Citation Nr: 22012009 Decision Date: 03/02/22 Archive Date: 03/02/22 DOCKET NO. 10-34 355 DATE: March 2, 2022 ORDER Entitlement to service connection for inguinal hernia, previously claimed as groin pain, is granted. Entitlement to service connection for a cardiac disability, previously claimed as chest pain, is granted. Entitlement to a rating of 30 percent for diverticulitis is granted. Entitlement to an initial rating in excess of 10 percent for hypertension, prior to July 14, 2015, and in excess of 20 percent, thereafter, is denied. Entitlement to a rating in excess of 10 percent for a left wrist disability is denied. Entitlement to a rating in excess of 20 percent lumbar spine degenerative disc disease (lumbar spine disability) is denied. Entitlement to a rating in excess of 10 percent for status post right ankle fracture (right ankle disability) is denied. Entitlement to a rating in excess of 20 percent for tendonitis, right knee (right knee disability) is denied. Entitlement to a rating in excess of 20 percent for tendonitis, left knee (left knee disability) prior to May 1, 2021, and in excess of 60 percent, thereafter, status post total knee replacement, is denied. Entitlement to a separate rating of 20 percent, beginning August 25, 2021, for left knee instability is granted. REMANDED Entitlement to service connection for syncope is remanded. Entitlement to service connection for a left-hand condition is remanded. Entitlement to service connection for sinusitis is remanded. Entitlement to a total rating based on individual unemployability (TDIU) is remanded. FINDINGS OF FACT 1. The most probative evidence supports that that the Veteran's inguinal hernia is related to service. 2. The most probative evidence supports that the Veteran's cardiac disability is related to service. 3. For the entire appeal period, the Veteran's service-connected diverticulitis was shown to be severe, with alternating diarrhea and constipation with more or less constant abdominal distress. 4. Prior to July 14, 2015, the Veteran's hypertension was not productive of diastolic pressure predominantly 110 or more, or systolic pressure predominantly 200 or more. 5. Since July 14, 2015, the Veteran's hypertension has been productive of diastolic pressure predominantly 110 or more, but predominantly less than 120. 6. The most probative evidence of record does not demonstrate that the Veteran's left wrist is ankylosed. 7. Throughout the period on appeal, the Veteran's lumbar spine disability was not manifested by forward flexion of the thoracolumbar spine 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine or incapacitating episodes. 8. Throughout the appeal period, the Veteran's right ankle disability has been manifested by at least 20 degrees of dorsiflexion and at least 40 degrees of plantar flexion with subjective reports of swelling and pain and objective reports of some tenderness to palpation considered to be no more than moderately disabling. 9. Throughout the period of appeal, the Veteran's right knee disability resulted in painful or limited motion at times due to pain and other factors, but with flexion to greater than 30 degrees and normal extension, and frequent episodes of pain, locking, and effusion. 10. Prior to May 1, 2021, the Veteran's left knee disability resulted in painful or limited motion at times due to pain and other factors, but with flexion to greater than 30 degrees and normal extension to 0 degrees and frequent episodes of pain, locking, and effusion. 11. Effective May 1, 2021, the Veteran's left knee disability is rated as 60 percent disabling, which is the maximum schedular rating permitted after the first four months following implantation of prosthesis, and manifest by chronic residuals consisting of severe painful motion or weakness in the affected extremity. 12. Since August 25, 2021, the Veteran's left knee disability is manifested by recurrent subluxation or persistent instability requiring a prescribed brace and cane for ambulation. CONCLUSIONS OF LAW 1. The criteria for service connection for inguinal hernia are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for service connection for mitral valve prolapse are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 3. The criteria for a rating of 30 percent for diverticulitis are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.114, Diagnostic Codes (DCs) 7327, 7319. 4. Prior to July 14, 2015, the criteria for a rating in excess of 10 percent for hypertension have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.104, DC 7101. 5. Beginning July 14, 2015, the criteria for a rating in excess of 20 percent for hypertension have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.104, DC 7101. 6. The criteria for a rating in excess of 10 percent for the Veteran's left wrist disability have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.7, 4.10, 4.40, 4.45, 4.69, 4.71a, DCs 5215, 5214. 7. The criteria for a rating in excess of 20 percent for lumbar spine disability are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, DC 5242,5237. 8. The criteria for a disability rating greater than 10 percent for a right ankle disability have not been met. 38 U.S.C. §§ 1155, 5107; 38C.F.R. §§4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, DC 5271. 9. The criteria for a disability rating greater than 20 percent for a right knee disability are not met. 38 U.S.C. § 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, DC 5260, 5258. 10. The criteria for a disability rating greater than 20 percent for a left knee disability are not met. 38 U.S.C. § 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, DC 5260, 5258. 11. The criteria for a rating in excess of 60 percent for left knee replacement are not met. 38U.S.C. §1155; 38C.F.R. §§4.1, 4.3, 4.7, 4.20, 4.71a, DC 5055. 12. The criteria for entitlement to a separate disability rating of 20 percent for left knee instability under DC 5257 from August 25, 2021 have been met. 38 U.S.C. §§ 1155, 5107, 7104; 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.3, 4.7, 4.20, 4.45, 4.59, 4.71a, DC 5257. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from September 1982 through August 1989 and May 1991 through December 2005. This matter comes before the Board of Veterans' Appeals (BVA or Board) on appeal from July 2006, July 2009, January 2013, November 2017, October 2020, and October 2021 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO). In December 2014 and May 2018, the Board remanded these matters to the Agency of Original Jurisdiction (AOJ) for additional development. The appeal has since returned to the Board. SERVICE CONNECTION Generally, service connection requires evidence of (1) a current disability, (2) in-service incurrence or aggravation of a disease or injury, and (3) a nexus, or link, between the current disability and the in-service disease or injury. 38 C.F.R. § 3.303(a). 1. Entitlement to service connection for inguinal hernia, previously claimed as groin pain, is granted. 2. Entitlement to service connection for a cardiac disability, previously claimed as chest pain, is granted. The Veteran contends that his inguinal hernia and cardiac disabilities are related to service. Historically, the Veteran has been denied service connection because he did not have a diagnosis related to his symptoms of groin and chest pain. However, in a June 2021 VA examination, an examiner noted a diagnosis of inguinal hernia related to the Veteran's groin pain. Likewise, the examiner found that the Veteran's chest pain was related to his cardiac disability with diagnoses of mitral valve prolapse with grade 1 diastolic dysfunction. Thus, the first element for establishing service connection has been satisfied. The remaining questions before the Board are whether there was an in-service incurrence of a disease or injury; and whether his current disabilities are related to an in-service incurrence, if any. In June 1994, the Veteran's service treatment records documented a history of mitral valve prolapse with occasional tightness in his chest. He continued to complain of occasional chest tightness throughout service. The Veteran was also diagnosed with, and received treatment for, portal system thrombosis and superior mesenteric venous thrombosis. In January 2003, a CT of the Veteran's abdomen confirmed the presence of fat-filled inguinal hernias. The remaining question for the Board is whether the Veteran's inguinal hernia and cardiac disabilities are related to his in-service presentations. In April 2006, August 2015, and October 2019, VA examiners offered a negative opinion for service connection for the Veteran's cardiac and inguinal hernia disabilities on the basis that the Veteran did not have diagnoses for these conditions. As noted above, in June 2021, a VA examiner determined that the record demonstrated that the Veteran had current cardiac and inguinal hernia disabilities. Additionally, the June 2021 VA examiner determined that these disabilities were related to the Veteran's service. It was explained, in relevant part, that the Veteran's cardiac disability is most likely a consequence of his SMV thrombosis/portal hypertension which occurred during active duty. Similarly, the Veteran's service treatment records documented a CT report that noted bilateral fat-filled inguinal hernias. The Veteran reported that this condition progressed to ultimately requiring bilateral inguinal hernia repair in 2012. A review of the Veteran's private treatment notes confirm inguinal hernia repair in 2011. The Board finds that the June 2021 VA examiner opinions are highly probative as they are supported by a thorough review of the record, adequately considered the Veteran's lay statements, and are rendered by a competent medical professional who is trained to make such assessments. As such, service connection is warranted for the Veteran's cardiac and inguinal hernia disabilities. The claims are granted. INCREASED RATINGS Disability evaluations are determined by the application of the VA Schedule for Rating Disabilities (Rating Schedule). 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.321, 4.1. VA should interpret reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability. 38 C.F.R. § 4.2. Any reasonable doubt regarding the degree of disability shall be resolved in favor of the claimant. 38 C.F.R. § 4.3. Where there is a question as to which of two evaluations apply, the higher of the two should be assigned where the disability picture more nearly approximates the criteria for the next higher rating. 38 C.F.R. § 4.7. The United States Court of Appeals for Veterans Claims (Court) has held that when a diagnostic code provides for compensation based upon limitation of motion, the provisions of 38C.F.R. §§4.40 and 4.45 must also be considered, and that examinations upon which the rating decisions are based must adequately portray the extent of functional loss due to pain "on use or due to flareups." DeLuca v. Brown, 8 Vet. App. 202, 206 (1995). Also, the Court has held that "to be adequate, a VA examination of the joints must, wherever possible, include the results of the range of motion testing described in the final sentence of" 38C.F.R. §4.59. See Correia v. McDonald, 28 Vet. App. 158 (2016). 38C.F.R. §4.59 states that "[t]he joints involved should be tested for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with the range of the opposite undamaged joint." As such, pursuant to Correia, an adequate VA joints examination must, wherever possible, include range of motion testing on active and passive motion and in weight-bearing and non-weight-bearing conditions. 1. Entitlement to a rating of 30 percent for diverticulitis is granted. The Veteran is currently assigned a 10 percent disability rating under DC 7327. He disagrees with the rating assigned. Disabilities of the digestive system are evaluated under 38 C.F.R. § 4.114, which provides that ratings under Diagnostic Codes 7301 to 7329, inclusive, 7331, 7342, and 7345 to 7348, inclusive, will not be combined with each other. Rather, a single rating will be assigned under the diagnostic code which reflects the predominant disability picture, with evaluation of the next higher rating where the severity of the overall disability warrants such rating. 38 C.F.R. § 4.114. DC 7327 instructs to rate diverticulitis as irritable colon syndrome, peritoneal adhesions, or ulcerative colitis, depending on the predominant disability picture. Irritable colon syndrome is evaluated under Diagnostic Code 7319, which provides a noncompensable rating for mild irritable colon syndrome, resulting in disturbances of bowel function with occasional episodes of abdominal distress. A 10 percent rating is assigned for moderate irritable colon syndrome, resulting in frequent episodes of bowel disturbance with abdominal distress. A maximum 30 percent rating is assigned for severe irritable colon syndrome, resulting in diarrhea, or alternating diarrhea and constipation, with more or less constant abdominal distress. 38 C.F.R. § 4.114, DC 7319. Peritoneal adhesions are evaluated under DC 7301, which provides for a noncompensable rating for mild peritoneal adhesions. A 10 percent rating is assigned for moderate peritoneal adhesions; pulling pain on attempting work or aggravated by movements of the body, or occasional episodes of colic pain, nausea, constipation (perhaps alternating with diarrhea) or abdominal distension. A 30 percent rating is assigned for moderately severe peritoneal adhesions; partial obstruction manifested by delayed motility of barium meal and less frequent and less prolonged episodes of pain. A maximum 50 percent rating is assigned for severe peritoneal adhesions; definite partial obstruction shown by X-ray, with frequent and prolonged episodes of severe colic distension, nausea or vomiting, following severe peritonitis, ruptured appendix, perforated ulcer, or operation with drainage. 38 C.F.R. § 4.114, DC 7301. Ratings for adhesions will be considered when there is history of operative or other traumatic or infectious (intraabdominal) process, and at least two of the following: disturbance of motility, actual partial obstruction, reflex disturbances, presence of pain. 38 C.F.R. § 4.114, Note to DC 7301. Ulcerative colitis is evaluated under DC 7323, which provides for a 10 percent rating for moderate ulcerative colitis with infrequent exacerbations. A 30 percent rating is assigned for moderately severe ulcerative colitis with frequent exacerbations. A 60 percent rating is assigned for severe ulcerative colitis with numerous attacks a year and malnutrition, with health only fair during remissions. A 100 percent rating is assigned for pronounced ulcerative colitis resulting in marked malnutrition, anemia, and general debility, or with serious complications, such as liver abscess. 38 C.F.R. § 4.114, DC 7323. Words such as "mild," "moderate," and "severe" are not defined in the Rating Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6. Historically, the Veteran's diverticulitis has been rated as analogous to irritable colon syndrome under DC 7319. In an April 2006 VA examination, the Veteran reported that diverticulitis affected his weight. He endorsed that he suffered from strong abdominal pain most of the year and experiencing nausea, vomiting, alternating diarrhea and constipation. His symptoms were constant. He was not receiving any treatment for his diverticulitis and it did not affect his work. On examination, the Veteran had tenderness to palpation of the abdomen. In the Veteran's August 2007 notice of disagreement, the Veteran asserted that he continued to experience bleeding, which caused him to miss many hours of work. In an August 2010 correspondence, the Veteran continued to complain of bleeding. At a December 2012 VA examination, the Veteran reported that his current symptoms included rectal bleeding, stomach pain, and nausea and vomiting. On examination, he had diarrhea often, alternating diarrhea and constipation, abdominal distension with lots of bloating with chronic abdominal pain, anemia, nausea with some vomiting, and excessive urinating, He had occasional episodes of bowel disturbance with abdominal distress and seven or more episodes of exacerbations or attacks of diverticulitis. He also had weight loss. The functional impact of his diverticulitis caused him to take time off during acute episodes. At an August 2015 VA examination, the Veteran endorsed that he had no current symptoms or treatment. In September 2017, the Veteran reported that he had bouts of diverticulitis with his last episode happening a year ago. Treatment notes thereafter does not show persistent complaints or treatment for diverticulitis. After a thorough review of the record, the Board finds that the evidence of record demonstrates that the Veteran's diverticulitis manifested with symptoms that are consistent with a higher rating of 30 percent. See 38 C.F.R. § 4.114, Diagnostic Code 7319. In so finding, the Board notes that the Veteran's diverticulitis has been historically associated with the symptom of rectal bleeding. See documents labeled "STR", receipt date, pages 23, 28 of 174. However, the Veteran also has significant symptoms of alternating diarrhea and constipation, nausea, vomiting, and abdominal distress. While there is some evidence that abdominal pain may also be due to a non-service-connected disability (portal vein thrombosis and portal hypertension), the evidence does not show another disability as the cause of his alternating diarrhea and constipation, nausea, and vomiting. These symptoms have been present (though have ebbed at times) throughout the entire appeal. The Board finds that a rating of 30 percent is warranted, as the record shows evidence of alternating diarrhea and constipation, with more or less constant abdominal distress. See 38 C.F.R. § 4.114, DC 7319. Higher ratings under other codes, however, are not warranted. There is no evidence of peritoneal adhesions or malnutrition, anemia, and general debility. See 38 C.F.R. § 4.114, DC 7301, 7323. Accordingly, a rating of 30 percent, but no higher, is granted. 2. Entitlement to an initial rating in excess of 10 percent for hypertension, prior to July 14, 2015, and in excess of 20 percent, thereafter, is denied. Prior to July 14, 2015, the Veteran was assigned a 10 percent disability rating for his service-connected hypertension under DC 7101. Beginning July 14, 2015, he is assigned a 20 rating. The Veteran disagrees with the ratings assigned. Under Diagnostic Code 7101, a 10 percent rating is applicable if diastolic pressure is predominantly 100 or more, or systolic pressure is predominantly 160 or more, or there is a history of diastolic pressure of predominantly 100 or more and continuous medication is required to control blood pressure. A 20 percent rating is warranted if diastolic pressure is predominantly 110 or more or systolic pressure is predominantly 200 or more. A 40 percent rating is warranted where diastolic pressure is predominantly 120 or more. A 60 percent rating is warranted where diastolic pressure is predominantly 130 or more. 38 C.F.R. § 4.104, Diagnostic Code 7101. Hypertension or isolated systolic hypertension must be confirmed by readings taken two or more times on at least three different days. 38 C.F.R. § 4.104, DC 7101, Note 1. For purposes of this section, the term hypertension means that the diastolic blood pressure is predominantly 90 mmHg or greater, and isolated systolic hypertension means that the systolic blood pressure is predominantly 160 mmHg or greater with a diastolic blood pressure of less than 90 mmHg. Id. Turning to the evidence of record, in an April 2006 VA examination, the Veteran endorsed having hypertension that was treated with medication. His blood pressure readings at the time were 140/100, 134/100, and 140/100. His hypertension caused no functional impairment and did not result in time lost from work. In a January 2009 treatment note, a history of the Veteran's vitals revealed blood pressure readings of 127/73 in September 2007, 120/72 in October 2007, and 126/77 in November 2007. In a December 2011 treatment note, the Veteran's historical vitals revealed blood pressure readings of 149/90 on July 2010, 143/93 on October 2011, and 144/92 on December 2011. In December 2012, the Veteran was afforded a VA examination for hypertension. The examiner noted the Veteran used continuous medication for his hypertension. The Veteran asserted that his hypertension had caused a stroke. Testing of his blood pressure revealed systolic blood pressure readings of 140, 138, and 140, respectively. Diastolic blood pressure readings were 88, 88, and 88, respectively. In July 2015, he was afforded another VA examination for hypertension. Here, he had systolic blood pressure readings of 191, 181, and 181 respectfully. He had diastolic blood pressure readings of 128, 108, and 115. His average blood pressure reading was 184/117. In an October 2016 private treatment note, historical vitals data revealed blood pressure readings of 156/109 in April 2016, 141/90 in June 2016, and 182/103. In May 2020, he was treated for high blood pressure after missing his medications for two days. At the time, he had a blood pressure reading of 163/82. The Board concludes that prior to July 14, 2015, a rating in excess of 10 percent for hypertension is not warranted. A 20 percent rating requires diastolic pressure of predominantly 110 or more or systolic pressure of predominantly 200 or more. Prior to July 14, 2015, the most probative evidence of record does not show a diastolic pressure of predominantly 110 or more, or a systolic pressure of predominantly 200 or more. During this time period, at most, the Veteran's diastolic readings were 100. His systolic blood pressure readings never reached 200 or greater. The Board finds that the clinical evidence of record is highly probative and does not show readings that would warrant a rating higher than 10 percent prior to July 14, 2015. Beginning July 14, 2015, the record demonstrates that the Veteran exhibited blood pressure readings with diastolic blood pressure readings of 110, but less than 120. A higher 30 percent rating is warranted where diastolic pressure is predominantly 120 or more. As discussed above, after July 14, 2015, the Veteran has diastolic pressure readings, at most 128. The recording of a diastolic blood pressure reading of 128 was recorded at his July 2015 VA examination on his first reading out of a series of three blood pressure readings. The subsequent readings at the July 2015 VA examinations were substantially lower at 108 and 115, respectively. All of the subsequent diastolic readings of record did not show diastolic pressure predominantly 120 or more. Note 1 of DC 7101 is clear that hypertension must be confirmed by readings taken two or more times on at least three different days. 38 C.F.R. § 4.104, DC 7101, Note 1. Simply put, the record has not shown diastolic pressure readings predominantly at 120 or more. The record does not demonstrate that a rating in excess of 20 percent for hypertension is warranted since July 14, 2015. Based on the aforementioned, a rating in excess of 10 percent for hypertension, prior to July 14, 2015, and in excess of 20 percent, thereafter, is not warranted. The Veteran's appeal for higher ratings for service-connected hypertension is denied. 3. Entitlement to a rating in excess of 10 percent for a left wrist disability is denied. The Veteran is currently assigned a 10 percent disability rating for his left wrist disability under DC 5215. The Veteran disagrees with the rating assigned. Pursuant to DC 5215, a 10 percent rating is warranted when palmar flexion is limited to a position in line with the forearm, or when dorsiflexion is less than 15 degrees. This 10 percent rating is applicable for either the major or minor limb. A 10 percent rating is the only, and therefore the maximum, rating available under this code, which the Veteran is already assigned. Also pertinent to this claim is DC 5214, which provides for higher evaluations for ankylosis of the wrist. Under this code, a 40 percent rating is warranted when there is unfavorable ankylosis, in any degree of palmar flexion, or with ulnar or radial deviation of the minor wrist. A 30 percent rating is warranted when there is ankylosis of the minor wrist in any other position, except favorable. Finally, a 20 percent rating is warranted when there is favorable ankylosis in 20 degrees to 30 degrees dorsiflexion in the minor wrist. Ankylosis is defined as "immobility and consolidation of a joint due to disease, injury or surgical procedure." See Colayong v. West, 12 Vet. App. 524, 528 (1999); Shipwash v. Brown, 8 Vet. App. 218, 221 (1995). Normal range of motion is: dorsiflexion (extension) to 70 degrees, palmar flexion to 80 degrees, ulnar deviation to 45 degrees, and radial deviation to 20 degrees. 38 C.F.R. § 4.71, Plate I. For rating purposes, a distinction is made between major (dominant) and minor musculoskeletal groups. Handedness for the purpose of a dominant rating will be determined by the evidence of record, or by testing on VA examination. Only one hand shall be considered dominant. The injured hand, or the most severely injured hand, of an ambidextrous individual will be considered the dominant hand for rating purposes. 38 C.F.R. § 4.69. Here, as the medical evidence shows that the Veteran is right-hand dominant, for rating purposes, his left wrist is part of his minor upper extremity. In an April 2006 VA examination, the Veteran exhibited wrist dorsiflexion to 70 degrees and palmar flexion to 40 degrees. He had pain with palmar flexion at 40 degrees. His joint function was additionally limited after repetitive use but did not cause an additional loss in range of motion. In a December 2012 VA examination, the Veteran endorsed severe left wrist pain. Upon examination, he had left wrist palmar flexion to 70 degrees with pain at 70 degrees and dorsiflexion to 60 degrees with pain at 60 degrees. Repetitive use testing did not cause additional loss in range of motion. There was no ankylosis. A July 2015 VA examination noted normal range of motion in the Veteran's left wrist and no evidence of pain. There was no additional loss of range of motion with repetitive use testing. There was also no ankylosis. The examiner opined that the Veteran would not have any additional functional loss with repeated use over time. The Veteran did not report flareups. In an October 2019 VA examination, the Veteran's left wrist palmar flexion was limited to 70 degrees and dorsiflexion limited to 60 degrees. There was no pain on examination. The examiner opined that repeated usage over time and during flareups would not cause additional loss of range of motion. There was no ankylosis. The Veteran continued to receive treatment for his left wrist throughout the period on appeal. However, the record did not demonstrate any evidence of left wrist ankylosis. As the Veteran is in receipt of the maximum schedular rating under DC 5215, a higher rating would only be available under DC 5214 which requires a diagnosis of ankylosis. As there is no evidence of ankylosis, the Veteran's claim for an increased rating under DCs 5214 or 5215 must be denied. Thus, the claim for an increased rating for the Veteran's left wrist disability is denied. 4. Entitlement to a rating in excess of 20 percent lumbar spine disability is denied. The Veteran is currently assigned a 20 percent rating for his lumbar spine disability under DC 5242. Historically, he was assigned a 20 percent rating under DC 5237 until October 23, 2020. DCs 5242 and 5237 are rated using the General Rating Formula for Diseases or Injuries of the Spine. 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. 38 C.F.R. § 4.71a , DC 5237-5242. A 10 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height. A 20 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent rating is assigned, if forward flexion of 30 degrees or less; or favorable ankylosis of the entire lumbar spine is present. Where there is unfavorable ankylosis of the entire thoracolumbar spine, a 50 percent is assigned. Finally, a maximum 100 percent rating is assigned where there is unfavorable ankylosis of the entire spine 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. Id. at Note (2). The combined ROM refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. Id. The normal combined ROM of the thoracolumbar spine is 240 degrees. Id. 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 ROM. Id. ROM measurements are to be rounded to the nearest five degrees. Id. at Note (4). Effective February 7, 2021, DC 5242 compensates for degenerative arthritis, DDD other than intervertebral disc syndrome (IVDS) (also, see either DC 5003 or 5010). Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 76453, 76462 (Nov. 30, 2020) (to be codified at 38 C.F.R. § 4.71a , DC 5242). The rating criteria under the general rating formula remained unchanged. Turning to the evidence of record, at an April 2006 VA examination, the Veteran complained of sharp pain and stiffness in his lumbar spine. He asserted that his pain travels to his legs. His lumbar spine disability did not cause incapacitation. Upon examination, he had flexion to 70 degrees, extension to 20, right and left lateral flexion to 20 degrees, and right and left rotation to 20 degrees. Pain was noted with range of motion. In a December 2012 VA examination, the Veteran endorsed flareups. He described flareups as constant and daily back pain which requires hot and cold compresses due to swelling. Upon examination, he had flexion to 40 with end-stage pain, extension to 10 degrees at end-stage pain, right and left lateral flexion to 15 degrees, and right and left rotation to 20 degrees. Repetitive testing did not cause additional limitation in range of motion. There was no radiculopathy or IVDS. At a July 2015 VA examination, the Veteran had lumbar flexion to 75 degrees, extension to 15 degrees, right and left lateral flexion to 30 degrees, and right and left lateral rotation to 30 degrees. He did not have pain with weightbearing. There was no additional loss in range of motion with repetitive testing. The examiner opined that he would not have additional functional loss with repeated use over time. Flareups were not endorsed. There was no radiculopathy or IVDS. In 2016 and 2017, the Veteran's treatment notes documented low back and radiating bilateral leg pain. In October 2019, the Veteran submitted to a lumbar spine VA examination, but his ROM could not be tested due to a recent left knee surgery. The examiner determined that the Veteran would not have additional loss of range of motion due to repeated use over time or doing flareups. There were no signs of radiculopathy. In September 2020, an examiner submitted an opinion supporting that Veteran's pain would limit flexion to 60 degrees historically. In September 2020, the Veteran had flexion to 60, extension to 30, left and right lateral rotation to 30, and left and right lateral flexion to 30. Pain would additionally limit range of motion to flexion of 50 degrees and extension to 10 degrees. There was no radiculopathy or IVDS. There was no pain in non-weightbearing status. Passive range of motion could not be completed due to lower leg edema. Based on the aforementioned, the Board finds that a disability rating in excess of 20 percent is not warranted at any time during the period on appeal. A higher 40 percent rating requires forward flexion of 30 degrees or less; or favorable ankylosis of the entire lumbar spine is present. The record does not demonstrate flexion limited to 30 degrees or unfavorable ankylosis. At most, the Veteran's flexion was limited to 50 degrees when considering additional limits imposed by pain during flareups. Such limitation was consistent with the Veteran's functioning during flareups and with repeated use over time as opined by the September 2020 VA examiner. There is no indication he had forward flexion of the thoracolumbar spine of 30 degrees or less at any time, nor favorable ankylosis of the entire thoracolumbar spine. The Board finds that the VA examinations are competent and probative, and the persuasive evidence is against the Veteran's claim. As such, a rating of 20 percent is not warranted at any time during the period on appeal. His associated neurological impairments under Note 1 are addressed below. The claim for a rating in excess of 20 percent for the Veteran's lumbar spine disability is denied. 5. Entitlement to a rating in excess of 10 percent for right ankle disability is denied. The Veteran is currently assigned a 10 percent rating for his right ankle disability under DC 5271. He disagrees with the rating assigned. The Veteran's right ankle disability is currently rated under 38 C.F.R. § 4.71a , Diagnostic Code (DC) 5271 for ankle limitation of motion. Specifically, DC 5271 provides for a 10 percent rating where there is moderate limitation of ankle motion and a 20 percent rating where there is marked limitation of ankle motion. Notably, normal ankle dorsiflexion is from 0 to 20 degrees and normal plantar flexion is from 0 to 45 degrees. 38C.F.R. §4.71a. Plate II. Also relevant are DCs 5270, 5272, 5273, and 5274. DC 5270 pertains to ankylosis of the ankle and provides for a 20 percent rating where there is ankylosis of the ankle in plantar flexion, less than 30 degrees. A 30 percent rating is warranted where there is ankylosis of the ankle in plantar flexion, between 30 degrees and 40 degrees, or in dorsiflexion, between zero degrees and 10 degrees. A 40 percent rating is warranted where there is ankylosis of the ankle in plantar flexion at more than 40 degrees, or in dorsiflexion at more than 10 degrees or with abduction, adduction, inversion or eversion deformity. DC 5272 pertains to ankylosis of the subastragalar or tarsal joint and provides for a 10 percent rating where such is in good weight-bearing position and a 20 percent rating where such is in poor weight-bearing position. DC 5273 pertains to malunion of the os calcis or astragalus and provides for a 10 percent rating where there is moderate deformity and a 20 percent rating where there is marked deformity. DC 5274 provides for a 20 percent rating for an astragalecotmy. Notably, beginning February 7, 2021 DC 5271 clarifies the meanings of marked and moderate. Specifically, a 10 percent rating where there is moderate (less than 15 degrees dorsiflexion or less than 30 degrees plantar flexion) limitation of ankle motion and a 20 percent rating where there is marked (less than 5 degrees dorsiflexion or less than 10 degrees plantar flexion) limitation of ankle motion. Turning to the evidence of record, in an April 2006 VA examination, the Veteran complained of right ankle soreness, stiffness, cramping, and swelling when walking prolonged distances. On examination, the right ankle joint showed signed of tenderness. His right ankle had dorsiflexion to 20 degrees and plantar flexion to 10 degrees. In a December 2012 VA examination, the Veteran endorsed having flareups described as deep throbbing and shocking pain that runs up and down his leg. On examination, the Veteran had right plantar flexion to 25 degrees with end stage pain and right ankle dorsiflexion to 15 degrees with end stage pain. There was no additional loss after repetitive testing. There was no ankylosis. In a July 2015 VA examination, the Veteran did not repot flareups. His right ankle range of motion was normal with dorsiflexion to 20 degrees and plantar flexion to 45 degrees. The examiner opined that the Veteran would not have additional functional loss with repeated use over time. There was no ankylosis. In an October 2019 VA examination, the Veteran did not repot flareups. He exhibited dorsiflexion to 20 degrees and plantar flexion to 40 degrees. There was no pain on examination or with weightbearing. Repetitive testing did not cause additional limitation. The examiner opined that the Veteran would not have any additional loss in range of motion with repeated use over time or during flareups. There was no ankylosis. There was also no pain in non-weightbearing status and passive range of motion was the same as active range of motion. Treatment notes thereafter show no further limits than documented in the VA examinations. Based on the foregoing, the Board finds that a disability rating greater than 10 percent for the Veteran's right ankle disability is not warranted. Significantly, the Veteran's right ankle disability is productive of no more than moderate limitation of motion. As noted above, the Veteran had dorsiflexion, at worst, limited to 15 degrees and plantar flexion, at worst, limited to 10 degrees. The Board has considered whether the limitation of plantar flexion of 10 degrees demonstrated in the April 2006 VA examination would warrant a higher rating at any point during the period at issue. However, the Veteran has historically demonstrated greater range of motion in plantar flexion. Every other time the Veteran's plantar flexion range of motion was tested, it showed range of motion limited to 25 degrees or greater. Thus, a showing of plantar flexion limited to 10 degrees solely within the April 2006 VA examination is not of sufficient frequency or duration to warrant a change in evaluation without violating the rule regarding stabilization of ratings. Therefore, the overall disability picture presented by the Veteran's right ankle disability is that of moderate limitation of motion, which is appropriately rated as 10 percent disabling under DC 5271. The Veteran's disability picture does not present such severe limitation of motion to the ankle to be characterized as marked limitation. Thus, a 20 percent disability rating under DC 5271 is not warranted. Furthermore, there is no indication of either ankylosis, ankylosis of the subastragalar or tarsal joint, malunion of the os calcis or astragalus, or astragalectomy such that DCs 5270, 5272, 5273, and 5274 are not for application. There are no other alternative diagnostic codes under 38C.F.R. §4.71a that could apply to the Veteran's right ankle disability. With regard to the potential for a higher rating based on additional loss of motion due to flare-ups of the right ankle pursuant to Sharp, while the Veteran reported experiencing flareups, the guidance on how to evaluate flare-ups has not been particularly clear and, pursuant to Mitchell, flareups must be quantifiable and must result in limitation of motion of function beyond that contemplated by the already provided evaluation. Additionally, because there is a regulation addressing the stabilization of ratings, flareups must be of such length as to establish that the overall impairment is more severe than currently evaluated. The statements made in this case do not show that any flareups or repeated use over time additionally limited function in a quantifiable way, nor did they show that they are of such length or duration that a higher or staged rating would not violate the rule regarding stabilization of ratings. Significantly, there is no rational basis to make a notation regarding any additional losses of function or motion during a flare-up. Notably, the Veteran had no additional loss with repetitive testing and VA examiners opined that repeated use over time and during flareups did not cause additional loss. The Board accepts that the Veteran has functional impairment, pain, and pain on motion (see DeLuca) and finds the Veteran's own reports of symptomatology to be credible. However, neither the lay nor medical evidence reflects the functional equivalent of symptoms required for a higher rating. The more probative evidence consists of that prepared by neutral skilled professionals, and such evidence demonstrates that the currently assigned 10 percent rating is warranted and no more. As the persuasive evidence is against a rating in excess of 10 percent for the right ankle disability at any time during the appeal period, the claim is denied. Increased Ratings for Knees Knee disabilities are unique in the rating code, as they are one of a few orthopedic disabilities in which a Veteran may receive multiple ratings based on separate symptoms in the same joint. Although the law generally prevents considering the same symptoms under various diagnoses to support separate ratings, some of the relevant DCs for the knee have been interpreted to apply to different functions of the knee, therefore warranting separate consideration. Specifically, the evidence may warrant separate ratings for limitation of flexion of the knee, limitation of extension of the knee, and recurrent subluxation or instability of the knee. A rating may also be assigned for meniscal impairment if there are non-overlapping symptoms. The Board will explore all possibilities in this case. To avoid unnecessary repetition, the potentially applicable legal criteria are set forth below, followed by application to the facts for the bilateral knee ratings. VA amended the regulations for rating knee disabilities, namely, DC 5257 (subluxation and instability), DC 5262 (tibia and fibula impairment), and DC 5055 (total knee replacement), effective February 7, 2021. See Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 76453, 76462 (Nov. 30, 2020). The criteria that are most favorable to the Veteran's pending claim will apply; however, an award based on the amended regulations may not be made effective before the effective date of the change. See 38 U.S.C. § 5110 (g); 38 C.F.R. § 3.114; Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). Under either version of the rating criteria, under DC 5010, traumatic arthritis is rated as degenerative arthritis. Under DC 5003 for degenerative arthritis, when limitation of motion of the specific joint is noncompensable under the appropriate diagnostic code, a rating of 10 percent will be assigned for each major joint or group of minor joints affected by limitation of motion, to be combined, not added under DC 5003. If there is no limitation of motion, ratings of 10 or 20 percent are available if there is x-ray evidence of two or more major joints or two or more minor joint groups, requiring occasional incapacitating exacerbations for a 20 percent rating. 38 C.F.R. § 4.71a. Similarly, where limitation of motion is not compensable under the specific code for a joint, 38 C.F.R. § 4.59 provides for a minimum compensable rating for actually painful joints in conjunction with a diagnostic code based on limitation of motion. Sowers v. McDonald, 27 Vet. App. 472, 479 (2016); Southall-Norman v. McDonald, 28 Vet. App. 346, 354 (2016). Normal knee range of motion is from 0 degrees of flexion to 140 degrees of extension. 38 C.F.R. § 4.71, Plate I. Under DC 5260, a 10 percent rating is assigned for limitation of flexion of the leg to 45 degrees. A 20 percent rating is assigned for flexion limited to 30 degrees. A 30 percent rating is assigned for flexion limited to 15 degrees. Id. Under DC 5261, a 10 percent rating is assigned for limitation of extension of the leg to 10 degrees. A 20 percent rating is assigned for extension limited to 15 degrees. A 30 percent rating is assigned for extension limited to 20 degrees. A 40 percent rating is assigned for extension limited to 30 degrees. A 50 percent rating is assigned for extension limited to 45 degrees. Id. Where there is painful or limited motion with both flexion and extension, but the compensable criteria are not met for either flexion (DC 5260) or extension (DC 5261), only one minimum rating of 10 percent should be assigned. Separate ratings may not be assigned for painful or noncompensable limitation of motion using DC 5003 or section 4.59 in connection with 5260, and compensable limitation of extension under DC 5261. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011). DC 5258 addresses a dislocated (torn) semilunar cartilage (meniscus), and assigns a 20 percent rating if there are frequent episodes of "locking," pain, and effusion into the joint. Under DC 5259, symptomatic removal of the meniscus is rated at 10 percent. 38 C.F.R. § 4.71a. DC 5055, for knee replacement (prothesis). Under DC 5055, a 100 percent rating is assigned for one year following implantation of a knee prosthesis for a service-connected knee disability, followed thereafter by a 60 percent rating when there are chronic residuals consisting of severe painful motion or weakness. With intermediate degrees of residual weakness, pain, or limitation of motion, a rating is made by analogy to DCs 5256, 5261, and 5262. The minimum rating is 30 percent. 38C.F.R. §4.71a , DC 5055. Under DC 5256, a 40 percent rating is warranted for knee ankylosis in flexion between 10 degrees and 20 degrees. A 50 percent rating is warranted for knee ankylosis in flexion between 20 degrees and 45 degrees. A 60 percent rating is warranted for extremely unfavorable knee ankylosis, in flexion at an angle of 45 degrees or more. 38C.F.R. §4.71a , The word "severe" is not defined by the VA Rating Schedule. 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. Rather than applying a mechanical formula, the Board must evaluate the evidence to the end that its decisions are "equitable and just as contemplated by the requirements of the law." See 38C.F.R. §4.6. Effective prior to February 7, 2021, under DC 5257, recurrent subluxation or lateral instability of the knee will be assigned a rating of 10 percent if it is mild, 20 percent if it is moderate, or 30 percent if it is severe. Id.. Under the criteria effective since February 7, 2021, DC 5257 provides that recurrent subluxation or instability will be assigned 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 will be assigned if there is one of the following: (a) sprain, incomplete ligament tear, or repaired complete ligament tear causing persistent instability, and a medical provider prescribes a brace and/or assistive device for ambulation; 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 requires an unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribes both an assistive device and bracing for ambulation. Id. There are also new criteria for patellar instability under DC 5257. A 10 percent rating is assigned for a diagnosed condition involving the patellofemoral complex with recurrent instability (with or without history of surgical repair) that does not require a prescription from a medical provider for a brace, cane, or walker. A 20 percent rating is assigned for a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for one of the following: a brace, cane, or walker. 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. Id. The patellofemoral complex consists of the quadriceps tendon, the patella, and the patellar tendon. Id. at Note (1). 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). Id. at Note (2). Ankylosis under DC 5256 requires fixation of the joint, or impairment approaching fixation, which is not argued or shown and need not be further addressed. Effective prior to February 7, 2021, under DC 5262, nonunion of the tibia or fibula, with loose motion, requiring a brace was assigned a 40 percent rating. Malunion was assigned a 30 percent rating. 38 C.F.R. § 4.71a (2020). Effective since February 7, 2021, under DC 5262, nonunion of the tibia or fibula, with loose motion, requiring a brace is still assigned a 40 percent rating. However, malunion is to be evaluated under DCs 5256 (ankylosis), 5257 (subluxation or instability), 5260 (limitation of flexion), or 5261 (limitation of extension) for the knee, whichever results in the highest evaluation. 38 C.F.R. § 4.71a. 6. Entitlement to a rating in excess of 20 percent for a right knee disability is denied. Historically, his right knee disability was rated under DC 5260. In an October 2021 rating decision, the RO assigned the Veteran a 20 percent rating for symptoms analogous to DC 5258. He disagrees with the rating assigned. At an April 2006 VA examination, the Veteran complained about severe pain in his knees with stiffness, swelling, and giveaway. On examination, he had bilateral knee flexion to 120 with end stage pain and extension to 0. In a December 2012 VA examination, the Veteran endorsed flareups. He described flareups as unbearable pain when walking any distance. On examination, his right knee flexion was limited to 75 degrees at end stage pain and extension to 0 degrees. His left knee flexion was to 70 degrees with extension to 0 degrees. He had pain of palpation. Repetitive testing did not cause additional functional loss. There was no subluxation or dislocation. He was noted to have meniscus dislocation in both knees with frequent episodes of locking and joint pain. A bilateral patellar spur was also documented. At a July 2015 VA examination, the Veteran did not endorse flareups. His bilateral range of motion was normal. There was no pain with weightbearing or crepitus. Repetitive testing did not cause additional loss of range of motion. There was no ankylosis, recurrent effusion, or instability. During an October 2019 VA examination, the Veteran revealed that he recently had left knee meniscus repair. Flareups were not reported. Range of motion testing could not be completed as a result of this surgery and the Veteran's use of crutches. The examiner opined that there was no expected loss in range of motion during repeated use over time or during flareups. He did not have symptoms of a meniscus condition for his right knee. A left side meniscus tear with recent surgery was documented. There was no objective evidence of pain in non-weightbearing status. Passive range of motion testing could not be performed. In a September 2020 VA examination, the Veteran had recently had a left knee total knee replacement. He endorsed constant aching pain in his bilateral knee pain. He did not endorse flareups. Range of motion testing could not be performed due to bilateral leg swelling. Meniscus conditions were not documented. In an August 2021 VA examination, the Veteran endorsed flareups in his bilateral knees. He had recurrent right knee swelling. There was no objective evidence of instability or subluxation, but the Veteran endorsed subjective right knee subluxation. On examination, right knee flexion was limited to 115 degrees and extension to 0. Passive range of motion was the same as active range of motion. His left knee flexion was to 95 degrees with pain at 65 degrees and extension to 10 degrees. Passive range of motion showed flexion to 90 degrees and extension to 10 degrees. There was additional loss of range of motion with repetitive testing to right knee flexion limited to 110 degrees and left knee flexion limited to 90 degrees. The examiner opined that the Veteran would have similar ranges of motion during repetitive use over time. During flareups, the Veteran would have right knee flexion to 110 degrees and flexion limited to 80 degrees. There was no additional loss in extension during repeated use over time or during flareups. There was no ankylosis. There was persist instability in the left knee. There was no meniscus conditions documented. There was moderate lateral instability and recurrent subluxation of the left knee measuring 2+ or 5-10 millimeters. Based on the aforementioned, the Board finds that a rating in excess of 20 percent rating is not warranted. The Veteran was granted a 20 percent rating for symptoms of frequent locking and effusion documented in the December 2012 VA examination, as consist with DC 5258. As a 20 percent rating is the maximum evaluation available under DC 5258, a rating in excess of 20 percent is not warranted. Likewise, a higher rating is not warranted under DC 5260 or 5261. Under DCs 5260 and 5261, a 30 percent rating is warranted when flexion is limited to 15 degrees or extension is limited to 20 degrees, respectively. Throughout the period on appeal, the Veteran's right knee has not manifested with limitation to motion consistent with a higher rating. Rather, the Veteran right knee flexion was limited to 75 degrees and extension to a normal 0 degrees, even when considering pain, repeated use over time, or during flareups. Thus, a higher rating is not warranted under DC 5260 or 5261 at any point during the period on appeal. With regard to DC 5257, while the Veteran suggested possible instability of the right knee during the April 2006 VA examination when he reported that his right knee has giveaway, examination reports are negative for a history of instability and testing was also negative for instability. Also, while pursuant to English v. Wilkie, 30 Vet. App. 347, 349 (2019), objective evidence of lateral instability is not required to assign a rating under DC 5257, the Board finds no other subjective complaints of right knee instability throughout years of treatment. As such, a separate rating is not warranted under DC 5257. There is no evidence of ankylosis, impairment of the tibia or fibula, or genu recurvatum, DCs 5256, 5262, and 5263 are not for application. According, a rating in excess of 20 percent for the Veteran's right knee disability is not warranted. The claim is denied. 7. Entitlement to a rating in excess of 20 percent for tendonitis, left knee (left knee disability) prior to May 1, 2021, and in excess of 60 percent thereafter, status post total knee replacement, is denied. Prior to May 1, 2021, the Veteran was assigned a 20 percent rating for his left knee disability under DC 5260. Beginning May 1, 2021, he is assigned a 60 percent rating for left knee status-post total knee replacement under DC 5055. He was assigned a total temporary rating from March 6, 2006 through May 1, 2006 and March 2020 through May 1, 2021. He disagrees with the 20 percent and 60 percent ratings assigned. As with the Veteran's right knee disability, he was assigned a 20 percent rating for his left knee disability, prior to May 1, 2021, for symptoms of frequent locking and pain under DC 5258. As a 20 percent rating is the maximum evaluation available under DC 5258, a rating in excess of 20 percent is not warranted. Prior to May 1, 2021, a higher rating is not warranted under DC 5260 or 5261. Under DCs 5260 and 5261, a 30 percent rating is warranted when flexion is limited to 15 degrees or extension is limited to 20 degrees, respectively. Throughout the period on appeal, the Veteran's left knee has not manifested with limitation to motion consistent with a higher rating. Rather, the Veteran flexion was limited to 70 degrees and normal extension to 0 degrees, even when considering pain, repeated use over time, or during flareups. Thus, a higher rating is not warranted under DC 5260 or 5261 at any point during the period on appeal. Beginning May 1, 2021, the Board finds that an evaluation in excess of 60 percent has not been met or approximated under Diagnostic Code 5055 or 38 C.F.R. § 4.30 as noted and appropriate. The Board does note that the Veteran had a total left knee replacement on March 5, 2021. As such, pursuant to DC 5055, the RO awarded a temporary total evaluation for fifteen months following the implantation of the prosthesis pursuant to DC 5055 to May 1, 2021, at which time the Veteran was assigned a 60 percent rating for his left knee. Pursuant to DC 5055, a 60 percent rating is the maximum rating for chronic residuals consisting of severe painful motion or weakness following a one-year period of convalescence. 38 C.F.R. § 4.71a, DC 5055. Additionally, there is no evidence of ankylosis, impairment of the tibia or fibula, or genu recurvatum, DCs 5256, 5262, and 5263 are not for application. Thus, a higher rating is not warranted under these codes. The Board acknowledges the Veteran's representative's argument that the Veteran should be assigned separate ratings for meniscus conditions bilaterally. The Board notes that the Veteran's ratings already account from symptomology possibly related to a meniscus condition. Accordingly, the Veteran's entitlement to a rating in excess of 20 percent, prior to May 1, 2021, and in excess of 60 percent, thereafter, is not warranted. The claim is denied. 8. Entitlement to a separate rating of percent, beginning August 25, 2021, for left knee instability is granted. The Board finds that entitlement to a separate 20 disability rating is warranted for the Veteran's left knee instability, as of August 25, 2021. In so finding, the Board notes that the Veteran meets the criteria for a 20 percent rating for left knee instability under DC 5257, under the revised criteria, as evidenced in the August 25, 2021 VA examination. Within the August 2021 VA examiner's report, the VA examiner noted objective evidence of recurrent subluxation or persistent instability that requires a prescription by a medical provider of a cane and brace for ambulation. The Board finds this is not pyramiding, or evaluating the same symptoms multiple times, because the Veteran's 60 percent rating is based on severe painful motion or weakness, whereas this rating is based on recurrent subluxation or persistent instability. As such, the Board finds that the Veteran is entitled to a separate 20 percent disability rating, but no higher, for his left knee instability effective August 25, 2021. REMANDED 1. Entitlement to service connection for syncope is remanded. 2. Entitlement to service connection for a left-hand condition is remanded. The Veteran contends that his syncope and left-hand disability is related to his service. In September 1995, service treatment records document that Veteran's complaint of "near syncope". Service treatment records also document the Veteran's complaints of a loss of consciousness and migraines with syncope in April and September of 2000. Occasional blackout episodes were also noted in July 2002. A diagnosis of vasovagal syncope was documented during in a neurological addendum during service in March 2005. In an April 2006 VA examination, the Veteran detailed that his left-hand swells and has pain. He explained that it was hard to make a fist. In an August 2020 correspondence, the Veteran described his left-hand disability as strong pain that causes tingling in his fingers and joints. Historically, the Veteran has been denied service connection for his syncope and left-hand disabilities due to a finding that there is not diagnosis for these conditions. However, the Board notes that despite the lack of a formal diagnosis, pain alone may constitute disability, even without an identifiable underlying pathology, if the pain reached the level of a functional impairment. Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018). Saunders was very recently interpreted as defining a "disability" as a functional impairment of earning capacity, and that applies broadly to include more than just pain. Martinez-Bodon v. Wilkie, No. 18-3721, (U.S. App. Vet. August 11, 2020). As the record stands, the Veteran has asserted that his syncope has caused him to have blackouts episodes. Additionally, the record has demonstrated that his left-hand disability caused pain and tingling in the fingers and joints. Despite this evidence, no VA examiner has opined whether these disabilities are more appropriately characterized of symptoms that are related to already service-connected disabilities or are separate conditions that cause a functional impairment in earning capacity. On remand, the Veteran should be afforded new VA examinations to clarify the nature and etiology of his syncope and left-hand conditions, to include whether he has any related diagnosed disability and if not, whether any functional impairment alone may constitute disability, even without an identifiable underlying pathology. 3. Entitlement to service connection for sinusitis is remanded. The Veteran contends that his sinusitis disability is related to his service. Historically, the Veteran has been denied service connection for sinusitis due to a lack of diagnosis. However, private treatment notes from Kaiser Permanente in December 2008 document a diagnosis, and treatment for, sinusitis. Despite evidence of a diagnosis during the period on appeal, no VA examiner has opined whether the Veteran's sinusitis disability is related to service. Thus, further development is necessary. 4. Entitlement to a separate rating for lumbar radiculopathy is remanded. The Veteran contends that his lumbar radiculopathy is caused by his service-connected lumbar spine disability. Service treatment records document a diagnosis of lumbar radiculopathy in December 2001. In an April 2006 VA examination, the Veteran complained that he had back pain that traveled to his legs. Treatment notes thereafter in April 2016 and August 2017 continued to document low back and radiating bilateral leg pain. In March 2021, private treatment notes document a diagnosis of lumbar radiculopathy. As addressed above, Note (1) of the General Rating Formula for Diseases and Injuries of the Spine instructs to evaluate any associated objective neurologic abnormalities under an appropriate diagnostic code. Lay statements and medical evidence of record are supportive of the presence of associated lumbar radiculopathy affecting the Veteran's bilateral extremities dating back to approximately 2001. While the Board does not ignore the September 2020 VA examiner's opinion evidence against finding a diagnosis of lumbar radiculopathy, the Board resolves all doubt in favor of the Veteran in light of the weight of evidence in favor of the existence of a lumbar radiculopathy disability throughout the period on appeal. Despite evidence supporting that the Veteran has a current lumbar radiculopathy disability, no VA examiner has considered the current severity of this disability. As such, further development is necessary. 5. Entitlement to a total rating based on individual unemployability (TDIU) is remanded. Because a decision on the issues of entitlement to service connection for syncope, a left-hand condition, and sinusitis and entitlement to a separate rating for lumbar radiculopathy impact a decision on the issue of entitlement to TDIU, these issues are inextricably intertwined. Thus, a remand for TDIU is required. The matters are REMANDED for the following action: 1. Schedule the Veteran for a VA examination(s) (or telehealth interview, review of the record, etc., if an in-person examination is not feasible) to determine the nature and etiology of the Veteran's syncope and left-hand condition. Based on the examination, the examiner is asked to address the following: (a) Opine whether the Veteran's syncope and left-hand condition are symptoms related to, or distinct from, his already service-connected disabilities. (b) If it is found that the Veteran's syncope and left-hand condition present as distinct symptoms from his already service-connected disabilities, identify any diagnosable pathology associated with the Veteran's syncope and left-hand condition. (c) If there is no diagnosable pathology for the Veteran's syncope and left-hand condition, the examiner must determine whether there is any objective evidence of syncope or a left-hand condition resulting in functional impairment? Specifically, does the Veteran's syncope and left-hand condition impair the Veteran's ability to function under the ordinary conditions of daily life, including employment? In answering this question, the examiner should ask the Veteran to explain the effect of syncope and left-hand condition. (d) Is it at least as likely as not (probability of 50 percent or higher) that any diagnosed syncope or left-hand condition pathology or identified functional impairment had its onset in or is otherwise related to active-duty service? (e) if the answer to (d) is no, it is at least as likely as not that the Veteran's syncope or left-hand condition or identified functional impairment is caused or aggravated (defined here as any increase in disability) by any of the Veteran's service-connected disabilities. Note that aggravation means any incremental increase in disability in non-service-connected disabilities (i.e., any additional impairment of earning capacity) resulting from service-connected conditions. 2. Schedule a VA examination with the appropriate clinician to consider the nature and etiology of the Veteran's sinusitis. The clinician is asked to opine whether it is at least as likely as not (i.e. probability of 50 percent or greater) that the Veteran's sinusitis is related to his active duty service? 3. Schedule the Veteran for a VA examination with appropriate clinician to determine the current severity of his lumbar radiculopathy. The examiner is also asked to opine on the severity of the Veteran's lumbar severity since 2006. 4. Readjudicate the claims, to include TDIU. Bethany L. Buck Veterans Law Judge Board of Veterans' Appeals Attorney for the Board N.B. Mmeje, 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.