Citation Nr: 22015446 Decision Date: 03/17/22 Archive Date: 03/17/22 DOCKET NO. 14-31 904A DATE: March 17, 2022 ORDER Entitlement to a rating in excess of 10 percent for postoperative right wrist strain and arthritis is denied. Entitlement to a compensable rating for postoperative right wrist scar is denied. Entitlement to a rating in excess of 10 percent for painful motion of the thumb of the right hand is denied. Entitlement to a rating in excess of 10 percent for painful motion of the index finger of the right hand is denied. Entitlement to a rating in excess of 10 percent for painful motion of the long finger of the right hand is denied. Entitlement to a compensable rating for painful motion of the ring and little finger of the right hand is denied. Prior to August 24, 2015, a rating of 20 percent, but no higher, for the Veteran's knee disability based on a meniscus tear is granted. From August 24, 2015, to September 30, 2016, entitlement to a rating greater than 100 percent disabling for a left knee condition is denied. From October 1, 2016, entitlement to a rating of 60 percent disabling for a left knee disability is granted. REMANDED Entitlement to service connection for an acquired psychiatric disorder is remanded. FINDINGS OF FACT 1. Throughout the period on appeal, the Veteran's right wrist disability has manifested as painful motion. 2. Throughout the period on appeal, the Veteran's right wrist scarring is not shown to be unstable or painful, deep, and nonlinear and at least 6 square inches in area, superficial and nonlinear and at least 144 square inches in area, or to cause any functional limitations. 3. The Veteran's thumb range of motion has not been limited to a gap of more than two inches (5.1 cm) between the thumb pad and the fingers, with the thumb attempting to oppose the fingers. 4. Throughout the period on appeal, the Veteran's right index finger condition has manifested as painful motion. 5. Throughout the period on appeal, the Veteran's right long finger condition has manifested as painful motion. 6. Throughout the period on appeal, the Veteran's right ring and little finger condition has manifested as painful motion, for which a compensable rating is not allowed under the rating schedule. 7. Prior to August 24, 2015, the Veteran's left knee condition manifested by symptoms such as frequent episodes of locking, pain, and swelling. 8. The Veteran underwent a total left knee replacement procedure on August 24, 2015. 9. From October 1, 2016, the Veteran's left knee condition has manifested as chronic residuals consisting of severe painful motion or weakness. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 10 percent for postoperative right wrist strain and arthritis are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Codes 5010, 5215. 2. The criteria for a compensable disability rating for postoperative right wrist scarring are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.118, Diagnostic Code 7805. 3. The criteria for a rating in excess of 10 percent for painful motion of the thumb of right hand are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.71a, Diagnostic Code 5228. 4. The criteria for a rating in excess of 10 percent for painful motion of the index finger of right hand are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.71a, Diagnostic Code 5229. 5. The criteria for a rating in excess of 10 percent for painful motion of the long finger of right hand are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.71a, Diagnostic Code 5229. 6. The criteria for a compensable disability rating for painful motion of right ring and little finger are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.71a, Diagnostic Code 5230. 7. Prior to August 24, 2015, the criteria for an additional rating of 20 percent for knee disorder (semilunar) are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Codes 5258. 8. From August 24, 2015, to September 30, 2016, the criteria for a rating in excess of 100 percent for status post left knee replacement are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5055. 9. From October 1, 2016, the criteria for a rating of 60 percent for status post left knee replacement are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5055. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from January 1972 to September 1992. This appeal comes before the Board of Veterans' Appeals (Board) from November 2013 and December 2014 rating decisions of a Department of Veterans Affairs (VA) Regional Office (RO). These issues were previously before the Board in July 2021, at which time they were remanded for further medical examinations and opinions. The Veteran was afforded new VA examinations from August 2021 to November 2021. Regarding the Veteran's claims for his right wrist, scarring of his right wrist, fingers of his right hand, and left knee, the examinations substantially complied with the Board's remand instructions. However, as will be discussed in greater detail in the Remand section below, the Board's instructions regarding the claim for an acquired psychiatric disorder were not substantially complied with, as the examiner did not provide opinions regarding secondary service connection. Stegall v. West, 11 Vet. App. 268 (1998). Increased Rating 1. Entitlement to a rating in excess of 10 percent for postoperative right wrist strain and arthritis is denied. The Veteran seeks an increased rating for his service-connected right wrist disability, which is presently evaluated as 10 percent disabling under diagnostic codes (DCs) 5010-5215. Disability ratings are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities (rating schedule). See 38 U.S.C. § 1155; 38 C.F.R. § 4.1. If two ratings are potentially applicable, the higher rating will be assigned if the disability more nearly approximates the criteria required for that rating; otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability will be resolved in favor of the veteran. See 38 C.F.R. § 4.3. Where a veteran is appealing the rating for an already established service-connected condition, his present level of disability is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1995). A veteran is presumed to be seeking the maximum possible evaluation. AB v. Brown, 6 Vet. App. 35 (1993). Separate ratings can be assigned for separate periods of time based on the facts found a practice known as "staged" ratings. Hyphenated diagnostic codes are used when a rating under one code requires use of an additional DC to identify the basis for the rating. 38 C.F.R. § 4.27. DC 5010 is for traumatic arthritis. The hyphenated diagnostic code here indicates that the Veteran is service connected for traumatic degenerative arthritis with limitation of motion of the right wrist. Traumatic arthritis, as shown by x-ray, is rated based on limitation of motion of the affected joint. 38 C.F.R. § 4.71a, DCs 5003, 5010. When, however, the limitation of motion is noncompensable under the appropriate DC, a rating of 10 percent may be applied to each such major joint or group of minor joints affected by limitation of motion. Id., DC 5003. The limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. Id. Diagnostic Codes 5214 and 5215 assign disability ratings for the wrist. Under DC 5215 (the code under which the Veteran's right wrist disability is rated), a 10 percent rating is warranted for limitation of dorsiflexion of the wrist to less than 15 degrees, or for palmar flexion limited in line with the forearm. This is the maximum possible schedular rating under DC 5215. Id., DC 5215. Higher ratings are available under DC 5214 for ankylosis of the wrist. Under DC 5214, a 30 percent rating is warranted where there is favorable ankylosis of the wrist in 20 to 30 degrees of dorsiflexion. A 40 percent rating is warranted where there is ankylosis of the wrist in any other position, except favorable. A maximum 50 percent rating is warranted where there is unfavorable ankylosis in any degree of palmar flexion, or with ulnar or radial deviation. A note to DC 5214 states that extremely unfavorable ankylosis will be rated as loss of use of hands under DC 5125. 38 C.F.R. § 4.71a, DC 5214. Normal range of motion of the wrist includes dorsiflexion (extension) from zero to 70 degrees, palmar flexion from zero to 80 degrees, ulnar deviation from zero to 45 degrees, and radial deviation from zero to 20 degrees. 38 C.F.R. § 4.71a, Plate I. The evaluation of a service-connected musculoskeletal disability requires adequate consideration of functional loss due to pain under 38 C.F.R. § 4.40, and of functional loss due to weakness, fatigability, incoordination or pain on movement of a joint under 38 C.F.R. § 4.45. See DeLuca v. Brown, 8 Vet. App. 202 (1995); Mitchell v. Shinseki, 25 Vet. App. 32, 38 (2011) (quoting 38 C.F.R. § 4.40). Examiners must also provide an opinion as to whether pain significantly limits functional ability on use and during flare-ups. Sharp v. Shulkin, 29 Vet. App. 26, 34 (2017). Further, in Correia v. McDonald, 28 Vet. App. 158, 168 (2016), the Court held that to be adequate, a VA examination of the joints must, wherever possible, include the result of range of motion testing on both active and passive motion, in weight bearing and non-weight bearing, and, if possible, with the range of the opposite undamaged joint. Id. at 169-70. Here, however, the Veteran is in receipt of the maximum schedular rating under DC 5215 for limitation of range of motion. As the maximum schedular evaluation is in effect, no additional schedular discussion is necessary and discussion of 38 C.F.R. §§ 4.40 at 4.45 and the DeLuca and Mitchell factors are moot. Johnston v. Brown, 10 Vet. App. 80, 85 (1995) (If the maximum schedular rating is in effect for loss of motion of a joint, and the disability does not meet the criteria for a higher evaluation under any other applicable diagnostic code, further consideration of functional loss is not required). The intent of the Rating Schedule is to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. In this instance, the minimum compensable rating for the Veteran's wrist disability under DC 5215 is also the maximum compensable rating. In May 2014, the Veteran underwent a VA examination of his wrist. The examiner confirmed the previous diagnoses of status post operative right wrist, right wrist strain, and arthritis of the lateral wrist. However, the Veteran was not shown to have ankylosis in his wrist. See May 2014 C&P Examination, p.13. Similarly, at his VA examination in September 2021, the Veteran did not have ankylosis. See October 2021 C&P Examination, p.13. There is no other competent evidence in the record showing any ankylosis of the right wrist during the period on appeal. Similarly, with no other competent evidence indicating the presence of extremely unfavorable ankylosis, an evaluation under DC 5125 for loss of use of the hand is not appropriate. The VA Rating Schedule will apply unless there are exceptional or unusual factors that render application of the schedule impractical. 38 C.F.R. § 3.321 (b)(1); Fisher v. Principi, 4 Vet. App. 57, 60 (1993). Here, the Veteran has not offered any reason that he should be afforded an extraschedular evaluation for his wrist, nor does the record show that there are any exceptional or unusual factors regarding the Veteran's painful and limited range of motion of his wrist. The Board therefore finds that an extraschedular assignment is not appropriate. Accordingly, as the Veteran is assigned the maximum evaluation under the relevant diagnostic code, a higher rating is inappropriate. Assignment of a separate rating under another code section is not warranted. As most of the evidence weighs against the claim (that is to say, is neither in approximate balance nor nearly equal), the benefit-of-the-doubt rule is inapplicable, and the claim must be denied. Lynch v. McDonough, 999 F.3d 1391, 1395 (Fed. Cir. 2021). 2. Entitlement to a compensable rating for postoperative right wrist scar is denied. The Board's July 2021 decision remanded the claim for a right wrist scar condition as it was inextricably intertwined with the Veteran's right wrist and finger claims. However, it should be noted that the Board at that time denied compensable evaluations for inguinal hernia scarring, left knee scarring, and right knee scarring, as none of the conditions were shown to be painful or unstable, deep and nonlinear and at least 6 square inches in area, superficial and nonlinear and at least 144 square inches in area, or to cause any functional limitations. The Veteran's right wrist postoperative scar condition is evaluated under 38 C.F.R. § 4.118, Diagnostic Code (DC) 7805. DC 7805 instructs the rater to evaluate any disabling effects not considered in a rating provided under DCs 7800-04 under an appropriate diagnostic code. 38 C.F.R. § 4.118, DC 7805. DCs 7800, 7801, and 7802 evaluate various types of burn scars, and thus those DCs are inappropriate to evaluate the Veteran's right wrist post-surgical scar condition. Under DC 7804 for unstable or painful scars, a 10 percent evaluation is warranted for one or two scars that are unstable or painful. A 20 percent evaluation is warranted for three or four scars that are unstable or painful. The maximum evaluation of 30 percent is warranted for five or more scars that are unstable or painful. See 38 C.F.R. § 4.118, DC 7804. At the Veteran's May 2014 VA examination, the examiner documented that the Veteran had a scar on his dorsal right wrist, 4 cm long x 0.5 cm wide. The examiner wrote that the scar was neither unstable nor painful, and described the condition as "quiescent." See May 2014 C&P Examination, pp. 3, 9. Similarly, at his VA examination in September 2021, the examiner measured a right wrist scar 4.5 x 1 cm in size, which was described as not tender, not unstable, and with no indication of underlying soft tissue damage. See October 2021 C&P Examination, pp. 2-4. The evidence does not show that the Veteran's right wrist scar warrants a compensable rating under any applicable rating criteria during the period on appeal. The scar on his wrist is approximately 4.5 x 0.1 centimeter in size. The record does not show that it is unstable or painful, due to a burn, adhering to any underlying tissue, measure more than 6 square inches, or result in any functional limitation or impact the Veteran's ability to work. Therefore, a compensable rating for the scar is not warranted under the rating schedule. As most of the evidence weighs against the claim (that is to say, is neither in approximate balance nor nearly equal), the benefit-of-the-doubt rule is inapplicable, and the claim must be denied. Lynch v. McDonough, 999 F.3d 1391, 1395 (Fed. Cir. 2021). 3. Entitlement to a rating in excess of 10 percent for painful motion of the thumb of the right hand is denied. The Veteran seeks increased ratings for his service-connected finger and thumb disabilities of his right hand, which are the result of his right wrist condition. The Veteran's thumb is currently rated 10 percent disabling under DC 5228, which evaluates limitation of motion of the thumb. Under DC 5228, the same ratings are given to thumbs of either the major (dominant) hand, or the minor hand. A noncompensable evaluation is warranted for a gap of less than one inch (2.5 cm) between the thumb and the pad of the fingers with the thumb attempting to oppose the fingers. A 10 percent evaluation is assigned for a gap of one to two inches (2.5 to 5.1 cm) between the thumb pad and the fingers, with the thumb attempting to oppose the fingers. The maximum evaluation of 20 percent is assigned for a gap of more than two inches (5.1 cm) between the thumb pad and the fingers, with the thumb attempting to oppose the fingers. 38 C.F.R. § 4.71a, DC 5228. As the Veteran's thumb is presently rated at 10 percent, the question before the Board is whether the evidence supports a finding that the Veteran cannot close his hand such that there is less than a two-inch gap between his thumb pad and the fingers. At a VA examination in November 2014, the examiner confirmed a previous diagnosis of "right hand / wrists, status post-surgery for spur / mass excision." The examiner documented the Veteran's reports of pain in all his fingers and his thumb, with flare-ups which would result in loss of coordination and loss of strength, including numbness and tingling in the fingers. The Veteran was able to touch his thumb to his fingers with no gap, but the examiner indicated this was done with painful motion at a gap of less than 1 inch (2.5 cm). No ankylosis was shown. The examiner wrote that due to the Veteran's wrist condition, he lost grip strength in his right wrist and hand. However, the examiner wrote that there were not any additional limitations of functional ability during flare-ups. See December 2014 C&P Examination, pp. 7, 8, 14. The Board remanded the Veteran's claim in July 2021 for a new examination to be conducted, as the Veteran had indicated worsening of his condition during the pendency of his claim. In September 2021, the Veteran was afforded a new VA examination. The examiner indicated that the Veteran did not experience flare-ups of his hand, fingers, or thumb. Range of motion was measured to be full, with no gap between the pad of the thumb and fingers. Again, no ankylosis was shown. The examiner indicated there was evidence of pain on active motion, however the examiner indicated it did not result in or cause functional loss. See October 2021 C&P Examination, pp. 5, 18. The Veteran has previously indicated he seeks a 30 percent assignment for his thumb disability. See January 2015 Notice of Disagreement. However, the Rating Schedule does not provide for a 30 percent disability rating for limitation of thumb motion. The VA Rating Schedule will apply unless there are exceptional or unusual factors that render application of the schedule impractical. 38 C.F.R. § 3.321 (b)(1); Fisher v. Principi, 4 Vet. App. 57, 60 (1993). Here, the Veteran has not offered any reason that he should be afforded an extraschedular evaluation for his thumb, nor does the record show that there are any exceptional or unusual factors regarding the Veteran's painful and limited range of motion. Indeed, the full extent of the Veteran's limited range of motion is contemplated by the Rating Schedule, and the Veteran's initial 10 percent assignment was based on painful motion of the thumb under 38 C.F.R. § 4.59, which allows consideration of functional loss due to painful motion to be rated to at least the minimum compensable rating for a particular joint. The Board therefore finds there are no exceptional or unusual factors regarding the Veteran's claim and an extraschedular assignment is not appropriate. The evidence does not support a finding at any time during the period on appeal that the Veteran's thumb range of motion has been limited to a gap of more than two inches (5.1 cm) between the thumb pad and the fingers, with the thumb attempting to oppose the fingers. During his first VA examination, the Veteran's painful motion was documented in the last one inch of his thumb range of motion. Similarly, at a subsequent examination, he was able to close his thumb to his fingertips. Accordingly, the present 10 percent rating for painful motion is appropriate, and a maximum rating of 20 percent is not warranted. As most of the evidence weighs against the claim (that is to say, is neither in approximate balance nor nearly equal), the benefit-of-the-doubt rule is inapplicable, and the claim must be denied. Lynch v. McDonough, 999 F.3d 1391, 1395 (Fed. Cir. 2021). 4. Entitlement to a rating in excess of 10 percent for painful motion of the index finger of the right hand is denied. The Veteran's right index finger is presently rated 10 percent disabling under DC 5229, which is the maximum allowable rating under that code section. Under DC 5229, a noncompensable evaluation is warranted for a gap of less than one inch (2.5 cm) between the fingertip and the proximal transverse crease of the palm, with the finger flexed to the extent possible, and; extension is limited by no more than 30 degrees. The maximum evaluation of 10 percent is warranted for a gap of one inch (2.5 cm) between the fingertip and the proximal transverse crease of the palm, with the finger flexed to the extent possible, or; extension limited by more than 30 degrees. 38 C.F.R. § 4.71a, DC 5229. At the VA examination of the Veteran's hand in November 2014, the examiner documented the Veteran's reports of painful motion in all his fingers and his thumb. The examiner recorded that there was no gap between any of the Veteran's fingertips and the proximal transverse crease of the palm. As with the Veteran's thumb, the examiner wrote that the Veteran experienced flare-ups characterized by loss of coordination and strength, but the examiner indicated there was not additional functional loss due to those flares. No ankylosis was shown. See December 2014 VA Examination, pp. 8, 11. At the VA examination in September 2021, the examiner documented the Veteran's reports of painful motion including stiffness and difficulty gripping small objects. The Veteran's had full range of motion for his index finger in all measured directions. There was no gap between the fingers and the proximal transverse crease of the hand on maximal finger flexion. There was no ankylosis. See September 2021 C&P Examination, pp. 4-7, 18. As with his thumb, the Veteran has previously indicated he seeks a 30 percent assignment for his index finger disability. See January 2015 Notice of Disagreement. However, the Rating Schedule does not provide for a 30 percent disability rating for limitation of index finger motion. The VA Rating Schedule will apply unless there are exceptional or unusual factors that render application of the schedule impractical. 38 C.F.R. § 3.321 (b)(1); Fisher v. Principi, 4 Vet. App. 57, 60 (1993). Here, the Veteran has not offered any reason that he should be afforded an extraschedular evaluation for his index finger, nor does the record show that there are any exceptional or unusual factors regarding the Veteran's painful motion. Indeed, the full extent of the Veteran's range of motion is contemplated by the Rating Schedule, and the Veteran's initial 10 percent assignment was based on painful motion of the thumb under 38 C.F.R. § 4.59, which allows consideration of functional loss due to painful motion to be rated to at least the minimum compensable rating for a particular joint. The Board therefore finds there are no exceptional or unusual factors regarding the Veteran's claim and an extraschedular assignment is not appropriate. As the Veteran is presently awarded the maximum possible evaluation under the rating schedule, a higher rating is inappropriate. As most of the evidence weighs against the claim (that is to say, is neither in approximate balance nor nearly equal), the benefit-of-the-doubt rule is inapplicable, and the claim must be denied. Lynch v. McDonough, 999 F.3d 1391, 1395 (Fed. Cir. 2021). 5. Entitlement to a rating in excess of 10 percent for painful motion of the long finger of the right hand is denied. The Veteran's long finger of his right hand is presently rated 10 percent under DC 5229, which is the same diagnostic code described above for rating of the index finger. 10 percent is the maximum evaluation under DC 5229. At the VA examination of the Veteran's hand in November 2014, the examiner documented the Veteran's reports of painful motion in all his fingers and his thumb. The examiner recorded that there was no gap between any of the Veteran's fingertips and the proximal transverse crease of the palm. As with the Veteran's thumb, the examiner wrote that the Veteran experienced flare-ups characterized by loss of coordination and strength, but the examiner indicated there was not additional functional loss due to those flares. No ankylosis was shown. See December 2014 VA Examination, pp. 8, 11. At the VA examination in September 2021, the examiner documented the Veteran's reports of painful motion in the fingers of his right hand, with functional impairment due to stiffness and difficulty gripping small objects. The Veteran's long finger flexion was shown to be limited in his metacarpophalangeal (MCP) joint to 55 degrees (of maximum 90) and limited in his proximal interphalangeal (PIP) joint to 90 degrees (of maximum 100), but with full range for his distal interphalangeal (DIP) joint to 70 degrees (of maximum 70). No ankylosis was shown. See September 2021 C&P Examination, pp. 4-7, 18. As with other fingers, the Veteran has previously indicated that he seeks a 30 percent assignment for his long finger disability. See January 2015 Notice of Disagreement. However, the Rating Schedule does not provide for a 30 percent disability rating for limitation of index finger motion. The VA Rating Schedule will apply unless there are exceptional or unusual factors that render application of the schedule impractical. 38 C.F.R. § 3.321 (b)(1); Fisher v. Principi, 4 Vet. App. 57, 60 (1993). Here, the Veteran has not offered any reason that he should be afforded an extraschedular evaluation for his long finger, nor does the record show that there are any exceptional or unusual factors regarding the Veteran's painful and limited motion. The Board therefore finds there are no exceptional or unusual factors regarding the Veteran's claim and an extraschedular assignment is not appropriate. Accordingly, as the Veteran is in receipt of the maximum evaluation for his finger, an increased rating is inappropriate. As most of the evidence weighs against the claim (that is to say, is neither in approximate balance nor nearly equal), the benefit-of-the-doubt rule is inapplicable, and the claim must be denied. Lynch v. McDonough, 999 F.3d 1391, 1395 (Fed. Cir. 2021). 6. Entitlement to a compensable rating for painful motion of the ring and little finger of the right hand is denied. The Veterans ring and little fingers are each presently rated as noncompensable under 38 C.F.R. § 4.71a, DC 5230. DC 5230 provides a noncompensable rating for any limitation of motion of the ring or little finger. 38 C.F.R. § 4.71a, DC 5230. A compensable rating for the right ring or little finger requires amputation, or the functional equivalent thereof. 38 C.F.R. § 4.71a, DCs 5155, 5156. It must also be considered whether an additional evaluation is warranted for resulting limitation of motion of other digits, or interference with overall function of the hand. Neither the VA examination in November 2014, nor the examination in September 2021 showed any indication that the Veteran's fingers required amputation, nor were they described as the functional equivalent of being amputated. Both examinations showed that the Veteran had limited ability to grip small objects, and that he experienced pain in his fingers due to his wrist condition. Additionally, the Veteran's ring and little fingers were not shown to be ankylosed or to have been amputated or in need of amputation. These findings thus do not support the assignment of a compensable rating under DC 5230. No ankylosis has been shown in either his right ring finger or little finger. The Board has considered whether a compensable rating can be assigned based on painful motion under 38 C.F.R. § 4.59. Generally, when painful motion is present, the minimum compensable rating for the joint should be assigned. However, in this case, the minimum (and maximum) rating under DC 5230 is 0 percent. Therefore, a compensable rating for painful motion cannot be assigned. See Sowers v. McDonald, 27 Vet. App. 472, 479-81 (2016). Accordingly, a compensable rating may not be awarded for the Veteran's right ring or little finger disabilities. As most of the evidence weighs against the claim (that is to say, is neither in approximate balance nor nearly equal), the benefit-of-the-doubt rule is inapplicable, and the claim must be denied. Lynch v. McDonough, 999 F.3d 1391, 1395 (Fed. Cir. 2021). 7. Prior to August 24, 2015, entitlement to additional ratings for a left knee disability. The Veteran seeks an increased rating for his left knee. The Veteran's left knee has been rated under several code sections during different stages of the period on appeal. From March 4, 2014, his left knee was rated at 10 percent disabling under DCs 5010-5260, for status post meniscectomy, with arthritis and crepitus. In the hyphenated diagnostic code, DC 5010 pertains to arthritis due to trauma, while DC 5260 pertains to limitation of flexion. The Veteran underwent a total knee replacement procedure in August 2015. Thus, he has been evaluated under DC 5055 since that time for status post total knee arthroplasty, with a temporary 100 percent evaluation from August 24, 2015, a 30 percent evaluation from October 1, 2016, and a 60 percent evaluation from December 7, 2020. This decision will discuss the Veteran's knee in three stages. The first stage begins based on the Veteran's initial claim and leads up to his total knee replacement in August 2015. The second stage contemplates the temporary 100 percent evaluation following the knee replacement. The third stage will discuss evaluation of the knee after the temporary 100 percent evaluation period expired. Disabilities of the knee joint, generally, are rated under diagnostic codes (DCs) 5256 through 5263. See 38 C.F.R. § 4.71a. In addition, there are special provisions for rating degenerative arthritis (to include osteoarthritis) under DC 5003. When there is painful motion of a major joint caused by degenerative arthritis that is detected on x-ray, such painful motion will be considered limited motion pursuant to 38 C.F.R. § 4.59. Painful motion is entitled to a minimum 10 percent rating, per joint, combined under DC 5003, even if there is no actual limitation of motion. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011); Lichtenfels v. Derwinski, 1 Vet. App. 484 (1991). Ankylosis is rated under DC 5256. DC 5257 provides for 10, 20, or 30 percent ratings for recurrent subluxation or lateral instability that is, respectively, slight, moderate or severe. Under DC 5258, a 20 percent evaluation is assigned for semilunar, dislocated cartilage with frequent episodes of "locking" pain, and effusion into the joint. Under DC 5259, a 10 percent evaluation is assigned for symptomatic removal of semilunar cartilage. Under DC 5260, a noncompensable evaluation is assigned for flexion limited to 60 degrees. A 10 percent rating is assigned for flexion limited to 45 degrees. A 20 percent rating is assigned for flexion limited to 30 degrees. A 30 percent rating is assigned for flexion limited to 15 degrees. Under DC 5261, a noncompensable evaluation is assigned for extension limited to 5 degrees. A 10 percent rating is assigned for extension limited to 10 degrees. A 20 percent rating is assigned for extension limited to 15 degrees. A 30 percent rating is assigned for extension limited to 20 degrees. A 40 percent rating is assigned for extension limited to 30 degrees. A 50 percent rating is assigned for extension limited to 45 degrees. Impairment of the tibia and fibula is rated under DC 5262 and genu recurvatum is rated under DC 5263. Generally, the evaluation of the same disability under various diagnoses is to be avoided. 38 C.F.R. §§ 4.14. However, the United States Court of Appeals for Veterans Claims has held that evaluation of a knee disability under DCs 5257 or 5261 (and by code 5260) or both does not, as a matter of law, preclude separate evaluation of a meniscal disability of the same knee under DCs 5258 or 5259. Lyles v. Shulkin, 29 Vet. App. 107 (2017). Entitlement to a separate evaluation depends on whether the manifestations of disability for which a separate evaluation is being sought have already been compensated by an assigned evaluation under a different DC. In the context of evaluating musculoskeletal disabilities based on limitation of motion, a manifestation of disability has not been compensated, for separate evaluation and pyramiding purposes, if that manifestation did not result in an evaluation under 38 C.F.R. §§ 4.40 and 4.45 pursuant to the principles set forth in DeLuca v. Brown, 8 Vet. App. 202, 207 (1995). Here, the Veteran underwent a left meniscectomy procedure shortly prior to the period on appeal, in January 2014. Private records show that following the surgery, the Veteran did not experience further effusion. See September 2016 Medical Treatment Record Non-Government Facility, pp. 18, 36 (November and February 2014 record). The Veteran's knee remained tender, but catching, locking and giving away had "improved." Id., p.34 (August 2014 record). The Board reads this assessment to indicate that although catching, locking and giving way were not as severe as they had been prior to surgery, they remained present. In November 2014, the Veteran underwent a VA examination for his left knee condition. The examiner indicated diagnoses of left knee status post meniscectomy, with moderate to severe degenerative arthritis, and crepitus. The Veteran reported that his knees had worsened over time, and that he experienced flare-ups which caused swelling, pain and discomfort on movement, random poor coordination, strength and circulation in his legs. The Veteran's left knee range of motion was measured from 80 degrees flexion (with pain) to 0 degrees extension (maximum 140 0 degrees). The opposing knee, which had also undergone surgery, was measured from 70 degrees flexion to 0 degrees extension. There were no changes to those measurements after repetitive use testing of three repetitions. However, the examiner indicated the Veteran had additional functional loss due to less movement than normal, pain on movement, and disturbance of locomotion. The Veteran also showed pain on movement. The examiner estimated that during flare-ups, the Veteran would lose approximately 5 more degrees of flexion, but his knee extension would remain the same. Joint stability testing was normal in all directions, and there was no evidence of recurrent patellar subluxation or dislocation. The examiner indicated that the Veteran had experienced bilateral meniscus tears, which had caused locking, pain and effusion, leading to a meniscectomy procedure in January 2014. Following the surgery, the Veteran had residual symptoms of swelling and pain on movement, and random poor coordination and strength. The Veteran reported his arthritis was at stage four, and he would soon undergo bilateral knee replacements. The examiner wrote that the Veteran used a scooter for assistance with locomotion, due to both his bilateral knee conditions and his bilateral diabetic neuropathy. See December 2014 C&P Examination. The Board affords this examination high probative value based on its thorough assessment of the Veteran's condition and thorough discussion of the Veteran's medical history. From March 4, 2014, to August 23, 2015, the 10 percent evaluation under DCs 5010-5260 are appropriate. During this stage on appeal, the Veteran's left knee flexion was limited by painful motion, to approximately 80 degrees of flexion and 75 degrees of flexion during flare-ups. The assignment of a 10 percent evaluation based on painful motion of the left knee is appropriate under 38 C.F.R. § 4.59. A higher evaluation under DC 5260 is not appropriate, as the evidence does not show that the Veteran's flexion was limited to 45 degrees or less during this stage on appeal. A separate rating of 20 percent under DC 5258 is warranted for the Veteran's knee prior to August 24, 2015. The Veteran has had a documented knee meniscus tear. Additionally, the evidence shows locking, pain, and swelling as reported by the 2014 examiner. The competent evidence tends to show that the pain associated with the Veteran's meniscus tear is separate than the pain associated with his painful range of motion. The Board acknowledges the private treatment records showing the Veteran did not have swelling, but when resolving reasonable doubt in favor of the Veteran, the evidence of records tends to show swelling during the period on appeal. Additional evaluation under DC 5256 is not warranted as there is no evidence of ankylosis. DC 5257 is not for application, as instability testing during this stage showed no instability in any direction. A higher rating would not result under DC 5261, as the Veteran had full extension of his left knee during this period, and thus was not limited to 15 degrees or more. DC 5262 is not for application as there is no showing of a tibia and fibula impairment. DC 5263 is not for application, as there is no showing of genu recurvatum. As found by the Board's July 2021 decision, a separate evaluation for knee scarring is inappropriate, as such scarring is not shown to be unstable or painful, deep and nonlinear and at least 6 square inches in area, superficial and nonlinear and at least 144 square inches in area, or to cause any functional limitations. The assignment of the additional rating under DC 5258 is warranted only until such time as the Veteran underwent a total knee replacement procedure in August 2015, at which time his knee is appropriately rated under DC 5055, as will be discussed below. In sum, the previously assigned evaluation of 10 percent under DCs 5010-5260 remains in effect, while entitlement to an additional assignment of 20 percent under DC 5258 is granted. 8. From August 24, 2015 to September 30, 2016, entitlement to a rating greater than 100 percent disabling for a left knee condition is denied. Following his left knee replacement procedure, the Veteran was assigned a temporary evaluation of 100 percent from August 24, 2015 to September 30, 2016 under DC 5055. The Board does not seek to disturb this evaluation, and notes only that the Veteran is in receipt of the maximum evaluation during this stage; thus, a higher rating is not warranted. 9. From October 1, 2016, entitlement to a rating of 60 percent disabling for a left knee disability is granted. The Veteran's knee has been rated as 30 percent disabling from October 1, 2016 to December 6, 2020, and as 60 percent disabling from December 7, 2020, under DC 5055 for status post knee replacement (prosthesis). For the reasons that follow, the Board finds that a 60 percent evaluation is warranted from October 1, 2016 onward. Under DC 5055, a 30 percent evaluation is warranted for a knee replacement with intermediate degrees of residual weakness, pain or limitation of motion. The DC further instructs that the rater should consider a rating by analogy under DCs 5256, 5261 or 5262. A 60 percent evaluation is warranted for chronic residuals consisting of severe painful motion or weakness in the affected extremity. A 100 percent evaluation is warranted during the 1 year following implantation of prosthesis. See 38 C.F.R. § 4.71a, DC 5055. The Veteran underwent a VA examination of his right knee in March 2018, which included ancillary measurements and discussion of the Veteran's left knee as well. The examiner indicated conducting an in-person examination, but without having reviewed the Veteran's VA claim folder. As the examination did not consider the Veteran's prior medical history and examinations, it cannot be considered adequate for rating purposes. See Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007). Additionally, the examiner did not provide an estimate of further loss of range of motion during flare-ups, stating he could not do so without resorting to speculation, which further reduces the probative value of this examination. See Sharp v. Shulkin, 29 Vet. App. 26 (2017). Nonetheless, the Board finds the examination does retain probative value insofar as it documented the state of the Veteran's condition at that time. See Monzingo v. Shinseki, 26 Vet. App. 97, 107 (2012) (noting that, even if a medical opinion is inadequate to decide a claim, it does not necessarily follow that the opinion is entitled to absolutely no probative weight). The examiner documented the Veteran's reports of left knee flare-ups, described as pain. The Veteran's left knee range of motion was measured from 0 to 95 degrees flexion, and from 95 to 0 degrees extension. Pain was noted on examination, causing functional loss. No ankylosis was shown. See March 2018 C&P Examination. In December 2020, the Veteran underwent another examination of his knees. The examiner indicated review of the Veteran's claim file and conducted an in-person examination. He indicated a current diagnosis of left knee replacement. The Veteran described pain and swelling in his knee, which precluded walking and bending. Flare-ups occurred after standing over 10-15 minutes. When the Veteran's left knee flared up, he would have to sit down or get off his knee. Such flares were precipitated by activity and alleviated by rest. The examiner measured knee range of motion from 0 to 90 degrees flexion, and 90 to 0 degrees extension, compared to 0 to 95 degrees and 95 to 0 degrees in the opposing leg. The examiner noted that pain was observed on examination, which caused functional loss. The examiner estimated that during flare-ups, both the Veteran's knees would be limited from 0 to 45 degrees flexion, and 45 to 0 degrees extension. No ankylosis was shown. Joint stability testing showed normal results in all tested directions, with no instability found. The examiner recorded both intermediate degrees of residual weakness, pain or limitation of motion, and chronic residuals consisting of severe painful motion or weakness. The above examiner made a notation that the Veteran had not ever experienced a meniscus condition. The Board remanded the Veteran's claim in July 2021, ordering that an examiner should clarify the Veteran's meniscus condition. Additionally, the examiner should address whether the Veteran's use of a wheelchair, cane or scooter for diabetic neuropathy and knee replacements was prescribed by a physician. In October 2021, the Veteran underwent another VA examination. Range of motion was measured from 100 to 0 degrees (flexion to extension endpoints), for both active and passive motion. The examiner indicated there was evidence of pain on movement but pain itself did not result in functional loss. The examiner described additional contributing factors of disturbance of locomotion, and difficulty with squatting and bending the knee. No ankylosis was shown. No subluxation or persistent instability was shown. The examiner indicated the Veteran's use of a cane was not prescribed by a physician. Regarding the previous VA examiner's notation of no history of meniscus problems, the examiner prepared an additional opinion to explain that because of the Veteran's total knee arthroplasty procedure, he no longer had a meniscus and therefore there was no remaining meniscus condition. However, the Veteran's pre-replacement knee condition was well characterized as a meniscus problem. See October and November 2021 C&P Examinations (multiple reports including addendum opinions). The competent and probative evidence is at least in approximate balance (or at least nearly equal) that from October 1, 2016, the Veteran's left knee condition has manifested as chronic residuals consisting of severe painful motion or weakness. At each VA examination during this stage of appeal, the examiners have documented evidence of pain in the Veteran's knee upon movement. Descriptions of such pain have varied. The Board finds the December 2020 examination most probative in describing that during flare-ups, the Veteran experienced increased pain which severely restricted his knee range of motion by nearly half. Prior VA examination during this stage on appeal did not sufficiently address the Veteran's condition during flare-ups. Thus, resolving reasonable doubt in the Veteran's favor, the Board concludes that the severely painful condition noted by the December 2020 examiner was ongoing throughout this stage on appeal. A 60 percent evaluation is thus warranted under DC 5055. As this is the maximum evaluation possible other than the temporary 100 percent assignment for the one year prior to surgery, a higher rating may not be awarded. In this regard, the "amputation rule" precludes the Board from assigning the Veteran a rating higher than 60 percent or any further separate ratings. The "amputation rule" provides that the combined rating for disabilities of an extremity shall not exceed the rating for the amputation at that elective level, were amputation to be performed. 38 C.F.R. § 4.68. A 60 percent rating is provided for an amputation of the thigh, above the knee, at the middle or lower third. 38 C.F.R. § 4.71, DCs 5162, 5163, 5164. Because the Veteran's disability is in the knee, or below the middle third of the thigh, the amputation rule precludes a schedular evaluation in excess of 60 percent. Accordingly, from October 21, 2016, entitlement to a 60 percent evaluation for status post left knee replacement is granted. REASONS FOR REMAND 1. Entitlement to service connection for an acquired psychiatric disorder is remanded. In July 2021, the Board remanded the Veteran's claim for service connection for an acquired psychiatric disorder. The Board ordered that the Veteran be provided with a new VA examination, and that the examiner should address whether the Veteran had an acquired psychiatric disorder which was caused or aggravated by another service-connected disability. In August 2021, the Veteran underwent a VA telehealth examination. The examiner found that the Veteran was not presently diagnosed with any psychiatric disability, and he indicated that it was "entirely likely" that the past diagnosis of major depression had "since resolved." However, the examiner did not provide opinions addressing secondary causation and aggravation as ordered by the Board, based on the Veteran's diagnosis during the appeal period. See August 2021 C&P Examination. Additionally, the Board observes that the examiner inappropriately relied upon the procedural history of the Veteran's claims as evidence to support his conclusions. Specifically, the examiner's rationale cited to past rating decisions which had denied service connection, as evidence that the Veteran's condition could not be linked to service. See August 2021 C&P Examination. The examiner's medical opinion should inform VA claim adjudicators; not the other way around. A medical opinion is adequate where it is based upon consideration of a veteran's prior medical history and examination and describes the disability at issue in sufficient detail to allow the Board's evaluation of a claim to be a fully informed one. Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007). Here, the opinion is not adequate because it is neither sufficient for the Board to determine whether the Veteran's diagnosed major depression was secondarily caused or aggravated by a service-connected condition. Moreover, the opinion is not adequate because it is not based on the Veteran's medical history and examination, but rather it is based on the VA procedural history of the Veteran's claim. As the exam is inadequate and unresponsive to the Board's questions, further development is necessary. The matters are REMANDED for the following action: 1. Obtain an addendum opinion to determine the likely nature and etiology of any acquired psychiatric disorder diagnosed during the period on appeal (i.e., from March 2013 to present), to include major depression. If it is determined that another examination is needed to provide the required opinions, then the Veteran must be afforded one. Following a review of all pertinent evidence (to include the April 2013 VA examination report's diagnosis of major depression), the examiner is asked to opine as to whether it is at least as likely as not (probability of approximately 50 percent) that the Veteran's acquired psychiatric disorder was caused or aggravated by any of his service-connected disabilities, to include the pain associated with his various service-connected orthopedic disabilities, tinnitus or hearing loss. If the examiner finds that the Veteran has not met the DSM-V criteria for a psychiatric diagnosis at any time during the rating period on appeal (i.e., from March 2013 to the present), then the examiner must discuss whether the diagnosis of major depression in the April 2013 VA examination report was based on a correct psychiatric diagnosis that has since resolved, or rather based on an incorrect psychiatric diagnosis. If it is the examiner's opinion that any of the psychiatric diagnoses rendered since March 2013 are accurate, then he or she should note that fact, directly discuss whether that psychiatric condition was caused or aggravated by another service-connected disability and provide reasons for the conclusion. A comprehensive rationale for all opinions is to be provided. All pertinent evidence, including both lay and medical, should be considered. If an opinion cannot be given without resorting to speculation, the examiner should explain why and state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), the record (additional facts are require), or the examiner (does not have the knowledge or training). Garrett Morales Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Hermsdorfer, 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.