine and hip osteoarthritis." The examiner further opined the Veteran's right knee condition is at least as likely aggravated beyond its natural progression by the service-connected left knee condition. The rationale was that the left knee condition is a natural progression of the condition. Left knee patellofemoral syndrome is not related to the right knee which is normal. The examiner has provided conflicting opinions regarding whether the Veteran's right knee condition is at least as likely as not proximately due or and/or aggravated by the Veteran's left knee condition. Further, positive opinions are supported by a rationale regarding the left knee condition and the back condition and not the right knee condition. Moreover, the negative opinions are based on a lack of a diagnosis of a right knee condition. As noted in the December 2015 VA examination and in the prior Board remand, the Veteran has been diagnosed with right knee osteoarthritis. The VA examiner did not acknowledge the diagnosis of osteoarthritis in the record. As the December 2019 medical opinion is based on factual inaccuracy, on remand, an addendum medical opinion should be obtained. Moreover, the Veteran, through her representative argues that other joints may be affected by a long-term altered gait and stance. See March 2020 Appellate Brief. The Veteran cited various online articles in support of her contention. Upon remand, the examiner should consider and discuss the Veteran's contention. 2. Entitlement to service connection for lumbar degenerative disc disease with spondylolisthesis, to include as secondary to service-connected left knee patellofemoral syndrome is remanded. The Veteran contends that her lumbar degenerative disc disease with spondylolisthesis is secondary to her service-connected left knee condition. The December 2017 VA examiner opined that the Veteran's DDD is less likely than not proximately due to or the result of the Veteran's left knee condition. The rationale was that the two conditions are medically unrelated. The claimed disorder, the Veteran's DDD, is a separate entity entirely from the Veteran's service-connected left knee condition and unrelated to it. The examiner stated that medical literature does not support a medical relationship. A January 2018 private DBQ from Dr. D.T. opines the Veteran's DDD is at least as likely as not proximately due to or the result of the Veteran's left knee condition. Dr. D.T. does not provide a rationale to support the opinion. Moreover, the DBQ does not reflect Dr. D.T. conducted a physical examination of the Veteran or reviewed the Veteran's VA file or medical records. The December 2019 VA examiner opined the Veteran's DDD is less likely than not proximately due to or the result of the Veteran's service-connected left knee patellofemoral syndrome or left knee instability. The rationale was that the Veteran's lumbar DDD with spondylolisthesis is not medically related to patellofemoral syndrome or left knee instability. The claimed DDD is a separate entity entirely from the service-connected left knee conditions and unrelated to them. The medical literature does not support a medical relationship. An addendum opinion was obtained in September 2020. The VA examiner opined the Veteran's DDD was not at least as likely as not aggravated beyond its natural progression by the service-connected left knee condition. The rationale is that medical literature does not support lumbar DDD with spondylolisthesis as being caused or aggravated by left knee patellofemoral syndrome with instability. The examiner stated that as you age, the soft discs between your vertebrae begin to dry out and shrink. This narrows the space between the vertebrae, which makes the spine less stable and decreases its flexibility. The examiner cited Cedars-Sinai which states that causes for this include age, daily activities, sports, and obesity. The Veteran, through her representative, argues that other joints may be affected by a long-term altered gait and stance. See March 2020 Appellate Brief. The Veteran cited various online articles in support of her contention. The various opinions of record do not discuss whether the Veteran's back condition is proximately due to or aggravated by a claimed altered gait and stance. Upon remand, the examiner should consider and discuss the Veteran's contention. The matters are REMANDED for the following action: 1. Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran's right knee osteoarthritis is at least as likely as not proximately due to or aggravated beyond its natural progression by the service-connected left knee patellofemoral syndrome with instability. The examiner must discuss the Veteran's diagnosis of right knee osteoarthritis and consider the medical literature cited by the Veteran regarding whether the Veteran's right knee condition is due to an altered gait and stance caused by the Veteran's service-connected left knee patellofemoral syndrome with instability. 2. Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran's lumbar degenerative disc disease with spondylolisthesis is at least as likely as not proximately due to or aggravated beyond its natural progression by the service-connected left knee patellofemoral syndrome with instability. The examiner must discuss and consider the medical literature cited by the Veteran regarding whether the Veteran's back condition is due to an altered gait and stance caused by the Veteran's service-connected left knee patellofemoral syndrome with instability. TANYA SMITH Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Alexia E. Palacios-Peters, Associate Counsel The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.