Citation Nr: 22016384 Decision Date: 03/22/22 Archive Date: 03/22/22 DOCKET NO. 17-53 185 DATE: March 22, 2022 ORDER A rating in excess of 10 percent for degenerative joint disease (DJD) of the right knee is denied. A rating in excess of 10 percent prior to January 2, 2020, and in excess of 40 percent thereafter, for peripheral neuropathy of the left upper extremity (LUE) is denied. A rating in excess of 10 percent prior to January 2, 2020, and in excess of 30 percent thereafter for peripheral neuropathy of the right upper extremity (RUE) is denied. A rating in excess of 10 percent prior to January 2, 2020, and in excess of 20 percent thereafter for peripheral neuropathy of the left lower extremity (LLE) (sciatic nerve) is denied. A rating in excess of 10 percent prior to January 2, 2020, and in excess of 20 percent thereafter for peripheral neuropathy of the right lower extremity (RLE) (sciatic nerve) is denied. Subject to the laws and regulations governing the award of VA monetary benefits, an effective date of September 29, 2016, for service connection for peripheral neuropathy of the LLE (femoral nerve) is granted. Subject to the laws and regulations governing the award of VA monetary benefits, an effective date of September 29, 2016, for service connection for peripheral neuropathy of the RLE (femoral nerve) is granted. Subject to the laws and regulations governing the award of VA monetary benefits, an initial 10 percent rating, but no more, prior to January 2, 2020, for peripheral neuropathy of the LLE (femoral nerve) is granted. Subject to the laws and regulations governing the award of VA monetary benefits, an initial 10 percent rating, but no more, prior to January 2, 2020, for peripheral neuropathy of the RLE (femoral nerve) is granted. A rating in excess of 20 percent from January 2, 2020, for peripheral neuropathy of the LLE (femoral nerve) is denied. A rating in excess of 20 percent for peripheral neuropathy of the RLE (femoral nerve) is denied. REMANDED Entitlement to service connection for obstructive sleep apnea (OSA) is remanded. FINDINGS OF FACT 1. At no point during the appeal period did the Veteran's right knee result in flexion limited to 30 degrees, either upon clinical examination or as determined to result with repeated use over time or during flare-ups. 2. Prior to January 2, 2020, the Veteran's LUE peripheral neuropathy resulted in mild incomplete paralysis; from January 2, 2020, it resulted in moderate incomplete paralysis. 3. Prior to January 2, 2020, the Veteran's RUE peripheral neuropathy resulted in mild incomplete paralysis; from January 2, 2020, it resulted in moderate incomplete paralysis. 4. Prior to January 2, 2020, the Veteran's LLE peripheral neuropathy involving the sciatic nerve resulted in mild incomplete paralysis; from January 2, 2020, it resulted in moderate incomplete paralysis. 5. Prior to January 2, 2020, the Veteran's RLE peripheral neuropathy involving the sciatic nerve resulted in mild incomplete paralysis; from January 2, 2020, it resulted in moderate incomplete paralysis. 6. The Veteran's peripheral neuropathy of the LLE and RLE involved the femoral nerve since the September 29, 2016, date of claim for increase. 7. Prior to January 2, 2020, the Veteran's LLE peripheral neuropathy resulted in mild incomplete paralysis; from January 2, 2020, it resulted in moderate incomplete paralysis. 8. Prior to January 2, 2020, the Veteran's RLE peripheral neuropathy resulted in mild incomplete paralysis; from January 2, 2020, it resulted in moderate incomplete paralysis. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 10 percent for DJD of the right knee have not been met. 38 U.S.C. § 1155, 5103, 5103A, 5107(b); 38 C.F.R. § 3.102, 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.71a, Diagnostic Code (DC) 5010-5260. 2. The criteria for a rating in excess of 10 percent prior to January 2, 2020, and in excess of 40 percent thereafter, for peripheral neuropathy of the LUE have not been met. 38 U.S.C. § 1155, 5103, 5103A, 5107(b); 38 C.F.R. § 3.102, 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.124a, DC 8513. 3. The criteria for a rating in excess of 10 percent prior to January 2, 2020, and in excess of 40 percent thereafter, for peripheral neuropathy of the RUE have not been met. 38 U.S.C. § 1155, 5103, 5103A, 5107(b); 38 C.F.R. § 3.102, 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.124a, DC 8513. 4. The criteria for a rating in excess of 10 percent prior to January 2, 2020, and in excess of 20 percent thereafter, for peripheral neuropathy of the LLE (sciatic nerve) have not been met. 38 U.S.C. § 1155, 5103, 5103A, 5107(b); 38 C.F.R. § 3.102, 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.124a, DC 8520. 5. The criteria for a rating in excess of 10 percent prior to January 2, 2020, and in excess of 20 percent thereafter, for peripheral neuropathy of the RLE (sciatic nerve) have not been met. 38 U.S.C. § 1155, 5103, 5103A, 5107(b); 38 C.F.R. § 3.102, 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.124a, DC 8520. 6. The criteria for an effective date of September 29, 2016, for service connection for peripheral neuropathy of the LLE (femoral nerve) have been met. 38 U.S.C. § 5110; 38 C.F.R. § 3.400. 7. The criteria for an effective date of September 29, 2016, for service connection for peripheral neuropathy of the RLE (femoral nerve) have been met. 38 U.S.C. § 5110; 38 C.F.R. § 3.400. 8. The criteria for an initial 10 percent rating, but no more, prior to January 2, 2020, for peripheral neuropathy of the LLE (femoral nerve) have been met. 38 U.S.C. § 1155, 5103, 5103A, 5107(b); 38 C.F.R. § 3.102, 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.124a, DC 8526. 9. Subject to the laws and regulations governing the award of VA monetary benefits, an initial 10 percent rating, but no more, prior to January 2, 2020, for peripheral neuropathy of the RLE (femoral nerve) is granted. 38 U.S.C. § 1155, 5103, 5103A, 5107(b); 38 C.F.R. § 3.102, 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.124a, DC 8526. 10. The criteria for a rating in excess of 20 percent from January 2, 2020, for peripheral neuropathy of the LLE (femoral nerve) have not been met. 38 U.S.C. § 1155, 5103, 5103A, 5107(b); 38 C.F.R. § 3.102, 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.124a, DC 8526. 11. The criteria for a rating in excess of 20 percent for peripheral neuropathy of the RLE (femoral nerve) have not been met. 38 U.S.C. § 1155, 5103, 5103A, 5107(b); 38 C.F.R. § 3.102, 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.124a, DC 8526. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from February 1969 to December 1976. These matters come before the Board of Veterans Appeals (Board) on appeal from a January 2017 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO). These matters were previously remanded by the Board in May 2019. Substantial compliance with the remand requests having been accomplished, the Board may proceed to consider the claims. See Stegall v. West, 11 Vet. App. 268 (1998). The Board has limited the discussion below to the relevant evidence required to support its finding of fact and conclusion of law, as well as to the specific contentions regarding the case as raised directly by the Veteran and those reasonably raised by the record. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015); Robinson v. Peake, 21 Vet. App. 545, 552 (2008). Increased Ratings Disability evaluations are determined by the application of the facts presented to VA's Schedule for Rating Disabilities (Rating Schedule) at 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and the residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.321(a), 4.1. In evaluating the severity of a particular disability, it is essential to consider its history. 38 C.F.R. § 4.1; Peyton v. Derwinski, 1 Vet. App. 282 (1991); Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Whether the issue is one of an initial rating or an increased rating, separate ratings can be assigned for separate periods of time based on the facts found, a practice known as "staged" ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007). In making all determinations, the Board must fully consider the lay assertions of record. A layperson is competent to report on the onset and recurrence of his symptoms. Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a veteran is competent to report on that of which he or she has personal knowledge). Any reasonable doubt regarding the degree of disability should be resolved in favor of the claimant. 38 C.F.R. § 4.3. Where there is a question as to which of two evaluations shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that evaluation. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. The Court, in Correia v. McDonald, 28 Vet. App. 158 (2016), held that the final sentence of 38 C.F.R. § 4.59 requires that VA examinations include joint testing for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint. Thus, the Court's holding in Correia establishes additional requirements that must be met prior to finding that a VA examination is adequate. Further, in evaluating joint disabilities, VA must consider granting a higher rating in cases in which functional loss due to pain, weakness, excess fatigability, or incoordination is demonstrated, and those factors are not contemplated in the relevant rating criteria. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202 (1995). The Court clarified that although pain may be a cause or manifestation of functional loss, limitation of motion due to pain is not necessarily rated at the same level as functional loss where motion is impeded. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011); cf. Powell v. West, 13 Vet. App. 31, 34 (1999); Hicks v. Brown, 8 Vet. App. 417, 421 (1995); Schafrath v. Derwinski, 1 Vet. App. at 592. Additionally, the Court has stated that flare-ups must be factored into an examiner's assessment of functional loss. Sharp v. Shulkin, 29 Vet. App. 26, 32 (2017). 1. Right Knee Service connection for the Veteran's right knee disability was granted at 10 percent disabling, effective July 30, 2002. He submitted a claim for an increased rating received September 29, 2016. Accordingly, the Board will consider entitlement to an increased rating from the September 29, 2016, date of claim, including whether there was a factually ascertainable increase in severity within the year preceding the increased rating claim. See 38 C.F.R. § 3.400(o)(2). The Veteran's right knee disability is rated under 38 C.F.R. § 4.71a, DC 5010-5260. Hyphenated diagnostic codes are used when a rating under one code requires use of an additional diagnostic code to identify the basis for the rating, with the first code representing the underlying condition and the second code representing the residuals. 38 C.F.R. § 4.27. Here, the hyphenated diagnostic code indicates that the right knee disability is rated based on evidence of traumatic arthritis with painful flexion. Effective February 7, 2021, VA revised the criteria for evaluating musculoskeletal disorders. See Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 76453, 76464 (Nov. 30, 2020); Correction, 86 Fed. Reg. 8142, 8143 (Feb. 4, 2021) (changing new diagnostic code applicable to plantar fasciitis from 5285 to 5269). VA's General Counsel has held that where a law or regulation changes during the pendency of a claim for a higher rating, the Board must first determine whether the revised version is more favorable to the veteran. In so doing, it may be necessary for the Board to apply both the old and new versions of the regulation. If the revised version of the regulation is more favorable, the retroactive reach of that regulation under 38 U.S.C. § 5110(g) can be no earlier than the effective date of that change. The Board must generally apply both the former and the revised versions of the regulation for the period prior and subsequent to the regulatory change, but an effective date based on the revised criteria may be no earlier than the date of the change. VA thus must consider the claims for a higher rating pursuant to the former and revised regulations during the latter part of this appeal. See VAOPGCPREC 3 2000, 65 Fed. Reg. 33,422 (2000); DeSousa v. Gober, 10 Vet. App. 461, 467 (1997). Therefore, the Board will consider the Veteran's claims under the old criteria prior to February 7, 2021, and both the old and new rating criteria from February 7, 2021. The criteria that is more favorable to the Veteran will be applied. The Board observes that former regulation 38 C.F.R. § 19.9(b)(2) (now renumbered as 38 C.F.R. § 20.904(d)(2)) provided that the Board has the authority to consider appeals in light of laws, including but not limited to statutes, regulations and court decisions that were not previously considered by the AOJ. In Disabled American Veterans v. Sec of Veterans Affairs, 327 F.3d 1339 (Fed. Cir. 2003), the United States Court of Appeals for the Federal Circuit (Federal Circuit) specifically upheld the validity of 38 C.F.R. § 19.9(b)(2) (now as noted renumbered as 38 C.F.R. § 20.904(d)(2)). Id. at 1349. As such, pursuant to 38 C.F.R. § 20.904(d)(2), the Board will proceed to adjudicate the Veteran's claims. Traumatic arthritis as shown by x-ray studies is rated based on limitation of motion of the affected joint. 38 C.F.R. § 4.71a, DCs 5010. When, however, the limitation of motion is noncompensable under the appropriate diagnostic code, a rating of 10 percent may be applied to each such major joint or group of minor joints affected by limitation of motion. A rating of 20 percent may be applied where there are occasional incapacitating exacerbations. 38 C.F.R. § 4.71a, DCs 2010. The limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. Id. Under DC 5260, flexion of the leg limited to 60 degrees is rated noncompensably (0 percent) disabling; flexion of the leg limited to 45 degrees is rated 10 percent disabling; flexion of the leg limited to 30 degrees is rated 20 percent disabling; and flexion of the leg limited to 15 degrees is rated 30 percent disabling. Also relevant to any discussion of knee disabilities are the criteria under Diagnostic Codes 5256 through 5263. 38 C.F.R. § 4.71a. Under DC 5256, favorable ankylosis of the knee, in full extension or in slight flexion between 0 degrees and 10 degrees warrants a 30 percent disability rating; ankylosis in flexion between 10 degrees and 20 degrees warrants a 40 percent disability rating; ankylosis in flexion between 20 degrees and 45 degrees warrants a 50 percent disability rating; and extremely unfavorable ankylosis in flexion at an angle of 45 degrees or more warrants a 60 percent disability rating. Under the pre-amended criteria, DC 5257 provides that slight recurrent subluxation or lateral instability will be rated as 10 percent disabling, moderate recurrent subluxation or lateral instability will be rated as 20 percent disabling, and severe recurrent subluxation or lateral instability warrants a 30 percent rating. Effective February 7, 2021, DC 5257 was amended to provide ratings for recurrent subluxation or lateral instability. A 30 percent rating is warranted for unrepaired or failed repair of complete ligament tear causing persistent instability and a medical provider prescribing both an assistive device (e.g., cane(s), crutch(es), walker) and bracing for ambulation. A 20 percent rating is warranted for either (a) sprain, incomplete ligament tear, or repaired complete ligament tear causing persistent instability, and a medical provider prescribing a brace and/or assistive device (e.g., cane(s), crutch(es), walker) for ambulation; or (b) unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribing either an assistive device (e.g., cane(s), crutch(es), walker) or bracing for ambulation. A 10 percent rating is warranted for sprain, incomplete ligament tear, or complete ligament tear (repaired, unrepaired, or failed repair) causing persistent instability, without a prescription from a medical provider for an assistive device (e.g., cane(s), crutch(es), walker) or bracing for ambulation. DC 5257 also provides for ratings based on patellar instability. A 30 percent rating is warranted for a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for a brace and either a cane or a walker. A 20 percent rating is warranted for a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for one of the following: a brace, cane, or walker. A 10 percent rating is warranted for a diagnosed condition involving the patellofemoral complex with recurrent instability (with or without history of surgical repair) that does not require a prescription from a medical provider for a brace, cane, or walker. Note [1] to DC 5257 states that for patellar instability, the patellofemoral complex consists of the quadriceps tendon, the patella, and the patellar tendon. Note [2] to DC 5257 states that a surgical procedure that does not involve repair of one or more patellofemoral components that contribute to the underlying instability shall not qualify as surgical repair for patellar instability (including, but not limited to, arthroscopy to remove loose bodies and joint aspiration. Under DC 5258, a claimant is entitled to a 20 percent rating for dislocated semilunar 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 5261, extension of the leg limited to 5 degrees is rated noncompensably (0 percent) disabling; extension of the leg limited to 10 degrees is rated 10 percent disabling; extension of the leg limited to 15 degrees is rated 20 percent disabling; extension of the leg limited to 20 degrees is rated 30 percent disabling; extension of the leg limited to 30 degrees is rated 40 percent disabling; and extension of the leg limited to 45 degrees is rated 50 percent disabling. Under the pre-amended criteria, DC 5262 provides that a 10 percent rating is warranted for malunion of the tibia and fibula with slight knee or ankle disability. A 20 percent rating is warranted for malunion of the tibia and fibula with moderate knee or ankle disability. A 30 percent rating is warranted for malunion of the tibia and fibula with marked knee or ankle disability. A maximum 40 percent rating is warranted with nonunion of the tibia and fibula, with loose motion, requiring a brace. Effective February 7, 2021, DC 5262 is amended to provide for a 40 percent rating for nonunion of the tibia and fibula, with loose motion, requiring brace. Malunion of the tibia and fibula are to be evaluated under diagnostic codes 5256, 5257, 5260, or 5261 for the knee or 5270 or 5271 for the ankle, whichever results in the highest evaluation. Under DC 5263, a 10 percent rating is warranted for genu recurvatum (acquired, traumatic, with weakness and insecurity in weight-bearing objectively demonstrated). Effective February 7, 2021, separate ratings are also provided for medial tibial stress syndrome (MTSS) or shin splints. Normal ranges of motion of the knee are to 0 degrees in extension, and to 140 degrees in flexion. 38 C.F.R. § 4.71, Plate II. Additionally, degenerative arthritis as shown by x-ray studies are rated based on limitation of motion of the affected joint. 38 C.F.R. § 4.71a, DCs 5003. When, however, the limitation of motion is noncompensable under the appropriate diagnostic code, a rating of 10 percent may be applied to each such major joint or group of minor joints affected by limitation of motion. A rating of 20 percent may be applied where there are occasional incapacitating exacerbations. 38 C.F.R. § 4.71a, DCs 2003. The limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. Id. Turning to the relevant evidence of record, the Veteran underwent a VA knee examination in January 2016. He reported that he had a hard time with standing, walking, and going to sleep. He endorsed flare-ups in which the right knee would swell up and burn. The knee also cramped up when he went to sleep. He described the functional impairment of the right knee disability as popping and swelling. Range of motion testing demonstrated flexion from 0 to 140 degrees and extension from 140 to 0 degrees. There was no pain noted upon examination. There was tenderness at the medial side of the right knee joint. There was no evidence of crepitus. The Veteran was able to perform repetitive-use testing without any additional loss of function or range of motion. The examiner determined that the examination was neither medically consistent or inconsistent with the Veteran's statements describing functional loss with repetitive use over time and during flare-ups. The examiner stated that the Veteran denied repeated use and flare-ups and had no functional limitations. Additional factors contributing to disability included weakened movement, swelling, disturbance of locomotion, and interference with sitting and standing. Muscle strength testing was 4 out of 5 and there was no atrophy. There was no ankylosis upon observation. The examiner indicated that the Veteran did not have a history of recurrent subluxation, lateral instability, and recurrent effusion. Joint stability testing yielded normal results. There was no tibial or fibular impairment, meniscal condition, surgical history, or other pertinent conditions. The Veteran did not use any assistive devices. The functional impact was determined to be an inability to walk or stand for long periods of time, squat, or climb stairs. Another VA examination was conducted in December 2016. The Veteran denied flare-ups in the right knee. He stated that the functional impairment was that it was hard to walk. Range of motion included flexion from 0 to 110 degrees and extension from 110 to 0 degrees. Functional loss resulting from limited range of motion was that the Veteran could not squat. There was mild joint line tenderness to palpation in the right knee. There was no pain with weight-bearing or nonweight-bearing. Pain was observed with passive range of motion. There was evidence of crepitus. The Veteran was able to perform repetitive-use testing without additional loss of function or range of motion. The examiner indicated that with repeated use over time, pain would result but would not cause additional loss of range of motion. Additional factors contributing to disability included disturbance of locomotion and interference with standing. Muscle strength testing was normal with no atrophy. There was no ankylosis upon observation. The examiner indicated the Veteran did not have a history of recurrent subluxation, lateral instability, or recurrent effusion. Joint stability testing yielded normal results. The Veteran had a history of a meniscal tear and underwent a meniscectomy in 1972. The Veteran did not have tibial or fibular impairment or other pertinent conditions. He used a knee brace about five times per week if he was leaving the house. The functional impact of the disability was determined to be no squatting, kneeling, or prolonged weight-bearing. The Veteran underwent another VA knee examination in March 2019. Current symptoms included aching and popping in the knees. He denied flare-ups and functional impairment. Active and passive range of motion testing demonstrated flexion from 0 to 110 degrees and extension from 110 to 0 degrees. The associated functional loss was limited kneeling and squatting. No pain was noted on examination and there was no tenderness to palpation. There was no pain with weight-bearing, nonweight-bearing, or passive range of motion testing. There was crepitus in the right knee. The Veteran was able to perform repetitive-use testing without additional loss of function or range of motion. The examiner indicated that pain, weakness, fatigability, and incoordination would not result with repeated use over time and that range of motion would not be affected. Additional contributing factors of disability included less movement than normal and interference with kneeling and squatting. Muscle strength testing was normal and there was no atrophy. There was no ankylosis in the right knee. The Veteran indicated that there was no history of recurrent subluxation, lateral instability, or recurrent effusion. Joint stability testing yielded normal results. The examiner indicated there were no tibial or fibular impairments, meniscal conditions, surgical procedures, or other pertinent conditions. The Veteran regularly used a cane due to his separately service-connected left knee disability. The functional impact was limited kneeling and squatting and going up and down stairs. VA treatment records from November 2019 and February 2020 noted corticosteroid injections in the right knee due to increased pain. A. A rating in excess of 10 percent for DJD of the right knee is denied. At the outset, the Board notes that although not all examinations conducted during the appeal period recorded passive range of motion or pain with nonweight-bearing, the most recent examination did record these values and the Veteran has not contended that his right knee disability has improved over time. As such, the most recent examination is an adequate reflection of the severity of the disability. As such, the VA examinations of record, taken in conjunction with records of VA medical treatment, provide an adequate basis upon which to determine the extent and severity of the Veteran's right knee disability. Given the totality of the information, including the Veteran's own descriptions of his limitations, the Board finds that the requirements of DeLuca, Sharp, and Correia have been adequately addressed. DeLuca v. Brown, 8 Vet. App. at 202; Sharp v. Shulkin, 29 Vet. App. at 32; Correia v. McDonald, 28 Vet. App. at 158. Additionally, as no medical evidence relevant to the right knee has been added to the record reflecting treatment since February 7, 2021, consideration under the amended criteria is not warranted. As such, the Board will consider the severity of the Veteran's right knee disability under the pre-amended criteria. At no point during the appeal period has the Veteran's right knee flexion been limited to 30 degrees either upon clinical examination or as determined to occur with repeated use over time or during flare-ups. As such, the criteria for a rating in excess of 10 percent under DC 5260 is not warranted. Further, there is no evidence of incapacitating exacerbations meriting a rating in excess of 10 percent under the criteria of DC 5010. As such, a rating in excess of 10 percent under DC 5010-5260 is not established. The Board has considered whether additional or alternative evaluations under other diagnostic codes relevant to the knees are indicated, as well. However, at no point has ankylosis or the functional equivalent of ankylosis been evident, deserving evaluation under DC 5256. No recurrent subluxation or lateral instability has been observed or contended warranting rating under DC 5257. Finally, the Veteran's left knee has not demonstrated nonunion or malunion of the tibia and fibula or genu recurvatum requiring rating under DC 5262 or 5263. Although the Veteran had a meniscal condition in the remote past and underwent a meniscectomy, the Board also finds that additional ratings under DC 5258 or DC 5259 is not warranted. His right knee has not had frequent episodes of locking and effusion in the joint at any point, meriting rating under DC 5258. Further, although cartilage was removed in a 1972 surgery, the only symptoms reported by the Veteran are pain and limitation of motion. The current 10 percent rating under DC 5010-5260 is based specifically upon painful limitation of motion. As such, an additional rating under DC 5259 for symptomatic residuals of the meniscectomy would constitute impermissible pyramiding. See Esteban v. Brown, 6 Vet. App. 259, 262 (1994) (a veteran is entitled to separate disability ratings for different manifestations of the same disability when the symptomatology of one manifestation is not duplicative or overlapping of the symptomatology of the other manifestations). As such, additional or alternative ratings under other diagnostic codes are not available. The Board determines that the Veteran's disability is fully capable of evaluation under the rating schedule. There is no applicable provision that would warrant a higher rating in this case. 2. Peripheral Neuropathy Service connection for the Veteran's LUE and RUE peripheral neuropathy was granted at 10 percent, respectively, effective October 3, 2008. The ratings were increased to 40 percent for the LUE and 30 percent for the RUE, effective January 2, 2020. Service connection for the Veteran's LLE and RLE peripheral neuropathy involving the sciatic nerve was granted at 10 percent, respectively, effective December 21, 2009. The ratings were increased to 20 percent each, effective January 2, 2020. Service connection for the Veteran's LLE and RLE peripheral neuropathy involving the femoral nerve was granted at 20 percent, respectively, effective January 2, 2020. The Veteran submitted a claim for increased ratings on September 29, 2016. Accordingly, the Board will consider entitlement to increased ratings from the September 29, 2016, date of claim, including whether there was a factually ascertainable increase in severity within the year preceding the increased rating claim. See 38 C.F.R. § 3.400(o)(2). The Veteran's bilateral upper extremity peripheral neuropathy is rated under 38 C.F.R. § 4.124a, DC 8513, pertaining to involvement of all radicular nerves, and bilateral lower extremity peripheral neuropathy is rated under DC 8520 and DC 8526, pertaining to involvement of the sciatic and femoral nerves. Under DC 8513, a 20 percent rating is assigned for mild incomplete paralysis of both the major and minor extremity; moderate incomplete paralysis warrants a 40 percent rating in the major extremity and a 30 percent rating in the minor extremity; severe incomplete paralysis warrants a 70 percent rating in the major extremity and a 60 percent rating in the minor extremity. A maximum 90 percent rating in the major extremity and 80 percent rating in the minor extremity are assigned for complete paralysis. Under DC 8520, a 10 percent rating is warranted for mild incomplete paralysis; a 20 percent rating contemplates moderate incomplete paralysis, while a 30 percent disability rating contemplates severe incomplete paralysis; a 40 percent disability rating contemplates moderately severe incomplete paralysis; and a 60 percent rating contemplates severe incomplete paralysis with marked muscular atrophy. A maximum disability rating of 80 percent contemplates complete paralysis as evidenced by the foot dangles and drops, no active movement possible of the muscles below the knee, flexion of the knee weakened, or very rarely lost. Under DC 8526, a 10 percent rating is warranted for mild incomplete paralysis; a 20 percent rating contemplates moderate incomplete paralysis, while a 30 percent disability rating contemplates severe incomplete paralysis. A maximum disability rating of 40 percent contemplates complete paralysis as evidenced by paralysis of the quadriceps extensor muscles. The term "incomplete paralysis" with peripheral nerve injuries indicates a degree of loss or impaired function substantially less than the type pictured for complete paralysis given with each nerve, whether due to the varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating should be for mild, or at most, the moderate degree. See Note at "Diseases of the Peripheral Nerves" in 38 C.F.R. § 4.124(a). Descriptive words such as "mild," "moderate," "moderately severe" and "severe" are not defined in the Rating Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6. According to Merriam Webster's Collegiate Dictionary 999 (11th Ed. 2007), "mild" means gentle in nature or temperate. "Moderate" means limited in scope or effect. "Severe" means very painful or harmful or of a great degree. Although a medical examiner's use of descriptive terminology such as "mild" is an element of evidence to be considered by the Board, it is not dispositive of an issue. The Board must evaluate all evidence in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6. Turning to the relevant evidence of record, the Veteran underwent a VA peripheral nerves examination in January 2016. He reported that his condition had worsened over the years and currently "burns more than ever." Symptoms included moderate constant pain in the LUE and RUE and severe constant pain in the LLE and RLE; and severe intermittent pain, paresthesias/dysesthesias, and numbness in all extremities. Strength testing yielded normal strength in bilateral wrist flexion and extension, grip, pinch, and ankle flexion and dorsiflexion. Strength was less than normal in bilateral elbow and knee flexion and extension. Deep tendon reflexes were absent at the bilateral biceps and brachioradialis and were decreased in the triceps, knees, and ankles. Light touch/monofilament testing had normal results in the bilateral shoulders and was decreased in the inner/outer forearms and hand/fingers. Results were normal in the bilateral knees/thighs and decreased in the ankles/lower legs and feet/toes. Vibration sensation testing was normal in the LUE and RUE and decreased in the LLE and RLE. There was no muscle atrophy or trophic changes in any extremity. The examiner indicated that incomplete paralysis with involvement of the radial nerve was mild in both upper extremities. Incomplete paralysis with involvement of the ulnar nerve was mild in both upper extremities. Incomplete paralysis with involvement of the sciatic nerve was mild in both lower extremities and with involvement of the femoral nerve was mild in both lower extremities. VA treatment records from March 2016 reflected the prescription of Gabapentin for the Veteran's peripheral neuropathy. In a December 2016 record, it was noted that he reported that his continued peripheral neuropathy was unchanged. Another peripheral nerves examination was conducted in December 2016. Associated symptoms were mild paresthesias/dysesthesias and mild numbness in the bilateral upper extremities. In the bilateral lower extremities, the Veteran had moderate intermittent pain, moderate paresthesias/dysesthesias, and mild numbness. Strength testing, deep tendon reflex testing, and light touch/monofilament testing yielded normal results. There was no muscle atrophy or trophic changes. The examiner determined that the Veteran did not have bilateral upper extremity peripheral neuropathy. Peripheral neuropathy in the lower extremities involving the sciatic nerve was mild bilaterally. The functional impact of the disabilities was no prolonged weight-bearing. A June 2019 VA treatment record noted that the Veteran had numbness and tingling in his bilateral upper and lower extremities. The Veteran underwent another VA examination in January 2020. He described current symptoms of numbness, tingling, and burning pain in his upper and lower extremities, treated by Gabapentin. The examiner determined that he had severe constant pain, paresthesias/dysesthesias, and numbness in the bilateral upper and lower extremities. Muscle strength testing was a 4 out of 5 in all extremities. Deep tendon reflexes were normal. Sensation to light touch was decreased in all extremities. Trophic changes were noted in the lateral shins. Gait was normal. The examiner determined that the Veteran had mild incomplete paralysis in the bilateral upper extremities involving the radial, median, ulnar, musculocutaneous, circumflex, long thoracic, upper radicular group, middle radicular group, and lower radicular group nerves. The examiner also indicated that he had mild incomplete paralysis of the sciatic, external popliteal, musculocutaneous, anterior tibial, internal popliteal, posterior tibial, anterior crural, internal saphenous, obturator, external cutaneous, and ilio-inguinal nerves. The functional impact of the disabilities was difficulty walking and standing for prolonged periods of time and difficulty gripping items and dropping them easily. A. A rating in excess of 10 percent prior to January 2, 2020, and in excess of 40 percent thereafter, for peripheral neuropathy of the LUE is denied. B. A rating in excess of 10 percent prior to January 2, 2020, and in excess of 30 percent thereafter for peripheral neuropathy of the RUE is denied. Based on the foregoing, the Board finds that increased ratings for the Veteran's bilateral upper extremity peripheral neuropathy are not warranted. Prior to the January 2, 2020, examination, the Veteran's LUE and RUE neuropathy were determined by VA examiners to be mild or absent. As such, moderate incomplete paralysis was not demonstrated and the criteria for a higher rating under the criteria of DC 8513 was not met in either extremity prior to January 2, 2020. The January 2, 2020, examination again reflected mild incomplete paralysis of the LUE and RUE with involvement of all radicular groups. However, constant pain, paresthesias/dysesthesias, and numbness were severe in the upper extremities. As such, 40 and 30 percent ratings for moderate incomplete paralysis were granted as of the date of the examination. The Veteran's dominant hand is his left hand; as such, a 40 percent rating is warranted for that extremity and a 30 percent rating for his nondominant RUE. Although pain, paresthesias, and numbness were determined to be severe, the incomplete paralysis itself has not been determined to be severe. As such, ratings in excess of 40 percent and 30 percent are not warranted. Additionally, there was no factually ascertainable increase throughout VA treatment records in the Veteran's bilateral upper extremity peripheral neuropathy prior to the January 2020 examination. The Board determines that the Veteran's disabilities are fully capable of evaluation under the rating schedule. There is no applicable provision that would warrant a higher rating in this case. C. A rating in excess of 10 percent prior to January 2, 2020, and in excess of 20 percent thereafter for peripheral neuropathy of the LLE (sciatic nerve) is denied. D. A rating in excess of 10 percent prior to January 2, 2020, and in excess of 20 percent thereafter for peripheral neuropathy of the RLE (sciatic nerve) is denied. E. An effective date of September 29, 2016, for service connection for peripheral neuropathy of the LLE (femoral nerve) is granted. F. An effective date of September 29, 2016, for service connection for peripheral neuropathy of the RLE (femoral nerve) is granted. G. An initial 10 percent rating, but no more, prior to January 2, 2020, for peripheral neuropathy of the LLE (femoral nerve) is granted. H. An initial 10 percent rating, but no more, prior to January 2, 2020, for peripheral neuropathy of the LLE (femoral nerve) is granted. I. A rating in excess of 20 percent from January 2, 2020, for peripheral neuropathy of the LLE (femoral nerve) is denied. J. A rating in excess of 20 percent from January 2, 2020, for peripheral neuropathy of the RLE (femoral nerve) is denied. Based on the foregoing, the Board finds that increased ratings for the Veteran's bilateral lower extremity peripheral neuropathy are not warranted at any point during the appeal period. Prior to the January 2, 2020, VA examination, the Veteran's LLE and RLE incomplete paralysis was determined to be mild. As such, moderate incomplete paralysis was not demonstrated and the criteria for a rating in excess of 10 percent under DC 8520 were not met. At the January 2, 2020, examination, significant worsening in the bilateral lower extremity peripheral neuropathy was observed. Although incomplete paralysis was again determined to be mild, sensation testing yielded decreased results and trophic changes were observed in the lateral shins. Pain, paresthesias/dysesthesias, and numbness were severe. The Board finds that this symptomology most closely approximates moderate incomplete paralysis. Although some symptoms were severe, incomplete paralysis itself was not determined to be severe or moderately severe. As such, ratings in excess of 20 percent are not warranted in either extremity under the criteria of DC 8520 and DC 8526. Additionally, there is no evidence of a factually ascertainable increase in severity reflected in VA treatment records prior to the January 2020 examination. As such, a date earlier than January 2, 2020, for the 20 percent ratings is not warranted. However, it is apparent that the Veteran's peripheral neuropathy involving the femoral nerve has been present throughout the entire appeal period and was not just ascertainable at the January 2020 examination. As such, the Board finds that entitlement to service connection for peripheral neuropathy of the LLE and RLE involving the femoral nerve is warranted as of September 29, 2016, the date of claim for increase. See 38 C.F.R. § 3.400. As noted above, incomplete paralysis in the bilateral lower extremities was determined to be mild prior to the January 2020 examination. As such, a 10 percent rating, but no more, is warranted from September 29, 2016, in both extremities for involvement of the femoral nerve. The Board notes that the January 2020 VA examiner indicated that all lower extremity nerves were involved in the Veteran's peripheral neuropathy. However, this is not supported by the record. It is likely that the examiner did not determine which specific nerve(s) were involved in his peripheral neuropathy and indicated all nerves in order to provide a conclusion regarding severity. Indeed, he indicated that there was a worsening of the Veteran's symptoms but no change to the service-connected diagnosis and no additional diagnoses. As such, additional ratings for involvement of other lower extremity nerves are not warranted. The Board determines that the Veteran's disabilities are fully capable of evaluation under the rating schedule. There is no applicable provision that would warrant a higher rating in this case. REASONS FOR REMAND Entitlement to service connection for OSA is remanded. The Veteran has contended that his currently diagnosed OSA is the result of his service, to include as caused or aggravated by his service-connected diabetes mellitus or post-traumatic stress disorder (PTSD). A March 2018 sleep study verified a diagnosis of OSA. A VA examination was conducted in January 2020. The examiner determined that it was less likely than not that OSA was the result of service as the Veteran's service treatment records did not have any mention of sleep apnea. He also concluded that it was less likely than not that OSA was proximately due to or the result of his service-connected PTSD or diabetes mellitus, as it was not to his knowledge that PTSD or diabetes causes OSA. An addendum opinion was obtained in April 2020. The January 2020 examiner stated that diabetes mellitus was diagnosed in approximately 2004 and OSA was diagnosed in 2018. OSA can be associated with obesity, which is a common cause of diabetes, however, to his knowledge, diabetes does not cause OSA. Both diabetes and PTSD are not common causes or risk factors for developing OSA and as such, it was less likely than not that the Veteran's OSA was the result of his service-connected diabetes or PTSD. The Board finds that a new VA medical opinion is needed before a decision may be rendered on the claim. The previous examiner did not provide an adequate rationale for his determination that neither service-connected PTSD or diabetes mellitus caused the Veteran's OSA and did not provide any opinion regarding aggravation. See El Amin v. Shinseki, 26 Vet. App. 136, 140 (2013). As such, a new opinion should be sought upon remand. The matters are REMANDED for the following action: 1. Obtain an addendum opinion regarding the Veteran's claim for service connection for OSA from an appropriate VA clinician. The need for an additional examination is left to the discretion of the clinician writing the opinion. Following a review of the claims file, the clinician is asked to address the following: (a.) Is the disability related to an in-service injury, event, or disease? (b.) Is the disability caused or aggravated (i.e., worsened beyond natural progression) by the service-connected diabetes mellitus and/or PTSD? (c.) The clinician is cautioned that the term "aggravated," as used in 38 C.F.R. § 3.310(b), does not require that there be "permanent worsening" of the nonservice-connected disability. Instead, secondary service connection is warranted for "any incremental increase in disability and any additional impairment of earning capacity in nonservice-connected disabilities resulting from service-connected conditions, above the degree of disability existing before the increase regardless of its permanence." See Ward v. Wilkie, 31 Vet. App. at 239. (d.) The clinician is advised that the Veteran is competent to report his symptoms and history, and such reports should be acknowledged and considered in formulating any opinion. (e.) If medical literature is relied upon in rendering this determination, the clinician should identify and specifically cite each reference material used. (f.) All opinions should be accompanied by supporting rationale explaining how the examiner arrived at the conclusions expressed. 2. After completing the above, and any additionally indicated development, readjudicate the claims. SHEREEN M. MARCUS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Rachel E. Jensen, 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.