Citation Nr: 22014236 Decision Date: 03/11/22 Archive Date: 03/11/22 DOCKET NO. 16-36 836 DATE: March 11, 2022 ORDER The application to reopen a claim of entitlement to service connection for loss of voice including due to chronic laryngitis is granted. The application to reopen a claim of entitlement to service connection for a right foot disorder is denied. The application to reopen a claim of entitlement to service connection for a left foot disorder is denied. Entitlement to service connection for a right ankle disorder is denied. Entitlement to service connection for a left hip disorder is denied. Entitlement to service connection for a left ankle disorder is denied. Entitlement to a 10 percent rating, but no higher, for right knee lost flexion is granted. Entitlement to a rating in excess of 30 percent for right knee instability is denied. Entitlement to a rating in excess of 30 percent for a left knee disorder (exclusive of periods of temporary 100 percent ratings), status post total knee replacement, is denied. Entitlement to a compensable rating for a left knee scar is denied. Entitlement to a total rating based on individual unemployability (TDIU) from February 26, 2015, to March 30, 2016, is granted. REMANDED Entitlement to service connection for a left hand disorder is remanded. Entitlement to a rating in excess of 10 percent for a back disability from February 26, 2015, to September 12, 2015, is remanded. Entitlement to a rating in excess of 20 percent for a back disability from September 12, 2015, to February 13, 2018, is remanded. Entitlement to a rating in excess of 10 percent for a back disability from February 14, 2018, is remanded. Entitlement to service connection for loss of voice including due to chronic laryngitis is remanded. FINDINGS OF FACT 1. A June 2007 Board of Veterans' Appeal (Board) decision earlier denied the Veteran's claims of service connection for right and left foot disorders and a December 2008 Board decision earlier denied her application to reopen a claim of service connection for loss of voice including due to chronic laryngitis. 2. Evidence received since the December 2008 Board decision is new, it is related to an unestablished fact necessary to substantiate the claim of service connection for loss of voice including due to chronic laryngitis and it raises a reasonable possibility of substantiating the claim. 3. Evidence received since the June 2007 Board decision does not relate to an unestablished fact necessary to substantiate the claims of service connection for right and left foot disorders. 4. The preponderance of the evidence shows that the Veteran was not diagnosed with a right ankle disorder at any time during the pendency of the appeal. 5. The preponderance of the evidence shows that left hip and left ankle disorders were not present in service or until many years thereafter, they are not caused by an injury while serving with a Reserve Component, and they are not caused or aggravated by a service-connected disability. 6. The preponderance of the evidence shows that the Veteran's right knee lost flexion is manifested by pain and lost motion but not flexion limited to at least 30 degrees, extension limited to at least 10 degrees, or ankylosis even when considering her complaints of pain with and without weight bearing and resistance in passive and active range of motion as well as during flare-ups nor is it manifested by at least tibia and fibula malunion, medial tibial stress syndrome, or tibia and fibula nonunion. 7. The preponderance of the evidence shows that the Veteran's right knee instability is manifested by no more than severe subluxation or lateral instability or a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription for brace and either a cane or a walker. 8. The preponderance of the evidence shows that the Veteran's left knee disorder, status post total knee replacement, is not manifested by at least severe painful motion or weakness, extension limited to at least 30, or ankylosis even when considering her complaints of pain with and without weight bearing and resistance in passive and active range of motion as well as during flare-ups nor is it manifested by at least tibia and fibula nonunion. 9. The preponderance of the evidence shows that the Veteran's left knee scar is not deep or cause limited motion in an area or areas exceeding 6 square inches (39 sq. cm.), superficial and nonlinear in an area or areas of 144 square inches (929 square centimeters) or greater, is not made up of 1 or 2 painful or unstable scars, and does not otherwise impair function. 10. From February 26, 2015, to March 30, 2016, the Veteran's service-connected disabilities precluded substantially gainful employment. CONCLUSIONS OF LAW 1. The June 2007 and December 2008 Board decisions are final. 38 U.S.C. § 7104; 38 C.F.R. §§ 3.104, 20.302, 20.1100. 2. Evidence submitted to reopen the claim of entitlement to service connection for loss of voice including due to chronic laryngitis is new and material and therefore the claim is reopened. 38 U.S.C. §§ 5108, 7104; 38 C.F.R. § 3.156. 3. New and material evidence has not been submitted sufficient to reopen claims of service connection for right and left foot disorders. 38 U.S.C. §§ 5108, 7104; 38 C.F.R. § 3.156. 4. The criteria for service connection for a left hip disorder as well as right and left ankle disorders have not been met. 38 U.S.C. §§ 101, 106, 1101, 1112, 1113, 1131, 5107; 38 C.F.R. §§ 3.6, 3.102, 3.303, 3.304, 3.307, 3.309, 3.310. 5. The criteria for a 10 percent rating, but no higher, for right knee lost flexion have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.7, 4.10, 4.71a, Diagnostic Codes 5003, 5256, 5260, 5261, 5261, 5262, and 5263; 85 Fed Reg 76453 (November 30, 2020); 85 Fed Reg 85523 (December 29, 2020); 86 Fed Reg 8142 (February 4, 2021). 6. The criteria for a rating in excess of 30 percent for right knee instability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.7, 4.10, 4.71a, Diagnostic Codes 5257; 85 Fed Reg 76453 (November 30, 2020); 85 Fed Reg 85523 (December 29, 2020); 86 Fed Reg 8142 (February 4, 2021). 7. The criteria for a rating in excess of 30 percent for a left knee disorder, status post total knee replacement, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.7, 4.10, 4.71a, Diagnostic Codes 5055, 5256, 5257, 5260, 5261, 5261, 5262, and 5263; 85 Fed Reg 76453 (November 30, 2020); 85 Fed Reg 85523 (December 29, 2020); 86 Fed Reg 8142 (February 4, 2021). 8. The criteria for a compensable rating for a left knee scar have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.6, 4.118, Diagnostic Codes 7801 to 7805. 9. From February 26, 2015, to March 30, 2016, the criteria for a TDIU have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.340, 3.341, 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served with the United States Army and a Reserve Component with various periods of active duty training to include from April 1979 to September 1979. In February 2019, the Veteran testified at a hearing before a Veterans Law Judge (VLJ) at the regional office (RO) that has since retired. A transcript of the hearing is associated with the claims file. As will be discussed below, the Veteran thereafter had another hearing before the undersigned VLJ. In September 2019 a VLJ not the undersigned issued a Board of Veterans' Appeal (Board) decision that denied service connection for a left hand disorder and denied increased ratings for the back disability as well as Remanded claims of service connection for a left hip disorder as well as right and left ankle disorders, applications to reopen claims of service connection for right and left foot disorders, increased ratings for left and right knee disorders as well as a left knee scar and the claim for a TDIU. The Veteran appealed the September 2019 Board decision to the United States Court of Appeals for Veterans Claims (Court). In a September 2020 order, which incorporated the parties Joint Motion for Partial Remand (JMPR), the Court vacating and remanded the Board decision to the extent that it denied service connection for a left hand disorder and denied increased ratings for the back disability. In October 2021, the Veteran testified at another hearing before the undersigned VLJ. A transcript of the hearing is associated with the claims file. Next, as to some of the issues being adjudicated below, the Board notes that additional evidence was added to the claims file since the RO issued a statement of the case or the supplemental statement of the case. However, the Board finds that this evidence is not pertinent because it does not establish any fact that was not already found in the record. Therefore, the Board finds that it may adjudicate the below issues without Remanding this evidence for RO review or obtaining a waiver of such review from the appellant. See 38 C.F.R. § 19.31 (a supplemental statement of the case will be furnished to the veteran when additional pertinent evidence is received after a statement of the case has been issued). Characterization of the Issues on Appeal Initially, as to the right and left foot as well as the ankle disorder claims, the Board notes that in September 2019 the VLJ remanded these claims for the issuance of a statement of the case. See Manlincon v. West, 12 Vet. App. 238 (1999). However, a subsequent review of the record shows that that Remand was in error because the Veteran in August 2019 withdrew her June 2018 notice of disagreement as to these issues. Nonetheless, given the post-Remand development by the RO and the Veteran's testimony as to these issues at the October 2021 personal hearing before the undersigned, the Board finds that it has jurisdiction over these claims. See, e.g., Percy v. Shinseki, 23 Vet. App. 37 (2009). Next, also as to the right and left foot disorder claims, the Board notes that the September 2019 Remand characterized these claims as service connection claims. However, a subsequent review of the record shows that this characterization was in error because both claims were the subject of an earlier and final June 2007 Board decision. Therefore, the Board finds that the issues need to be characterized as claims to reopen. Similarly, as to the claim for loss of voice including due to chronic laryngitis, the Board notes that the September 2019 statement of the case characterized this claim as a service connection claim. However, the record shows that this characterization was in error because the claim was most recently the subject of an earlier and final December 2008 Board decision. Therefore, the Board finds that the issue also needs to be characterized as a claim to reopen. As to the right knee disorders, the Board notes that an August 2019 rating decision granted the Veteran a separate noncompensable rating for lost right knee flexion under Diagnostic Code 5260 in addition to the 30 percent rating she already had for right knee instability under Diagnostic Code 5257. Therefore, the Board finds that the current adjudication must consider if the Veteran met the criteria for increased ratings for right knee instability and lost right knee flexion at all times during the pendency of her appeal. See 38C.F.R. §3.400(o)(2); AB v. Brown, 6 Vet. App. 35 (1993) (in an appeal in which the veteran expresses general disagreement with the assignment of a particular rating and requests an increase, the RO and the Board are required to construe the appeal as an appeal for the maximum benefit allowable by law or regulation); Fenderson v. West, 12 Vet. App. 119, 125-26 (1999). As to the TDIU claim, the Board notes that a February 2020 rating decision granted the Veteran a TDIU effective from March 30, 2016. However, the Board also notes that under Rice v. Shinseki, 22 Vet. App. 447 (2009) her claim for a TDIU had been pending since she filed her claim for an increased rating for her back disability on February 25, 2016. Therefore, the Board finds that the relevant rating period for the TDIU claim is from February 26, 2015, one year prior to receipt of the back rating claim, and the issue on appeal is as listed above. Id. As to the claims for increased ratings for the back disability, the Board also finds it has been pending since February 26, 2015, one year prior to receipt of the back rating claim. Therefore, the Board finds that its' jurisdiction encompasses whether the Veteran meets the criteria for increased ratings for her back disability at all times from February 26, 2015. Id. As to the claim for an increased rating for the left knee disorder, status post total knee replacement, the Board notes that in February 2020 the Veteran attempted to have this issue adjudicated under the Appeals Modernization Act (AMA) review system. See 84 Fed. Reg. 138 (Jan. 18, 2019). However, this attempt was not successful. Therefore, the Board finds that this issue can be addressed in the below decision. Post-Remand Compliance As to post-Remand compliance, the Board finds that the RO's development substantially complied with the Remand because it finds that the VA left hip opinions and scar examination obtained in August 2020 provide all needed information to adjudicate the claim of service connection for a left hip disorder and a compensable rating for a left knee scar. The Board has reached this conclusion because the examiners considered the claims under all theories of entitlement or under all potentially applicable rating criteria, they considered the competent and credible lay claims regarding observable symptomatology, they considered the in-service and post-service medical record, and their conclusions are supported by medical reasoning. See 38 U.S.C. § 5103A(d); Barr v. Nicholson, 21 Vet. App. 303 (2007); Stegall v. West, 11 Vet. App. 268 (1998); D'Aries v. Peake, 22 Vet. App. 97 (2008) (holding that only substantial, and not strict compliance with the terms of a remand request is required); Dyment v. West, 13 Vet. App. 141, 146-47 (holding that there was no Stegall violation when the examiner made the ultimate determination required by the Board's remand, because such determination more than substantially complied with the Board's remand order). The Board also finds that the VA's development of the claims substantially complied with the Remand because all identified and available VA and private treatment records, including from the Washington, D.C., and Houston VA Medical Centers, were obtained and associated with the claims file. See 38 U.S.C. § 5103A(b). In this regard, the Board notes that the Veteran recently testified before the undersigned that she received treatment at the Washington, D.C., VA Medical Center since approximately 1984. Tellingly, a review of the record on appeal shows that the RO on many occasions requested all of the Veteran's medical records from this VA Medical Center and obtained and associated with the record 1000s of pages of her treatment records dating back to the mid-1980s. In this regard, the Board notes that there is a presumption of regularity under which it is presumed that government officials "have properly discharged their official duties." See United States v. Chemical Foundation, Inc., 272 U.S. 1, 14-15 (1926); Mindenhall v. Brown, 7 Vet. App. 271, 274 (1994) (VA need only mail notice to the last address of record for the presumption to attach). This presumption of regularity in the administrative process may be rebutted by "clear evidence to the contrary." See Schoolman v. West, 12 Vet. App. 307, 310 (1999). Given the RO's many requests for all of the Veteran's treatment records from the Washington, D.C., VA Medical Center and the fact that the appellant has not made any contrary argument much less "clear evidence to the contrary," the Board finds that the "presumption of regularity" applies to this appeal as it relates to the RO requesting and the VA Medical Center providing all of the appellant's treatment records from the Washington, D.C., VA Medical Center. Id. Similarly, while the Veteran recently testified about possible outstanding private treatment records, the Board notes that the record contains 100s of pages of private treatment records dating back to 1980 including the records on file with the Social Security Administration (SSA). Moreover, the pre and post-personal hearing record does not show that she ever provided VA with authorizations to obtain these other records despite being asked to do so on a number of occasions. Likewise, the record does not show that she provided these records to the RO. Therefore, given the Veteran's failure to take either action, the Board finds that it can adjudicate the appeal without first looking for these records. See Loving v. Nicholson, 19 Vet. App. 96, 99-100 (2005) (holding that VA is under no duty to obtain records for which the Veteran has not provided an authorization as the claimant cannot remain in a passive role); Wood v. Derwinski, 1 Vet. App. 190. 192 (1991) (holding that "the duty to assist is not always a one-way street. If a veteran wishes help, he cannot passively wait for it in those circumstances where he may or should have information that is essential in obtaining the putative evidence.") Therefore, the Board finds that further delay by remanding these issues to provide the Veteran with new VA examinations or to obtain additional records is not required. See 38 U.S.C. § 5103A(b), (d); Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (remands which would only result in unnecessarily imposing additional burdens on VA with no benefit flowing to the veteran are to be avoided). Further development or analysis does not serve the interests of the Veteran or the VA for this appellant who had four months of active duty training and already has a TDIU since 2015. There is no indication in this record that another remand of this case will provide more information. Context in this case is important: The Veteran served with the United States Army and a Reserve Component with various periods of active duty training to include from April 1979 to September 1979 and has had a TDIU since 2016. She has filed many claims. The Applications to Reopen The Veteran claims, in substance, that she has right and left foot disorders as well as loss of her voice due to chronic laryngitis due to her military service which, service, according to her personal hearing testimony, included a lot of physical training with heavy loads on her back which damaged her feet and yelling which damaged her vocal cords so know her voice is permanently deep like a man's. As to reopening a prior final decision, the law provides that if new and material evidence has been presented or secured with respect to matters which have been disallowed, these matters may be reopened and the former disposition reviewed. 38 U.S.C. § 5108. New evidence means existing evidence not previously submitted to agency decision makers. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). The United States Court of Appeals for Veterans Claims (Court) has held that in determining whether the evidence is new and material, the credibility of the newly presented evidence is to be presumed. Justus v. Principi, 3 Vet. App. 510, 513 (1992). The Board is required to consider all the evidence received since the first denial of the claim in light of the totality of the record. See Hickson v. West, 12 Vet. App. 247, 251 (1999). In this regard, the Court in Shade v. Shinseki, 24 Vet. App. 110 (2010) held that the language of 38 C.F.R. § 3.156(a) created a low threshold and viewed the phrase "raises a reasonable possibility of substantiating the claim" as "enabling rather than precluding reopening." Further, in determining whether this low threshold is met, VA should not limit its consideration to whether the newly submitted evidence relates specifically to the reason why the claim was last denied, but instead should ask whether the evidence could reasonably substantiate the claim were the claim to be reopened, either by triggering VA's duty to assist or through consideration of an alternative theory of entitlement. Id. at 118. The Court in Turner v. Shulkin, 29 Vet. App. 207 (2018), also held that for purposes of finality VA treatment records dated during the appeal period are consider in VA's possession even if these records are not physically associated with the claims file until many years after the RO issued a rating decision if the RO had sufficient knowledge of the existence of the records within the one-year appeal period. The Court also held that these VA treatment records will thereafter only trigger VA's duty under 38 C.F.R. § 3.156(b) if they are new and material evidence. Thereafter, in Lang v. Wilkie, 971 F.3d 1348 (2020), the United States Court of Appeals for the Federal Circuit removed the sufficient knowledge of the existence of the VA records requirement in Turner. In evaluating the evidence, the Board has been charged with the duty to assess the credibility and weight given to evidence. Davidson v. Shinseki, 581 F. 3d 1313 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007). Indeed, the Court has declared that in adjudicating a claim, the Board has the responsibility to do so. Bryan v. West, 13 Vet. App. 482, 488-89 (2000). In doing so, the Board is free to favor one medical opinion over another, provided it offers an adequate basis for doing so. Owens v. Brown, 7 Vet. App. 429, 433 (1995). Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits under the laws administered by VA. VA shall consider all information and medical and lay evidence of record. Where there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; see also Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021) (en banc). With the above criteria in mind, the record shows that a June 2007 Board decision earlier denied the Veteran's claims of service connection for right and left foot disorders. The Board denied the claims because, in substance, they were not present during active duty for training or for many years thereafter and they are not shown to be related to service or to any incident or injury during active duty training. Similarly, a December 2008 Board decision earlier denied the Veteran's application to reopen a claim of service connection for loss of voice including due to chronic laryngitis. The Board denied the claim because, in substance, the evidence associated with the claims file subsequent to the November1987 Board decision does not relate to an unestablished fact necessary to substantiate the claim and does not raise a reasonable possibility of substantiating the claim because none of the records associated with the record since that time contains competent evidence that tends to show that the appellant's laryngitis with loss of voice was either incurred in or aggravated during her periods of active duty training. The Board finds that both earlier decisions are final. 38 U.S.C. § 7104; 38 C.F.R. §§ 20.1100. Since this final June 2007 and December 2008 Board decisions, the RO, the Veteran, and/or her representative filed with the VA additional post-service treatment records, the appellant was provided with VA examinations, the Veteran and her representative filed with the RO additional written statements in support of the claims, and the Veteran testified at a personal hearing before another VLJ as well as the undersigned VLJ. a. Loss of voice including due to chronic laryngitis Since the final December 2008 Board decision, the Veteran in November 2018 filed a letter dated earlier in the month from Philip B. Mussenden, Sr., M.D., in which it was opined, in substance, that her current voice problem was due to yelling while in service. Therefore, the Board finds that because the credibility of the newly presented evidence is to be presumed and because an etiology opinion was not part of the record at the time of the December 2008 Board decision, that the opinion is new and material evidence and the claim is reopened because it raises a reasonable possibility of substantiating the claim. 38 U.S.C. §§ 5108, 7107; 38 C.F.R. § 3.156; Justus, supra. b. Right and left foot disorders As to the additional post-service treatment records and VA examinations, while they document the Veteran's periodic reports of foot problems, they continue to be negative for the Veteran sustaining a disease or injury while on a period of active duty or an injury while serving during a period of inactive duty that caused the current disorders, being diagnosed with arthritis in either foot in a first post-active duty year, having continuity of symptomatology of either of the claimed disorders since a qualifying period of service, a medical opinion linking her disorders to a qualifying period of service, or a medical opinion linking her disorders to an already service-connected disability. See 38 U.S.C. §§ 101, 106, 1101, 1112, 1113, 1131, 5107; 38 C.F.R. §§ 3.6, 3.102, 3.303, 3.304, 3.307, 3.309, 3.310. Therefore, the Board finds that this medical evidence is neither new nor material evidence as defined by 38 C.F.R. § 3.156(a) because it is duplicative. Simply stated, they continue to document her post-service complaints or treatment for foot problems which information was in the claims file at the time of the final Board decision without providing new and material evidence. As to the written statements in support of the claims as well as the personal hearing testimony, the Board notes that they stated, in substance, that the appellant is entitled to service connection for right and left foot disorders due to the appellant's military service. However, these assertions were, in substance, before VA at the time of the earlier final Board decision. They are simply repeating the prior claims. Moreover, in 2007 as well as today, lay persons like the Veteran and her representative are not competent to provide nexus opinions because it takes special medical training that they do not have. See Davidson v. Shinseki, 581 F. 3d 1313 (Fed. Cir. 2009). Therefore, the Board finds that these statements and personal hearing testimony are neither new nor material evidence as defined by 38 C.F.R. § 3.156(a) because they are duplicative. Simply stated, the Veteran and her representative have repeated the appellant's earlier claims without providing new and material evidence. In summary, the Board finds that the additional evidence added to the claims file since the time of the prior final June 2007 Board decision do not provide evidence that the Veteran's post-service foot disorders are due to her military service. See 38 U.S.C. §§ 101, 106, 1101, 1112, 1113, 1131, 5107; 38 C.F.R. §§ 3.6, 3.102, 3.303, 3.304, 3.307, 3.309. Instead, the Board finds that additional evidence added to the claims file since that time is, in substance, duplicative of evidence found in the record at the time of the prior final June 2007 Board decisions or a repeat of the same claims. Accordingly, these claims are denied. 38 C.F.R. § 3.156(a). The Service Connection Claims The Veteran claims, in substance, that she has left hip as well as her right and left ankle disorders due to her military service. She also claims that they are due to her bilateral knee disabilities and/or her back disability to include residuals of her knee surgery and an altered gait caused by her bilateral knee disabilities. Service connection is warranted where the evidence of record establishes that a particular injury or disease resulting in disability was incurred in the line of duty in the active military service or, if pre-existing such service, was aggravated thereby. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. Additionally, service connection may be granted for disability resulting from disease or injury incurred or aggravated while performing active duty for training (ACDUTRA) or from injury incurred or aggravated while performing inactive duty training (INACDUTRA). 38 U.S.C. §§ 101(24), 106, 1110, 1131. If a condition noted during service is not shown to be chronic, then generally a showing of continuity of symptomatology after service is required for service connection if the disability is one that is listed in 38 C.F.R. § 3.309. 38 C.F.R. § 3.303(b); see also Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). In addition, service connection may also be granted on the basis of a post-service initial diagnosis of a disease, where the physician relates the current condition to the period of service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(d). Other specifically enumerated disorders, including arthritis, will be presumed to have been incurred in service if they manifested to a compensable degree within the first year following separation from active duty. 38 U.S.C. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. Active military, naval, or air service includes any period of ACDUTRA during which the individual concerned was disabled or died from a disease or injury incurred in or aggravated in line of duty, or any period of INACDUTRA during which the individual concerned was disabled or died from injury incurred in or aggravated in line of duty. 38 U.S.C. §§ 101(21) and (24); 38 C.F.R. §§ 3.6(a) and (d). ACDUTRA is, inter alia, full-time duty performed by member of the National Guard of any State. 38 C.F.R. § 3.6(c)(3). In this regard, to establish service connection for the claimed disorders, there must be (1) medical evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999). Service connection may also be established on a secondary basis for a disability proximately due to or aggravated by a service-connected disease or injury. See 38 C.F.R. § 3.310; see also Allen v. Brown, 7 Vet. App. 439 (1995) (en banc). To establish secondary service connection, a Veteran must show: (1) the existence of a present disability; (2) the existence of a service-connected disability; and (3) a causal relationship between the present disability and the service-connected disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998); see also Ward v. Wilkie, 31 Vet. App. 233 (2019). The requirement of a current disability is "satisfied when a claimant has a disability at the time a claim for VA disability compensation is filed or during the pendency of that claim." See McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). a. The Right Ankle Disorder As to the claim of service connection for a right ankle disorder, the Board finds that the Veteran is competent to report on the events she experienced while in service as well as manifestations of her disorder such as pain. See Davidson, supra. However, service and Reserve Component treatment records, including the February 1979 and August 1979 examinations, are negative for an injury, complaints, treatment, or diagnosis of a right ankle disorder despite the Veteran pulling a right leg muscle in June 1981 and having some leg pain. See Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991) (VA may only consider independent medical evidence to support its findings and is not permitted to base decisions on its own unsubstantiated medical conclusions). Likewise, and more importantly, while the post-service treatment records document the Veteran's periodic reports of right ankle pain these records, including the May 2015 VA examination, are likewise negative for her being diagnosed with a right ankle disorder. Id. In fact, at the May 2015 VA examination which was held for the purpose of obtaining such a diagnosis the examiner specifically opined that she did not have a right ankle disorder. Moreover, the Board finds this opinion the most competent and credible medical opinion of record because it was provided after a review of the record on appeal, an examination of the claimant, because it is supported by citation to evidence found in the record, because it is supported by medical reasoning, and because it is not contradicted by any other medical evidence of record. See Owens, supra; Colvin, supra; Guerrieri v. Brown, 4 Vet. App. 467, 473 (1993) ("the probative value of medical opinion evidence is based on the medical expert's personal examination of the patient, the physician's knowledge and skill in analyzing the data, and the medical conclusion the physician reaches.... As is true with any piece of evidence, the credibility and weight to be attached to these opinions [are] within the province of the [Board as] adjudicators..."). Further, while the Veteran is competent to report on the symptoms she observes, the Board finds that she is not competent to diagnose a right ankle disorder because diagnosing it requires special medical training that she does not have and therefore she cannot provide the missing diagnosis. See Davidson, supra. The Board also finds that the facts of this appeal are distinguishable from those in Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018) because the findings by the May 2015 VA examiner shows that the claimed disability does not result in functional impairment that affects earning capacity despite the reports of pain seen in the record. See Owens, supra; also see Wait v. Wilkie, 33 Vet. App. 8, 17 (2020). Accordingly, the Board finds that the most probative evidence of record shows that the Veteran did not have a diagnosis of a right ankle disorder at any time during the pendency of the appeal and this claim is denied. 38 U.S.C. §§ 101, 106, 1110, 1112, 1113, 1131, 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310. b. The Left Hip and Left Ankle Disorders As to current disabilities, the record shows the Veteran being diagnosed with left hip trochanteric bursitis (see VA examination dated in August 2020) and left ankle Haglund deformity, retro calcaneal, retro-Achilles' bursitis, Achilles' tendinopathy, partial tear of the peroneus brevis tendon, brevis tenosynovitis, and edema (see VA left ankle magnetic resonance imaging evaluation (MRI) dated in May 2016). Next, the Board finds that the Veteran is competent to report on the events she experienced while in service as well as manifestations of her disabilities. See Davidson, supra. The Board also notes that an undated service treatment record noted skeletal pain. However, service and Reserve Component treatment records, including the February 1979 and August 1979 examinations, are otherwise negative for injuries, history, complaints, diagnoses, or treatment for left hip and left ankle disorders. See Colvin, supra. Tellingly, at the February 1979 and August 1979 examinations the Veteran denied having a history of arthritis, bursitis, bone/joint deformity, lameness, and foot trouble. It is important to note that at this key point, it was the Veteran herself that provides evidence against the claims. Likewise, on examination in February 1979 and August 1979 it was opined that the Veteran's feet and lower extremities were normal. See Colvin, supra. Accordingly, the Board finds that the most probative evidence of record shows that the Veteran did not sustain a disease or injury while on active duty or an injury while on inactive duty that caused her post-service left hip and left ankle disorders. See 38 U.S.C. §§ 101, 106, 1131; 38 C.F.R. § 3.303(a). In this regard, the Board finds that the highly detailed service record, which documents the Veteran's complaints, diagnoses, or treatment for a number of other problems, weights against her current claims that she had problems with observable symptoms of left hip and left ankle disorders while in service over 40 years ago. See Owens, supra. Again, it is important for the Veteran to understand that at some points in this record it was the Veteran that provided evidence against these claims. Further, a detailed review of this record undermines some of the claims not before the Board. As to service connection for left hip and left ankle disorders based on the presumptions found at 38 C.F.R. § 3.309(a), the record does not show her being diagnosed with arthritis in either joint in the first year following her separation from a qualifying period of service. Therefore, the Board finds that the presumptions found at 38 C.F.R. § 3.309(a) do not help the Veteran establish service connection for left hip and left ankle disorders. See 38 U.S.C. §§ 1101, 1112, 1113; 38 C.F.R. § 3.307. Next, the Board will consider whether the Veteran is entitled to service connection for left hip and left ankle disorders due to continuity of symptomatology under 38 U.S.C. §§ 101, 106, 1131; 38 C.F.R. § 3.303(b). In this regard, in a non-precedential Memorandum Decision, Judge Toth of the United States Court of Appeals for Veterans Claims (Court) emphasized that it is the Board's duty to determine whether evidence shows that the principal fact is true with a degree of certainty that satisfies the requisite standard of proof. See Davis v. McDonough, No. 20-3267 (September 22, 2021). Mere circumstantial evidence such as this can be compared with the annotations of Henry David Thoreau, who observed of "unscrupulous dairymen who diluted their milk with water to increase its volume, '[s]ome circumstantial evidence is very strong, as when you find a trout in the milk.'" See id. (citing Journal, 11 Nov. 1850, in 2 Journal of Henry D. Thoreau 94 (Bradford Torrey & Francis H. Allen eds., 1962)); Also see Bethea v. Derwinski, 2 Vet. App. 252, 254 (1992) (single judge decisions may be relied upon for any persuasiveness or reasoning they contain). With the above standard in mind, the Board notes that the post-service record does not show that the Veteran had a continued problem with left hip and left ankle disorders in and since her service ended over 40 years ago. In fact, service and Reserve Component treatment records, including February 1979 and August 1979 examinations, are negative for injuries, complaints, treatment, or diagnoses of left hip and left ankle disorders. In this regard, at the February 1979 and August 1979 examinations the Veteran denied having a history of arthritis, bursitis, bone/joint deformity, lameness, and foot trouble and on examination it was opined that her feet and lower extremities were normal. Likewise, and as important, the post-service is negative for any complaints, diagnoses, or treatment for a left hip and left ankle problems until 2000 (see VA treatment records dated in January 2000); decades after her separation from her last period of qualifying service. Given this record, the Board finds that the evidence in the form of the service medical records and the post-service medical evidence provides highly probative evidence, overall, against the claims which evidence the Board finds more probative than the Veteran's claims that she had observable symptoms of them in service and since her service ended in over 40 years earlier. See Owens, supra. For the reasons noted above, the Board finds that the service and post-service medical records provide highly probative evidence against the claims. Id. The service and post-service records in this case provide particularly negative evidence against the claims (both are highly detailed; clearly indicating problems that began years after service). Therefore, the Board finds that the most probative evidence of record shows that the Veteran did not have a continued problem with left hip and left ankle disorders in and since her service ended over 40 years ago. See 38 U.S.C. §§ 101, 106, 1131; 38 C.F.R. § 3.303(b). The Board also finds that the record does not show that the Veteran's post-service left hip and left ankle disorders are due to her military service. See 38 U.S.C. §§ 101, 106, 1131; 38 C.F.R. § 3.303(d); also see Rabideau v. Derwinski, 2 Vet. App. 141, 143 (1992) (establishing service connection requires finding a relationship between a current disability and events in service or an injury or disease incurred therein). In fact, as to the left hip disorder, the August 2020 VA examiner opined that it is not due to her military service and the Board finds this opinion is the most probative evidence of record. The Board has reached this conclusion because the opinion was provided after a review of the record on appeal, an examination of the Veteran, it supported by citation to evidence found in the record and at the examination, it is supported by medical reasoning, and because it is not contradicted by any other medical evidence of record. See Owens, supra, Colvin, supra; Guerrieri, supra. As to the claim of service connection a left ankle disorder, the Board notes that VA did not obtain an etiology opinion. However, given the above record which is negative for the claimed disorder while in service and for decades after service, the Board finds that VA had no obligation to obtain a medical opinion as to this claim. See Paralyzed Veterans of America, et. al., v. Secretary of Veterans Affairs, 345 F.3d 1334 (Fed. Cir. 2003) (holding that the criteria for obtaining an etiology opinion have not been met when the evidence of record does not establish that the veteran suffered an event, injury, or disease in service because no reasonable possibility exists that providing a medical examination or obtaining a medical opinion would substantiate the claim); Duenas v. Principi, 18 Vet. App. 512, 519 (2004) (VA is not obligated to provide an examination for a medical nexus opinion where, as here, the supporting evidence of record consists only of a lay statement). It is important for the Veteran to understand that at this point both the factual evidence and the medical evidence (treatment records and the best medical opinions) provides highly probative evidence against the claims that the Board cannot ignore, in some cases providing evidence against claims that have been granted in the past. In addition, the Board finds that the Veteran is not competent to provide the missing nexus opinions because she does not have the required medical expertise to provide answers to these complex medical questions (i.e., what caused her current left hip and left ankle disorders). See Davidson, supra. In this regard, the Board finds that she simply does not have the medical qualifications to provide a nexus opinion given the negative service treatment records and the many decades gap between service and the first diagnoses of these disorders post-service. Therefore, the Board finds that the most probative evidence of record also shows that the Veteran's post-service left hip and left ankle disorders are not due to her military service. See 38 U.S.C. § 101, 106, 1131; 38 C.F.R. § 3.303(d); also see Rabideau, supra. Similarly, the Veteran's claim that her left hip and left ankle disorders are secondary to her service-connected bilateral knee disabilities and/or back disability, to include a residual of the surgery she had on her left knee. However, the Board finds that the record does not show that either disorder was caused or aggravated by a service-connected disability. See 38 U.S.C. §§ 1131; 38 C.F.R. § 3.310; Also see Allen, supra; Wallin, supra; Ward, supra. Specifically, as to the left hip and left ankle disorders, the January 2014, June 2015 and/or the August 2020 VA examiners opined that they were not caused or aggravated by her already service-connected bilateral knee disabilities and/or back disability to include any altered gait caused by the bilateral knee disabilities. Moreover, the Board finds that the VA opinions are the most competent and credible medical opinions of record because they were provided after a review of the record on appeal and/or an examination of the Veteran as well as because they are supported by citation to evidence found in the record and controlling medical literature as well as because they are supported by medical reasoning and not contradicted by any other medical evidence of record. See Owens, supra; Guerrieri, supra; Colvin, supra. The Board also finds that the Veteran is not competent to provide the missing nexus opinions because she does not have the required medical expertise to provide an answer to this complex medical question (i.e., what is the relationship between her service-connected bilateral knee disabilities/back disability and her left hip and left ankle disorder). See Davidson, supra. Therefore, the Board finds that the most probative evidence of record shows that the Veteran's left hip disorder is not caused or aggravated by an already service-connected disability. See 38 U.S.C. § 1131; 38 C.F.R. § 3.310; also see Allen, supra. In this regard, the key question in this case is not if the Veteran had a disease or injury while in service. The key issue is whether any disease or injury the Veteran had during service, over 40 years ago, was at least as likely as not (a 50 percent or greater chance) the cause of her current left hip and left ankle disorders. The fact that she may, or may not, have had problems while in service does not always provide the basis to find that the post-service left hip and left ankle disorders are the result of that injury from over 40 years ago. Sometimes, in some cases, the best evidence provides evidence against such claims. In this case, the Board finds that there is now significant evidence in this record, in both the service and post-service (and sometimes the Veteran's own statements), that provides highly probative evidence against the claims that clearly outweigh all evidence that supports the claims. See Owens, supra. It is vital for the appellant to understand that the Board has taken her concerns seriously, however, there is now overwhelming medical and factual evidence against the claims that the Board cannot ignore, including at some points from the Veteran. The service and post-service treatment records have been found by the Board to provide highly probative evidence against the claims and standing alone provide a valid basis to deny these claims. There is no basis to assume that obtaining an additional medical opinion in this case will provide a basis to grant the claims in light of this record. With regard to any contention from the Veteran that she had continued problems for over 40 years since service, the Board must find that any such statements are outweighed by the evidence of record and are not credible in light of the evidence of record. Accordingly, the Board finds that the preponderance of the evidence is also against the Veteran's claims of service connection for left hip and left ankle disorders. 38 U.S.C. §§ 101, 106, 1101, 1112, 1113, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310. In reaching the above conclusions, the Board has also considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the probative evidence is against the claims, the Board finds that this doctrine is not applicable in the instant appeal. See 38 U.S.C. § 5107(b); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Lynch, supra. The Rating Claims The Veteran contends that her right and left knee disorders as well as her knee scar are more severely disabling than represented by the ratings assigned. In this regard, disability evaluations are determined by the application of a schedule of ratings which is based, as far as can practically be determined, on the average impairment of earning capacity. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Each service-connected disability is rated on the Veteran of specific criteria identified by a Diagnostic Code. 38 C.F.R. § 4.27. When rating the Veteran's service-connected disability, the entire medical history must be borne in mind. Schafrath v. Derwinski, 1 Veteran. App. 589 (1991). Separate higher or lower compensable evaluations may be assigned for separate periods of time if such distinct periods are shown by the competent evidence of record during the appeal, a practice known as "staged" ratings. See Hart v. Mansfield, 21 Veteran. App. 505 (2007); Fenderson v. West, 12 Veteran. App. 119, 126 (1999). Regulations require that where there is a question as to which of two evaluations is to be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. The assignment of a particular diagnostic code is "completely dependent on the facts of a particular case." See Butts v. Brown, 5 Veteran. App. 532, 538 (1993). One diagnostic code may be more appropriate than another based on such factors as an individual's relevant medical history, the current diagnosis and demonstrated symptomatology. Any change in a diagnostic code by VA must be specifically explained. Pernorio v. Derwinski, 2 Veteran. App. 625 (1992). I. The Right and Left Knee Disorders The Veteran's right knee lost flexion is rated as 0 percent disabling under 38 C.F.R. § 4.71a, Diagnostic Code 5003-5260. The Veteran's right knee instability is rated as 30 percent disabling under 38 C.F.R. § 4.71a, Diagnostic Code 5260-5257. The Veteran's left knee disorder, status post total knee replacement, is rated as 30 percent disabling (exclusive of periods of temporary 100 percent ratings), under 38 C.F.R. § 4.71a, Diagnostic Code 5055. i. The Recent Amendments to the Musculoskeletal Rating Criteria Initially, the Board notes that during the pendency of the appeal VA amended some of its' criteria for rating musculoskeletal disabilities effective February 7, 2021. See 85 Fed Reg 76453 (November 30, 2020); 85 Fed Reg 85523 (December 29, 2020); 86 Fed Reg 8142 (February 4, 2021). Claims pending prior to the effective date will be considered under both old and new rating criteria, and whatever criteria is more favorable to the Veteran will be applied. The Board cannot apply a current regulation prior to its effective date unless the regulation explicitly provides otherwise. See Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). In this case, the regulation does not provide for retroactive application. 85 Fed. Reg. 76453, 76463 (Nov. 30, 2020) (to be codified at 38 C.F.R. § 4.71a). Moreover, the Board finds that none of the amendments change how this Veteran's right and left knee disorders are rated. See Owens, supra. The Board has reached this conclusion because the specific rating criteria were not amended or because the Veteran's disability is not ratable under the amended criteria. Therefore, the Board finds that a Remand to provide the Veteran with notice of these new rating criteria and have the claims adjudicating applying them is not required. See Sabonis, supra. ii. The Old and New Rating Criteria Under Diagnostic Code 5003 degenerative arthritis established by x-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. When, however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion. A rating of 20 percent is assigned for each such major joint or group of minor joints, with occasional incapacitating exacerbations, affected by limitation of motion. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. 38 C.F.R. § 4.71a. Old Diagnostic Code 5010 provides, in substance, that traumatic arthritis is rated under Diagnostic Code 5003. 38 C.F.R. § 4.71a. New Diagnostic Code 5010 provides, in substance, that post-traumatic arthritis is rated as limitation of motion, dislocation, or other specified instability under the affected joint. See 85 Fed Reg 76453 (November 30, 2020); 85 Fed Reg 85523 (December 29, 2020); 86 Fed Reg 8142 (February 4, 2021). Under old and new Diagnostic Code 5055 provides, following a total knee replacement, a 60 percent rating for chronic residuals consisting of severe painful motion or weakness in the affected area and, otherwise, a minimum 30 percent evaluation is warranted. See 38 C.F.R. § 4.71a. They also provide that intermediate degrees of residual weakness, pain, or limitation of motion are rated by analogy to Diagnostic Codes 5256, 5261, or 5262. Id. Old Diagnostic Code 5055 also provided for a 100 percent rating for one year following implantation of prosthesis and new Diagnostic Code 5055 only provides a 100 percent rating for four months following implantation of prosthesis or resurfacing. Id. Under 38 C.F.R. § 4.71a, Diagnostic Code 5256, ankylosis at a favorable angle in full extension or in slight flexion between 0 degrees and 10 degrees warrants a 30 percent rating; ankylosis with flexion between 10 degrees and 20 degrees warrants a 40 rating; ankylosis with flexion between 20 degrees and 45 degrees warrants a 50 rating; and extremely unfavorable ankylosis (flexion at an angle of 45 degrees or more) warrants a 60 percent rating. Under old 38 C.F.R. § 4.71a, Diagnostic Code 5257, slight recurrent subluxation or lateral instability will be rated as 10 percent disabling. Moderate recurrent subluxation or lateral instability will be rated as 20 percent disabling. And, severe recurrent subluxation or lateral instability, warrants a 30 percent rating. The terms "mild," "moderate," "moderately severe" 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. The use of terminology such as "mild" or "moderate" by VA examiners and others, although an element of evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6. Effective February 7, 2021, VA amended Diagnostic Code 5257. For recurrent subluxation or lateral instability, a 10 percent rating is assigned for a sprain, incomplete ligament tear or complete ligament tear causing persistent instability without prescribed assistive device or bracing for ambulation. A 20 percent rating is warranted when a) a sprain, incomplete ligament tear, or repaired complete ligament tear causes persistent instability; or b) an unrepaired or failed repair of a complete ligament tear causes peristent instability. A prescribed assistive device or bracing for ambulation is required. A 30 percent rating requires unrepaired or failed repair of complete ligament tear causing persistent instability and a prescription for both an assistive device and bracing for ambulation. For patellar instability also rated under Diagnostic Code 5257, a 10 percent rating is assigned for a diagnosed condition that does not require a prescription from a medical provider for a brace, cane, or walker. A 20 percent rating is warranted when there is a diagnosed condition with a prescription for either a brace, cane, or walker. A 30 percent rating requires a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription for brace and either a cane or a walker. Id. NOTE 1 following the criteria provides, for patellar instability, the patellofemoral complex consists of the quadriceps tendon, the patella, and the patellar tendon. NOTE 2 following the criteria provides 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). Under 38 C.F.R. § 4.71a, Diagnostic Code 5258, dislocated semilunar cartilage with frequent episodes of locking, pain, and effusion into the joint warrants a 20 percent rating. Under 38 C.F.R. § 4.71a, Diagnostic Code 5259, removal of the semilunar cartilage when symptomatic warrants a 10 percent rating. Under 38 C.F.R. § 4.71a, Diagnostic Code 5260, if flexion of the knee is limited to 45 degrees a 10 percent rating is in order. If flexion of the knee is limited to 30 degrees a 20 percent rating is in order. If flexion of the knee is limited to 15 degrees a 30 percent rating is in order. Under 38 C.F.R. § 4.71a, Diagnostic Code 5261, if extension of the knee is limited to 10 degrees a 10 percent rating is in order. If extension of the knee is limited to 15 degrees a 20 percent rating is in order. If extension of the knee is limited to 20 degrees a 30 percent rating is in order. If extension of the knee is limited to 30 degrees a 40 percent rating is in order. If extension of the knee is limited to 45 degrees a 50 percent rating is in order. Full range of motion of the knee is from 0 to 140 degrees. 38 C.F.R. § 4.71, Plate II. Under old 38 C.F.R. § 4.71a, Diagnostic Code 5262, impairment of the tibia and fibula with slight knee or ankle disability warrants a 10 percent rating; with moderate knee or ankle disability warrants a 20 percent rating; with marked knee or ankle disability warrants a 30 percent rating; and with nonunion (loose motion requiring brace) warrants a 40 percent rating. Effective February 7, 2021, VA amended Diagnostic Code 5262. Medial tibial stress syndrome (MTSS), or shin splints is rated as 0 percent disabling with treatment less than 12 consecutive months, one or both lower extremities; 10 percent disabling when requiring treatment for no less than 12 consecutive months, and unresponsive to either shoe orthotics or other conservative treatment, one or both lower extremities; 20 percent disabling when requiring treatment for no less than 12 consecutive months, and unresponsive to surgery and either shoe orthotics or other conservative treatment, one lower extremity; and 30 percent disabling when requiring treatment for no less than 12 consecutive months, and unresponsive to surgery and either shoe orthotics or other conservative treatment, both lower extremities. Tibia and fibula are rated as 40 disabling with nonunion with loose motion, requiring brace. Tibia and fibula with malunion are evaluated under diagnostic codes 5256, 5257, 5260, or 5261 for the knee, or 5270 or 5271 for the ankle, whichever results in the highest evaluation. Under 38 C.F.R. § 4.71a, Diagnostic Code 5263, Genu recurvatum (acquired, traumatic, with weakness and insecurity in weight-bearing objectively demonstrated) warrants a 10 percent rating. As noted above, prior to February 7, 2021, the Board will apply the prior rating criteria. See Kuzma, supra. From February 7, 2021, onward, the Board applies the criteria that is more favorable to the Veteran. Id. When evaluating joint disabilities rated on the basis of limitation of motion, VA must consider granting a higher rating in cases in which functional loss due to pain, weakness, excess fatigability, or incoordination is demonstrated, and those factors are not contemplated in the relevant rating criteria. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202 (1995). The Court has clarified that although pain may be a cause or manifestation of functional loss, limitation of motion due to pain is not necessarily rated at the same level as functional loss where motion is impeded. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011); cf. Powell v. West, 13 Vet. App. 31, 34 (1999); Hicks v. Brown, 8 Vet. App. 417, 421 (1995); Schafrath v. Derwinski, 1 Vet. App. 589, 592 (1991). Instead, the Mitchell Court explained that pursuant to 38 C.F.R. §§ 4.40 and 4.45, the possible manifestations of functional loss include decreased or abnormal excursion, strength, speed, coordination, or endurance, as well as less or more movement than is normal, weakened movement, excess fatigability, and pain on movement (as well as swelling, deformity, and atrophy) that affects stability, standing, and weight-bearing. See 38 C.F.R. §§ 4.40, 4.45. Thus, functional loss caused by pain must be rated at the same level as if the functional loss were caused by any of the other factors cited above. Therefore, in evaluating the severity of a joint disability, VA must determine the overall functional impairment due to these factors. The provisions of 38 C.F.R. § 4.59, which relate to painful motion, are not limited to arthritis and must be considered when raised by the claimant or when reasonably raised by the record. See Burton v. Shinseki, 25 Vet. App. 1 (2011). Moreover, the United States Court of Appeals for Veterans Claims (Court) in Southall-Norman v. McDonald, 28 Vet. App. 346, 352 (2016) held that the provisions of 38 C.F.R. § 4.59, which relate to painful motion, are not limited to the evaluation of musculoskeletal disabilities under Diagnostic Codes predicated on range of motion measurements. In Burton v. Shinseki, 25 Vet. App. 1 (2011), the Court held that 38 C.F.R. § 4.59 is not limited to disabilities involving arthritis. Furthermore, in Jones Shinseki, 26 Vet. App. 56, 61-63 (2012) the Court held that the Board may not deny entitlement to an increased rating on the basis of relief provided by medication when those effects are specifically contemplated by the rating criteria. Lastly, in Chavis v. McDonough, __ F.3d __, No. 18-2928 (Fed. Cir. April 16, 2021) the United States Court of Appeals for the Federal Circuit held that ankylosis of the spine may be shown based on symptoms of fixation of the joint equivalent to ankylosis. In Esteban v. Brown, 6 Vet. App. 259, 261 (1994), that Court held that in cases where the record reflects that the appellant has multiple problems due to service-connected disability, it is possible for an appellant to have "separate and distinct manifestations" from the same injury, permitting separate disability ratings. The critical element is that none of the symptomatology for any of the conditions is duplicative or overlapping with the symptomatology of the other conditions. Id. In this regard, VA General Counsel has held that separate ratings may be assigned in cases where a service-connected knee disorder includes both a compensable limitation of flexion under Diagnostic Code 5260, and a compensable limitation of extension under Diagnostic Code 5261 provided that the degree of disability is compensable under each set of criteria. VAOPGCPREC 9-2004; 69 Fed. Reg. 59990 (2004). The basis for the opinion was a finding that a limitation in planes of movement were each compensable. Id. VA General Counsel has also held that separate ratings may be assigned in cases where the service-connected knee disorder includes both arthritis and instability, provided of course, that the degree of disability is compensable under each set of criteria. VAOPGCPREC 23-97 (July 1, 1997). iii. Correia, and Sharp Compliance Next, in adjudicating below whether the Veteran meets the criteria for a higher evaluation right knee lost flexion, the Board has not overlooked the Court's holdings in Correia v. McDonald, 28 Vet. App. 158, 169-70 (2016), and Sharp v. Shulkin, 29 Vet. App. 26 (2017). Tellingly, the Board finds that the record is adequate to address the concerns raised by the Court in both these cases because at the February 2018, July 2019, and/or March 2020 VA examinations the examiners when providing the range of motion of the knees considered her complaints of pain with and without weight bearing and resistance in passive and active range of motion and/or during flare-ups. Therefore, the Board finds that further delay by remanding the issues to provide the Veteran with a new VA examination is not required. See Sabonis, supra. a. Right knee lost flexion As to a compensable rating for the right knee lost flexion under Diagnostic Code 5260, the Veteran has reported problems with pain and lost motion and the Board find's these reports both competent and credible because it is something she can feel and are consistent with the nature of her service-connected disability. See Davidson, supra. Likewise, the Board notes that right knee pain with motion was objective confirmed by the Veteran's VA examiners. See VA examinations dated in January 2014, June 2014, May 2015, September 2016, February 2018, July 2019, and March 2020. Therefore, considering 38 C.F.R. §§ 4.40, 4.45, 4.59 and the Court's holdings in Correia, Sharp, Mitchell, Burton, Southall-Norman, and DeLuca, as well as when considering the appellant's competent reports of her observable adverse symptomatology (see Davidson, supra), the Board finds that the Veteran's symptoms met the criteria for at least a 10 percent rating at all times during her appeal under Diagnostic Code 5260. 38 C.F.R. § 4.71a; Also see Hart, supra; Fenderson, supra. As to a rating in excess of 10 percent for the Veteran's right knee lost flexion under Diagnostic Code 5260, the Board finds that even when considering functional limitations due to pain with and without weight bearing and resistance in passive and active range of motion as well as during flare-ups and the other factors identified in 38 C.F.R. §§ 4.40, 4.45, 4.59 as well as the Court's holdings in Correia, Sharp, Mitchell, Burton, Southall-Norman, and DeLuca, and when considering the appellant's competent reports of her observable adverse symptomatology (see Davidson, supra), her functional losses do not equate to the criteria required for at least a 20 percent rating because the most probative evidence of record shows that flexion of the right knee was not limited to at least 30 degrees at all times during the appeal. See Owens, supra. The Board has reached this conclusion because the range of motion studies provided by the Veteran's VA examiners show that right knee flexion was as follows: 100 degrees at the January 2014 VA examination; 100 degrees at the June 2014 VA examination; 100 degrees at the May 2015 VA examination; 100 degrees at the September 2016 VA examination; 85 degrees at the February 2018 VA examination; 60 degrees at the July 2019 VA examination; and 40 degrees at the March 2020 VA examination. In this regard, the Board finds that the above range of motion studies are both competent and credible as well as the most probative evidence of record because they are supported by the examinations as well as the Veteran's treatment records. See Owens, supra. Moreover, while the Veteran's treatment records document her complaints and treatment for right knee problems, the Board finds that above VA examiners ranges of motion are not contradicted by any other medical evidence of record because treatment records never document less flexion in the right knee. Id. Furthermore, the Board finds that the Veteran is not qualified to provide range of motion findings in the right knee because these are medical findings. See Davidson, supra. Therefore, the Board finds that the criteria for a rating in excess of 10 percent for the right knee lost flexion under Diagnostic Code 5260 are not met at any time during the pendency of the appeal. See 38 C.F.R. §§ 4.2, 4.3, 4.7, 4.71a; Hart, supra; Fenderson, supra. As to a higher rating and/or a separate compensable rating for the right knee disorder characterized as lost flexion under Diagnostic Code 5261 and VAOPGCPREC 9-2004 due to lost extension, the Board finds that even when considering functional limitations due to pain with and without weight bearing and resistance in passive and active range of motion as well as during flare-ups and the other factors identified in 38 C.F.R. §§ 4.40, 4.45, 4.59 as well as the Court's holdings in Correia, Sharp, Mitchell, Burton, Southall-Norman, and DeLuca, and when considering the appellant's competent reports of her observable adverse symptomatology (see Davidson, supra), her functional losses do not equate to the criteria required for at least a 10 percent rating at all times during the pendency of the appeal. See Owens, supra. The Board has reached this conclusion because extension of the right knee is not limited to the 10 degrees required for a compensable rating at all times during the appeal because it was 0 degrees at the January 2014, June 2014, May 2015, September 2016, February 2018, July 2019, and March 2020 VA examinations. See Colvin, supra. Moreover, while the Veteran's treatment records document her complaints and treatment for right knee problems (this is not in dispute: if she did not have right knee problems there would be, by definition, no basis for the current ratings it would be unusual for the Veteran to not have treatment for this problem), the Board finds that above examiners range of motion finding are not contradicted by any other medical evidence of record because treatment records never document less extension in the right knee. Id. Furthermore, the Board finds that the Veteran is not qualified to provide range of motion findings in the right knee because these are medical findings. See Davidson, supra. Therefore, the Board finds that the criteria for an increased rating as well as a separate compensable rating for the right knee disorder due to lost extension under Diagnostic Code 5261 are not met at any time during the pendency of the appeal. See 38 C.F.R. §§ 4.2, 4.3, 4.7, 4.71a; Hart, supra; Fenderson, supra. As to a higher evaluation for the Veteran's the right knee disorder characterized as lost flexion under Diagnostic Code 5256 due ankylosis, the Board finds that even when considering the Veteran's reports of pain as per 38 C.F.R. §§ 4.40, 4.45, 4.59 and the Court's holding in Correia, Sharp, Mitchell, Burton, Southall-Norman, DeLuca, and Chavis, as well as when considering her competent reports of observable adverse symptomatology (see Davidson, supra), the knee does not meet the criteria for a higher rating by rating it as ankylosis. See Owens, supra. The Board has reached this conclusion because the record is uniform in documenting at least some right knee motion and ankylosis is defined as immobility and consolidation of a joint due to disease, injury, or surgical procedure. See Lewis v. Derwinski, 3 Vet. App. 259 (1992); Also see Owens, supra. In fact, the VA examiners in May 2015, September 2016, February 2018, July 2019, and March 2020 opined that the right knee is not ankylosed and these medical opinions are not contradicted by any other medical evidence of record. See Colvin, supra. Moreover, the Board finds that the Veteran is not competent to provide the missing diagnosis of ankylosis because this is a medical finding. See Davidson, supra. Consequently, the Board finds that a higher evaluation is not warranted for the Veteran's service-connected right knee disorder characterized as lost flexion by rating by analogy to ankylosis under Diagnostic Code 5256 at any time during the pendency of the appeal. See 38 C.F.R. § 4.71a; Fenderson, supra; Hart, supra. As to higher evaluations for the Veteran's the right knee disorder characterized as lost flexion under Diagnostic Code 5258 for symptomatic removal of semilunar cartilage, Diagnostic Code 5259 for removal of the semilunar cartilage when symptomatic, under Diagnostic Code 5262 for impairment of the tibia and fibula, and/or under Diagnostic Code 5263 for Genu recurvatum, the Board finds that the right knee disorder does not include any of the above adverse symptomatology and/or the 10 percent rating already assigned meets the maximum rating possible under these Diagnostic Codes. See 38 C.F.R. § 4.71a; Also see VA examinations dated in January 2014, June 2014, May 2015, September 2016, February 2018, July 2019, and March 2020; Colvin, supra. In fact, the May 2015 and September 2016 VA examiners specifically opined that the Veteran did not have recurrent patellar dislocation, "shin splints" (medial tibial stress syndrome), stress fractures, chronic exertional compartment syndrome or any other tibial and/or fibular impairment and these medical opinions are not contradicted by any other medical evidence of record. Id. Therefore, the Board finds that an increased rating under these criteria is not warranted at any time during the pendency of the appeal. See 38 C.F.R. § 4.71a; Butt's, supra; Hart, supra; Fenderson, supra. In reaching all of the above conclusions, the Board has also not overlooked the claims from the Veteran regarding her adverse symptomatology. See Davidson, supra. However, the Board finds the examiners opinions as to the Veteran's adverse symptomatology more probative than the lay claims from the appellant to the contrary even though her symptomatology is observable by a lay person because the examiners have medical training. See Black v. Brown, 10 Vet. App. 297, 284 (1997) (in evaluating the probative value of medical statements, the Board looks at factors such as the individual knowledge and skill in analyzing the medical data). b. Right knee instability As to rating in excess of 30 percent for the right knee instability under old and new Diagnostic Code 5257, the Board notes that the disability rating already assigned the Veteran's disorder meets the maximum rating possible under this code section. See 38 C.F.R. § 4.71a. Accordingly, because the Veteran is in receipt of the maximum schedular rating (i.e., a 30 percent rating) under old and Diagnostic Code 5257, the Board finds that there is no legal basis for assignment of a higher scheduling rating at any time during the appeal and the claim is denied. See 38 C.F.R. § 4.71a; Butt's, supra; Hart, supra; Fenderson, supra; Sabonis, supra. c. Left knee status post total knee replacement As to a rating in excess of 30 percent for the left knee disorder, status post total right knee replacement, under old and new Diagnostic Code 5055, the Board notes that the Veteran has not again undergone surgery on the knee. Therefore, the Board finds that the criteria for a 100 percent rating for the left knee disorder under old and new Diagnostic Code 5055 for the 1 year/6 month period following the new surgery are not met at any she did not already have the 100 percent rating. See 38 C.F.R. §§ 4.2, 4.3, 4.7, 4.71a; Hart, supra; Fenderson, supra. As to a rating in excess of 30 percent for the left knee disorder, status post total left knee replacement, under Diagnostic Code 5055 due to severe painful motion or weakness, the Board finds that even when considering functional limitations due to pain with and without weight bearing and resistance in passive and active range of motion as well as during flare-ups and the other factors identified in 38 C.F.R. §§ 4.40, 4.45, 4.59 as well as the Court's holdings in Correia, Sharp, Mitchell, Burton, Southall-Norman, and DeLuca, and when considering the appellant's competent reports of her observable adverse symptomatology (see Davidson, supra), her functional losses do not equate severe painful motion or weakness and therefore to not meet the criteria required for a 60 percent rating at all times during the pendency of the appeal. See Owens, supra. The Board has reached this conclusion because it finds that extension of the left knee being 0 degrees and flexion, being at its worst 60 degrees, at the January 2014, June 2014, May 2015, September 2016, February 2018, and July 2019 VA examinations even when it could not be tested due to pain at the March 2020 VA examination does not equate to severe painful motion as contemplated by Diagnostic Code 5055. See Colvin, supra. In reaching this conclusion the Board finds it significant that the Veteran's subjective reports of pain that prevented range of motion studies at the March 2020 VA examination are not otherwise supported by her treatment records during the same period of time and therefore it has limited probative value. See Madden v. Gober, 125 F.3d. 1477 1481 (Fed. Cir. 1997) (holing that the Board is entitled to discount the credibility of evidence in light of its own inherent characteristics and its relationship to other items of evidence). The Board has also reached this conclusion because it finds that the January 2014, June 2014, May 2015, September 2016, February 2018, July 2019, and March 2020 VA examiners opinions that the Veteran did not have muscle atrophy and her strength being 5/5 at the 2014 to 2019 VA examinations and still 4/5 at the March 2020 VA examination does not equate severe weakness as contemplated by Diagnostic Code 5055. Id. Moreover, while the Veteran's treatment records document her complaints and treatment for left knee problems (this is not in dispute: if she did not have left knee problems there would be, by definition, no basis for the current ratings it would be unusual for the Veteran to not have treatment for this problem), the Board finds that above examiners range of motion and muscle strength findings are not contradicted by any other medical evidence of record because treatment records never document less range of motion or strength in the left knee. Id. Furthermore, the Board finds that the Veteran is not qualified to provide range of motion and strength findings in the left knee because these are medical findings. See Davidson, supra. Therefore, the Board finds that the criteria for a rating in excess of 30 percent for the left knee disorder under Diagnostic Code 5055 are not met at any time during the pendency of the appeal. See 38 C.F.R. §§ 4.2, 4.3, 4.7, 4.71a; Hart, supra; Fenderson, supra. The Board also notes that a rating under Diagnostic Code 5055 encompasses all identifiable residuals of post total knee replacement, including limitation of motion, instability, and functional impairment. The rule against pyramiding prohibits compensating twice for the same manifestations. See 38 C.F.R. § 4.14. Therefore, the Board finds that separate ratings under Diagnostic Codes 5256 through 5263 (discussed above), are not warranted for her left knee disorder, status post total knee replacement. See 38 U.S.C. § 5107; 38 C.F.R. §§ 3.102, 4.2, 4.3, 4.7, 4.71a; Fenderson, supra; Hart, supra. As to a rating in excess of 30 percent for the Veteran's left knee disorder, status post total knee replacement, under Diagnostic Code 5256 due ankylosis, the Board finds that even when considering the Veteran's reports of pain as per 38 C.F.R. §§ 4.40, 4.45, 4.59 and the Court's holding in Correia, Sharp, Mitchell, Burton, Southall-Norman, DeLuca, and Chavis, as well as when considering her competent reports of observable adverse symptomatology (see Davidson, supra), the knee does not meet the criteria for a higher rating by rating it as ankylosis. See Owens, supra. The Board has reached this conclusion because the record is uniform in documenting at least some left knee motion even though it was note tested and the March 2020 VA examination and ankylosis is defined as immobility and consolidation of a joint due to disease, injury, or surgical procedure. See Lewis v. Derwinski, 3 Vet. App. 259 (1992); Also see Owens, supra. In fact, the VA examiners in May 2015, September 2016, February 2018, July 2019, and March 2020 opined that the left knee is not ankylosed and these medical opinions are not contradicted by any other medical evidence of record. See Colvin, supra. Moreover, the Board finds that the Veteran is not competent to provide the missing diagnosis of ankylosis because this is a medical finding. See Davidson, supra. Consequently, the Board finds that a rating in excess of 30 percent for the Veteran's left knee disorder, status post total knee replacement, is not warranted by rating it by analogy to ankylosis under Diagnostic Code 5256 at any time during the pendency of the appeal. See 38 C.F.R. § 4.71a; Fenderson, supra; Hart, supra. As to a rating in excess of 30 percent for the left knee disorder, status post total knee replacement, under Diagnostic Code 5261 due to lost extension, the Board finds that even when considering functional limitations due to pain with and without weight bearing and resistance in passive and active range of motion as well as during flare-ups and the other factors identified in 38 C.F.R. §§ 4.40, 4.45, 4.59 as well as the Court's holdings in Correia, Sharp, Mitchell, Burton, Southall-Norman, and DeLuca, and when considering the appellant's competent reports of her observable adverse symptomatology (see Davidson, supra), her functional losses do not equate to the criteria required for at least a 40 percent rating at all times during the pendency of the appeal. See Owens, supra. The Board has reached this conclusion because extension of the left knee is not limited to the 30 degrees required for a 40 percent rating at all times during the appeal because it was 0 degrees at the January 2014, June 2014, May 2015, September 2016, February 2018, and July 2019 VA examinations. See Colvin, supra. In this regard, and as discussed above, the Board does not find the fact that the March 2020 VA examiner was not able to provide range of motion studies for the left knee due to subjective reports of pain probative as to the knee lost extension because her reports of pain are not otherwise supported by her treatment records during the same period of time. See Madden, supra. Moreover, while the Veteran's treatment records document her complaints and treatment for left knee problems (this is not in dispute: if she did not have left knee problems there would be, by definition, no basis for the current ratings it would be unusual for the Veteran to not have treatment for this problem), the Board finds that above examiners range of motion finding are not contradicted by any other medical evidence of record because treatment records never document less extension in the left knee. Id. Furthermore, the Board finds that the Veteran is not qualified to provide range of motion findings in the left knee because these are medical findings. See Davidson, supra. Therefore, the Board finds that the criteria for a rating in excess of 30 percent for the left knee disorder, status post total knee replacement, due to lost extension under Diagnostic Code 5261 are not met at any time during the pendency of the appeal. See 38 C.F.R. §§ 4.2, 4.3, 4.7, 4.71a; Hart, supra; Fenderson, supra. As to a rating in excess of 30 percent for the Veteran's left knee disorder, status post total knee replacement, under old and new Diagnostic Code 5262 for impairment of the tibia and fibula, the Board finds that the disorder does not include at least tibia and fibula nonunion. See 38 C.F.R. § 4.71a; Also see VA examinations dated in January 2014, June 2014, May 2015, September 2016, February 2018, July 2019, and March 2020. In fact, the knee x-ray and MRI cited to by the January 2014 and June 2014 VA examiners shows that she did not have nonunion. Similarly, the May 2015 and September 2016 VA examiners specifically opined that the Veteran did not have tibial and/or fibular impairment. See Colvin, supra. Therefore, the Board finds that a rating in excess of 30 percent under Diagnostic Code 5262 is not warranted at any time during the pendency of the appeal. See 38 C.F.R. § 4.71a; Butt's, supra; Hart, supra; Fenderson, supra. Lastly, a review of old and new Diagnostic Codes 5257, 5258, 5259, 5260, and 5263 reveals that there is no rating higher than 30 percent under these codes. Therefore, the Board finds that the Veteran is not entitled to a rating in excess of 30 percent for her left knee disorder, status post total knee replacement, under these Diagnostic Codes. See 38 U.S.C. § 5107; 38 C.F.R. §§ 3.102, 4.2, 4.3, 4.7, 4.71a; Fenderson, supra; Hart, supra. II. The Left Knee Scar The Veteran's left knee scar is rated as noncompensable under 38 C.F.R. § 4.118, Diagnostic Code 7805. Under the rating criteria that has been in effect since before the Veteran filed her claim, Diagnostic Code 7801 provides that, scars, other than the head, face, or neck, that are deep or that cause limited motion in an area or areas exceeding 6 square inches (39 sq. cm.) are rated 10 percent disabling. Scars that are deep or that cause limited motion in an area or areas exceeding 12 square inches (77 sq. cm.) are rated 20 percent disabling. Scars that are deep or that cause limited motion in an area or areas exceeding 72 square inches (465 sq. cm.) are rated 30 percent disabling. Scars that are deep or that cause limited motion in an area or areas exceeding 144 square inches (929 sq.cm.) are rated 40 percent disabling. Note (1) to Diagnostic Code 7801 provides that scars in widely separated areas, as on two or more extremities or on anterior and posterior surfaces of extremities or trunk, will be separately rated and combined in accordance with 38 C.F.R. § 4.25. Note (2) provides that a deep scar is one associated with underlying soft tissue damage. Under Diagnostic Code 7802, scars, other than the head, face, or neck, that are superficial and nonlinear that are of an area or areas of 144 square inches (929 square centimeters) or greater warrant a 10 percent disability rating. A superficial scar is not one associated with underlying soft tissue damage. See Note (1). Diagnostic Code 7804 provides that unstable or painful scars are rated as follows: 10 percent for one or two scars; 20 percent for three or four scars; and 30 percent for five or more scars. 38 C.F.R. § 4.118. Diagnostic Code 7805 directs that any other disabling effects of a scar not described in Code 7802 or 7804, are to be evaluated under an appropriate Diagnostic Code. Id. As to compensable rating for the left knee scar under Diagnostic Code 7801, the Board notes that the May 2015, September 2016, February 2018, March 2020, and August 2020 VA examinations are uniform in reporting or showing that the Veteran's scar does not cover an area or areas exceeding 6 square inches (39 sq. cm.). See Colvin, supra. Next, the Board notes that the Veteran's treatment records periodically document her complaints regarding her scar. However, the Board finds that nothing in these records shows her adverse symptomatology to be worse than what was reported by the above VA examiners because they also do not show the left knee scar covers an area or areas exceeding 6 square inches (39 sq. cm.). See Colvin, supra. Moreover, neither the Veteran nor her representative has provided VA with alternative measurements as to the area covered by the knee scar. See Davidson, supra. Therefore, the Board finds that the most probative evidence of record shows that the Veteran's left knee scar is not deep or cause limited motion in an area or areas exceeding 6 square inches (39 sq. cm.). See Owens, supra. Accordingly, the Board finds that a compensable rating is not warranted for the Veteran's left knee scar under Diagnostic Code 7801 at any time during the pendency of the appeal. See 38 C.F.R. § 4.118; Fenderson, supra; Hart, supra. As to a compensable rating for the left knee scar under Diagnostic Code 7802, the Board notes that the May 2015, September 2016, February 2018, March 2020, and August 2020 VA examinations are uniform in showing that the Veteran's left knee scar was not superficial and nonlinear that are of an area or areas of 144 square inches (929 square centimeters) or greater. See Colvin, supra. In this regard, the Board finds it significant that the May 2015 VA examiner reported that the Veteran had one left knee scar that was 16 cm long and 1 cm wide which was not painful or unstable. Similarly, the September 2016 VA examiner reported that the Veteran had one left knee scar that was 21 cm long and 1 cm wide which was well healed and superficial not painful or unstable. Likewise, in February 2018 the VA examiner opined that the Veteran had one left knee scar that was 22.5 cm long and 1.5 cm wide which was not painful or unstable. The March 2020 VA examiner opined that the Veteran had one left knee scar that was 15 cm long and 0.5 cm wide which was not painful or unstable. Furthermore, the August 2020 VA examiner opined that the Veteran had one left knee scar that was 20 cm long and 0.7 cm wide which was not painful or unstable. These medical opinions are not contradicted by the Veteran's medical treatment records or her lay claims. See Colvin, supra. Accordingly, the Board finds that a compensable rating for the left knee scar is not warranted under Diagnostic Code 7802 at any time during the pendency of the appeal. See 38 C.F.R. § 4.118; Fenderson, supra; Hart, supra. As to a compensable rating for the left knee scar under Diagnostic Code 7804, the Veteran at her personal hearing and statements in support of claim has reported, in substance, that her post operative left knee scar is painful. Moreover, the Board notes that the appellant is competent and credible to report on her observable adverse symptomatology. See Davidson, supra. However, the May 2015, September 2016, February 2018, March 2020, and August 2020 VA examinations are uniform in reporting that the Veteran had only 1 scar that was not painful or unstable. Moreover, these medical opinions are not contradicted by the Veteran's medical treatment records or her lay claims. See Colvin, supra. Specifically, while the Veteran's treatment records periodically document her complaints regarding her scar, the Board finds that nothing in these records shows her adverse symptomatology to be worse than what was reported by the above VA examiners because they also do not show she had more than one scar or that it was painful or unstable. See Colvin, supra. Given the above medical record, the Board finds the opinions by the May 2015, September 2016, February 2018, March 2020, and August 2020 VA examiners that the Veteran has only 1 none-painful and stable left knee scar more probative than the personal hearing and statements in support of claims from the Veteran and her representative to the contrary because the VA examiners have greater medical training even though pain is observable by a lay person and because the VA examiners opinions are supported by the appellant's treatment records. See Black, supra; Owens, supra. Therefore, the Board finds that the preponderance of the evidence of record shows that the Veteran's left knee scar does not meet the criteria for a compensable rating under Diagnostic Code 7804 because she does not have at least 1 or 2 painful or unstable scars. See Owens, supra. Accordingly, the Board finds that a compensable rating for the left knee scar is not warranted under Diagnostic Code 7804 at all times during the pendency of the appeal. See 38 C.F.R. § 4.118; Fenderson, supra; Hart, supra. As to a compensable rating for the left knee scar under Diagnostic Code 7805, the Board notes that the Veteran testified that it "... burns, it itches, it's like a sticking. The scar got wider. It's very unattractive. It swelled down in the lower part of my . . . knee" Moreover, the Board finds that the Veteran is competent and credible to report on her observable adverse symptomatology. See Davidson, supra. However, at the May 2015, September 2016, February 2018, March 2020, and August 2020 VA examiners were uniform in showing that the 1 scar had no adverse symptomatology. These medical findings are not contradicted by any other medical evidence of record. See Colvin, supra. Tellingly, the August 2020 VA examiner opined that the scar did not limit function. Id. Next, the Board notes that while the Veteran's treatment records periodically document her complaints regarding her left knee scar, nothing in these records shows her adverse symptomatology to be worse than what was reported by the above VA examiners. See Colvin, supra. Similarly, the Board finds the opinions by the May 2015, September 2016, February 2018, March 2020, and August 2020 VA examiners that the Veteran's scar did not have any objective adverse symptomatology more probative than any lay claims from the Veteran or her representative to the contrary because the VA examiners have greater medical training. See Black, supra. Accordingly, the Board finds that a compensable rating for the left knee scar is not warranted under Diagnostic Code 7805 at all times during the pendency of the appeal. See 38 C.F.R. § 4.118; Fenderson, supra; Hart, supra. The TDIU Claim As to the claim for a TDIU, as noted above, the Veteran TDIU claim has been pending since from February 26, 2015, (see Rice, supra.) and the RO already granted her a TDIU effective from March 30, 2016. Therefore, the sole question remaining for adjudication is whether the Veteran also met the criteria for a TDIU at any time from February 26, 2015, to March 30, 2016. See AB, supra; Fenderson, supra. In this regard, a total disability will be considered to exist when there is present any impairment of mind or body which is sufficient to render it impossible for the average person to follow a substantially gainful occupation. 38 C.F.R. § 3.340. If the total rating is based on a disability or combination of disabilities for which the Schedule for Rating Disabilities provides an evaluation of less than 100 percent, it must be determined that the service-connected disabilities are sufficient to produce unemployability without regard to advancing age. 38 C.F.R. § 3.341. If the schedular rating is less than total, a total disability evaluation can be assigned based on individual unemployability if the Veteran is unable to secure or follow a substantially gainful occupation because of a service-connected disability, provided that the Veteran has one service-connected disability rated at 60 percent or higher; or two or more service-connected disabilities, with one disability rated at 40 percent or higher and the combined rating is 70 percent or higher. In calculating if the Veteran met the above schedular criteria VA combines the Veteran's service-connected orthopedic disorders. The existence or degree of non-service-connected disabilities will be disregarded if the above-stated percentage requirements are met and the evaluator determines that the Veteran's service-connected disabilities render her incapable of substantial gainful employment. 38 C.F.R. § 4.16(a). A TDIU may be assigned where the schedular rating is less than total if a veteran is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities. 38 C.F.R. § 4.16(a). Generally, total disability will be considered to exist when there is present any impairment of mind or body that is sufficient to render it impossible for the average person to follow a substantially gainful occupation. 38 C.F.R. § 3.340. Further, marginal employment, defined as an amount of earned annual income that does not exceed the poverty threshold determined by the United States Department of Commerce, Bureau of the Census, shall not be considered substantially gainful employment. 38 C.F.R. § 4.16(a). The record shows that the Veteran was service-connected for the following disabilities from February 26, 2015, to March 30, 2016: Right knee instability rated as 30 percent disabling from November 21, 2000; Right knee lost flexion rated as 10 percent disabling with as yet no effective date; Left knee disorder, status post total knee replacement, rated as 100 percent disabling from October 9, 2014, 30 percent disabling from December 1, 2015, and 100 percent disabling from February 2, 2016; Back disability rated as 10 percent disabling from October 16, 2014, and 20 percent disabling from September 12, 2015, to February 13, 2018; and Left knee scar rated as 0 percent disabling from October 9, 2014. In summary, the Board finds that this record shows that the Veteran met the schedular requirements of 38 C.F.R. § 4.16(a)(1) to (5) from February 26, 2015, to March 30, 2016, given the fact that the service connected disabilities relate to both disabilities as well as have a common etiology. The next question for the Board to consider is when, if ever, her service-connected disabilities rendered her incapable of substantial gainful employment from February 26, 2015, to March 30, 2016. 38 C.F.R. § 4.16(a). In this regard, the Veteran's VA Form 21-8940, Veterans Application for Increased Compensation Based on Unemployability (TDIU Claim Form), dated in March 2016, August 2017, and October 2019 reported, in substance, that she had not worked full-time since May 2014 and became too disabled to work full time in May or October 2014 because of her service-connected disabilities. As to her work history, the Veteran reported that from 2002 to 2014 she worked as a farebox puller/bus driver for the Metro Trainset authority. As to her education, the Veteran reported that she had 2-years of college. As to the Veteran's being able to work performing jobs that require sedentary employment and non-sedentary employment, including her past employment as a bus driver as well as other possible employment that could make use of her work experience and 2-years of college from February 26, 2015, to March 30, 2016, the Board finds that the medical records show that the problems caused by her service-connected right knee instability and lost flexion, left knee disorder, status post total knee replacement, back disability, and left knee scar adversely impacted her ability to work in any field because of the overall impairment they had to her body and mind to include the stamina needed to work a full-day and, because of the pain, concentrate on the tasks required by employment, interact effectively with co-workers and/or customers as well as carry out the tasks required by employment. See Geib v. Shinseki, 733 F.3d 1350 (Fed. Cir. 2013) (holding that the determination of whether a Veteran is unable to secure or follow a substantially gainful occupation due to service-connected disabilities is a factual rather than a medical question and that it is an adjudicative determination properly made by the Board or the regional office). The Board also finds that her service-connected right knee instability and lost flexion, left knee disorder, status post total knee replacement, back disability, and left knee scar also would have made it dangerous for the Veteran and her co-workers for her to work in most non-sedentary employments. Id. Similarly, the Board finds that that the pain caused by her right knee instability and lost flexion, left knee disorder, status post total knee replacement, and back disability would have made it very difficult for her to work in most sedentary employments because of the problems that they would have caused in carrying out the duties required by such employment. Id. Given the above, the Board finds that the Veteran's service-connected disabilities prevented her from securing or following a "substantially gainful" occupation given her prior vocational history, work experience, and the impact her service-connected right knee instability and lost flexion, left knee disorder, status post total knee replacement, back disability, and left knee scar have on obtaining and maintaining substantially gainful non-sedentary employment and sedentary employment, including in her past employment as a bus driver, because of the problems they would cause in any work environment from February 26, 2015, to March 30, 2016. Further development of this issue is simply not warranted in light of the history of this case. Therefore, the Board concludes that the most probative evidence of record shows that the Veteran's service-connected disabilities rendered her incapable of substantial gainful employment given her prior vocational history, work experience, and the impact her service-connected disabilities have on all employment from February 26, 2015, to March 30, 2016, and the claim for a TDIU is granted for this time period. See 38 U.S.C. § 510738 C.F.R. §§ 3.102, 4.16(a). Conclusion In reaching all of the above conclusions, the Board has also not overlooked the claims from the Veteran regarding her observable symptomatology. See Davidson, supra. However, the Board finds the examiners opinions as to the severity of the Veteran's adverse symptomatology more probative than the lay claims from the appellant to the contrary even though her symptomatology is observable by a lay person because the examiners have medical training. See Black, supra. In reaching all the above conclusions, the Board considered the doctrine of reasonable doubt. 38 U.S.C. § 5107(b). However, as the preponderance of the evidence is against the claims to the extent outlined above, the Board finds that the doctrine is not for application. See also, e.g., Ortiz, supra; Lynch, supra. REASONS FOR REMAND Initially, and as discussed above, the record shows that the Veteran will be in receipt of a TDIU at all times since February 26, 2015, due to problems related to her four months of active duty training. Therefore, while the below issues are in remand status the Veteran may wish to consider withdrawing these issues after consultation with her representative. Entitlement to service connection for a left hand disorder as well as the claims for higher ratings for the back disability are remanded. As to the claims of service connection for a left hand disorder as well as the claims for higher ratings for the back disability, the JMPR vacated and remanded the September 2019 Board decision because of the following reasons: As to the left hand disorder, "... because the March 2016 VA examiner noted that a diagnosis could not be provided based on the available 'medical documentation,' and no addendum opinion was subsequently provided..." after the RO associated with the record "... an orthopedist [record dated] in April 2016 and an MRI that showed 'a very small ganglion 5mm at the base of her left thumb;'" As to the claims for higher ratings for the back disability, the February 2018 VA examination was not adequate because the examiner did not have the claims file and therefore could not take into account the Veteran's prior lay statements when opining as to the severity of her disability; and As to the claims for higher ratings for the back disability, the September 2015 VA examination was not adequate because it did not take into account the Court's holding in Sharp, supra, because it did not provide range of motion studies that took into account the Veteran's reports of flare-ups, Therefore, and notwithstanding the fact that the Court did not issue Sharp until 2017 (i.e., 2 years after the 2015 VA examination), the Board finds that these issues need to be Remanded to provide the Veteran with new VA examinations that address the above concerns raised in the JMPR. See 38 U.S.C. § 5103A(d); Forcier v. Nicholson,19 Vet. App. 414, 425 (2006) (holding that the duty to ensure compliance with the Court's order extends to the terms of the agreement struck by the parties that forms the basis of the joint motion to remand); cf. McBurney v. Shinseki, 23 Vet. App. 136, 140 (2009) (Board has a duty on remand to ensure compliance with the favorable terms stated in the joint motion for remand or explain why the terms will not be fulfilled); Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (holding that when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate). As to the claim of service connection for a left hand disorder, given the Veteran's personal hearing testimony regarding the left hand cyst being due to the cane she was given by VA because of the instability caused by her service-connected bilateral knee disabilities, the examiner must also provide an opinion as to this secondary service connection. See ElAmin v. Shinseki, 26 Vet. App. 136, 140-41 (2013) (holding that, when multiple theories of entitlement are at issue, the Board must ensure that the medical opinions of record directly address all theories reasonably raised by the record). Also, as to the claim of service connection for a left hand disorder, the Board notes that the Court in Ward v. Wilkie, 31 Vet. App. 233 (2019) redefined aggravation to know include temporary flare-ups. As to the claim for higher ratings for the back disability, the Board finds that while the rating claims are at the RO it needs to provide the appellant with a supplemental statement of the case (SSOC) that provide him with notice of the new musculoskeletal rating criteria and adjudicates the claims applying these criteria from there effective date of February 7, 2012. See 38 C.F.R. § 19.31 (a SSOC will be furnished to the veteran when additional pertinent evidence is received after a statement of the case has been issued); 85 Fed Reg 76453 (November 30, 2020); 85 Fed Reg 85523 (December 29, 2020); 86 Fed Reg 8142 (February 4, 2021); Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). While all these issues are Remand status, any outstanding VA and private treatment records should also be obtained and associated with the record. See 38 U.S.C. § 5103A(b). Entitlement to service connection for loss of voice including due to chronic laryngitis is remanded. As to the newly reopened claim for loss of voice including due to chronic laryngitis, the Board finds that the etiology opinion from Dr. Mussendenis not adequate to adjudicate the claims because it is not supported by clinical evidence. See Black v. Brown, 5 Vet. App. 177, 180 (1995) (holding that a medical opinion is inadequate when it is unsupported by clinical evidence). Therefore, the Board finds that a Remand to obtain an adequate opinion is needed. See 38 U.S.C. § 5103A(d); McLendon v. Nicholson, 20 Vet. App. 79, 84-86 (2006). These issues are REMANDED for the following actions: 1. After obtaining all needed authorizations from the Veteran, associate with the claims file any outstanding private treatment records. If possible, the Veteran or her representative should submit and new pertinent evidence the Board/VA does not have (if any). Any help with the above would be appreciated. 2. Obtain and associate with the claims file any outstanding VA treatment records. 3. In order to comply with the JMPR, schedule the Veteran for a VA examination with a suitably-qualified medical professional to address the claim of service connection for a left hand disorder. The claims folder should be made available to and reviewed by the examiner. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. Following consideration of the evidence of record (both lay and medical) and the results of the examination, the examiner is asked to address the following: a. Provide diagnoses for all left hand disorders. b. As to each diagnosed left hand disorder, including the cyst seen on the MRI, provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that it was caused by a disease or injury while on active duty or an injury while serving on inactive duty for training with a Reserve Component. c. Provide an opinion as to whether arthritis in the left hand manifested in the first post-service year following any period of qualifying service. d. Provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that any left hand disorder, including the cyst seen in the MRI, was caused by any of the Veteran's service connected musculoskeletal disabilities to include the need to use the cane given to her by VA because of instability caused by these musculoskeletal disabilities. e. Provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that any left hand disorder, including the cyst seen in the MRI, was, was aggravated by any of the Veteran's service connected musculoskeletal disabilities to include the need to use the cane given to her by VA because of instability caused by these musculoskeletal disabilities. In providing answers to the above questions, the examiner should consider and discuss all the pertinent service treatment records. In order to comply with the JMPR, in providing answers to the above questions the examiner should consider and discuss the Veteran's competent lay claims regarding observable symptomatology. In providing answers to the above questions, the examiner should not rely solely on negative evidence. In providing answers to the above questions, the examiner is advised that the term "at least as likely as not" does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of conclusion as it is to find against it. In providing answers to the above questions, the examiner is advised that the Court held in Ward, supra, that a "permanent worsening" of a non-service-connected disability is not required to establish secondary service connection on the basis of aggravation (i.e., aggravation may include temporary worsening of a disability). In answering all questions, please articulate the reasoning underpinning your conclusions. That is, (1) identify what facts and information--whether found in the record or outside the record--support your opinion, and (2) explain how that evidence justifies your opinion. If the examiner cannot respond to an inquiry without resort to speculation he or she should so state, and must further explain why it is not feasible to provide a medical opinion, indicating whether the need to speculate is caused by a deficiency in the state of general medical knowledge (i.e. no one could respond given medical science and the known facts) or by a deficiency in the record or in the examiner (i.e. additional facts are required, or the examiner does not have the needed knowledge or training). 4. Schedule the Veteran for a VA examination with a suitably-qualified medical professional to address the claim of service connection for loss of voice including due to chronic laryngitis. The claims folder should be made available to and reviewed by the examiner. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. Following consideration of the evidence of record (both lay and medical) and the results of the examination, the examiner is asked to address the following: a. Provide diagnoses for all disorders. b. As to each diagnosed disorder, provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that it was caused by a disease or injury while on active duty or an injury while serving on inactive duty for training with a Reserve Component. In providing answers to the above questions, the examiner should consider and discuss all the pertinent service treatment records including those documenting treatment for laryngitis. In providing answers to the above questions the examiner should consider and discuss the Veteran's competent lay claims regarding observable symptomatology to include having a deeper voice since yelling and had laryngitis in service. In providing answers to the above questions the examiner should consider and discuss Dr. Mussendenis November 2018 opinion. In providing answers to the above questions, the examiner should not rely solely on negative evidence. In providing answers to the above questions, the examiner is advised that the term "at least as likely as not" does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of conclusion as it is to find against it. In answering all questions, please articulate the reasoning underpinning your conclusions. That is, (1) identify what facts and information--whether found in the record or outside the record--support your opinion, and (2) explain how that evidence justifies your opinion. If the examiner cannot respond to an inquiry without resort to speculation he or she should so state, and must further explain why it is not feasible to provide a medical opinion, indicating whether the need to speculate is caused by a deficiency in the state of general medical knowledge (i.e. no one could respond given medical science and the known facts) or by a deficiency in the record or in the examiner (i.e. additional facts are required, or the examiner does not have the needed knowledge or training). 5. In order to comply with the JMPR, schedule the Veteran for a VA examination with a suitably-qualified medical professional to address the severity of her back disability since February 26, 2015. The claims folder should be made available to and reviewed by the examiner. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. Following consideration of the evidence of record (both lay and medical) and the results of the examination, the examiner is asked to address the following: (a) The examiner should identify all back pathology found to be present. (b) The examiner should conduct all indicated tests and studies, to include range of motion studies. (c) In order to comply with Correia, supra, the back should be tested in both active and passive motion, in weight-bearing and non-weight-bearing and range of motion estimates should be provided. The examiner should describe any pain, weakened movement, excess fatigability, instability of station and incoordination present. (d) In order to comply with the JMPR and Sharp, supra, the examination should identify the back range of motion during a period of flare-up. If the examination is taking place during a flare-up, the examiner should provide range of motion estimates in both active and passive motion, in weight-bearing and non-weight-bearing during the flare-up. If the examination is NOT taking place during a flare-up, the examiner should ask the Veteran to describe the flare-ups she experiences, including the following: frequency, duration, characteristics, precipitating and alleviating factors, severity and/or extent of functional impairment she experiences during a flare-up of symptoms and/or after repeated use over time. Based on the Veteran's lay statements and the other evidence of record, the examiner should provide an opinion estimating any additional degrees of back flexion, extension, side to side bending, and rotation caused by functional loss during a flare-up and after repeated use over time. (e) Based on the Veteran's range of motion studies, the examiner should also provide an opinion as to whether the lost motion equates to ankylosis. (f) The examiner should also state the number of weeks of incapacitating episodes caused by the back disability in each 12-month period during the pendency of the appeal. (g) The examiner should state the nature, extent, and severity of any loss of sphincter and bladder control caused by the service-connected back disability. If the examiner cannot provide any the above range of motion estimates without resorting to speculation, the examiner should state whether the need to speculate is caused by a deficiency in the state of general medical knowledge (i.e., no one could respond given medical science and the known facts) or by a deficiency in the record or the examiner (i.e., additional facts are required, or the examiner does not have the needed knowledge or training). If the examiner cannot provide any of the range of motion estimate without resorting to speculation because of a deficiency in the record or the examiner, all appropriate steps should be taken to correct the deficiency. In providing the opinions the examiner should consider the Veteran's competent lay claims regarding observable symptomatology. In answering all questions, please articulate the reasoning underpinning your conclusions. That is, (1) identify what facts and information--whether found in the record or outside the record--support your opinion, and (2) explain how that evidence justifies your opinion. 5. After undertaking the above development, the RO should issue the Veteran a SSOC that, among other things, provides the appellant with notice of the new musculoskeletal Diagnostic Codes. See 85 Fed Reg 85523 (December 29, 2020); 86 Fed Reg 8142 (February 4, 2021). John J. Crowley Veterans Law Judge Board of Veterans' Appeals Attorney for the Board N.T. Werner, 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.