Citation Nr: 22015356 Decision Date: 03/17/22 Archive Date: 03/17/22 DOCKET NO. 13-09 949 DATE: March 17, 2022 ISSUES 1. Entitlement to a disability rating in excess of 10 percent for a left knee disability (previously instability) prior to July 13, 2021 and 20 percent thereafter. 2. Entitlement to an increased disability rating in excess of 10 percent for residuals of right tibia fractures. 3. Entitlement to an increased disability in excess of 10 percent for a left ankle strain prior to July 13, 2021 and 20 percent thereafter. 4. Entitlement to a disability rating in excess of 10 percent for left lower extremity radiculopathy prior to August 6, 2020 and 40 percent thereafter. 5. Entitlement to a combined schedular disability rating in excess of 90 percent. ORDER Entitlement to a disability rating in excess of 10 percent for a left knee disability prior to July 13, 2021 and 20 percent thereafter is denied. Entitlement to a disability rating of 20 percent, but no higher, for residuals of a right tibia fractures is granted, subject to the laws and regulations governing the payment of monetary benefits. For the period prior to July 13, 2021, entitlement to a disability rating of 20 percent rating, but no higher, for a left ankle disability is granted, subject to the laws and regulations governing the payment of monetary benefits. For the period from July 13, 2021, a disability rating in excess of 20 for a left ankle disability is denied. For the period prior to August 6, 2020, entitlement to a disability rating of 40 percent, but no higher, for left lower extremity radiculopathy is granted, subject to the laws and regulations governing the payment of monetary benefits. From August 6, 2020 forward, entitlement to a disability rating in excess of 40 for left lower extremity radiculopathy is denied. A combined disability rating in excess of 90 percent is granted from August 18, 2008. FINDINGS OF FACT 1. Prior to July 13, 2021, the Veteran's left knee disability was manifested by limitation of flexion to no more than 70 degrees and limitation of extension limited to 0 degrees. 2. From July 13, 2021, the Veteran's left knee disability has been manifested by flexion limited to no less than 95 degrees and extension to 15 degrees. 3. Throughout the increased rating period on appeal, the probative evidence of record shows that the residuals of the Veteran's right tibia fractures are manifested by moderate, but not marked ankle disability. 4. Throughout the appeal period, the Veteran's left ankle disability has been manifested by marked limitation of motion, but not ankylosis. 5. Prior to August 6, 2010, the Veteran's left lower extremity radiculopathy is manifested by symptoms that more nearly approximate moderate incomplete paralysis of the sciatic nerve. 6. From August 6, 2020, the Veteran's left lower extremity radiculopathy is not manifested by symptoms that more nearly approximate severe incomplete paralysis of the sciatic nerve. 7. Given the grant of benefits herein, the Veteran's combined rating exceeds 90 percent from August 18, 2008. CONCLUSIONS OF LAW 1. Prior to July 13, 2021, the criteria for a disability rating in excess of 10 percent for a left knee disability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.321, 4.40, 4.71a Diagnostic Code (Code) 5010-5261. 2. From July 13, 2021, the criteria for a disability rating in excess of 20 percent for a left knee disability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.321, 4.40, 4.71a, Diagnostic Code (Code) 5010-5261. 3. Resolving reasonable doubt in favor of the Veteran, the criteria for a 20 percent disability rating for the residuals of a right tibia stress fracture have been met for the entire period on appeal. 38 U.S.C. §§ 1155, 5103(a), 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code (DC) 5262. 4. For the period prior to July 13, 2021, the criteria for a disability rating of 20 percent for a left ankle disability have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code (DC) 5271. 5. For the period from July 13, 2021, the criteria for a disability rating in excess of 20 percent for a left ankle disability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code (DC) 5271. 6. For the period prior to August 6, 2020, the criteria for a disability rating of 40 percent, but no higher, for left lower extremity radiculopathy have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. § 4.124a, Diagnostic Code 8520. 7. For the period from August 6, 2020, the criteria for a rating in excess of 40 percent for left lower extremity radiculopathy have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. § 4.124a, Diagnostic Code 8520. 8. The Veteran's combined disability rating exceeds 90 percent from August 18, 2008. 38 C.F.R. § 4.25. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from September 1975 to March 1996. These claims come before the Board of Veterans' Appeals (Board) on appeal from May 2009 and April 2016 rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO). This appeal was last before the Board in June 2017, February 2020 and April 2021. Along with the above listed issues, the Board remanded the matter of entitlement to service connection for a right knee disability. In an August 2020 rating decision, the Veteran was granted service connection for a right knee disability, and therefore, that matter is no longer before the Board. The appeal has been returned for further appellate review. The Board also notes, in a January 7, 2021 rating decision, the Veteran was assigned a 30 percent disability rating for impairment of this left knee based on severe instability based on clear and unmistakable error. This is considered the highest schedular evaluation for impairment of the knee. In a July 2021 rating decision, the Veteran's disability rating for a left knee strain (previously rated as instability) currently rated as 10 percent disabling was increased to 20 percent disability, effective July 13, 2021. The Veteran's disability rating for a left ankle sprain currently rated as 10 percent disabling was also increased to 20 percent disability, effective July 13, 2021. In a July 2021 Supplemental Statement of the Case, the Veteran petition for entitlement to a rating in excess of 10 percent for the residuals of a right tibia fracture remained denied. Furthermore, the Veteran's petition for entitlement to a rating in excess of 10 percent prior to August 6, 2020, and 40 percent thereafter, for left lower extremity radiculopathy remained denied. Hence, the issues on appeal before the Board are as reflected on the title page of this decision. Entitlement to an initial disability rating in excess of 10 percent for a left knee disability prior to July 13, 2021 and 20 percent thereafter. The Veteran contends that a higher rating for his left knee disability is warranted. See February 4, 2010 Notice of Disagreement (NOD). The Veteran filed his claim for an increased rating August 18, 2008; therefore, the appeal period begins August 18, 2008, the date the VA received the Veteran's claim for an increased rating, plus the one-year look back. Gaston v. Shinseki, 605 F.3d 979, 982 (Fed. Cir. 2010). The Veteran's left knee disability is rated as 10 percent disabling prior to July 13, 2021 and 20 percent disabling thereafter for left knee strain under Diagnostic Code 5299-5260. The Board notes that the Veteran's left knee disability was previously rated under Diagnostic Code 5257 for left knee instability. This 10 percent rating was the minimum evaluation for painful motion. Further, as referenced in the introduction of this decision, the Veteran's left knee is separately rated as 30 percent disabling under Diagnostic Code 5257 for instability. Increased Ratings Disability ratings are determined by the application of the VA's Schedule for Rating Disabilities. 38 C.F.R. Part 4 (2018). The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during service and their residual conditions in civil occupations. 38 U.S.C. § 1155 (West 2014); 38 C.F.R. §§ 3.321 (a), 4.1 (2018). It is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified. Findings sufficient characteristic to identify the disease and the disability therefrom are sufficient; and above all, a coordination of rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21 (2018). Where there is a question as to which of two ratings shall be applied, the higher rating 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 (2018). The rating of the same disability under various diagnoses is to be avoided. 38 C.F.R. § 4.14 (2018). However, that does not preclude the assignment of separate ratings for separate and distinct symptomatology where none of the symptomatology justifying a rating under one diagnostic code is duplicative of or overlapping with the symptomatology justifying a rating under another diagnostic code. Esteban v. Brown, 6 Vet. App. 259 (1994). In all claims for an increased disability rating, VA has a duty to consider the possibility of assigning staged ratings. See Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Where the evidence contains factual findings that demonstrate distinct time periods in which the service-connected disability exhibited diverse symptoms meeting the criteria for different ratings during the course of the appeal, the assignment of staged ratings is necessary. Musculoskeletal system Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. It is essential that the examination on which ratings are based adequately portrays the anatomical damage, and the functional loss, with respect to those elements. Functional loss may be due to pain, supported by adequate pathology and evidenced by the visible behavior of the Veteran undertaking the motion. Weakness is as important as limitation of motion, and a part which becomes painful on use must be regarded as seriously disabled. 38 C.F.R. § 4.40 (2018). The rating of a service-connected disability involving a joint rated on limitation of motion requires adequate consideration of functional loss due to pain and functional loss due to weakness, fatigability, incoordination, or pain on movement of a joint. 38 C.F.R. §§ 4.40, 4.45 (2018). Knee and Leg Under Diagnostic Code 5260, used for rating limitation of flexion of a knee, a 10 percent rating is warranted for knee flexion limited to 45 degrees. A 20 percent rating is warranted for knee flexion limited to 30 degrees. A maximum 30 percent rating is warranted for knee flexion limited to 15 degrees. 38 C.F.R. § 4.71a, DC 5260 (2018). With regard to limitation of extension, a 10 percent rating is warranted for knee extension limited to 10 degrees. A 20 percent rating is warranted for knee extension limited to 15 degrees. A 30 percent rating is warranted for knee extension limited to 20 degrees. A 40 percent rating is warranted for knee extension limited to 30 degrees. A maximum 50 percent rating is warranted for knee extension limited to 45 degrees. 38 C.F.R. § 4.71a, DC 5261 (2018). Separate ratings under Diagnostic Code 5260 for limitation of flexion of the leg and Diagnostic Code 5261 for limitation of extension of the leg may be assigned for disability of the same joint, but only where the criteria for a compensable rating are met under each Diagnostic Code. VAOGCPREC 9-2004 (2004), 69 Fed. Reg. 59,990 (2004). A claimant who has arthritis or limitation of motion and instability of a knee may be rated separately under Diagnostic Codes 5003 and 5257. However, any separate rating must be based on additional disabling symptomatology that meets the criteria for a compensable rating. VAOPGCPREC 23-97 (1997), 62 Fed. Reg. 63,604 1997); VAOPGCPREC 9-98 (1998), 63 Fed. Reg. 56,704 (1998). Under Diagnostic Code 5257 (Knee, other impairment of), recurrent subluxation or lateral instability of the knee that is slight warrants a 10 percent rating; that is moderate warrants a 20 percent rating; and that is severe warrants a 30 percent rating. Other diagnostic codes relating to the knee are Diagnostic Codes 5256 (ankylosis), 5257 (instability), 5258 and 5259 (symptomatic dislocation or removal of semilunar cartilage), 5262 (impairment of the tibia and fibula) and 5263 (genu recurvatum). DC 5258 contemplates a maximum 20 percent rating for dislocated semilunar cartilage (meniscus) with frequent episodes of locking, pain, and effusion into the joint. DC 5257 and DC 5258-9 both contemplate disabilities of the knee manifested by instability. DC 5257 contemplates impairment of the knee manifested by recurrent subluxation or lateral instability. Where instability is severe, moderate and slight, disability evaluations of 30, 20, and 10 are assigned, respectively. Under DC 5259, a maximum 10 percent rating is assigned for removal of semilunar cartilage which is symptomatic. That is, there are two requirements for a compensable rating under DC 5259. First, the semilunar cartilage or meniscus must have been removed. Second, it must be symptomatic. Looking to the plain meaning of the terms used in the rating criteria, "symptomatic" means indicative, relating to or constituting the aggregate of symptoms of disease. STEDMAN'S MEDICAL DICTIONARY, 1743 (27th ed., 2000). A symptom is any morbid phenomenon or departure from the normal in a structure, function, or sensation, experienced by a patient and indicative of disease. Id. at 1742. Thus, DC 5259's second requirement of being "symptomatic" is broad enough to encompass all symptoms, including instability. DC 5258 contemplates a maximum 20 percent rating for dislocated semilunar cartilage (meniscus) with frequent episodes of locking, pain, and effusion into the joint. Amendments During the pendency of this claim, the criteria for rating disabilities of the musculoskeletal system in the VA Schedule for Rating Disabilities was revised effective February 7, 2021. The February 7, 2021 amendments did not result in changes to DCs 5256, 5258, 5259, 5260, 5261, or 5263. Significant changes were made to DC 5257. Accordingly, there are essentially two sets of criteria, the earlier criteria and the current criteria. The Board may not apply a current regulation prior to its effective date unless the regulation explicitly provides otherwise, and thus may not apply the current rating criteria prior to its February 7, 2021 effective date. See VAOPGCPREC 7-2003 (Nov. 19, 2003); Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003) (overruling Karnas v. Derwinski, 1 Vet. App. 308 (1991) to the extent it conflicts with the precedents of the United States Supreme Court and the Federal Circuit). However, this rule does not prohibit the Board from applying the earlier criteria to the period on or after the effective dates of the new rating criteria if the prior versions were in effect during the pendency of the appeal, as is the case here. Therefore, the Board may evaluate the Veteran's ankle and knee disabilities under the earlier diagnostic codes and the current diagnostic codes, as of their effective dates, in order to determine which version would afford the highest rating. DC 5003 provides that when limitation of motion is noncompensable under the appropriate code or codes, a rating of 10 percent may be applied to each major joint or group of minor joints affected by limitation of motion. Such limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. If there is no limitation of motion, a 10 percent rating will be assigned where there is x-ray evidence of involvement of two or more major joints or minor joint groups, and a 20 percent rating will be assigned where there is such involvement along with occasional incapacitating exacerbations. 38 C.F.R. § 4.71a, DC 5003. Disabilities can be rated under DCs 5256, 5257, 5258, 5258, 5260, 5261, 5262, and 5263. As noted above, the February 7, 2021 amendments did not result in changes to DCs 5256, 5258, 5259, 5260, 5261, or 5263. Discussion The Veteran was afforded a March 2009 VA examination to determine the severity of his left knee disability. The March 2009 examiner found: "crepitus and lateral joint line tenderness without guarding. Painful with motion. No evidence of weakness, fatigue, spasm, lack of endurance, incoordination, atrophy, tone, or decreased strength with ROM." There was full range of motion without limitations following repetitive use and instability tests were negative. See March 5, 2009 VA examination, pg. 6. In January 2016, the Veteran was afforded a Knee and Lower Leg Conditions examination to determine the severity of his left knee disability. The Veteran reported that he was not having significant issues. The Veteran denied flare-ups. The Veteran did not report functional loss or impairment, including with respect to repeated use over time. See January 5, 2016 Knee and Lower Leg Conditions examination, pg. 2 Upon physical examination the Veteran's range of motion was limited to 120 degrees flexion, but there was no limitation of extension. There was no pain with weight bearing, no objective evidence of localized tenderness or pain on palpitation of the joint or associated soft tissue, or objective evidence of crepitus. There was no additional loss of function after observed repetitive use or after repeated use over time. No flare ups were recorded. Id. at pgs. 3-4. Muscle strength was 5 out of 5. There was no muscle atrophy. There was no ankylosis. Id. at 5. The examiner found no history of recurrent subluxation or lateral instability. Joint stability testing was negative. Id. at 6-7. The Veteran was noted to regularly use canes and braces. The examiner explained the cane was for the Veteran's service-connected back disability, and the brace was for the left ankle disability. Id. at 8. The Board remanded the matter again in February 2020 to afford the Veteran a new VA examination in compliance with Correia v. McDonald, 28 Vet. App. 158 (2016). Pursuant to the Board's February 2020 remand, the Veteran was afforded an August 2020 Knee and Lower Conditions examination to determine the severity of his left knee disability. In this examination, the Veteran denied flare-ups. The Veteran had left knee range of motion limited to 70 degrees flexion. There was no loss of range of motion on extension. There was pain noted on rest/non-movement with flexion and extension. The report documented no objective evidence of localized tenderness or pain on palpitation of the join or associated tissue. See August 6, 2020 Knee and Lower leg Condition examination, pgs. 4-6. There was evidence of pain with weight bearing and crepitus. There was no additional los of motion after repetitive use testing. The examiner found pain, weakness, and fatigue limited functional ability with repeated use over a period of time but noted that this did not result in any additional loss in range of motion. Id. at pgs. 6-7. No flare ups were recorded. The examiner reported that the examination is medically consistent with the Veteran's statements describing functional loss during flare ups. The examiner reported that pain, weakness, fatigability or incoordination did not significantly limit functional ability with flare ups. The examiner estimated there was no additional loss in range of motion (flexion limited to 70 degrees and extension, 0 degrees.) Id. at 8-9. Muscle strength testing was 5/5. Id. at 9. There was no ankylosis. Id. at 10. The examiner found moderate history of recurrent subluxation and lateral instability. The results of the anterior and instability tests were normal, while the results of the medial and lateral instability tests revealed a value of 3+. Id. at 11-12. The Veteran reported constant use of a cane and braces for his bilateral knee and ankle conditions. Passive range of motion testing was the same as active range of motion. Id. at 17. As referenced above, based upon the findings of the August 2020 examiner, the RO granted the Veteran a separate disability rating for his left knee based upon instability in a January 7, 2021 rating decision. The RO assigned a rating of 30 percent for severe instability of the left knee and set an effective date of August 6, 2020, the day of the VA examination. Pursuant to the Board's April 2021 Remand directives, the Veteran was afforded a July 13, 2021 Knee and Lower Leg examination to determine the severity of his knee disability and to obtain a retrospective medical opinion as to the nature and severity of the Veteran's knee instability prior to August 6, 2020. At this July 2021VA examination, the Veteran's diagnosis of left knee strain and left knee instability was confirmed. Id. at 2. The Veteran endorsed buckling and pain with walking. The Veteran denied flare-ups. July 13, 2021 Knee and Lower Leg examination, pg. 3. The Veteran reported functional loss as difficulty with standing or walking more than 5 minutes. Id. at 4. Initial range of motion revealed flexion to 100 degrees, extension to 10 degrees with pain noted on flexion and extension. Pain was noted with weight-bearing, active and passive range of motion which causes functional loss described as difficulty with standing or walking more than 5 minutes. Id. at 7. Repetitive use testing: The Veteran was able to perform repetitive use testing after three repetitions, with additional loss of function after three repetitions. Range of motion after three repetitions revealed flexion to 95 degrees, extension to 15 degrees with pain to cause this functional loss. Id. at 8. Repetitive use over time: The examiner estimated that there was no additional functional loss after repeated use over time: flexion to 95 degrees, extension to 15 degrees. Id. at 10. The examiner described additional factors contributing to disability as difficulty with standing or walking greater than 5 minutes. There was no muscle atrophy. Id. at 12. There was no ankylosis. There was no recurrent subluxation or persistent instability. The examiner reported an incomplete partial ligament tear. Id. at 13. There was no recurrent patellar instability. The examiner reported that the Veteran utilized a cane for an assistive device for the left knee. Id. at pgs. 13-14 & 17. The Veteran was not diagnosed with recurrent patellar dislocation, shin splints (medial tibial stress syndrome), stress fractures, or any other tibial or fibular impairment, no meniscal conditions. Id. at 15-16. Addressing the Veteran left knee disability (instability) prior to August 6, 2020, the July 2021 examiner reported in a retrospective medical opinion that the Veteran left knee disability prior to August 6, 2020 was mild. The examiner explained that the Veteran had a left knee strain with no signs of ligamental instability. The examiner explained that on January 5, 2016, the Veteran's left knee extension/flexion was found to be 0 to 120 degrees. See July 13, 2021, Medical Opinion, pg. 5. The examiner added that at today's examination, the Veterans left knee active and passive range of motion was as follows: extension/flex was found to be 10 to 100 degrees. The examiner explained that the Veteran's left knee strain has progressed to a significant reduction in range of motion. The examiner reported that there is no new diagnosis, but definitely a worsened knee strain. Id. at 5. Additional treatment records do not show any evidence that would warrant higher or separate ratings other than what ratings for the Veteran has already been assigned for his left knee disability. Analysis In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive and provide the reasons for its rejection of any material evidence favorable to the claimant. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Based on the evidence of record, the Board concludes that a higher disability rating in excess of 10 percent is not warranted based on limitation of motion for the period prior to July 13, 2021. The Board finds that the persuasive evidence of records demonstrates at worst, with consideration of pain, that the Veteran's left knee flexion was limited to 70 degrees and extension was to 0 degrees. See August 6, 2020 Knee and Lower leg Condition examination, pgs. 4-5 re: range of motion testing. Accordingly, a higher rating is not warranted for his left knee strain during this period as his left knee flexion is not limited to 30 degrees, which would warrant a 20 percent rating. See Code 5260. The Board also notes that in the July 2021 Addendum opinion, after review of the Veteran's medical history and treatment records, the examiner determined that the Veteran's left knee disability prior to August 6, 2020 was best characterized as mild. See July 13, 2021, Medical Opinion, pg. 5. The July 2021 examiner explained that the Veteran had a left knee strain with no signs of ligamental instability. Second, the examiner further explained that on January 5, 2016, the Veteran's left knee extension/flexion was found to be 0 to 120 degrees. Id. at pg. 5. The Board recognizes the Veteran has described left knee instability, to include buckling, and falling throughout the period on appeal; however, the Veteran has already been assigned a separate rating that contemplates his left knee instability under DC 5257. Further, as outlined above, the July 2021 examiner characterized the Veteran's left knee disability (instability) prior to August 6, 2020 as mild. The examiner explained that the Veteran had a left knee strain with no signs of ligamental instability. For the period from July 13, 2021, the evidence demonstrates flexion to 95 degrees at worst, and extension to 15 degrees, with repetitive use over time. See, July 13, 2021 Knee and Lower Leg examination, pgs. 8-10. As such, a disability rating in excess of 20 percent is not warranted based upon limitation of extension, and a compensable disability rating is not warranted based upon limitation of flexion of the left knee. Critically, functional loss must be rated under the diagnostic code pertaining to limitation of motion of the affected joint, pursuant to 38 C.F.R. § 4.40; Schafrath v. Derwinski, 1 Vet. App. 589, 592 (1991) (noting that functional loss due to pain is to be rated at the same level as where motion is impeded); DeLuca v. Brown, 8 Vet. App. 202, 205-06 (noting that the disabling effect of painful motion must be considered when rating joint disabilities) (1995); Mitchell v. Shinseki, 25 Vet. App. 32, 37 (2011) (stating that functional loss caused by pain must be rated at the same level as if that functional loss were caused by some other factor that actually limited motion)); c.f., Petitti v. McDonald, 27 Vet. App. 415 (2015). Hence, there is no basis upon which to find additional limitation due to functional factors. See 38 C.F.R. §§ 4.40, 4.45; DeLuca, 8 Vet. App. at 202; Mitchell, 25 Vet. App. at 32. As indicated above, the Veteran's functional impairment and impaired motion during flare-ups is contemplated in the assigned disability ratings. The Board also notes that the Veteran denied flare-ups on examination. See e.g., August 6, 2020 Knee and Lower leg Condition examination, pgs. 4-5; See also, July 13, 2021 Knee and Lower Leg examination, pg. 3. The evidentiary record does not suggest nonunion or malunion of the tibia and fibula or genu recurvatum of the right knee. As such, separate disability ratings under Diagnostic Codes 5262 and 5263 are not warranted. Further, the Veteran has not exhibited ankylosis of the right knee. Hence, a separate rating under Diagnostic Code 5256 is not warranted. Additionally, no examiner has indicated that the Veteran had a left knee meniscal condition and neither dislocation nor removal of semilunar cartilage is shown in the record. Thus, a separate rating under Diagnostic Codes 5258 or 5259 is not warranted. In summary, the Board finds for the period prior July 13, 2021, the Veteran's left knee disability was manifested by limitation of flexion to no more than 70 and limitation of extension limited to 0 degrees. See August 6, 2020 Knee and Lower leg Condition examination, pgs. 4-5 re: range of motion testing. From the period of July 13, 2021, the Veteran's left knee disability has been manifested by flexion limited to no less than 95 degrees and extension to 15 degrees. See, July 13, 2021 Knee and Lower Leg examination, pgs. 8-10. All potentially applicable Diagnostic Codes have been considered. See Schafrath v. Derwinski, 1 Vet. App. 589, 593 (1991). Accordingly, the Board finds the probative evidence of record is persuasively against the claim. As there is not an approximate balance of positive and negative evidence, the benefit-of-the-doubt doctrine is not applicable and the claim for entitlement to a disability rating in excess of 10 percent prior to July 13, 2021 and 20 percent thereafter for a left knee disability is denied. See 38 U.S.C. § 5107(b). Entitlement to a rating in excess of 10 percent for residuals of right tibia fractures. The Veteran contends that he is entitled to a higher rating for the residuals of a right tibia fracture. In his February 2010 Notice of disagreement, the Veteran argued that he was entitled to a higher disability rating because he wore a brace and experienced instability and continuing, daily pain, resulting in an abnormal gait. The Veteran's right tibia fracture is rated under 38 C.F.R. § 4.71a, DCs 5271-5262. Hyphenated diagnostic codes are used when a rating under one Diagnostic Code requires use of an additional diagnostic code to identify the basis for the evaluation assigned. See 38 C.F.R. § 4.27 Under DC 5262, a 10 percent disability rating is warranted for malunion of the tibia and fibula with slight knee or ankle disability; a 20 percent disability rating is warranted for malunion of the tibia and fibula with moderate knee or ankle disability; a 30 percent disability rating is warranted for malunion of the tibia and fibula with marked knee or ankle disability; and a maximum schedular 40 percent disability rating is warranted for nonunion of the tibia and fibula with loose motion, requiring a brace. Id. According to MERRIAM WEBSTER'S COLLEGIATE DICTIONARY 999 (11th Ed. 2007), "slight" means small in amount. "Moderate" means limited in scope or effect. "Marked" means having a distinctive or emphasized character. Discussion During the course of this appeal, the Veteran been provided with VA examinations in March 2009, January 2016, August 2020 and July 2021. In his March 2009 VA examination, physical inspection showed no lesions, deformities, erythema, ecchymosis, scars or swelling. Palpation showed crepitus slight tenderness to the medial malleolus without guarding. Painful motion was shown. The examiner diagnosed recurrent right ankle sprains status post right tibia fracture. See March 5, 2009 VA examination, pgs. 1, 7-8. The examiner reported there was no evidence of weakness, fatigue, spasm, lack of endurance, incoordination, atrophy, tone, or decreased strength with range of motion. Dorsiflexion was 20 out of 20 degrees; plantar flexion was 45 out of 45 degrees; inversion was 30 out of 30 degrees; and eversion was 20 out of 20 degrees. No additional loss of range of motion was shown by repetitions times three. There were no varus/valgus angulations of the os calcis in relation to long axis or tibia/fibula. X-ray showed no acute fracture or dislocation but did show calcaneal bone spurs. The examiner diagnosed recurrent right ankle sprains status post right tibia fracture. Id. at 7-8. In January 2016, the Veteran was afforded a new VA examination for his right tibia disability. The Veteran reported ankle rolling while walking and stated that he occasionally wore a brace. See January 5, 2016 Ankle Conditions examination, pg. 2. Upon physical examination the Veteran range of motion was limited to 10 degrees dorsiflexion, but there was no limitation of plantar flexion. There was no pain with weight bearing, no objective evidence of localized tenderness or pain on palpitation of the joint or associated soft tissue, or objective evidence of crepitus. The Veteran was not able to perform repetitive use testing with at least three repetitions. The examiner explained that range of motion was based on passive range only. The examiner reported that the Veteran has foot drop due to back condition of the right foot and is unable to move the foot actively at all. Id. at 4. While the examiner noted that weakness significantly limited functional ability with repeated use over a period of time, the examiner explained that the limiting function was due to the Veteran's service-connected back disability which was unrelated to his primary ankle joint pathology or after repeated use over time. Id. at 4 & 6. The Veteran reported flare ups during which pain and lack of endurance limited functional ability. However, the examiner was not able to able to describe this in terms of degrees of range of motion, stating: "The Veteran is examined at baseline." Id. at 5. Because this January 2016 examination was not in compliance with the Court's holding in Correia supra., the Veteran was afforded and additional examination to evaluate the severity of his right tibial fracture. In an August 2020 Ankle Conditions examination, the examiner determined that the Veteran's ankle was clinically normal. Range of motion revealed dorsiflexion to 20 degrees, with plantar flexion to 45 degrees. See August 6, 2020 Ankle Conditions examination, pg. 4. The examiner reported that no pain noted on exam or evidence of pain with weight bearing. Id. at 5. The Veteran was able to perform repetitive use testing with at least three repetitions with no additional loss of function or range of motion lost. Id. at 6. Repeated use over time: The examiner reported that the examination is medically consistent with the Veteran's statements describing functional loss with repetitive use over time. Described in terms of range of motion the examiner estimated dorsiflexion to 20 degrees, with plantar flexion to 45 degrees. Id. at 7. Flare-ups: The examiner reported that although the examination was not conducted during a flare-up, the examination is medically consistent with the Veteran's statements describing functional loss during flare-up. Described in terms of range of motion, the examiner reported dorsiflexion to 20 degrees, with plantar flexion to 45 degrees. Id. at 8. Muscle strength testing was 5/5 for dorsiflexion and plantar flexion. There was no ankylosis, no joint instability, "shin splints", stress fractures, Achilles' tendonitis, Achilles' tendon rupture, malunion of calcaneus (os calcis) or talus (astragalus), or has the Veteran had a talectomy(astragalectomy). Id. at 10-1l. The examiner reported that the Veteran uses a left ankle brace. Id. at 13. Relevant to this discussion includes an August 6, 2020 Knee and Lower Leg condition examination in the evaluation of this Veteran's right tibia fracture. In this examination, the Veteran denied flare-ups. See August 6, 2020 Knee and Lower leg Condition examination, pg. 4. The Veteran had right knee range of motion limited to 70 degrees flexion. There was no loss of range of motion of extension. There was pain noted on rest/non-movement with flexion and extension. See August 6, 2020 Knee and Lower leg Condition examination, pgs. 4-5. There was evidence of pain with weight bearing and crepitus. Id. at 5. There was no additional loss of motion after repetitive use testing. Id. at 6. The examiner found pain, weakness, and fatigue limited functional ability with repeated use over a period of time but noted that this did not result in any additional loss in range of motion. Id. at pgs. 6-7. No flare ups were recorded. The examiner reported that the examination is medically consistent with the Veteran's statements describing functional loss during flare ups. The examiner reported that pain, weakness, fatigability or incoordination did not significantly limit functional ability with flare ups. The examiner estimated there was no additional loss in range of motion (flexion limited to 70 degrees and extension, 0 degrees.) Id. at 7-8. Muscle strength testing was 5/5. There was no ankylosis. Id. 8-10. The examiner found moderate history of recurrent subluxation and lateral instability. The results of the anterior and instability tests were normal, while the results of the medial and lateral instability tests for the right knee revealed a value of 3+. Id. at 11-12. The Veteran reported constant use of a cane and braces for his bilateral knee and ankle conditions. Passive range of motion testing was the same as active range of motion. Id. at 15-16. The Veteran was afforded a July 13, 2021 Ankle Conditions examination to address the Veteran's contention of flare-ups noted in the August 2020 examination. The examiner was also requested to address whether the residuals of the Veteran's right tibia fracture no longer manifest as disability of the ankle, but rather as a right knee disability. The July 2021 Ankle Conditions examiner reported that the experienced daily flare-ups. See July 13, 2021, Ankle Conditions examination, pg. 3. Range of motion revealed dorsiflexion to 10 degrees, with plantar flexion to 40 degrees. See July 13, 2021 Ankle Conditions examination, pg. 5. Range of motion was same for passive range of motion. There was evidence on pain on weight bearing and with active and passive range of motion which causes functional loss, described as difficulty with standing or walking more than 5 minutes. Id. at 5. The Veteran was no objective evidence of crepitus. Id. at 6. The Veteran was able to perform repetitive use testing with at least three repetitions with dorsiflexion to 12 degrees, plantar flexion limited to 38 degrees and pain causing functional loss. Id. at 8. Addressing repeated use over time: The examiner reported that the estimated range of motion was based on a review of all procurable information to include the Veteran's statement on examination, case-specific evidence (to include medical treatment records when applicable and lay evidence), and the examiner's medical expertise. Described in terms of range of motion: dorsiflexion to 12 degrees, with plantar flexion to 38 degrees. Id. at 9. Flare-ups: The examiner reported that although the examination was not conducted during a flare-up, the examiner reported that estimated range of motion based on a review of all procurable information to include the Veteran's statement on examination, case-specific evidence (to include medical treatment records when applicable and lay evidence), and the examiner's medical expertise. Described in terms of range of motion: dorsiflexion to 35 degrees, with plantar flexion to 10 degrees. Id. at 10. There was no muscle atrophy. There was no ankylosis, no joint instability, "shin splints", stress fractures, Achilles' tendonitis, Achilles' tendon rupture, malunion of calcaneus (os calcis) or talus (astragalus), or has the Veteran had a talectomy(astragalectomy). Id. at 12 -14. The examiner reported that the Veteran utilizes a brace and cane for a left ankle sprain and right ankle residual pain from prior fracture. Id. at 16. Medical Opinion Addressing whether the residuals of this Veteran's right tibia fracture manifest as a right knee or right ankle disability, the July 2021 examiner reported that the distal aspects of the Veteran's right tibia and ankle co-function. The examiner reported the right ankle still has residual defects that alter gait. The examiner reported that the Veteran is dependent on an ankle brace for balance and stability. The examiner reported that the right distal tibia fracture showed reduced range of motion and significant decreased strength. See July 13, 2021 Medical Opinion, pg. 4. Analysis Upon review of the lay and medical evidence of record, and resolving reasonable doubt in favor of the Veteranwith particular consideration given to the July 2021 VA examination and medical opinion regarding the interplay between the residuals of this Veteran's right tibia fracture and right anklethe Board finds that the symptomology of this Veteran right tibia fracture (manifested by moderate ankle disability) most nearly approximates the assignment of a 20 percent disability rating. Diagnostic Code (DC) 5262. The Board finds however that the persuasive evidence of record is against a finding that the Veteran's residuals of a right tibia fracture more nearly approximate marked ankle disability, which would warrant a 30 percent disability rating under DC 5262. More to this point: Even considering the Veteran's lay reports of symptoms and noted functional loss, the degree of additional limitation reflected by the Veteran's statements would not result in symptoms more nearly approximating malunion of the tibia or fibula with marked knee or ankle disability. The Board notes at worse, dorsiflexion has been limited 20 degrees and plantar flexion to 10 degrees. See August 6, 2020 Ankle Conditions examination, pg. 8 re: range of motion during flare-ups: dorsiflexion to 20 degrees, with plantar flexion to 45 degrees at pg. 8; See also, July 13, 2021 Ankle Conditions Examination, pg. 10 re: range of motion during flare-ups, at worse: dorsiflexion to 35 degrees, with plantar flexion to 10 degrees. The Board finds that such limitation represents, at worst, right tibia fracture residuals with moderate ankle disability. The Board further observes that both the August 2020 Ankle Conditions and July 2021 Ankle Condition examinations indicated that the Veteran's muscle strength testing was 5/5. There was no ankylosis. See August 6, 2020, Ankle Conditions examination, pgs., 8-10; See also, July 13, 2021 Ankle Conditions examination pgs., 12-14. Thus, the criteria for the next higher 30 percent disability rating (marked ankle disability) have not been met for any part of the rating period on appeal. The Board has also considered the other Diagnostic Codes pertaining to the knee and leg. Other disability ratings may be assigned only if the symptomatology for a disability is not duplicative or overlapping with the symptomatology of any other disability. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994); Lyles v. Shulkin, 29 Vet. App. 107 (2017) (holding that 38 C.F.R. § 4.14 prohibits paying compensation twice for the same symptoms or functional impairment). However, the Veteran is already receiving a separate rating for his right knee disability that contemplates his right knee and leg symptoms. See January 7, 2021 rating decision. The Board has considered whether any other Diagnostic Codes related to disabilities of the ankle would provide for a higher disability rating. However, the evidence does not reflect that the symptoms would warrant a higher rating under a different Diagnostic Code. See 38 C.F.R. § 4.71a. Indeed, only DC 5270 provides rating criteria for evaluations higher than the current 20 percent rating and those ratings are only available for ankylosis of the ankle, which as referenced above, is not shown here. See August 6, 2020, Ankle Conditions examination, pg., 9. See also, July 13, 2021 Ankle Conditions examination pg. 12. In sum, resolving reasonable doubt in favor of the Veteran, the Board finds that the there is an approximate balance of positive and negative evidence as to whether a 20 percent disability rating is warranted for the residuals of this Veteran's right tibia fractures, manifested with moderate ankle disability, for the entire increased rating period on appeal. To the extent any higher level of compensation is sought, the Board finds the evidence is persuasively is against this claim, and, hence, the benefit-of-the-doubt doctrine does not apply. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3, 4.7; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). Entitlement to a rating in excess of 10 percent prior to July 13, 2021 and in excess of 20 percent thereafter for a left ankle disability. The Veteran contends that his service-connected left ankle disability warrants a higher rating. In his February 2010 Notice of disagreement, the Veteran argued that he was entitled to a higher disability rating because he wore a brace and experienced instability and continuing, daily pain, resulting in an abnormal gait. The Veteran's Achilles tendonitis of the left ankle is rated under 38 C.F.R. § 4.71a, Diagnostic Code 5271, for limitation of motion of the ankle. Under Diagnostic Code 5271, a 10 percent rating is warranted for moderate limited motion of the ankle and a 20 percent rating is warranted for marked limited motion of the ankle. Id. Effective February 7, 2021, VA amended the rating criteria for Diagnostic Code 5271. Under the new criteria, a 10 percent rating is warranted for moderate limited motion of the ankle (less than 15 degrees dorsiflexion or less than 30 degrees plantar flexion.) A 20 percent rating is warranted for marked limited motion of the ankle (less than 5 degrees dorsiflexion or less than 10 degrees plantar flexion.) As this regulatory change was enacted during the pendency of this appeal, the Board will consider both the old and new versions of the rating criteria from the effective date and apply the version most favorable to the Veteran. As referenced in an earlier section of this decision, according to MERRIAM WEBSTER, "moderate" means "tending toward the mean or average amount or dimension". See www.merriam-webster.com/dictionary/moderate. "Marked" means "having a distinctive or emphasized character". See www.merriam-webster.com/dictionary/marked. Discussion In March 2009 the Veteran was afforded a VA examination which found crepitus and tenderness to the entire left ankle without guarding. The examiner noted painful motion with evidence of weakness and decreased strength with range of motion, but recorded normal range of motion. There was no ankylosis noted. See March 5, 2009 VA examination. examination, pgs. 6-7. In January 2016, the Veteran was afforded a new VA examination for his left ankle disability. The Veteran reported ankle rolling while walking and stated that he occasionally wore a brace. See January 5, 2016, Ankle Conditions examination, pg. 2. Upon physical examination the Veteran's range of motion was limited to 10 degrees dorsiflexion, but there was no limitation of plantar flexion. There was no pain with weight bearing, no objective evidence of localized tenderness or pain on palpitation of the joint or associated soft tissue, or objective evidence of crepitus. There was no additional loss of function after observed repetitive use or after repeated use over time. Id. at pgs. 3-4. The Veteran reported flare ups during which pain and lack of endurance limited functional ability. The examiner reported that the examination is medically consistent with the Veteran's statements describing functional loss during flare-ups. However, the examiner was not able to able to describe this in terms of degrees of range of motion, stating: "The Veteran is examined at baseline." Id. at pgs. 5-6. Because the January 2016 examination was not in compliance with Correia, the Veteran was afforded an additional VA examination in August 2020. In the August 2020 Ankle Conditions examination revealed dorsiflexion limited to 10 degrees and plantar flexion limited to 15 degrees. See August 6, 2020 Ankle Conditions examination pg. 5. Pain was noted on examination on rest/non-movement in moth dorsiflexion and plantar flexion. There was evidence of pain with weight bearing and crepitus. There was no additional functional loss after repetitive-use testing. While pain, weakness, and fatigue limited functional ability with repeated use over time, there was no additional loss of range of motion. Id. at pgs. 5-7. The examiner reported that the examination is medically consistent with the Veteran's statements describing functional loss during flare-ups. The examiner reported that pain, weakness, fatigability or incoordination did not significantly limit functional ability with flare-ups. Id. at 8. There was no ankylosis. Left ankle instability was suspected, and the joint displayed laxity compared with the opposite side according to testing. The Veteran was noted to wear a left ankle brace constantly. Id. at 11 & 13. The Veteran was afforded an additional a July 13, 2021 Ankle Conditions examination because the August 2020 examiner did not address the Veteran's report of flare-ups noted in an earlier (January 5, 2016) Ankle Conditions examination. The July 2021 VA examiner confirmed the diagnosis of lateral collateral ligament sprain and residual from right ankle fracture. See July 13, 2021 Ankle Conditions examination, pgs. 2-3. The examiner reported the Veteran symptoms of reported intermittent pain with the with frequent episodes of the ankle rolling, particularly on uneven walking surfaces. See July 13, 2021 Ankle Conditions examination, pg. 3. The examiner reported daily flare-ups, lasting 2-3 hours, precipitated by extending standing or walking. The examiner reported that the severity of the flare-ups was severe. Instability: The Veteran reported that he feels both ankles will collapse outwards. Id. at 4. The examiner reported that the Veteran's abnormal range of motion did not contribute to functional loss. Id. at 6. On examination, left ankle dorsiflexion was measured at 10 degrees, and plantar flexion was measured at 45 degrees, with pain noted on plantar flexion and dorsiflexion. Passive range of motion was the same as active range of motion. There was evidence of pain on weight bearing, with active and passive motion which causes functional loss, described as difficulty with standing or walking more than 5 minutes. Id. at pgs. 6-7. Repetitive-use testing with at least three repetitions: Range of motion testing revealed left ankle dorsiflexion was measured at 5 degrees, and plantar flexion was measured at 30 degrees, with pain noted on plantar flexion and dorsiflexion. Id. at 8. With repeated use over time, range of motion testing revealed left ankle dorsiflexion was measured at 5 degrees, and plantar flexion was measured at 30 degrees, with pain noted on plantar flexion and dorsiflexion. Id. at 8-10. The examiner noted that the Veteran's estimated range of motion for repeated use over time was based on a review of all procurable information to include the Veteran's statement on examination, case-specific evidence (to include medical treatment records when applicable and lay evidence), and the examiner's medical expertise. Id. at 10. With flare ups, range of motion testing revealed left ankle dorsiflexion, measured at 3 degrees, and plantar flexion was measured at 25 degrees, with pain noted on plantar flexion and dorsiflexion. The examiner noted that the Veteran's estimated range of motion for flare-ups was based on a review of all procurable information to include the Veteran's statement on examination, case-specific evidence (to include medical treatment records when applicable and lay evidence), and the examiner's medical expertise. Id. at 11. The examiner reported there was no muscle atrophy, no ankylosis. The examiner reported that there was no joint instability. 12-14. The examiner reported that the Veteran utilized a brace and cane for the left ankle and right ankle residual pain. Id. at 16. The examiner reported that there is a worsening of the Veteran's symptoms however no change to the service-connected diagnosis and no additional diagnoses have been rendered. Id. at 18. Analysis Based on the lay and medical evidence of record, the Board finds that the Veteran's left ankle disability most nearly approximates a 20 percent rating for the entire period on appeal. Although the RO staged this Veteran's disability rating increase, the Board finds that the overall symptomology of this Veteran's left ankle disability approximates marked limitation of motion during the entire course of this appeal. Indeed, all VA examinations of record note the Veteran's left ankle instability and his use of a brace. Additionally, the Board finds the July 2021 examination to be the most probative evaluation on the severity of this Veteran's left ankle disability during the course of this appeal as it included estimated range of motion measurements during flare-ups based on all procurable data, including the Veteran's own statements. See July 13, 2021 Ankle Conditions examination, pgs. 10-11. The Board also notes that the Veteran's left ankle disability limits his ability to perform normal activities of daily living, such as walking for more than five minutes. Accordingly, the Board finds a 20 percent rating under Diagnostic Code 5271 is warranted for marked limitation of motion of the left ankle for the entire period on appeal. The Board does not find however that a higher rating is warranted under any other diagnostic code. The maximum rating for limitation of motion of the ankle is 20 percent. As in this case, the Veteran is being awarded the maximum rating assignable for limitation of motion (i.e., 20 percent under Diagnostic Code 5271), additional consideration of the provisions of DeLuca is not required. Johnston v. Brown, 10 Vet. App. 80, 85 (1997). Hence, a higher rating is not warranted under the governing criteria pertaining to limitation of ankle motion. Without evidence of ankylosis or malunion of the ankle, the Board finds that no other diagnostic code provides for a higher or separate rating. Resolving reasonable doubt in favor of the Veteran, a 20 percent disability rating for marked limitation of motion of the left ankle under DC 5003-5271 is warranted for the entire period on appeal. To this extent, the appeal is granted. Entitlement to a rating in excess of 10 percent prior to August 6, 2020, and 40 percent thereafter, for left lower extremity radiculopathy. The Veteran claims that he is entitled to increased disability ratings for his left lower extremity radiculopathy. He is in receipt of a 10 percent disability rating prior to August 6, 2020 and 40 percent thereafter. The Veteran's left lower extremity radiculopathy of the sciatic nerve is currently rated under dialogistic code DC 8520. Under DC 8520, a 20 percent evaluation is warranted for moderate incomplete paralysis; a 40 percent evaluation is warranted for moderately severe incomplete paralysis; a 60 percent evaluation is warranted for severe, with marked muscular atrophy, incomplete paralysis; and the highest evaluation of 80 percent evaluation is warranted for complete paralysis where the foot dangles and drops, no active movement possible of muscles below the knee, flexion of knee weakened or (very rarely) lost. 38 C.F.R. § 4.124a, DC 8520. Diagnostic Codes 8520, 8620, and 8720 provide ratings for paralysis, neuritis, and neuralgia of the sciatic nerve. Neuritis and neuralgia are rated as incomplete paralysis. Disability ratings of 10, 20, and 40 percent are warranted, respectively, for mild, moderate, and moderately severe incomplete paralysis of the sciatic nerve. 38 C.F.R. § 4.124a. Diagnostic Codes 8526, 8626, and 8726 provide ratings for paralysis, neuritis, and neuralgia of the anterior crural nerve (femoral). A 10 percent disability rating is warranted for mild of the anterior crural nerve, a 20 percent disability rating is warranted for moderate paralysis of the anterior crural nerve, a 30 percent disability rating is warranted for severe paralysis of the anterior crural nerve, and a 40 percent disability rating (the maximum) is warranted for complete paralysis of the anterior crural nerve. 38 C.F.R. § 4.124a. The term "incomplete paralysis" indicates a degree of lost or impaired function substantially less than the type picture for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. 38 C.F.R. § 4.124a, Diseases of the Peripheral Nerves. When the involvement is only sensory, the rating should be for the mild, or at most, the moderate degree. In rating peripheral nerve disability, neuritis, characterized by loss of reflexes, muscle atrophy, sensory disturbances, and constant pain, at times excruciating, is to be rated on the scale provided for injury of the nerve involved, with a maximum equal to severe, incomplete paralysis. The maximum rating to be assigned for neuritis not characterized by organic changes referred to in this section will be that for moderate incomplete paralysis. 38 C.F.R. § 4.123. The words "mild," "moderate" and "severe" are not defined in the 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. Although the use of similar terminology by medical professionals should be considered, it is not dispositive of an issue. Rather, all evidence must be evaluated in arriving at a decision regarding a request for an increased disability rating. 38 U.S.C. § 7104; 38 C.F.R. §§ 4.2, 4.6. Discussion For the entire period on appeal, the Board finds that the probative and persuasive medical evidence supports entitlement to a disability rating of 40 percent, and no higher under 38 C.F.R. § 4.124a, Diagnostic Code 8520, for the Veteran's left lower extremity radiculopathy. A March 2009 VA lumbar spine examination found that the Veteran had constant sharp, dull pain radiating to the Veteran's left lower extremity. However, the examiner did not indicate the severity of the radiculopathy. See March 5, 2009 VA examination, pgs. 1-2. The Veteran submitted private medical records from Dr. V.R. which documented "moderate" radiculopathy and symptoms of numbness, weakness, gait disturbance, paresthesias, and pain. See April 8, 2013 Correspondence (Dr. V.R.); See also, March 2012 private treatment records. (The Board notes that this physician reported that the Veteran had been under their care since November 2008. *Spine and Nerve Diagnostic Center.) The Veteran was afforded a January 2016 Back Conditions examination to evaluate the severity of his left lower extremity radiculopathy. See January 5, 2016, Back Conditions examination. Muscle strength testing for his left lower extremity was normal. The Veteran did not have muscle atrophy. Id. at 5. The Veteran had decreased sensation in his left lower leg/ankle and foot/toes. The Veteran had the following radiculopathy symptoms: constant pain, none for the right lower extremity, none for the left lower extremity; intermittent pain, none for the right lower extremity; paresthesias and/or dysesthesias mild for the right lower extremity, none for the left lower extremity, numbness, mild for the right lower extremity, mild for the left lower extremity. The examiner described the Veteran radiculopathy as mild on the left lower extremity. Id. at pgs. 5-7. Representative Statement: In July 2016, the Veteran's representative submitted a statement contending that the Veteran's balance was impaired due to his left leg radiculopathy, and that he had continued to suffer from symptoms of numbness and pain throughout the period on appeal. Additionally, the statement suggested that the Veteran's symptoms were alleviated somewhat by medication and that physical therapy had failed to improve the Veteran's symptoms. See July 9, 2016 VA Form 646. In August 2020, the Veteran was afforded a Peripheral Nerve Conditions to assess the severity of his left lower extremity radiculopathy. The August 2020 examiner recorded moderate numbness, intermittent pain, and paresthesias and/or dysesthesias. Specifically, it was reported that the Veteran had the following peripheral nerve symptoms: constant pain, none for the right lower extremity, none for the left lower extremity; intermittent pain, none for the right lower extremity, moderate intermittent pain for the left lower extremity; paresthesias and/or dysesthesias none for the right lower extremity, moderate for the left lower extremity, numbness, none for the right lower extremity, moderate for the left lower extremity. See August 6, 2020 Peripheral Nerve Conditions examination, pgs. 1-3. Muscle strength testing for the normal for the right lower extremity; muscle strength testing the left lower extremity was 5 out of 5 for grip, 5 out of 5 for pinch (thumb to index finger); 4 out 5 for knee extension; 4 out of 5 for ankle plantar flexion and 4 out of 5 for ankle dorsiflexion. The Veteran did not have muscle atrophy. Id. at 3-4. The Veteran also had decreased sensation in the upper anterior thigh, thigh/knee, lower let/ankle, and foot/toes. The report recorded antalgic gait. Id. at 5. The examiner found incomplete paralysis of the left sciatic nerve characterized as moderately severe and incomplete paralysis. Id. at 8. Pursuant to the Board's April 2021 Remand directives, the Veteran was afforded an additional July 13, 2021 Peripheral Nerve Conditions examination to determine the severity of this Veteran's left lower extremity radiculopathy. The examiner was also requested to provide a retrospective medical opinion regarding the severity of this Veteran's radiculopathy prior to August 6, 2020. The examiner confirmed the diagnosis of left lower extremity radiculopathy. The examiner noted that the Veteran complained of pain when walking and being unable to his left foot off the ground since10 years ago. See July 13, 2021 Peripheral Nerve Conditions examination, pg. 2. The examiner reported the following peripheral nerve symptoms: constant pain, none for the right lower extremity, moderate for the left lower extremity; intermittent pain, none for the right lower extremity, severe intermittent pain for the left lower extremity; paresthesias and/or dysesthesias none for the right lower extremity, severe for the left lower extremity, numbness, none for the right lower extremity, none for the left lower extremity. Id. at pgs. 2-3. Muscle strength testing for the normal for the right lower extremity; muscle strength testing the left lower extremity was 5 out of 5 for grip, 5 out of 5 for pinch (thumb to index finger) 5 out of 5 for ankle plantar flexion and 3 out of 5 for ankle dorsiflexion. The Veteran did not have muscle atrophy. Id. at 3-4. Reflex testing revealed 2+ plus in the biceps, triceps, brachioradiales, for the right and left extremities, 3 + for the left ankle on reflex testing. Id. at 4. Upon reflex and sensory examination, the Veteran tested normal for the left lower extremity. Id. at pgs. 4-5. The examiner reported there was a left sided antalgic gait due to DDD with left sided sciatica. Id. at 5. The examiner indicated that there was moderately severe incomplete paralysis of sciatic nerve. Id. at pg. 8. Addressing functional impact, the examiner reported that the Veteran has difficulty with standing or walking more than 5 minutes. Id. at 12. Retrospective medical opinion Evaluating the severity of the Veteran's left lower radiculopathy prior to August 6, 2021, including without the ameliorating effects of medications, the July 2013 VA examiner indicated that by history, the Veteran states pain started to move into the left leg. The Veteran's symptoms were controlled with a neurostimulator that has successfully reduced the needle like pain and increasing his ability to function in increased manor for a short period of time. Physical examination showed noted no paresthesias in the left lower extremity, but there was numbness noted down the left lower extremity. The severity was noted as mild. An MRI from 2013 has noted multi-level disc bulging, central canal narrowing at L5-S1 and broad disc bulging at L4-5a. The examiner reported that in 2016, the Veteran's moderate lumbar pathology causing radiculopathy was mostly resolved from the neurostimulator placed by his pain specialist. The MRI from 2013 shows significant central canal narrowing. On today's examination, the examiner reported that the Veteran had moderate daily left lower extremity chronic nerve pain and the paresthesias were described as severe in nature. The was a + SLR test of the left lower extremity. See July 13, 2021 Medical Opinion, at pgs. 5-6. The July 13, 2021 examiner also noted review of the Veteran's representative 2016 statement regarding the Veteran's balance being impaired due to his left leg radiculopathy, and that he had continued to suffer from symptoms of numbness and pain throughout the period on appeal. This statement suggested that the Veteran's symptoms were alleviated somewhat by medication and that physical therapy had failed to improve the Veteran's symptoms. Id. at 6. The July 2021 examiner reported that the Veteran's chronic back condition is causing severe radiculopathy symptoms in the left lower extremity. The combination of the three conditions (right ankle, left ankle and back) are acting in synchronicity causing a moderate to severe pain, antalgic gait and weakness of the lower extremities. Id. Analysis Based on the evidence of record, to the include July 2016 statement from the Veteran's representative regarding his balance being impaired due to his left leg radiculopathy, and that he had continued to suffer from symptoms of numbness and pain throughout the period on appeal, the Board finds that when viewed in conjunction with the August 2021 examination and July 2021 examination (which provided a retrospective medical opinion on the Veteran's radiculopathy prior to August 6, 2021), resolving any doubt in the Veteran's favor, the Board finds the Veteran's radiculopathy symptoms are consistent with a characterization of moderately severe incomplete paralysis and a 40 percent rating under DC 8520 is warranted for the entire period on appeal. The Board observes that while the July 2021 examiner does discuss the Veteran use of a neurostimulator (which appears to ameliorate his radiculopathy symptoms prior to August 6, 2020), the examiner also points out the Veteran's symptoms are relieved for a short period of time. See July 13, 2021 Medical Opinion, pgs. 5-6 re: reducing needle like pain and increasing ability to function for short period of time. To underscore, the Board finds the Veteran's July 2016 representative statement, viewed in conjunction with the August 2020 examination, July 2021 Peripheral Nerve Conditions examination and July 2021 retrospective medical opinion on the severity of this Veteran's left lower extremity radiculopathy prior to August 6, 2020, the most probative and persuasive evidence of record regarding the severity of this Veteran's radiculopathy during the course of this appeal. Resolving any doubt in the Veteran's favor, his left lower extremity radiculopathy symptoms have been consistent with a characterization of moderately severe incomplete paralysis; thus, a 40 percent rating under DC 8520 is warranted for the entire period on appeal. See e.g., August 6, 2020 Peripheral Nerve Conditions examination, pg. 8. Notwithstanding, the Board does not find however that a rating in excess of 40 percent is warranted for left lower extremity radiculopathy for any period on appeal. In April 2013 correspondence, the Veteran's physician described the Veteran's lower extremity radiculopathy at most to be of moderate severity. See April 8, 2013 Correspondence (Dr. V.R.). The Board does note that in the January 2016 Back Conditions examination, muscle strength testing for his left lower extremity was normal. The Veteran did not have muscle atrophy. The examiner reported that the Veteran did not have constant, intermittent pain, or paresthesias and/or dysesthesias for the left lower extremity. See January 2016 Back Conditions examination, pgs., 5-6. On the August 6, 2020 examination, the Board notes the Veteran did have decreased sensation in his lower extremities, (upper anterior thigh; thigh/knee; lower leg ankle; foot/toes); however, reflex examination was normal and there was no muscle atrophy. The Veteran's muscle strength testing primarily ranged from 4/5 to normal and the examiner noted that the Veteran had moderate intermittent pain, numbness and paresthesias or dysesthesias left lower extremity. The Board also notes that the August 2020 and July 2021 examiners specifically determined that the incomplete paralysis of the Veteran's sciatic nerve was, at most, moderately severe. Thus, a rating in excess of 40 percent from August 6, 2020 for left lower extremity radiculopathy is not warranted. See August 6, 2020 Peripheral Nerve Conditions examination, 3-6 & 8 re: moderately severe, incomplete paralysis; See also, See July 13, 2021, Peripheral Nerve Conditions examination, pg. 8 re: moderately severe, incomplete paralysis. The Board is reminded, a 60 percent evaluation is warranted for severe radiculopathy, with marked muscular atrophy, incomplete paralysis. 38 C.F.R. § 4.124a, DC 8520. The Board has also considered whether any other applicable rating criteria may enable a higher evaluation. As discussed above, the evidence shows that the Veteran's neurological impairment of the lower extremities involves the sciatic nerve. It is noteworthy that no other diagnostic code provides for higher ratings and to assign additional separate ratings under other diagnostic codes pertaining to the peripheral nerves of the lower extremities would constitute prohibited pyramiding as the Veteran would be compensated twice for the same symptomatology in his lower extremities, namely pain, numbness, and locally impaired sensation already used to support the ratings that he has been assigned. See 38 C.F.R. § 4.14. In conclusion, the Board finds that an increased rating prior to August 6, 2020 is warranted for the Veteran's left lower extremity radiculopathy. However, a rating higher than 40 percent, from August 6, 2020 is not warranted. In making this determination, all reasonable doubt has been resolved in favor of the Veteran. See Gilbert, 1 Vet. App. at 55. Entitlement to a combined schedular rating in excess of 90 percent. In his April 2017 Notice of Disagreement (NOD), the Veteran appealed his combined rating and asserted that he should be entitled to a 100 percent rating. See April 29, 2016 NOD; See also December 10, 2013 VA Form 9. In the June 2017 Board decision, the Veteran's claim was remanded because it was "inextricably intertwined" with the issue of entitlement to a higher rating for his service-connected left knee disability, residual right tibia fracture disability, left ankle disability and left lower extremity radiculopathy. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (holding that where a decision on one issue would have a "significant impact" upon another, and that impact in turn could render any appellate review on the other claim meaningless and a waste of judicial resources, the two claims are inextricably intertwined). In February 2020 and April 2021, the Board again remanded the claims as inextricably intertwined. The sole issue before the Board is whether the Veteran's combined disability rating exceeds 90 percent. Given the grant of the benefits herein for the period on appeal, the Veteran's rating now exceeds 90 percent: it is 100 percent from August 18, 2008. 38 C.F.R. § 4.25. Thus, the claim is granted. (Continued on the next page) The Veteran and/or his representative has not raised any other issues, nor have any other issues been reasonably raised by the record in regard to the increased rating claims adjudicated herein. Doucette v. Shulkin, 28 Vet. App. 366 (2017). R. Erdheim Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board C. Little, Associate Counsel The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.