Citation Nr: 22013669 Decision Date: 03/10/22 Archive Date: 03/10/22 DOCKET NO. 15-22 138 DATE: March 10, 2022 ORDER Entitlement to a compensable rating for residuals of left thumb laceration prior to October 10, 2019 is denied. Effective October 10, 2019, a 20 percent rating, but no higher, for residuals of left thumb laceration is granted. A 10 percent rating, but no higher, for costalgia is granted. Entitlement to a rating greater than 10 percent for right hip bursitis is denied. A 20 percent rating, but no higher, for left shoulder degenerative joint disease is granted. A 20 percent rating, but no higher, for right shoulder degenerative joint disease is granted. REMANDED Entitlement to a compensable rating for onychomycosis is remanded. Entitlement to service connection for a left knee condition is remanded. FINDINGS OF FACT 1. Prior to October 10, 2019, the Veteran's left thumb laceration is manifest by numbness; the residuals thereof do not more closely approximate mild incomplete paralysis of the middle radicular group. 2. Effective October 10, 2019, the Veteran's left thumb laceration is manifest by numbness and pain, similar to mild incomplete paralysis of the middle radicular group. 3. The Veteran's costalgia is manifest by pain with noncompensable limitation of motion. 4. The Veteran's right hip bursitis is manifest by pain with flexion limited to 55 degrees. 5. The Veteran's left shoulder degenerative joint disease is manifest by flexion and abduction limited to 90 degrees. 6. The Veteran's right shoulder degenerative joint disease is manifest by flexion limited to 85 degrees and abduction limited to 90 degrees, CONCLUSIONS OF LAW 1. Prior to October 10, 2019, the criteria for a compensable disability rating for residuals of left thumb laceration have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.124a, Diagnostic Code 8699-8611. 2. Effective October 10, 2019, the criteria for 20 percent, but no higher, for residuals of left thumb laceration have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.124a, Diagnostic Code 8699-8611. 3. The criteria for 10 percent, but no higher, for costalgia have been met. 38 U.S.C. § 1155, 5103, 5103A, 5107(b); 38 C.F.R. § 3.102, 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.72, DC 5321-5297. 4. The criteria for a rating in excess of 10 percent for right hip bursitis have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.59, 4.7, 4.71a, Diagnostic Code 5019. 5. The criteria for a rating of 20 percent, but no higher, for left shoulder degenerative joint disease have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5003-5201. 6. The criteria for a rating of 20 percent, but no higher, for right shoulder degenerative joint disease have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5003-5201. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from January 1980 to July 2002. For his meritorious service, the Veteran was awarded (among other decorations) the Meritorious Service Medal and the Army Commendation and Achievement Medals. This matter comes before the Board of Veterans' Appeals (Board) from an October 2013 rating decision from the Department of Veterans Affairs (VA) Regional Office (RO). This claim was previously remanded by the Board in July 2018 for further development, to include providing VA examinations and updating VA treatment records. For the issues decided herein, the Board finds those directives to be completed, and there has been substantial compliance with the Board's instructions. Stegall v. West, 11 Vet. App. 268, 271 (1998). Increased Rating The Veteran filed the instant claim for an increased rating in September 2012. As an increased rating claim, the Board looks at the evidence in the year prior to this date to see the earliest date that it is factually ascertainable that an increase occurred. 38 C.F.R. § 3.400. A disability rating is determined by the application of VA's 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. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. VA has a duty to acknowledge and consider all regulations that are potentially applicable through the assertions and issues raised in the record, and to explain the reasons and bases for its conclusions. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary importance. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, separate ratings may be assigned for separate periods of time based on the facts found. This practice is known as "staged" ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). Moreover, the Board must consider functional loss caused by pain or other factors listed in 38 C.F.R. §§ 4.40 and 4.45. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Nonetheless, despite the relevance of the background factors delineated in § 4.40 or 4.45 when evaluating a disability, the rating to be assigned is based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a; therefore, a separate or higher rating predicated solely on §§ 4.40 or 4.45 is not appropriate. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016). Functional impairment as contemplated by 38 C.F.R. §§ 4.40 and 4.45 includes less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca, 8 Vet. App. at 202; see also Mitchell, 25 Vet. App. at 44. Joint pain alone, without evidence of decreased functional ability, does not warrant a higher rating. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. During the pendency of the appeal, the rating criteria for evaluating musculoskeletal disabilities under 38 C.F.R. § 4.71a were amended effective February 7, 2021. 85 Fed. Reg. 230 (Nov. 30, 2020). Left Thumb Laceration Residuals 1. A compensable rating for left thumb laceration prior to October 10, 2019 is denied 2. A 20 percent rating, but no higher, for left thumb laceration, is granted effective October 10, 2019 The Veteran contends that his residuals of a left thumb laceration disability warrants a compensable rating. An August 2002 rating decision granted service-connection for residuals of a left thumb laceration with an initial noncompensable disability rating, effective August 1, 2002. This condition is currently evaluated under Diagnostic Code 8699-8611 for neuritis. DC 8699 indicates the disability is not listed in the rating schedule and the Veteran's disability has been rated by analogy under a closely related disease or injury, DC 8611, pertaining to neuritis of the middle radicular group. Paralysis of the middle radicular group is evaluated in accordance with the criteria set forth in 38 C.F.R. § 4.124a, Diagnostic Code 8511. Neuritis and neuralgia of that group are evaluated under Diagnostic Codes 8611 and 8711, respectively. Under these criteria, mild incomplete paralysis is rated as 20 percent for both the major and minor extremity. Moderate incomplete paralysis is rated as 40 percent for the major extremity and 30 percent for the minor extremity. Severe incomplete paralysis is rated as 50 percent for the major extremity and 40 percent for the minor extremity. Complete paralysis is rated as 70 percent for the major extremity and 60 percent for the minor extremity. 38 C.F.R. § 4.124a. The words "mild," "moderate," and "severe" as used in the various Diagnostic Codes are not defined in the Rating Schedule. Regulations provide that ratings for peripheral neurological disorders are to be assigned based the relative impairment of motor function, trophic changes, or sensory disturbance. 38 C.F.R. § 4.120. Consideration is also given for loss of reflexes, pain, and muscle atrophy. See 38 C.F.R. §§ 4.123, 4.124. The term "incomplete paralysis" indicates a degree of lost or impaired function substantially less than the type picture for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating is for the mild, or at most, the moderate degree. The disability ratings for the peripheral nerves are for unilateral involvement; when bilateral, the ratings combine with application of the bilateral factor. 38 C.F.R. § 4.124a, Note at "Diseases of the Peripheral Nerves." The Note to 38 C.F.R. § 4.124a establishes a maximum disability rating for conditions that are wholly sensory, as opposed to a minimum disability rating for conditions that are more than wholly sensory. See Miller v. Shulkin, 28 Vet. App. 376 (2017). Neuritis, cranial or peripheral, characterized by loss of reflexes, muscle atrophy, sensory disturbances, and constant pain, at times excruciating, is to be rated on the scale provided for injury of the nerve involved, with a maximum equal to severe, incomplete, paralysis. The maximum rating which may be assigned for neuritis not characterized by organic changes referred to in this section will be that for moderate, or with sciatic nerve involvement, for moderately severe, incomplete paralysis. 38 C.F.R. § 4.123 Neuralgia, cranial or peripheral, characterized usually by a dull and intermittent pain, of typical distribution so as to identify the nerve, is to be rated on the scale provided for injury of the nerve involved, with a maximum equal to moderate incomplete paralysis. 38 C.F.R. § 4.124. Turning to the Veteran's condition, the August 2019 and October 2019 VA examiners clarified that the Veteran's diagnosis is hypoesthesia, which is a reduced sensation or touch or a partial loss of sensitivity to sensory stimuli due to locally damaged nerve from the laceration and not involving a particular nerve root. Thus, all VA examinations have indicated that no nerve roots are involved and have therefore not characterized his condition according to the mild to severe complete or incomplete paralysis scale under the criteria set forth in 38 C.F.R. § 4.124a. In summary, the Board finds the Veteran's condition is manifest by sensory disturbance, and as of the October 10, 2019 VA examination, also by pain. Accordingly, the criteria for a 20 percent rating are met as of October 10, 2019. Regarding sensory disturbance, throughout the appellate period the Veteran has consistently reported numbness over the tip of his left thumb. While all VA examinations of record found no decreased sensation objectively on examination, the Board nevertheless finds the Veteran's reports of numbness to be competent and credible, and therefore entitled to great probative weight. Regarding loss of reflexes and trophic changes, all VA examinations and treatment records report normal reflexes and no trophic changes over the left thumb. Similarly, there is no competent medical evidence of muscle atrophy or complete paralysis. See, e.g., September 2013 and October 2019 VA examinations. Regarding impairment of motor functions, the Veteran reported difficulty grasping objects at the October 2019 VA examination, but all examinations of record show normal strength and reflexes. Here, the Board finds the medical of evidence of record to be more probative because this symptom was not reported to his treating providers despite seeking treatment for his left thumb on various occasions. See, e.g., August 2015 VA treatment records. Further, all VA examinations of record show normal strength and reflexes, indicating an unimpaired ability to grasp. Accordingly, the Board gives more weight to the contemporaneous medical statements made by the Veteran and finds there is no evidence of motor function impairment. Curry v. Brown, 7 Vet. App. 59 (1994). Regarding pain, the Veteran first reported pain at the October 2019 VA examination. The examiner characterized his pain symptoms as mild constant pain which may be excruciating at times, and intermittent pain which is usually dull. The Board notes that the Veteran reported a worsening in his condition in his 2014 notice of disagreement, but medical records do not reflect reports of pain until the October 2019 VA examination. For example, at the Veteran's August 2014 annual examination he endorsed multi-joint pain in his left hand. While his physician noted pain in the pinkie and index fingers, his thumb was noted to be normal. Additionally, in August 2015 VA treatment records the Veteran reported numbness of his left thumb with no other symptoms. The Veteran also reported numbness only to the August 2019 VA examiner. Accordingly, the Board gives more weight to the contemporaneous medical statements made by the Veteran and finds that his condition did not manifest in pain until the October 10, 2019 VA examination. Curry, supra. Based on the above, the Board finds that the disability is primarily manifest by sensory disturbance throughout the appellate period, and also pain as of the October 2019 VA examination. The Board further finds that the most probative evidence of record is against a finding that the disability is manifest by impairment of motor functions, trophic changes, loss of reflexes, muscle atrophy, and complete paralysis throughout the appellate period, and pain prior to October 10, 2019. The Board thus finds that the level of impairment is most analogous to mild incomplete paralysis effective October 10, 2019. Prior this date, the Board finds the Veteran's level of impairment did not rise to level of mild incomplete paralysis warranting a compensable rating. The Board has considered all other potentially applicable Diagnostic Codes, but there is no evidence showing the Veteran has neurological impairment associated with any other peripheral nerves that have not already been service-connected. Therefore, a separate or higher rating under a different Diagnostic Code is not warranted. In conclusion, the Board finds that the evidence of record persuasively weighs against the Veteran's claim for a compensable rating prior to October 10, 2019, and in excess of 20 percent thereafter, for residuals of a left thumb laceration. As the evidence of record persuasively weighs against a rating, the benefit-of-the-doubt rule does not apply. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 4.3, 4.7; Lynch v. McDonough, No. 2020-2067, 2021 U.S. App. LEXIS 37307 (Fed. Cir. Dec. 17, 2021). Musculoskeletal Conditions The Board notes that during the pendency of the Veteran's appeal, VA amended the criteria for rating musculoskeletal disabilities. The new regulation applies to claims received on or after February 7, 2021 or previously filed claims that are pending on February 7, 2021 if the new regulation will render more favorable result for the Veteran. As such, the Board will evaluate the Veteran's disability under both the old and new regulations for the entire appeal period and choose the more favorable result. 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). 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). 3. A 10 percent rating is granted for costalgia The Veteran contends that his costalgia disability warrants a compensable rating. An August 2002 rating decision granted service-connection for costalgia with an initial noncompensable disability rating, effective August 1, 2002. This condition is currently evaluated under Diagnostic Code 5321-5297. Hyphenated diagnostic codes signify that the rating for a service-connected disability is based upon how another disability would be rated. 38 C.F.R. § 4.27. The diagnostic code for the service-connected disability is after the hyphen. Here, Diagnostic Code 5321 refers to muscle injuries of the muscles of respiration in the thoracic muscle group, while Diagnostic Code 5297 refers to removal of ribs. Thus, the Veteran's rating has been assigned based on the criteria for Diagnostic Code 5297 for removal of the ribs. Under Diagnostic Code 5297, a 10 percent rating is warranted for removal of one rib or resection of two or more ribs without regeneration. A 20 percent rating is warranted for removal of two ribs. A 30 percent rating is warranted where three or four ribs have been removed. A 40 percent rating is warranted where five or six ribs have been removed. A maximum (50 percent) rating is warranted for the removal of six or more ribs. 38 C.F.R. § 4.71a. At the outset, the Board notes that the Veteran has no history of rib removal or resection. Thus, the Veteran's disability does not meet the listed criteria for a compensable rating pursuant to Diagnostic Code 5297. However, the Board also notes that the Veteran's rib disability is not without residuals. The September 2013 VA examination noted that the Veteran broke his ribs and suffered an injury to his sternum in service. Since then, he has been treated for many instances of chest pain without an exact determination of cause. Upon examination the Veteran's sternum was tender to touch. However, there were no injuries to any of the muscle groups and the Veteran had none of the cardinal signs and symptoms of a muscle disability. At the August 2019 VA examination the examiner noted that the Veteran has a non-penetrating muscle injury to the thoracic muscle group (Group XXI). The Veteran reports intermittent pain, and that he can no longer lift weight because it was causing flare-ups of the pain. The Veteran also described flare-ups as a deep pain that is reproducible with deep breaths or palpation of the area, which usually lasts about two weeks. The Veteran takes Motrin or Mobic for pain. The October 2019 VA examiner indicated that the Veteran has the cardinal muscle injury symptom of fatigue-pain, described as a constant dull pain at a severity of 5 or 6/10 that worsens once per week and lasts for two to three days at a severity of 9/10. Upon examination he was tender over his chest wall. The Veteran missed two to four weeks of work in last 12 months, and has difficulty with bending, pulling and lifting objects. While a rib is not considered a joint in the traditional sense, the Board finds no reason why, under the facts of this case, the rationale underlying the regulations and case law pertaining to rating joints is also not applicable to the Veteran's disability. In reaching this determination, the Board reiterates that both the Veteran's disability and the case law and regulations pertaining to the joints relate to disabilities of the musculoskeletal system. See 38 C.F.R. Part 4, Subpart B. Specifically, the intent of the schedular rating criteria to recognize a healed musculoskeletal injury as productive of a disability and subject to a minimal compensable disability rating of 10 percent. 38 C.F.R. § 4.59. Accordingly, the Board finds that the Veteran's residuals of pain, painful movement, flare-ups, and excess fatigability pain, and his functional impairments that result from these symptoms support the grant of the minimum compensable rating of 10 percent pursuant to Diagnostic Code 5297. Burton, 25 Vet. App. at 3-5. Again, a higher 20 percent rating is available for removal of two ribs; however, as discussed above, removal of two ribs, or even more ribs, was not demonstrated or approximated at any point during the appeal period. Thus, a 20 percent evaluation is not warranted under Diagnostic Code 5297. The Board has also considered whether a higher rating is warranted under a different diagnostic code. While VA examinations have identified the injury as involving the thoracic muscle group (Group XXI), the Veteran's residuals do not more closely approximate a severe or moderately severe disability of those muscles as required for a 20 percent rating under Diagnostic Code 5321. The initial injury was not a through and through or deep penetrating wound, or with shattering bone fracture or open comminuted fracture with extensive debridement, prolonged infection, or sloughing of soft parts, intermuscular binding, and scarring. See 38 C.F.R. § 4.56. Additionally, the Veteran is not service connected for any other identified residuals to warrant consideration of other diagnostic codes. Thus, as the evidence of record persuasively weighs against a rating in excess of 20 percent, the benefit-of-the-doubt rule does not apply. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 4.3, 4.7; Lynch v. McDonough, No. 2020-2067, 2021 U.S. App. LEXIS 37307 (Fed. Cir. Dec. 17, 2021). 4. A rating in excess of 10 percent for right hip bursitis is denied The Veteran contends that his right hip right subtrochanteric bursitis disability warrants a rating in excess of 10 percent due to functional loss during flare-ups or following repetitive use over time. An August 2002 rating decision granted service-connection for the disability with an initial noncompensable disability rating, effective August 1, 2002. The Veteran is presently rated as 10 percent disabled effective September 24, 2012. The Veteran's right hip bursitis is evaluated under Diagnostic Code 5019, which directs that the disease be evaluated as degenerative arthritis based on limitation of motion of affected parts. The October 2013 rating decision assigned a 10 percent rating based on painful limitation of flexion of the joint. Thus, the Veteran's Diagnostic Code is properly assigned as 5019-5252. Degenerative arthritis of the hip and thigh are evaluated under Diagnostic Codes 5250 through 5255. Under Diagnostic Code 5251, a maximum 10 percent rating is warranted for extension of the thigh limited to 5 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5251. Under Diagnostic Code 5252, 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 20 degrees. A maximum 40 percent rating is warranted for flexion limited to 10 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5252. Under Diagnostic Code 5253, a 10 percent rating is warranted for limitation of rotation of the affected leg, cannot toe out more than 15 degrees. A 10 percent rating is also warranted for limitation of adduction, cannot cross legs. A maximum 20 percent rating is warranted for limitation of abduction, motion lost beyond 10 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5253. The Board notes that while portions of the Rating Schedule addressing the musculoskeletal system were revised effective February 7, 2021, Diagnostic Codes 5251 through 5253 were not changed. The Board finds that the evidence of record persuasively weighs against a rating in excess of 10 percent for right hip bursitis. The Board acknowledges the Veteran's lay reports of symptoms and that there was functional loss due to pain, repetitive use, and pain during flare-ups. However, even considering the Veteran's lay reports of symptoms and noted functional loss, the degree of additional limitation reflected by the Veteran's statements would not result in symptoms more nearly approximating flexion limited to 30 degrees. In the Board's July 2018 remand, the Board found the September 2013 and January 2017 VA examinations do not adequately address the Veteran's reports of flare-ups as required under Sharp v. Shulkin, 29 Vet. App.26, 33 (2017). Accordingly, the Veteran was afforded VA examinations in August and October 2019. At the August 2019 examination the Veteran reported constant right hip pain that is worse with cold raining weather, and a flare-up requiring a "injection for pain" every two years. During flare-ups, he reported difficulty lifting his right leg, and pain with walking. The examiner noted that the examination was being conducted during a flare-up. Range of motion was limited on examination as follows: flexion to 85 degrees, extension to 20 degrees, abduction to 40 degrees, adduction to 20 degrees, external rotation to 55 degrees, and internal rotation to 40 degrees. Adduction was not limited such that the Veteran cannot cross his legs. With flare-ups and repeated use over time the examiner estimated his flexion was further limited to 55 degrees; abduction, external rotation, and internal rotation were estimated to be limited by another 5 degrees; and extension and adduction were not further limited. The examiner also noted that x-ray of the right hip now showed degenerative arthritis which was at least as likely related to the bursitis. At the October 2019 VA examination, the Veteran reported symptoms of weakness, instability, locking and pain, and that his pain increases monthly. During these times his pain is a 9 to 10/10 in severity and lasts for four days. He reported that he cannot move during flare-ups. Range of motion was limited on examination by pain as follows: flexion to 70 degrees, extension to 30 degrees, abduction to 30 degrees, adduction to 25 degrees, external rotation to 35 degrees, and internal rotation to 30 degrees. Adduction was not limited such that the Veteran cannot cross his legs. While the examiner noted that pain causes functional loss with repeated use over time, the examiner noted no reductions in range of motion. In summary, over the appellate period, the Veteran's range of motion at its worst, including during flare-ups and after repetitive use over time, was limited by pain as follows: flexion to 55 degrees, extension to 20 degrees, abduction to 30 degrees, adduction to 20 degrees, external rotation to 35 degrees, and internal rotation to 30 degrees. The Veteran's adduction was not limited such that the Veteran could not cross his legs, and there was no competent medical evidence that rotation was limited such that he could not toe-out more than 15 degrees. All examiners noted no ankylosis of the joint. Thus, the Veteran's limitation of flexion, abduction, and adduction is noncompensable. However, as the Veteran exhibits pain with motion, the minimum 10 percent rating for limitation of flexion is assigned. 38 C.F.R. § 4.59. The Board has also considered the other Diagnostic Codes pertaining to the hip and thigh. 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); see also 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 notes that assigning a compensable rating based on painful motion pursuant to Diagnostic Codes 5251 or 5253 would amount to pyramiding insofar as the 10 percent rating currently in effect under Diagnostic Code 5252 is based on the Veteran's painful limitation of motion which is not compensable. See 38 C.F.R. § 4.59. Additionally, there is no competent medical evidence of ankylosis of the hip, flail joint of the hip, or impairment of the femur, thus diagnostic codes 5250, 5254 and 5255 are inapplicable. In conclusion, the Board finds that the evidence of record persuasively weighs against a rating in excess of 10 percent for right hip bursitis. Accordingly, the benefit-of-the-doubt rule does not apply. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 4.3, 4.7; Lynch, supra. 5. A 20 percent rating is granted for left shoulder degenerative joint disease 6. A 20 percent rating is granted for right shoulder degenerative joint disease The Veteran contends that he is entitled to a higher rating for his left and right shoulder degenerative joint disease (arthritis). Service connection for bilateral should arthritis was granted in an August 2002 rating decision and was originally evaluated with his lumbar spine disability. The combined disabilities were rated as 10 percent disabling effective August 1, 2002. An October 2013 rating decision granted separate 10 percent ratings for each shoulder effective September 24, 2012. A May 2020 rating decision granted a 20 percent rating for each shoulder effective October 10, 2019. The Veteran's right and left shoulder disabilities are each evaluated under Diagnostic Code 5003-5201. Thus, the Veteran's bilateral shoulder disabilities are rated based on limitation of motion of the arm. 38 C.F.R. § 4.71a, Diagnostic Code 5201. Under the pre-February 2021 diagnostic criteria, limitation of motion of the arm at shoulder level warrants a 20 percent rating for both the major and minor extremity. Limitation of motion of the arm midway between side and shoulder warrants a 20 percent rating for the minor extremity and a 30 percent rating for the major extremity. Limitation of motion of the arm to 25 degrees from side warrants a maximum 30 percent rating for the minor joint and a maximum 40 percent rating for the major joint. 38 C.F.R. § 4.71a, Diagnostic Code 5201. Effective February 7, 2021, VA amended Diagnostic Code 5201 to reflect that limitation of motion may be shown by flexion and/or abduction and clarified the degrees of limitation of motion that correspond to each rating. Now, limitation of motion at the shoulder level (flexion and/or abduction limited to 90 degrees) warrants a 20 percent rating for both the major and minor extremity. Limitation of motion of the arm midway between side and shoulder level (flexion and/or abduction limited to 45 degrees) warrants a 20 percent rating for the minor extremity and a 30 percent rating for the major extremity. Flexion and/or abduction limited to 25 degrees from the side warrants a maximum 30 percent rating for the minor joint and a maximum 40 percent rating for the major joint. Diagnostic Code 5201 "does not provide separate ratings for limitation of motion in the flexion and abduction planes, but rather is addressed generically to limitation of motion of the arm." Yonek v. Shinseki, 722 F.3d 1355, 1358 (Fed. Cir. 2013). The Board finds that the evidence of record is in relative equipoise regarding whether the Veteran is entitled to separate 20 percent ratings for left shoulder and right shoulder arthritis for the entire appeal period, i.e., from September 24, 2012 onward. However, the evidence persuasively weighs against a rating in excess of 20 percent for both shoulders. The Board acknowledges the Veteran's lay reports of symptoms and functional loss due to pain, repetitive use, and pain during flare-ups. However, even considering the Veteran's lay reports of symptoms and noted functional loss, the degree of additional limitation reflected by the statements that his bilateral shoulder pain requires consistent use of medication and physical therapy, and that flare-ups cause pain and difficulty with overhead lifting, would not result in symptoms more nearly approximating limitation of motion of the arm midway between side and shoulder level of the major extremity or limitation of motion of the arm to 25 degrees from the side of the major or minor extremity. In July 2016 private treatment records the Veteran reported new onset left shoulder pain several months ago. He described the pain as intermittent but causing limitation of activities with that arm. Active range of motion was measured as follows: flexion to 170 degrees, external rotation to 0 degrees, and abduction to 45 degrees. The shoulder was tender to touch and showed signs of laxity. An x-ray showed mild degenerative changes in the AC joint. He was diagnosed with pain and impingement of the left shoulder and was given an injection into the subacromial space. At the August 2019 VA examination the Veteran's range of motion on the left was limited as follows: flexion to 100 degrees, abduction to 90 degrees, external rotation to 80 degrees, and internal rotation to 75 degrees. The Veteran's range of motion on the right was limited as follows: flexion to 80 degrees, abduction to 90 degrees, external rotation to 85 degrees, and internal rotation to 70 degrees. The examiner noted that due to limited motion the Veteran has difficulty lifting his arms overhead. Further, pain was noted on examination bilaterally in active and passive range of motion, and in weight-bearing. The examiner noted that range of motion was further limited bilaterally by pain and weakness after repeated use over time and during flare-ups but provided identical range of motion measurements as the initial measurements. The examiner also noted the examination was being conducted during a flare-up. At the October 2019 VA examination the Veteran reported constant pain, and weakness and stiffness. He described the pain as 8/10 in severity and reported that his pain becomes more severe twice a week, lasting for three to four days each time. Further, the Veteran reported functional loss in that he has altered the way he washes himself, can no longer mow his grass, and must be careful in how he reaches for things and reaches overhead. The examiner measured range of motion on the left as 95 degrees of flexion, 90 degrees of abduction, 40 degrees of external rotation, and 70 degrees of internal rotation. Range of motion on the right was measured as 85 degrees of flexion, 90 degrees of abduction, 40 degrees of external rotation, and 65 degrees of internal rotation. Pain was noted bilaterally on examination to cause functional loss in all areas of range of motion, and there was pain with weight-bearing. The examiner noted that range of motion was further limited bilaterally by pain and weakness after repeated use over time and during flare-ups but provided identical range of motion measurements as the initial measurements. In summary, regarding the left shoulder, the Veteran's range of motion is limited by pain and weakness, at worst, as follows: flexion and abduction to 90 degrees, external rotation to 40 degrees, and internal rotation to 70 degrees. This is consistent with the 20 percent rating criteria for limitation of motion of the arm at the shoulder level. Though the July 2017 private treatment records appear to indicate new onset of left shoulder pain in 2016, the Veteran reported left shoulder pain in his 2014 notice of disagreement, and the evidence as a whole indicates limited motion of the left shoulder prior to 2016. 38 C.F.R. § 4.59; see Sowers v. McDonald, 27 Vet. App. 472, 481-82 (2016). Accordingly, the Board finds the Veteran's left shoulder arthritis has been consistent with the 20 percent rating criteria for the entire appellate period. Further, regarding the right shoulder, the Veteran's range of motion is limited by pain and weakness, at worst, as follows: flexion to 85 degrees, abduction to 90 degrees, external rotation to 40 degrees, and internal rotation to 65 degrees. While this is 5 degrees of limitation more than the 20 percent rating criteria, the competent medical evidence of record, does not reflect any additional limitations or symptoms that result in a limitation more nearly approximately 45 degrees of flexion or abduction as required for a 30 percent rating of the major extremity. Thus, resolving reasonable doubt in favor of the Veteran, the Board finds the 20 percent rating is warranted for the entire appeal period for both the left and right shoulders. The Board has considered whether any other Diagnostic Codes related to disabilities of the shoulder would provide for a higher disability rating. However, the evidence does not reflect that the symptoms would warrant a higher rating under a different Diagnostic Code. See 38 C.F.R. § 4.71a. The VA examinations of records show no ankylosis, and no impairment of the humerus, clavicle, or scapula of either shoulder. Thus, separate ratings under Diagnostic Codes 5200, 5202, and 5203 are not warranted. In conclusion, the Board finds that the evidence is in relative equipoise regarding whether the Veteran is entitled to a 20 percent rating for painful limited motion of the left shoulder and right shoulder for the entire period on appeal, i.e., September 24, 2010 onward. However, the evidence of record persuasively weighs against the Veteran's appeal for a rating in excess of 20 percent for left and right shoulder arthritis. As the evidence of record persuasively weighs against a rating in excess of 20 percent, the benefit-of-the-doubt rule does not apply. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 4.3, 4.7; Lynch v. McDonough, No. 2020-2067, 2021 U.S. App. LEXIS 37307 (Fed. Cir. Dec. 17, 2021). REASONS FOR REMAND 1. Entitlement to a compensable rating for onychomycosis of the feet is remanded. In July 2018 the Board remanded this issue to obtain a new VA examination based on allegations of worsening. No VA examination was obtained. As there has not been substantial compliance with the Board's previous remand directives, another remand is required. Stegall, 11 Vet. App. at 271. 2. Entitlement to service connection for a left knee condition is remanded. In July 2018 the Board remanded this issue to obtain a VA examination and opinion regarding the etiology of the Veteran's bilateral knee conditions. The Veteran underwent a VA examination in August 2019; however, the examiner's opinion regarding direct service connection for the left knee relies exclusively on a lack of records showing a diagnosis or treatment during the Veteran's service. In addition, the examiner did not consider the Veteran's contentions. A negative opinion based solely on the lack of evidence in service treatment records is inadequate. See generally, Dalton v. Nicholson, 21 Vet. App. 23 (2007). As the opinion of record is inadequate, there has not been substantial compliance with the Board's previous remand directives. Another remand is required to obtain an addendum opinion. Stegall, 11 Vet. App. at 271. Additionally, subsequent to the prior Board decision, service connection came into effect for a right knee condition. The Veteran now contends that his left knee disability is secondary to his right knee disability. Alternatively, he contends his left knee disability is secondary to weight gain, which was either caused or aggravated by his lumbar spine and right knee disability. See Marcelino v. Shulkin, 29 Vet. App. 155 (2018); Walsh v. Wilkie, 32 Vet. App. 300, 305-07 (2020). Medical evidence of record indicates the Veteran has had a BMI of 30-31.5 throughout the appellate period. See, e.g., July 2013 and August 2017 VA treatment records. Thus, based on the contentions of record, additional opinion evidence is necessary regarding the theory of secondary service connection. The matters are REMANDED for the following action: 1. Schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his service-connected bilateral onychomycosis. The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran's disability under the rating criteria. 2. Obtain an addendum opinion from an appropriate clinician regarding the Veteran's left knee condition. The claims file should be made available to and reviewed by the examiner and all necessary tests should be performed. All findings should be reported in detail. The examiner is asked to answer the following questions: (a.) Is any diagnosed left knee condition at least as likely as not (50 percent or greater probability) proximately due to service-connected right knee disability or lumbar spine disability? (b.) Is the Veteran's obesity at least as likely as not (50 percent or greater probability) proximately due to service-connected right knee disability or lumbar spine disability? (c.) Is the Veteran's obesity at least as likely as not (50 percent or greater probability) aggravated, i.e., worsened beyond its natural progression, by service-connected right knee disability or lumbar spine disability? (d.) If, and only if, the Veteran's obesity is deemed to have been caused or aggravated by his service-connected right knee or lumbar spine disability, please explain whether any diagnosed left knee disability would not have occurred but for the obesity caused or aggravated by service-connected right knee or lumbar spine disability. The examiner must provide a complete explanation for all opinions. The need for additional physical examination of the Veteran is left to the discretion of the examiner. Evan M. Deichert Veterans Law Judge Board of Veterans' Appeals Attorney for the Board K.L. Blevins, 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.