Citation Nr: 22016451 Decision Date: 03/22/22 Archive Date: 03/22/22 DOCKET NO. 11-08 161 DATE: March 22, 2022 ORDER Entitlement to a 10 percent disability rating for right knee strain with retropatellar pain syndrome (herein right knee disability), effective January 20, 2009, is granted. Entitlement to a 10 percent disability rating for a right knee disability, prior to January 20, 2009, is denied. Entitlement to a disability rating in excess of 10 percent for a right knee disability, from January 20, 2009, is denied. Entitlement to a 10 percent disability rating for left knee patellofemoral pain syndrome and calcium pyrophosphate deposition disease (herein left knee disability), effective September 1, 2009, is granted. Entitlement to a disability rating in excess of 10 percent for a left knee disability, from September 1, 2009, is denied. Entitlement to a 10 percent disability rating for a right ring finger fracture (herein right ring finger disability), prior to September 1, 2009, is denied. Entitlement to a disability rating in excess of 10 percent for a right ring finger disability is denied. Entitlement to a 10 percent disability rating for little toe, left foot, fracture, with excision of left metatarsal osteophytes, due to middle to painful bone spurs (herein left foot disability), prior to September 1, 2009 is denied. Entitlement to a disability rating in excess of 10 percent for a left foot disability, from September 1, 2009 and prior to August 11, 2021, is denied. Entitlement to a 20 percent disability rating for a left foot disability, effective August 11, 2021, is granted. Entitlement to a disability rating in excess of 20 percent for a left foot disability, from August 11, 2021, is denied. Entitlement to a separate 10 percent disability rating for a left foot scar under Diagnostic Code (DC) 7804, effective August 11, 2021, is granted. Entitlement to a disability rating in excess of 10 percent for a left foot scar under DC 7804, from August 11, 2021, is denied. Entitlement to a 10 percent disability rating for left thumb laceration with repair of extension pollicis longus (herein left thumb disability), effective September 1, 2009, is granted. Entitlement to a 10 percent disability rating for a left thumb disability prior to September 1, 2009 is denied. Entitlement to a disability rating in excess of 10 percent for a left thumb disability, from September 1, 2009, is denied. Entitlement to a 10 percent disability rating for costochondritis (chest pain); diaphragmatic hernia (herein costochondritis), effective September 1, 2009, is granted. Entitlement to a disability rating in excess of 10 percent for costochondritis, from September 1, 2009, is denied. Entitlement to service connection for gastroesophageal reflux disease (GERD) is granted. Entitlement to service connection for esophagitis is granted. Entitlement to service connection for gastritis is granted. FINDINGS OF FACT 1. It was factually ascertainable that an increase in the Veteran's right knee disability occurred as of January 20, 2009, specifically in the form of right knee pain. 2. It was not factually ascertainable that an increase in the Veteran's right knee disability occurred prior to January 20, 2009. 3. From January 20, 2009, the Veteran's right knee instability symptoms did not more nearly approximate moderate severity and, from February 7, 2021, he was not prescribed by a medical provider a brace and/or assistive device. 4. From September 1, 2009, the Veteran's left knee disability was manifested by pain. 5. From September 1, 2009, the Veteran's left knee instability symptoms did not more nearly approximate moderate severity and, from February 7, 2021, he was not prescribed by a medical provider a brace and/or assistive device. 6. It was not factually ascertainable that an increase in the Veteran's right ring finger disability occurred prior to September 1, 2009. 7. From September 1, 2009, the Veteran has been assigned in excess of the maximum schedular rating under DC 5527 and the evidence did not demonstrate right ring finger limitation of motion with a gap of one inch (2.5 cm.) or more between the fingertip and the proximal transverse crease of the palm, with the finger flexed to the extent possible, or; with extension limited by more than 30 degrees. 8. It was not factually ascertainable that an increase in the Veteran's left foot disability occurred prior to September 1, 2009. 9. From September 1, 2009 and prior to August 11, 2021, the Veteran's left foot disability did not more nearly approximate that of a moderately severe other foot injury. 10. Effective August 11, 2021, the Veteran's left foot disability more nearly approximated that of a moderately severe other foot injury. 11. From August 11, 2011, the Veteran's left foot disability did not more nearly approximate that of a severe other foot injury. 12. Effective August 11, 2021, the Veteran's left foot disability manifestations included one painful left foot scar. 13. From August 11, 2021, the Veteran's left foot disability manifestations did not include at least three painful scars. 14. Effective September 1, 2009, the Veteran's left thumb disability more nearly approximated that of a moderate muscle disability. 15. It was not factually ascertainable that an increase in the Veteran's left thumb disability occurred prior to September 1, 2009. 16. From September 1, 2009, the Veteran's left thumb disability did not more nearly approximate that of a moderately severe muscle disability. 17. Effective September 1, 2009, the Veteran's costochondritis more nearly approximated that of a moderate muscle disability. 18. From September 1, 2009, the Veteran's costochondritis did not more nearly approximate that of a moderately severe muscle disability. 19. The Veteran's GERD is related to his active service. 20. The Veteran's gastritis is related to his active service. 21. The Veteran's esophagitis is related to his active service. CONCLUSIONS OF LAW 1. Effective January 20, 2009, the criteria for a 10 percent rating for the Veteran's right knee disability were met. 38 U.S.C. § 1155; 38 C.F.R. § 4.71a, DC 5257. 2. The criteria for a 10 percent rating for the Veteran's right knee disability, prior to January 20, 2009, were not met. 38 U.S.C. § 1155; 38 C.F.R. § 4.71a, DC 5257. 3. From January 20, 2009, the criteria for a rating in excess of 10 percent for the Veteran's right knee disability were not met. 38 U.S.C. § 1155; 38 C.F.R. § 4.71a, DC 5257. 4. Effective September 1, 2009, the criteria for a 10 percent rating for the Veteran's left knee disability were met. 38 U.S.C. § 1155; 38 C.F.R. § 4.71a, DC 5257. 5. From September 1, 2009, the criteria for a rating in excess of 10 percent for the Veteran's left knee disability were not met. 38 U.S.C. § 1155; 38 C.F.R. § 4.71a, DC 5257. 6. The criteria for a 10 percent rating for the Veteran's right ring finger disability, prior to September 1, 2009, were not met. 38 U.S.C. § 1155; 38 C.F.R. § 4.71a, DC 5227. 7. From September 1, 2009, the criteria for a rating in excess of 10 percent for the Veteran's right ring finger disability were not met. 38 U.S.C. § 1155; 38 C.F.R. § 4.71a, DC 5227. 8. The criteria for a 10 percent rating for the Veteran's left foot disability, prior to September 1, 2009, were not met. 38 U.S.C. § 1155; 38 C.F.R. § 4.71a, DC 5284. 9. From September 1, 2009 and prior to August 11, 2021, the criteria for a rating in excess of 10 percent for the Veteran's left foot disability were not met. 38 U.S.C. § 1155; 38 C.F.R. § 4.71a, DC 5284. 10. Effective August 11, 2021, the criteria for a 20 percent rating for the Veteran's left foot disability were met. 38 U.S.C. § 1155; 38 C.F.R. § 4.71a, DC 5284. 11. From August 11, 2021, the criteria for a rating in excess of 20 percent for the Veteran's left foot disability were not met. 38 U.S.C. § 1155; 38 C.F.R. § 4.71a, DC 5284. 12. Effective August 11, 2021, the criteria for a separate 10 percent rating for a painful left foot scar were met. 38 U.S.C. § 1155; 38 C.F.R. § 4.118, DC 7804. 13. From August 11, 2021, the criteria for a rating in excess of 10 percent for the Veteran's left foot scar were not met. 38 U.S.C. § 1155; 38 C.F.R. § 4.118, DC 7804. 14. The criteria for a 10 percent rating, effective September 1, 2009, for the Veteran's left thumb disability were met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.73, DC 5308; 4.118, DC 7805. 15. The criteria for a 10 percent rating for the Veteran's left thumb disability, prior to September 1, 2009, were not met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.73, DC 5308; 4.118, DC 7805. 16. From September 1, 2009, the criteria for a rating in excess of 10 percent for the Veteran's left thumb disability were not met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.73, DC 5308; 4.118, DC 7805. 17. The criteria for a 10 percent rating, effective September 1, 2009, for the Veteran's costochondritis were met. 38 U.S.C. § 1155; 38 C.F.R. § 4.73, DC 5321. 18. From September 1, 2009, the criteria for a rating in excess of 10 percent for the Veteran's costochondritis were not met. 38 U.S.C. § 1155; 38 C.F.R. § 4.73, DC 5321. 19. The criteria for entitlement to service connection for GERD were met. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. 20. The criteria for entitlement to service connection for gastritis were. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. 21. The criteria for entitlement to service connection for esophagitis were met. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Air Force from September 1978 to September 1982 and the United States Army from October 1983 to September 1992. This case comes before the Board of Veterans' Appeals (Board) from June 2010 and October 2011 rating decisions. The Board previously remanded these claims in March 2018 and August 2021. The Board finds that there has been substantial compliance with the prior Board remands (with an exception discussed below with respect to the GERD, esophagitis and gastritis claims). See Stegall v. West, 11 Vet. App. 268 (1998). In this regard, the Board notes that the August 2021 Board remand was to afford the Veteran a Veterans Benefits Administration (VBA) hearing and in August 2021, at the Veteran's representative's request, an informal conference was held in lieu of a formal in person hearing. The Board additionally notes that in August 2021 the Board remanded the issues of an increased rating in excess of 30 percent for sinusitis and entitlement to a total disability rating based on individual unemployability (TDIU). Subsequently, in an August 2021 rating decision, VBA granted an increased 50 percent rating for sinusitis and entitlement to a TDIU, both effective September 1, 2009. These claims were not included by VBA on the most recent August 2021 supplemental statement of the case (SSOC) and in a September 2021 statement, the Veteran's representative specifically expressed satisfaction with the outcome of the sinusitis and TDIU claims. As such, these claims are no longer on appeal and will not be addressed by the Board in this decision. Besides the issues addressed below, neither the Veteran nor his representative has raised any issues with the duty to notify or duty to assist. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board...to search the record and address procedural arguments when the veteran fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). 1. Increased Rating Right Knee Disability Procedural History and Legal Criteria A July 1993 rating decision granted service connection for right knee strain with retropatellar pain syndrome. A 0 percent rating was assigned under DC 5299-5257, which indicates that this disability has been rated by analogy. See 38 C.F.R. §§ 4.20 ("When an unlisted condition is encountered it will be permissible to rate under a closely related disease or injury in which not only the functions affected, but the anatomical localization and symptomatology are closely analogous"); 4.27 ("When an unlisted disease, injury, or residual condition is encountered, requiring rating by analogy, the [DC] number will be built-up as follows: The first 2 digits will be selected from that part of the schedule most closely identifying the part, or system, of the body involved; the last 2 digits will be '99' for all unlisted conditions and if the rating is determined on the basis of residual conditions, the number appropriate to the residual condition will be added, preceded by a hyphen"). The rating decision stated regarding the right knee disability that such was "without limitation of movement or instability identified at separation." The Veteran filed a September 1, 2009 claim (via VA Form 21-526). He listed a disability of bilateral knee condition and also stated "I was made aware that I was service connected for some (4 cond[ition]s) and consider this claim for increase." In the June 2010 rating decision on appeal for this claim, VBA granted an increased 10 percent rating under the same prior DC (5299-5257), effective September 1, 2009. The rating decision noted that the effective date was based on "the day we received your claim." The rating decision also stated, regarding the 10 percent rating assigned, that "[e]ven though your disability on the VA examination does not meet the schedular requirements, we are increasing the evaluation to 10 percent based on the findings of limitation due to pain on motion," with reference to 38 C.F.R. §§ 4.40 and 4.45 and the case of DeLuca v. Brown, 8 Vet. App. 202, 208 (1995). The Board notes that, while not cited by VBA, 38 C.F.R. § 4.59 (titled "Painful motion") states "[i]t is the intention to recognize actually painful...joints...as entitled to at least the minimum compensable rating for the joint." Under DC 5257 ("Knee, other impairment of"), a 10 percent rating is warranted for slight recurrent subluxation or lateral instability. A 20 percent rating is warranted for moderate recurrent subluxation or lateral instability. A 30 percent rating, the highest schedular rating available, is warranted for severe recurrent subluxation or lateral instability. According to MERRIAM WEBSTER'S COLLEGIATE DICTIONARY 999 (11th Ed. 2007), "slight" means small in amount. "Moderate" means limited in scope or effect. "Severe" means very painful or harmful or of a great degree. Objective medical evidence is not required to establish lateral knee instability under DC 5257, so objective medical evidence cannot be categorically found more probative than lay evidence with respect to this DC. See English v. Wilkie, 30 Vet. App. 347, 352-53 (2018). Effective February 7, 2021, VA amended the rating criteria for disabilities of the knee and leg. The amended DC 5257 provides ratings for other impairment of the knee based on recurrent subluxation or instability, and patellar instability. Claims pending prior to the effective date will be considered under both old and new rating criteria, and whatever criteria is more favorable to the veteran will be applied. The Board may not apply a current regulation prior to its effective date, unless the regulation explicitly provides otherwise. Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). However, the Board is not precluded from applying prior versions of the applicable regulation to the period on or after the effective dates of the new regulation if the prior version was in effect during the pendency of the appeal. Under the amended DC 5257, for recurrent subluxation or instability, 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. A 20 percent rating is warranted for one of the following: (a) Sprain, incomplete ligament tear, or repaired complete ligament tear causing persistent instability, and a medical provider prescribes 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 prescribes either an assistive device (e.g., cane(s), crutch(es), walker) or bracing for ambulation. A maximum 30 percent rating is warranted for unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribes both an assistive device (e.g., cane(s), crutch(es), walker) and bracing for ambulation. For patellar instability, 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. 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 maximum 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. Note (1) provides that, for patellar instability, the patellofemoral complex consists of the quadriceps tendon, the patella, and the patellar tendon. Note (2) provides 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 a surgical repair for patellar instability (including, but not limited to, arthroscopy to remove loose bodies and joint aspiration). When evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use and, therefore, not be reflected on range-of-motion testing. 38 C.F.R. § 4.45 requires consideration also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Nonetheless, even when the background factors listed in § 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a; a separate or higher rating under § 4.40 or 4.45 itself is not appropriate. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016) ("[I]t is clear that the guidance of § 4.40 is intended to be used in understanding the nature of the veteran's disability, after which a rating is determined based on the § 4.71a criteria."). Under 38 C.F.R. § 4.59, painful motion is a factor to be considered with any form of arthritis; however, 38 C.F.R. § 4.59 is not limited to disabilities involving arthritis. See Burton v. Shinseki, 25 Vet. App. 1 (2011). Analysis DC 5257 Prior to September 1, 2009 Initially, after resolving reasonable doubt in the Veteran's favor, the Board finds that the previously assigned 10 percent rating is warranted as of January 20, 2009. See 38 C.F.R. §§ 3.102 ("When...a reasonable doubt arises regarding...the degree of disability, or any other point, such doubt will be resolved in favor of the claimant"), 4.3 ("When...a reasonable doubt arises regarding the degree of disability such doubt will be resolved in favor of the claimant"), 4.7 ("Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating"). In this regard, as explained, the Veteran filed the increased rating claim on appeal on September 1, 2009 and this date was used by VBA as the effective date for the granted increased 10 percent rating. For increased rating claims, 38 U.S.C. § 5110(b)(3) and 38 C.F.R. § 3.400(o)(2) potentially allow for an increase in disability compensation of up to one year prior to the date of claim, if it is factually ascertainable based on all evidence of record that an increase in disability had occurred. See Gaston v. Shinseki, 605 F.3d 979, 982 (Fed. Cir. 2010) (referencing the "'one-year look-back period'"). In this case, within the one-year look-back period, is a January 20, 2009 VA treatment record. This record stated that the Veteran "has bilateral knee pain with burning sensation worse when walk fast" and noted an assessment of "knee pain." The Board notes that prior electronic VA treatment records of record, which date back to 1998, did not appear to note treatment related to the right knee, to include right knee pain. As noted, VBA assigned an increased 10 percent rating "based on the findings of limitation due to pain on motion." Resolving reasonable doubt in the Veteran's favor, the Board finds that the January 20, 2009 VA treatment record described right knee pain on motion. Further, again resolving reasonable doubt in the Veteran's favor, in light of the lack of prior VA treatment records related to the right knee, the Board finds that it is factually ascertainable that an increase in the Veteran's right knee disability occurred as of the January 20, 2009 VA treatment record. As such, the Board finds that the previously assigned 10 percent rating is warranted as of January 20, 2009. The Board further finds that an even earlier effective date for the increased 10 percent rating for a right knee disability is not warranted. In this regard, as explained, January 20, 2009 is the date of a specific VA treatment record that documented relevant findings for the Veteran's right knee disability, which thus allows the Board to factually ascertain that an increase in disability occurred. While it is possible that the Veteran's right knee disability increased in disability earlier in the relevant one-year look-back period prior to January 20, 2009, an earlier date cannot be factually ascertained based on all the evidence of record and would require speculation. Application of the benefit of the doubt doctrine is not appropriate under these circumstances. See 38 C.F.R. § 3.102 (discussing reasonable doubt as "a substantial doubt and one within the range of probability as distinguished from pure speculation or remote possibility"). As such, the Board finds that a 10 percent disability rating for a right knee disability, prior to January 20, 2009, is not warranted. Analysis "Old" DC 5257 from January 20, 2009 As noted, DC 5257 was amended during the appeal period. As such, the Board will initially address whether an increased rating is warranted under the "old" DC 5257 for the entire appeal period, followed by addressing whether an increased rating is warranted from February 7, 2021 under the "new" DC 5257. Upon review, the Board finds that a rating in excess of 10 percent under the old DC 5257 is not warranted at any point from January 20, 2009. As noted, the next higher 20 percent rating is warranted for moderate recurrent subluxation or lateral instability. The Board has carefully considered the Veteran's reports about instability. English, 30 Vet. App. 347, 352-53. However, overall, the lay and medical evidence indicates that the instability symptoms have varied and do not suggest the presence of symptoms more nearly approximating moderate severity. In this regard, the relevant evidence for this appeal primarily consists of various VA examination reports from October 2009, September 2011, October 2014 and November 2020. The October 2009 Joints examination report noted for the right knee, under the "summary of joint symptoms" heading (presumably based on the Veteran's reports), instability, but not giving way or episodes of subluxation. Assistive devices were noted as "[n]one." Upon physical examination, it was noted that there was no instability or patellar abnormality. The September 2011 Joints examination report noted for the right knee, under the "summary of joint symptoms" heading (presumably based on the Veteran's reports), giving way, but not instability or episodes of subluxation. Assistive devices were noted as "[n]one." Upon physical examination, it was noted that there was no instability or patellar instability. In addition, a subsequent September 2011 general medical examination report was completed. It was stated that the Veteran "complain[]s of recurrent right knee pain and instability several times per week." The October 2014 Knee and Lower Leg Conditions Disability Benefits Questionnaire (DBQ) noted under the medical history section (presumably based on the Veteran's reports) "no giving out." Joint stability testing was performed and noted as normal for all tests conducted (specifically, anterior instability (Lachman test), posterior instability (Posterior drawer test) and medial-lateral instability (Apply valgus/varus pressure to knee in extension and 30 degrees of flexion). It was noted that there was not evidence or history of recurrent patellar subluxation/dislocation. It was noted that the Veteran did not use any assistive devices as a normal mode of locomotion. The November 2020 Knee and Lower Leg Conditions Disability Benefits Questionnaire (DBQ) noted under the medical history section (presumably based on the Veteran's reports) as current symptoms only knee pain. It was noted that there was not a history of lateral instability or recurrent subluxation. Joint stability testing was performed and it was specifically noted that there was not joint instability. All joint stability testing conducted was noted as normal (specifically, anterior instability (Lachman test), posterior instability (Posterior drawer test), medial instability (Apply valgus pressure to knee in extension and with 30 degrees of flexion) and lateral instability (Apply varus pressure to knee in extension and with 30 degrees of flexion). It was noted that the Veteran did not use any assistive devices as a normal mode of locomotion. In review of the four VA exams conducted at various points during the appeal period, instability was reported at the 2009 exam, giving way was reported at the 2011 joints exam and instability was reported at the September 2011 general medical exam. The 2009 exam, however, also noted no giving way and the 2011 exam noted no instability. The 2014 exam specifically noted "no giving out" and the 2020 exam only documented current symptoms of pain, without mention of instability. Moreover, upon physical examination at the 2009, 2011, 2014 and 2020 exams, joint stability was noted as normal. Overall, the Board finds that the lay and medical evidence indicates that the Veteran's instability symptoms have varied and that such symptoms do not more nearly approximate moderate severity. As such, the Board finds that a rating in excess of 10 percent is not warranted under old DC 5257 at any point from January 20, 2009. Analysis "New" DC 5257 from February 7, 2021 Upon review, the Board also finds that a rating in excess of 10 percent under the new DC 5257 is not warranted at any point from February 7, 2021 (the effective date of the new criteria and thus when it can be applied). Under the new DC 5257, the next higher 20 percent rating is warranted for, as relevant, recurrent subluxation or lateral instability for a "[s]prain...causing persistent instability, and a medical provider prescribes a brace and/or assistive device (e.g., cane(s), crutch(es), walker) for ambulation." A 20 percent rating is warranted for, as relevant, patellar instability 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." Putting aside any other criteria, a higher 20 percent rating under DC 5257 based on recurrent subluxation, lateral instability or patellar instability all require a medical provide to prescribe either a brace or an assistive device (such as a cane, crutches or walker). The evidence of record did not show that this criterion was met. In this regard, the four VA exams during the appeal period (in 2009, 2011, 2014 and 2020) all indicated that the Veteran did not use any assistive devices. Other evidence of record, to include that dated after February 7, 2021, did not indicate the use of a brace or assistive devices. See, e.g., March 2021 VA Treatment Record ("Patient currently uses assistive devices with ambulation: No"). As such, the Board finds that a rating in excess of 10 percent is not warranted under new DC 5257 at any point from February 7, 2021. Analysis Other DCs from January 20, 2009 The Board has also considered the other DCs pertaining to the knee and leg. Other disability ratings may be assigned only if the symptomatology for a disability is not duplicative or overlapping with the symptomatology of any other disability. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994); Lyles v. Shulkin, 29 Vet. App. 107 (2017) (holding that 38 C.F.R. § 4.14 prohibits paying compensation twice for the same symptoms or functional impairment). Under DCs 5260 and 5261, disability ratings are warranted based on specific limitation of motion findings. In this regard, under DC 5260 a 10 percent rating is warranted based on flexion limited to 45 degree and under DC 5261 a 10 percent rating is warranted for extension limited to 10 degrees. The evidence of record did not show that either of these criteria were met. In this regard, the four VA exams during the appeal period (in 2009, 2011, 2014 and 2020) all included range of motion findings that did not meet those required for the minimum 10 percent ratings under DC 5260 or 5261. Other evidence of record also did not document range of motion findings sufficient to warrant a compensable rating under DC 5260 or 5261. As such, the Board finds that a separate (or higher) rating is not warranted under DCs 5260 or 5261 at any point during the appeal period. The Board specifically acknowledges the Veteran's lay reports of symptoms and that evidence of record demonstrated flare-ups, functional loss and functional impairment. Even considering such, however, the Board finds that the Veteran's disability picture, or any additional limitation of motion, would not more nearly approximate the criteria for a higher rating. As such, while the Board has considered 38 C.F.R. § 4.40 and § 4.45, the Board finds that a rating in excess of 10 percent is still not warranted at any point during the appeal period. Conclusion In sum, the Board finds that it was factually ascertainable that an increase in the Veteran's right knee disability occurred as of January 20, 2009, specifically in the form of right knee pain. The Board further finds that it was not factually ascertainable that an increase in the Veteran's right knee disability occurred prior to January 20, 2009. The Board additionally finds that, from January 20, 2009, the Veteran's right knee instability symptoms did not more nearly approximate moderate severity and that, from February 7, 2021, he was not prescribed by a medical provider a brace and/or assistive device. As such, the Board concludes that, effective January 20, 2009, the criteria for a 10 percent rating for the Veteran's right knee disability were met. The Board further conclude that the criteria for a 10 percent rating for the Veteran's right knee disability, prior to January 20, 2009, were not met. The Board additionally concludes that, from January 20, 2009, the criteria for a rating in excess of 10 percent for the Veteran's right knee disability were not met. 38 U.S.C. § 1155; 38 C.F.R. § 4.71a, DC 5257 (for all conclusions). 2. Increased Rating Left Knee Disability Procedural History and Legal Criteria The October 2011 rating decision on appeal for this claim granted service connection for a left knee disability and assigned a 0 percent rating, effective September 1, 2009. The rating was assigned under the same DC as the Veteran's right knee disability, 5299-5257. The rating decision stated that "[a] non-compensable evaluation is assigned unless there is recurrent subluxation or lateral instability of the knee which is slight." In an October 2014 rating decision, VBA increased the Veteran's left knee disability rating to 10 percent under DC 5299-5257, effective October 3, 2014. The effective date was noted to be due to "the date entitlement arose as per VA examination showing a higher evaluation." The 10 percent rating was assigned based on "[p]ainful motion of the knee (38 CFR §4.59 allows consideration of functional loss due to painful motion to be rated to at least the minimum compensable rating for a particular joint. Since you demonstrate painful motion of the knee, the minimum compensable evaluation of 10 percent is assigned)." The applicable legal criteria were discussed above in the right knee increased rating section. Analysis DC 5257 prior to October 3, 2014 Initially, after resolving reasonable doubt in the Veteran's favor, the Board finds that the previously assigned 10 percent rating (effective by VBA as of October 3, 2014) is warranted as of September 1, 2009. In this regard, as explained, September 1, 2009 is the date service connection was granted for the Veteran's left knee disability. VBA initially assigned a 0 percent rating, which it increased effective October 3, 2014 based on a showing of painful motion based on an examination that date. Review of evidence prior to October 3, 2014, however, indicated that the Veteran's left knee was painful prior to the date used by VBA. Such evidence included a previously discussed January 20, 2009 VA treatment record that stated that the Veteran "has bilateral knee pain with burning sensation worse when walk fast" and noted an assessment of "knee pain." A subsequent October 2009 VA treatment record stated that the Veteran "has knee pain while walking." An October 2009 VA joints examination report noted under the summary of joint symptoms (presumably based on the Veteran's reports) left side knee pain. In addition, upon physical examination and range of motion testing, it was noted that there was objective evidence of pain with active motion on the left side. While the September 2011 VA joints examination report noted that there was not objective evidence of pain with active motion on the left side, this examination specifically related to the Veteran's right knee disability claim and did not include complete findings as to the Veteran's left knee disability (to include a summary of joint symptoms section completed for the left knee). This examination report, however, also noted that there was objective evidence of pain following repetitive motion, without specifically noting if such finding applied to the left or right knees. Overall, in light of the evidence demonstrating that the Veteran's left knee was painful prior to October 3, 2014, and after resolving reasonable doubt in the Veteran's favor, the Board finds that a 10 percent rating is warranted for the entire appeal period from September 1, 2009. See 38 C.F.R. § 4.59 ("It is the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint"); Petitti v. McDonald, 27 Vet. App. 415, 425 (2015) ("Under § 4.59, the trigger for a minimum disability rating is an "actually painful, unstable, or malaligned joint[ ]"). Analysis "Old" DC 5257 from September 1, 2009 Upon review, the Board finds that a rating in excess of 10 percent under the old DC 5257 is not warranted at any point during the appeal period (from September 1, 2009). As noted, the next higher 20 percent rating is warranted for moderate recurrent subluxation or lateral instability. The Board has carefully considered the Veteran's reports about instability. English, 30 Vet. App. 347, 352-53. However, overall, the lay and medical evidence indicates that the instability symptoms have varied and do not suggest the presence of symptoms more nearly approximating moderate severity. In this regard, the relevant evidence for this appeal primarily consists of various VA examination reports from October 2009, September 2011, October 2014 and November 2020. The October 2009 Joints examination report noted for the left knee, under the "summary of joint symptoms" heading (presumably based on the Veteran's reports), instability, but not giving way or episodes of subluxation. Assistive devices were noted as "[n]one." Upon physical examination, it was noted that there was no instability. Patellar abnormality was noted, specifically "[s]ubpatellar [t]enderness." The September 2011 Joints examination report, as noted above, did not include complete findings as to the Veteran's left knee disability, to include findings as to instability. The examination report noted assistive devices as "[n]one." The October 2014 Knee and Lower Leg Conditions Disability Benefits Questionnaire (DBQ) noted under the medical history section (presumably based on the Veteran's reports) "no giving out." Joint stability testing was performed and noted as normal for all tests conducted (specifically, anterior instability (Lachman test), posterior instability (Posterior drawer test) and medial-lateral instability (Apply valgus/varus pressure to knee in extension and 30 degrees of flexion). It was noted that there was not evidence or history of recurrent patellar subluxation/dislocation. It was noted that the Veteran did not use any assistive devices as a normal mode of locomotion. The November 2020 Knee and Lower Leg Conditions Disability Benefits Questionnaire (DBQ) noted under the medical history section (presumably based on the Veteran's reports) as current symptoms only knee pain. It was noted that there was not a history of lateral instability or recurrent subluxation. Joint stability testing was performed and it was specifically noted that there was not joint instability. All joint stability testing conducted was noted as normal (specifically, anterior instability (Lachman test), posterior instability (Posterior drawer test), medial instability (Apply valgus pressure to knee in extension and with 30 degrees of flexion) and lateral instability (Apply varus pressure to knee in extension and with 30 degrees of flexion). It was noted that the Veteran did not use any assistive devices as a normal mode of locomotion. In review of the three VA exams conducted specifically for the left knee disability at various points during the appeal period, instability was reported at the 2009 exam. The 2009 exam, however, also noted no giving way. The 2014 exam specifically noted "no giving out" and the 2020 exam only documented current symptoms of pain, without mention of instability. Moreover, upon physical examination at the 2009, 2014 and 2020 exams, joint stability was noted as normal. Overall, the Board finds that the lay and medical evidence indicates that the Veteran's instability symptoms have varied and that such symptoms do not more nearly approximate moderate severity. As such, the Board finds that a rating in excess of 10 percent is not warranted under old DC 5257 at any point during the appeal period from September 1, 2009. Analysis "New" DC 5257 from February 7, 2021 Upon review, the Board also finds that a rating in excess of 10 percent under the new DC 5257 is not warranted at any point from February 7, 2021 (the effective date of the new criteria and thus when it can be applied). As noted above, putting aside any other criteria, a higher 20 percent rating under new DC 5257 based on recurrent subluxation, lateral instability or patellar instability all require a medical provide to prescribe either a brace or an assistive device (such as a cane, crutches or walker). The evidence of record did not show that this criterion was met. In this regard, the four VA exams during the appeal period (in 2009, 2011, 2014 and 2020) all indicated that the Veteran did not use any assistive devices. Other evidence of record, to include that dated after February 7, 2021, did not indicate the use of a brace or assistive devices. See, e.g., March 2021 VA Treatment Record ("Patient currently uses assistive devices with ambulation: No"). As such, the Board finds that a rating in excess of 10 percent is not warranted under new DC 5257 at any point from February 7, 2021. Analysis Other DCs from September 1, 2009 The Board has also considered the other DCs pertaining to the knee and leg. As noted above, under DCs 5260 and 5261, disability ratings are warranted based on specific limitation of motion findings. The evidence of record did not show that the criteria for a 10 percent rating under DC 5260 or 5261 were met. In this regard, four VA exams during the appeal period (in 2009, 2011, 2014 and 2020) all included range of motion findings that did not meet those required for the minimum 10 percent ratings under DC 5260 or 5261. Other evidence of record also did not document range of motion findings sufficient to warrant a compensable rating under DC 5260 or 5261. As such, the Board finds that a separate (or higher) rating is not warranted under DCs 5260 or 5261 at any point during the appeal period. The Board specifically acknowledges the Veteran's lay reports of symptoms and that evidence of record demonstrated flare-ups, functional loss and functional impairment. Even considering such, however, the Board finds that the Veteran's disability picture, or any additional limitation of motion, would not more nearly approximate the criteria for a higher rating. As such, while the Board has considered 38 C.F.R. § 4.40 and § 4.45, the Board finds that a rating in excess of 10 percent is still not warranted at any point during the appeal period. Conclusion In sum, the Board finds that, from September 1, 2009, the Veteran's left knee disability was manifested by pain. The Board additionally finds that, from September 1, 2009, the Veteran's left knee instability symptoms did not more nearly approximate moderate severity and that, from February 7, 2021, he was not prescribed by a medical provider a brace and/or assistive device. As such, the Board concludes that, effective September 1, 2009, the criteria for a 10 percent rating for the Veteran's left knee disability were met. The Board further conclude that the criteria for a 10 percent rating for the Veteran's left knee disability, from September 1, 2009, were not met. 38 U.S.C. § 1155; 38 C.F.R. § 4.71a, DC 5257 (for both conclusions). 3. Increased Rating Right Ring Finger Procedural History and Legal Criteria A July 1993 rating decision granted service connection for fracture right ring finger. A 0 percent rating was assigned under DC 5299-5227. The rating decision stated regarding the right ring finger disability that such was "without residual repairment identified." The Veteran filed a September 1, 2009 claim (via VA Form 21-526). He stated "I was made aware that I was service connected for some (4 cond[ition]s) and consider this claim for increase." In the June 2010 rating decision on appeal for this claim, VBA granted an increased 10 percent rating under the same prior DC (5299-5277), effective September 1, 2009. The rating decision noted that the effective date was based on "the day we received your claim." The rating decision also stated, regarding the 10 percent rating assigned, that "[t]his evaluation is not based on evaluation criteria in the rating schedule" and that "[t]he reason this non-schedular evaluation is assigned is because [DC] 5227 provides that a noncompensable evaluation is assigned for ankylosis of the right or little finger and this is the highest evaluation under this particular [DC]." The rating decision further stated that "we are increasing the evaluation to 10 percent based on the findings of limitation due to pain on motion." Under DC 5227, the highest schedular rating available is 0 percent, for unfavorable or favorable ankylosis of the ring or little finger. Under the potentially applicable alternative DC 5229, a 10 percent rating is the highest schedular rating and such is warranted for limitation of motion, specifically with a gap of one inch (2.5 cm.) or more between the fingertip and the proximal transverse crease of the palm, with the finger flexed to the extent possible, or; with extension limited by more than 30 degrees. Analysis 10 Percent Rating prior to September 1, 2009 Upon review, the Board finds that a 10 percent rating for a right ring finger disability, prior to September 1, 2009, is not warranted. In this regard, as explained, the Veteran filed the increased rating claim on appeal on September 1, 2009 and this date was used by VBA as the effective date for the granted increased 10 percent rating. For increased rating claims, the one-year look-back period potentially allow for an increase in disability compensation of up to one year prior to the date of claim, if it is factually ascertainable based on all evidence of record that an increase in disability had occurred. In this case, the Board finds that it was not factually ascertainable that an increase in the Veteran's right ring finger disability occurred prior to September 1, 2009. As such, the Board concludes that the criteria for a 10 percent rating for the Veteran's right ring finger disability, prior to September 1, 2009, were not met. Analysis 10 Percent Rating from September 1, 2009 Upon review, the Board finds that a rating in excess of 10 percent is not warranted at any point from September 1, 2009. As noted above, VBA has assigned a 10 percent rating for the entire appeal period for this disability under DC 5299-5227. In fact, a 10 percent rating is not available under DC 5227. As such, a rating in excess of 10 percent is not warranted under this DC. In addition, under the potentially applicable alternative DC 5229, a 10 percent rating is the highest schedular rating and such is warranted for specifically defined limitation of motion. The evidence of record did not show that this criterion were met. In this regard, relevant VA exams during the appeal period (in 2009 (a Hand, Thumb and Fingers exam report) and 2020 (a Hand and Finger Conditions DBQ) included range of motion findings that did not meet those required for the 10 percent rating DC 5229. Other evidence of record also did not document range of motion findings sufficient to warrant a compensable rating under DC 5229. As such, the Board finds that a separate (or higher) rating is not warranted under DC 5229 at any point during the appeal period. In sum, the Board finds that, from September 1, 2009, the Veteran has been assigned in excess of the maximum schedular rating under DC 5527 and that the evidence did not demonstrate right ring finger limitation of motion with a gap of one inch (2.5 cm.) or more between the fingertip and the proximal transverse crease of the palm, with the finger flexed to the extent possible, or; with extension limited by more than 30 degrees. As such, the Board concludes that, from September 1, 2009, the criteria for a rating in excess of 10 percent for the Veteran's right ring finger disability were not met. 38 U.S.C. § 1155; 38 C.F.R. § 4.71a, DC 5227. 4. Increased Rating Left Foot Disability Procedural History and Legal Criteria A July 1993 rating decision granted service connection for fracture middle toe left foot with excision osteophyte metatarsal left little toe secondary to painful bone spur. A 0 percent rating was assigned under DC 5284. The rating decision stated regarding the left foot disability that such was "without residual impairment identified at separation." The Veteran filed a September 1, 2009 claim (via VA Form 21-526). He stated "I was made aware that I was service connected for some (4 cond[ition]s) and consider this claim for increase." In the June 2010 rating decision on appeal for this claim, VBA granted an increased 10 percent rating under the same prior DC (5284), effective September 1, 2009. The rating decision noted that the effective date was based on "the day we received your claim." The rating decision also stated, regarding the 10 percent rating assigned, that "[w]e are increasing the evaluation to 10 percent based on the findings of limitation due to pain (tenderness)." Under DC 5284 ("Foot injuries, other"), a 10 percent rating is warranted for moderate other foot injuries. A 20 percent rating is warranted for moderately severe other foot injuries. A 30 percent rating is warranted for severe other foot injuries. A Note to DC 5284 instructs that with actual loss of use of the foot rate as a maximum 40 percent. 38 C.F.R. § 4.71a, Diagnostic Code 5284. According to MERRIAM WEBSTER, "moderate" means "tending toward the mean or average amount or dimension". See www.merriam-webster.com/dictionary/moderate. "Severe" means "of a great degree". See www.merriam-webster.com/dictionary/severe. Analysis 10 Percent Rating prior to September 1, 2009 Upon review, the Board finds that a 10 percent rating for a left foot disability, prior to September 1, 2009, is not warranted. In this regard, as explained, the Veteran filed the increased rating claim on appeal on September 1, 2009 and this date was used by VBA as the effective date for the granted increased 10 percent rating. For increased rating claims, the one-year look-back period potentially allow for an increase in disability compensation of up to one year prior to the date of claim, if it is factually ascertainable based on all evidence of record that an increase in disability had occurred. In this case, the Board finds that it was not factually ascertainable that an increase in the Veteran's left foot disability occurred prior to September 1, 2009. As such, the Board concludes that the criteria for a 10 percent rating for the Veteran's left foot disability, prior to September 1, 2009, were not met. Analysis 10 Percent Rating from September 1, 2009 and prior to August 11, 2021 Upon review, the Board finds that a rating in excess of 10 percent under DC 5284 is not warranted from September 1, 2009 and prior to August 11, 2021. As noted, the next higher 20 percent rating is warranted for moderately severe other foot injuries. The Board acknowledges the Veteran's lay reports of symptoms and that there was functional loss. However, even considering the Veteran's lay reports of symptoms and functional loss, the degree of additional limitation reflected would not result in symptoms more nearly approximating moderately severe other foot injuries. In this regard, the relevant evidence for this appeal primarily consists of various VA examination reports from October 2009, September 2011 and November 2020. The October 2009 VA Feet examination report stated that, during active service, the Veteran "went to jump in a diving board and when he landed he felt some pain at the left foot." It was further noted that the Veteran had surgery during active service. It was also noted that the Veteran "stated that he has been with pain in the fifth metatarsal area since the accident, pain intensity 7/10. Pain is worst when prolonged walking and when he used to run." The course since onset was noted as "[i]ntermittent w[ith] remissions." Left foot symptoms were noted as "[p]ain (while standing, while walking)" and symptoms noted as not identified were swelling, heat, redness, stiffness, fatigability, weakness and lack of endurance. Flare-ups were noted as having a usual frequency of "[s]everal times a year, but less than monthly," with a usual duration noted of "[m]ore than 2 but less than 7 days." Precipitating factors were noted of change of weather and standing and walking for prolonged time. Functional limitations on standing were noted as "[a]ble to stand for 15-30 minutes" and functional limitations on walking were noted as "[n]o limitation to walking." Upon physical examination, it was noted that there was no evidence of painful motion, swelling, instability or weakness and that there was evidence of tenderness and abnormal weight bearing. It was noted that the Veteran's left foot disability had no significant general occupational effects. It was also noted, without elaboration, that there were effects of the left foot disability on daily activities, specifically preventing sports; severe effects for chores, shopping, recreation, bathing, dressing and toileting; moderate effects for traveling and grooming; and mild effects for driving. The September 2011 VA Joints examination report noted that the course since onset was "[p]rogressively worse." Also noted for the left ankle (presumably including the left foot disability) was that there was pain, stiffness, decreased speed of joint motion, daily or more often locking episodes, and symptoms of inflammation of tenderness. Symptoms not noted were deformity, giving way, instability, weakness or incoordination. Flare-ups were noted to have a severity of moderate, with a frequency of every two to three weeks and a duration of hours. Precipitating factors were noted of "prolonged standing exacerbate pain." Standing limitations were noted as "[a]ble to stand for 15-30 minutes" and functional limitations on walking were noted as "[a]ble to walk 14 mile." Upon physical examination, it was noted for the left little toe that there was tenderness, pain at rest and guarding of movement. Addressed together were the functional effects of the Veteran's left foot disability, right knee disability and left thumb disability. It was noted that such disabilities had no significant effects on the Veteran's usual occupation. As to effects on daily activities, noted was prevents exercise, mild effects for chores, sports and recreation and no effects for shopping, traveling, bathing, dressing, toileting, grooming and driving. A subsequent separate September 2011 VA General Medical examination report noted a complaint of "recurrent left foot pain." A November 2020 VA Foot Conditions DBQ noted current symptoms as recurrent left foot pain at the third and fifth metatarsal, to include a specific report of pain on use. The course since onset as noted as "[s]tayed the same." Flare-ups were noted as "increased pain with prolonged use" and functional loss or functional impairment was noted as "difficulty with prolonged walking." The examiner noted that the Veteran had a moderate left foot injury. The foot injury was described as "recurrent left foot pain at 3rd and 5th [metatarsal]." Functional loss was noted as pain with weight-bearing and also noted was increased pain with prolonged use. It was noted that the Veteran's foot condition chronically compromised weight bearing, but that no arch supports, custom orthotic inserts or shoe modifications were used. It was noted that the Veteran's left foot disability impacted his ability to work, specifically that there was "difficulty with prolonged standing/ambulation." The examiner also noted that "there is a worsening of the Veteran's symptoms." In review, the Veteran was afforded multiple VA examinations at various points during the appeal period. As outlined, the examination reports primarily noted a symptom of pain, as well as restrictions and difficulty with standing and walking. The Board notes that the November 2020 VA examiner characterized the Veteran's foot injury as moderate. Overall, the Board finds that the disability picture during this period did not more nearly approximate that of a moderately severe other foot injury. Analysis 20 Percent Rating from August 11, 2021 Upon review, the Board finds that an increased 20 percent rating under DC 5284 is warranted from August 11, 2021. An August 11, 2021 VA Foot Conditions DBQ noted current symptoms as "required surgery to correct and now pain continues today." Pain was reported as a "dull ache." The course since onset as noted as "[p]rogressed/[w]orsened." Flare-ups were not reported. Functional loss or functional impairment was noted as "no standing for long periods." The examiner noted that the Veteran had a moderate left foot injury. The foot injury was described as "pain is constant now" and "tender lateral foot with decreased sensation mid foot and lateral foot and toe." It was noted that the Veteran's foot condition chronically compromised weight bearing, but that no arch supports, custom orthotic inserts or shoe modifications were used. Functional loss was noted as interference with standing "for more than 5 minutes." Noted was pain on active movement and weight-bearing. It was noted that the Veteran's left foot disability impacted his ability to work, with elaboration of "[u]nable to stand or walk prolonged. Unable to work as school teacher, paramedic, fire fighter, or any other occupation requiring full use and weight bearing feet." The examiner also noted that "there is a worsening of the Veteran's symptoms." Resolving reasonable doubt in the Veteran's favor, the Board finds that the disability picture described by the August 2021 DBQ more nearly approximated that of a moderately severe foot injury. In making this determination, the Board finds particularly probative that the examiner noted that the Veteran was "[u]nable to stand or walk prolonged." The Board finds that this level of functional impairment more nearly approximates that of moderately severe. As such, the Board finds that a 20 percent rating is warranted as of the August 11, 2021 VA exam. The Board notes that, while it is possible that the Veteran's left foot disability increased in disability earlier than the August 11, 2021 VA exam, an earlier date cannot be factually ascertained based on all the evidence of record and would require speculation. Application of the benefit of the doubt doctrine is not appropriate under these circumstances. In this regard, the Board highlights that the October 2009 examination report noted functional limitations on standing as "[a]ble to stand for 15-30 minutes" and functional limitations on walking as "[n]o limitation to walking," that the September 2011 examination report noted standing limitations as "[a]ble to stand for 15-30 minutes" and functional limitations on walking as "[a]ble to walk 14 mile" and that the November 2020 examination report noted "difficulty with prolonged standing/ambulation." By contrast, the August 11, 2021 VA examination report was the earliest factually ascertainable date describing the Veteran's impairment in prolonged standing and walking in more severe terms of being "[u]nable" to do such. As such, the Board finds that an earlier date for the increased 20 percent rating is not warranted. The Board further finds that, from August 11, 2021, a rating in excess of 20 percent is not warranted. As noted, the next higher 30 percent rating under DC 5284 is warranted for severe other foot injuries. The Board acknowledges the Veteran's lay reports of symptoms and that there was functional loss. However, even considering the Veteran's lay reports of symptoms and functional loss, the degree of additional limitation reflected would not result in symptoms more nearly approximating severe other foot injuries. The Board notes that the August 2021 examiner characterized the Veteran's left foot injury as moderate severity. Overall, the Board finds that the disability picture during this period did not more nearly approximate that of a moderately severe other foot injury. Analysis Separate Rating under DC 7804 The Board also finds that a separate 10 percent rating is warranted for a painful left foot scar under DC 7804, effective August 11, 2021. As noted, the Veteran's specific service-connected left foot disability is little toe, left foot, fracture, with excision of left metatarsal osteophytes, due to middle to painful bone spurs. This specifically includes an "excision." The August 11, 2021 Foot Conditions DBQ noted that the Veteran had a left foot surgery in 1989, specifically "removal of osteophytes [left] digit #5 [status post] fracture." Residual signs or symptoms due to the foot surgery were noted as "residual pain and painful scar." It was also noted that the Veteran had a scar related to the Veteran's left foot disability. A separate Scars/Disfigurement DBQ was also completed on the same date. Noted was a "painful residual scar, left foot," with a date of diagnosis noted of 1989. It was noted that the Veteran had a fracture in 1988 and such "required surgery to correct and now pain continues today, tender and irritated scar." One painful scar was noted, with the pain noted as "tender and irritated." Under DC 7804, a 10 percent rating is warranted for "[o]ne or two scars that are unstable or painful." Based on the August 11, 2021 DBQs, the Board finds that a separate 10 percent rating under DC 7804 is warranted for the Veteran's painful left foot scar. These DBQs, essentially, documented a painful scar and associated such with the Veteran's active service and the Veteran's service-connected left foot disability. The Board finds that this separate rating is appropriate in this case because the symptomatology considered under DC 7804 (a painful scar) is not duplicate or overlapping with the symptomatology, but is distinct and separate, from that considered under DC 5284, as was discussed further in detail above. See Esteban v. Brown, 6 Vet. App. 259, 262 (1994) (finding that three separate ratings were warranted where "none of the symptomatology for any one of these three conditions is duplicative of or overlapping with the symptomatology of the other two conditions" and referencing that the Veteran's "symptomatology is distinct and separate"). The Board also finds that the newly assigned 10 percent rating is not warranted prior to August 11, 2021. The Board notes that, while it is possible that the Veteran's left foot disability increased in disability, by way of the scar becoming painful, earlier than the August 11, 2021 VA exam, an earlier date cannot be factually ascertained based on all the evidence of record and would require speculation. Application of the benefit of the doubt doctrine is not appropriate under these circumstances. In this regard, while the November 2020 Foot Conditions DBQ noted that the Veteran had a "surgery scar at left lateral foot scar along distal 5th [metatarsal]" related to the service-connected left foot disability, the DBQ also specifically noted that there were no scars that were painful or unstable. The Board further finds that, from August 11, 2021, a rating in excess of 10 percent is not warranted under DC 7804. The next higher rating under this DC requires at least three painful scars and this was not shown by the evidence of record, to specifically include the August 2021 Scar DBQ that noted one painful scar. As such, from August 11, 2021, the Board finds that a rating in excess of 10 percent under DC 7804 is not warranted. Conclusion For the entire appeal period, the Board has considered the other DCs pertaining to the foot, but finds that the ratings assigned under DC 5284 are appropriate in this case (with the exception of the period where a separate rating is warranted for a painful scar). In this regard, the Veteran's left foot disability is not specifically listed in the other foot DCs (DCs 5276-5283) and is related to a foot injury (recall that the specific service-connected foot disability is "fracture middle toe left foot..."). As such, the Board finds that DC 5284 is the appropriate DC to rate the Veteran's left foot disability. See Yancy v. McDonald, 27 Vet. App. 484, 491 (2016) ("The Court therefore holds that the plain meaning of the word "injury" limits the application of DC 5284 to disabilities resulting from actual injuries to the foot"). In sum, the Board finds that it was not factually ascertainable that an increase in the Veteran's left foot disability occurred prior to September 1, 2009. The Board also finds that, from September 1, 2009 and prior to August 11, 2021, the Veteran's left foot disability did not more nearly approximate that of a moderately severe other foot injury. The Board additionally finds that, effective August 11, 2021, the Veteran's left foot disability more nearly approximated that of a moderately severe other foot injury and that such did not more nearly approximate that of a severe other foot injury. The Board further finds that, effective August 11, 2021, the Veteran's left foot disability manifestations included one painful left foot scar. As such, the Board concludes that the criteria for a 10 percent rating for the Veteran's left foot disability, prior to September 1, 2009, were not met. The Board also concludes that, from September 1, 2009 and prior to August 11, 2021, the criteria for a rating in excess of 10 percent for the Veteran's left foot disability were not met. The Board additionally concludes that, effective August 11, 2021, the criteria for a 20 percent rating for the Veteran's left foot disability were met and that, from August 11, 2021, the criteria for a rating in excess of 20 percent for the Veteran's left foot disability were not met. The Board further concludes that, effective August 11, 2021, the criteria for a separate 10 percent rating for a painful left foot scar were met and that, from August 11, 2021, the criteria for a rating in excess of 10 percent for the Veteran's left foot scar were not met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.71a, DC 5284; 4.118, DC 7804 (for all conclusions). 5. Increased Rating Left Thumb Disability Procedural History and Legal Criteria A July 1993 rating decision granted service connection for left thumb laceration with repair of extensor pollicis longus. A 0 percent rating was assigned under DC 7805. The rating decision stated regarding the left thumb disability that such was "without residual impairment identified." The Veteran filed a September 1, 2009 claim (via VA Form 21-526). He stated "I was made aware that I was service connected for some (4 cond[ition]s) and consider this claim for increase." In the June 2010 rating decision on appeal for this claim, VBA continued the previously assigned 0 percent rating under the same prior DC (7805). DC 7805 ("Scars, other (including linear scars) and other effects of scars evaluated under [DCs] 7800, 7801, 7802, and 7804") instructs to evaluate any disabling effect(s) not considered in a rating provided under DCs 7800-04 under an appropriate Diagnostic Code. As will be discussed further below, the Board finds that an alternative DC is potentially relevant, specifically DC 5308. DC 5308 is titled "Group VIII. Function: Extension of wrist, fingers, and thumb; abduction of thumb. Muscles arising mainly from external condyle of humerus: Extensors of carpus, fingers, and thumb; supinator." Under DC 5308, a 0 percent rating is warranted for slight disability; a 10 percent rating is warranted for moderate disability; a 20 percent rating is warranted for moderately severe disability; and a 30 percent rating is warranted for severe disability (all ratings are the same for the dominant and non-dominant side). 38 C.F.R. § 4.56, titled "Evaluation of muscle disabilities", contains information relevant to rating muscle disabilities. 38 C.F.R. § 4.56(c) states that "[f]or VA rating purposes, the cardinal signs and symptoms of muscle disability are loss of power, weakness, lowered threshold of fatigue, fatigue-pain, impairment of coordination and uncertainty of movement." 38 C.F.R. § 4.56(d) states that: Under [DCs] 5301 through 5323, disabilities resulting from muscle injuries shall be classified as slight, moderate, moderately severe or severe as follows: (1) Slight disability of muscles. (i) Type of injury. Simple wound of muscle without debridement or infection. (ii) History and complaint. Service department record of superficial wound with brief treatment and return to duty. Healing with good functional results. No cardinal signs or symptoms of muscle disability as defined in paragraph (c) of this section. (iii) Objective findings. Minimal scar. No evidence of fascial defect, atrophy, or impaired tonus. No impairment of function or metallic fragments retained in muscle tissue. (2) Moderate disability of muscles. (i) Type of injury. Through and through or deep penetrating wound of short track from a single bullet, small shell or shrapnel fragment, without explosive effect of high velocity missile, residuals of debridement, or prolonged infection. (ii) History and complaint. Service department record or other evidence of in-service treatment for the wound. Record of consistent complaint of one or more of the cardinal signs and symptoms of muscle disability as defined in paragraph (c) of this section, particularly lowered threshold of fatigue after average use, affecting the particular functions controlled by the injured muscles. (iii) Objective findings. Entrance and (if present) exit scars, small or linear, indicating short track of missile through muscle tissue. Some loss of deep fascia or muscle substance or impairment of muscle tonus and loss of power or lowered threshold of fatigue when compared to the sound side. (3) Moderately severe disability of muscles. (i) Type of injury. Through and through or deep penetrating wound by small high velocity missile or large low-velocity missile, with debridement, prolonged infection, or sloughing of soft parts, and intermuscular scarring. (ii) History and complaint. Service department record or other evidence showing hospitalization for a prolonged period for treatment of wound. Record of consistent complaint of cardinal signs and symptoms of muscle disability as defined in paragraph (c) of this section and, if present, evidence of inability to keep up with work requirements. (iii) Objective findings. Entrance and (if present) exit scars indicating track of missile through one or more muscle groups. Indications on palpation of loss of deep fascia, muscle substance, or normal firm resistance of muscles compared with sound side. Tests of strength and endurance compared with sound side demonstrate positive evidence of impairment. (4) Severe disability of muscles. (i) Type of injury. Through and through or deep penetrating wound due to high-velocity missile, or large or multiple low velocity missiles, or with shattering bone fracture or open comminuted fracture with extensive debridement, prolonged infection, or sloughing of soft parts, intermuscular binding and scarring. (ii) History and complaint. Service department record or other evidence showing hospitalization for a prolonged period for treatment of wound. Record of consistent complaint of cardinal signs and symptoms of muscle disability as defined in paragraph (c) of this section, worse than those shown for moderately severe muscle injuries, and, if present, evidence of inability to keep up with work requirements. (iii) Objective findings. Ragged, depressed and adherent scars indicating wide damage to muscle groups in missile track. Palpation shows loss of deep fascia or muscle substance, or soft flabby muscles in wound area. Muscles swell and harden abnormally in contraction. Tests of strength, endurance, or coordinated movements compared with the corresponding muscles of the uninjured side indicate severe impairment of function. If present, the following are also signs of severe muscle disability: (A) X-ray evidence of minute multiple scattered foreign bodies indicating intermuscular trauma and explosive effect of the missile. (B) Adhesion of scar to one of the long bones, scapula, pelvic bones, sacrum or vertebrae, with epithelial sealing over the bone rather than true skin covering in an area where bone is normally protected by muscle. (C) Diminished muscle excitability to pulsed electrical current in electrodiagnostic tests. (D) Visible or measurable atrophy. (E) Adaptive contraction of an opposing group of muscles. (F) Atrophy of muscle groups not in the track of the missile, particularly of the trapezius and serratus in wounds of the shoulder girdle. (G) Induration or atrophy of an entire muscle following simple piercing by a projectile. The United States Court of Appeals for Veterans Claims (Court) has stated that "38 C.F.R. § 4.56(d) is essentially a totality-of-the-circumstances test and no single factor is per se controlling." See Tropf v. Nicholson, 20 Vet. App. 317, 325 (2006). Analysis Scar Entire Appeal Period Initially, the Board finds that a higher rating is not warranted at any point during the appeal period strictly based on the manifestations of the Veteran's left thumb scar. In this regard, DC 7800 is not applicable because the Veteran's scar is not of the head, face or neck. DC 7801 is not applicable because the Veteran's scar was not shown to be at least 39 square centimeters and DC 7802 is not applicable (among other reasons) because it was not shown to have an area of at least than 929 square centimeters. See October 2009 Scars Examination Report (noting the Veteran's left thumb scar as being 0.2 centimeters wide and 5 centimeters long); June 2021 Scars/Disfigurement DBQ (noting the Veteran's left thumb scar as being 1 centimeter by 0.1 centimeter and noting a combined total area for the Veteran's left upper extremity as 0.1 square centimeters). DC 7804 is not applicable because the evidence did not show that the Veteran's left thumb scar was painful or unstable. See October 2009 Scars Examination Report ("Scar is not painful"); June 2021 Scars/Disfigurement DBQ (noting that there were no painful or unstable extremity scars). As such, the Board finds that an increased rating is not warranted at any point during the appeal period strictly based on the Veteran's left thumb scar. Analysis 10 Percent Rating under DC 5308 from September 1, 2009 The Board, however, notes that the Veteran's service-connected disability is not just a left thumb scar, but specifically is left thumb laceration with repair of extensor pollicis longus. The extensor pollicis longus is a muscle, specifically the "long extensor muscle of thumb" and the action is "extends thumb, abducts and rotates thumb laterally." See Dorland's Illustrated Medical Dictionary 1204-05 (32nd ed. 2012). In light of the fact that the Veteran's service-connected disability is for repair of a muscle, combined with the instruction under DC 7805 to rate disability effects not considered under DCs 7800-7804, the Board finds that it is appropriate in this case to rate the Veteran's left thumb disability under DCs related to the muscles. In this regard, DC 5308 appears to be the most appropriate DC, as such is related to the function of extension of the thumb, which is similar to the action of extension of the thumb in the definition of the extensor pollicis longus noted above. Upon review, the Board finds that a 10 percent rating, is warranted under DC 5308 from September 1, 2009. The Board finds that a 10 percent rating is warranted from September 1, 2009 because the Veteran's left thumb disability more nearly approximated that of a moderate muscle disability. 38 C.F.R. § 4.56(d) notes that a slight muscle disability has "[n]o cardinal signs or symptoms of muscle disability" and that a moderate muscle disability has "[r]ecord of consistent complaint of one or more of the cardinal signs and symptoms of muscle disability." One cardinal sign or symptom of muscle disability pursuant to 38 C.F.R. § 4.56 is "fatigue-pain." The Board finds that, resolving reasonable doubt in the Veteran's favor, the Veteran's left thumb disability was manifested by pain throughout the period from September 1, 2009. As to this point, of record are various VA examination reports, though no specific muscle examination report or DBQ was completed for the left thumb during the appeal period. An October 2009 Hand, Thumb and Finger VA examination report noted that there was not objective evidence of left thumb pain on range of motion testing, but such did not address whether there was left thumb pain generally. An October 2009 Scars VA examination report noted "no pain," but such appeared to be in relation to just the Veteran's left thumb scar. A September 2011 VA joints examination report noted regarding the left "thumb area" that there was tenderness and pain at rest upon physical exam and noted a diagnosis of left thumb tendon laceration status post repairment. A subsequent separate September 2011 VA General Medical examination report noted a complaint of "intermittent left thumb discomfort related to 'cold or rainy weather.'" An April 2021 Elbow and Forearm Conditions DBQ noted the onset of the Veteran's left thumb disability in 1988 and stated that "[V]eteran reports the condition has stayed the same with episodes of pain to left thumb." Current symptoms were noted as "thumb pain that radiates to elbow." Flare-ups were noted as having characteristics of "achy thumb pain that radiates to elbow." The flare-ups were noted to occur one to two days a week for a duration of one to four hours, with a severity noted as mild. It was noted that there was pain on weight-bearing and that such caused functional loss, specifically that "[p]ain with lifting and carrying items using the left arm." In review of the evidence, the Board finds that a cardinal sign of muscle disability of pain was noted at various points during the appeal period, to include on the April 2021 Elbow and Forearm Conditions DBQ which included the Veteran's report that "the condition has stayed the same with episodes of pain to left thumb." As such, the Board finds that the Veteran's left thumb disability more nearly approximated that of a moderate muscle disability. Resolving reasonable doubt in the Veteran's favor, the Board finds that a 10 percent rating is therefore warranted for the entire appeal period from the September 1, 2009 increased rating claim. Analysis 10 Percent Rating under DC 5308 prior to September 1, 2009 Upon review, the Board finds that a 10 percent rating for a left thumb disability, prior to September 1, 2009, is not warranted. In this regard, as explained, the Veteran filed the increased rating claim on appeal on September 1, 2009. For increased rating claims, the one-year look-back period potentially allow for an increase in disability compensation of up to one year prior to the date of claim, if it is factually ascertainable based on all evidence of record that an increase in disability had occurred. In this case, the Board finds that it was not factually ascertainable that an increase in the Veteran's left thumb disability occurred prior to September 1, 2009. As such, the Board concludes that the criteria for a 10 percent rating for the Veteran's left thumb disability, prior to September 1, 2009, were not met. Analysis Excess of 10 Percent Rating under DC 5308 from September 1, 2009 The Board additionally finds that, for the entire period from September 1, 2009, a rating in excess of 10 percent is not warranted for the Veteran's left thumb disability under DC 5308. As noted above, the next higher 20 percent rating is warranted under DC 5308 for moderately severe muscle injury. The Board finds that the Veteran's left thumb disability did not more nearly approximate this level of disability when considering the factors outlined in 38 C.F.R. § 4.56. In this regard, 38 C.F.R. § 4.56 describes a moderately severe muscle disability as having a type of injury of "[t]hrough and through or deep penetrating wound by small high velocity missile or large low-velocity missile, with debridement, prolonged infection, or sloughing of soft parts, and intermuscular scarring" and as having a history of "Service department record or other evidence showing hospitalization for a prolonged period for treatment of wound." The evidence of record showed that the Veteran's muscle injury in this case did not meet these criteria, as the Veteran had a machete injury, not a missile injury, and was hospitalized for one day for treatment, not for a prolonged period. See October 2009 VA Scar Examination Report (noting the etiology of the left thumb scar as "was sharpening a 'machete'"); November 1988 Service Treatment Record (STR) ("incision on [left] thumb...states he was sharpening a machete"); November 1988 STR Operation Report (noting the operation performed as repair of extensor pollicis longus left thumb and that the Veteran "had a traumatic laceration with a machet[]e...lacerating through his extensor pollicis longus"); November 1988 STR Inpatient Treatment Record Cover Sheet (noting one bed day). Overall, the type of injury that the Veteran sustained, as well as the related history, was clearly not of the severity contemplated by the moderately severe disability described in 38 C.F.R. § 4.56(d). The Board has considered the totality-of-the circumstances related to the Veteran's left thumb disability and finds that the disability picture did not more nearly approximate that of a moderately severe disability, as described in 38 C.F.R. § 4.56. As such, a rating in excess of 10 percent is not warranted. Conclusion In sum, the Board finds that a higher rating is not warranted at any point during the appeal period strictly based on the manifestations of the Veteran's left thumb scar. The Board also finds that, effective September 1, 2009, the Veteran's left thumb disability more nearly approximated that of a moderate muscle disability. The Board additionally finds that it was not factually ascertainable that an increase in the Veteran's left thumb disability occurred prior to September 1, 2009. The Board further finds that, from September 1, 2009, the Veteran's left thumb disability did not more nearly approximate that of a moderately severe muscle disability. As such, the Board concludes that the criteria for a 10 percent rating, effective September 1, 2009, for the Veteran's left thumb disability have been met. The Board also concludes that the criteria for a 10 percent rating for the Veteran's left thumb disability, prior to September 1, 2009, were not met. The Board additionally concludes that, from September 1, 2009, the criteria for a rating in excess of 10 percent for the Veteran's left thumb disability were not met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.73, DC 5308; 4.118, DC 7805 (for all conclusions). 6. Increased Rating Costochondritis Procedural History and Legal Criteria The June 2010 rating decision on appeal for this claim granted service connection for costochondritis and assigned a 0 percent rating, effective September 1, 2009. The rating was assigned under DC 5399-5321. The rating decision stated that "[STR] shows treatment for this condition in 1987. VA medical opinion found that currently claimed costal costochondritis condition is most likely related to your military service period" and that "[a] noncompensable evaluation is assigned for slight muscle disability." DC 5321 is titled "Group XXI. Function: Respiration. Muscles of respiration: Thoracic muscle group." Under DC 5321, a 0 percent rating is warranted for slight disability, a 10 percent rating is warranted for moderate disability and a 20 percent rating is warranted or severe or moderately severe disability. The criteria related to evaluation of muscle disabilities was outlined above. Analysis 10 Percent Rating from September 1, 2009 Upon review, the Board finds that a 10 percent rating is warranted from September 1, 2009. The Board finds that a 10 percent rating is warranted from September 1, 2009 because the Veteran's costochondritis more nearly approximated that of a moderate disability of the muscles. As discussed above, 38 C.F.R. § 4.56(d) notes that a slight muscle disability has "[n]o cardinal signs or symptoms of muscle disability" and that a moderate muscle disability has "[r]ecord of consistent complaint of one or more of the cardinal signs and symptoms of muscle disability." One cardinal sign or symptom of muscle disability pursuant to 38 C.F.R. § 4.56 is "fatigue-pain." The Board finds that, resolving reasonable doubt in the Veteran's favor, the Veteran's costochondritis was manifested by pain throughout the period from September 1, 2009. As to this point, of record are various VA examinations. An October 2009 VA Bones examination report stated "Veteran alleged that since long time ago [V]eteran feels costal pain, it is worst when he run." A September 2011 VA Bones examination report noted chest well pain and pain in the anterior chest wall. A November 2020 Muscle Injuries DBQ noted that the date of onset of costochondritis as 1991 and stated "began experiencing anterior chest wall pain along the sternum, began during battalion run" and noted the course of the condition since onset as "[s]tayed the same." Current symptoms were noted as "recurrent anterior chest wall pain even at rest." As to cardinal signs and symptoms of muscle disability, fatigue and/or pain was noted as consistent. Functional impact was noted as "difficulty lifting/carry/pushing/pulling heavy objects." A separate opinion was also provided that "costochondritis, while painful, would not impair respiratory functions in and of itself." In review of the evidence, the Board finds that a cardinal sign of muscle disability of pain was noted at various points during the appeal period. This included on the November 2020 Muscle Injuries DBQ, which was the only such specific muscle examination report during the appeal period, that noted chest pain and that the course of the condition since onset as "[s]tayed the same." As such, the Board finds that the Veteran's costochondritis more nearly approximated that of a moderate muscle disability. Resolving reasonable doubt in the Veteran's favor, the Board finds that a 10 percent rating is therefore warranted for the entire appeal period from the September 1, 2009 effective date of service connection. Analysis Excess of 10 Percent Rating under DC 5308 from September 1, 2009 The Board additionally finds that, for the entire period from September 1, 2009, a rating in excess of 10 percent is not warranted for the Veteran's costochondritis. As noted above, the next higher 20 percent rating is warranted under DC 5308 for moderately severe muscle injury. The Board finds that the Veteran's costochondritis did not more nearly approximate this level of disability when considering the factors outlined in 38 C.F.R. § 4.56. As discussed above, 38 C.F.R. § 4.56 describes a moderately severe muscle disability as having a type of injury of "[t]hrough and through or deep penetrating wound by small high velocity missile or large low-velocity missile, with debridement, prolonged infection, or sloughing of soft parts, and intermuscular scarring." The evidence of record showed that the Veteran's muscle injury in this case did not meet these criteria, as the Veteran did not have a missile injury (or any penetrating injury). See November 2020 Muscle Injuries DBQ (noting that the Veteran "began experiencing anterior chest wall pain along the sternum, began during battalion run" and noting that the Veteran did not have a penetrating muscle injury). Overall, the type of injury that the Veteran sustained was clearly not of the severity contemplated by the moderately severe disability described in 38 C.F.R. § 4.56(d). In addition, the November 2020 Muscle Injuries DBQ noted no other cardinal signs and symptoms of disability besides fatigue and/or pain. Moreover, this DBQ noted that the Veteran did not have any scars associated with a muscle injury, did not have any known fascial defects and that the Veteran's muscle injuries did not affect muscle substance or function. Such findings weigh against a finding of a moderately severe muscle disability in this case. The Board has considered the totality-of-the circumstances related to the Veteran's costochondritis and finds that the disability picture did not more nearly approximate that of a moderately severe disability, as described in 38 C.F.R. § 4.56. As such, a rating in excess of 10 percent is not warranted. Conclusion In sum, the Board finds that, effective September 1, 2009, the Veteran's costochondritis more nearly approximated that of a moderate muscle disability. The Board further finds that, from September 1, 2009, the Veteran's costochondritis did not more nearly approximate that of a moderately severe muscle disability. As such, the Board concludes that the criteria for a 10 percent rating, effective September 1, 2009, for the Veteran's costochondritis were met. The Board further concludes that, from September 1, 2009, the criteria for a rating in excess of 10 percent for the Veteran's costochondritis were not met. 38 U.S.C. § 1155; 38 C.F.R. § 4.73, DC 5321 (for both conclusions). 7. Service Connection GERD, Esophagitis, Gastritis Legal Criteria Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. See 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Generally, in order to establish direct service connection, three elements must be established: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury, which is often referenced as the "nexus" element. See Saunders v. Wilkie, 886 F.3d 1356, 1361 (Fed. Cir. 2018) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Procedural History The Veteran filed a September 1, 2009 claim (via VA Form 21-526). He listed a disability of Barrett's Esophagus. The October 2011 rating decision on appeal for this claim denied service connection for Barrett's Esophagitis, essentially finding that this disability had not been diagnosed. In March 2018, the Board recharacterized this claim, pursuant to Clemons v. Shinseki, 23 Vet. App. 1 (2009), broadly as service connection for a gastrointestinal (GI) disability, to include Barrett's esophagitis. The Board remanded this claim for a new VA examination. The remand directives included a request for a direct service connection opinion and specifically stated that the examiner should "[i]dentify the likely etiology for each GI disability entity diagnosed, specifically indicating whether it is at least as likely as not (a 50 percent or greater probability) that the disability is related to the Veteran's service/to include the GI complaints noted therein." Analysis Upon review, and after resolving reasonable doubt in the Veteran's favor, the Board finds that service connection is warranted for a GI disability, specifically GERD, esophagitis and gastritis. The Veteran has, essentially, contended that has a GI disability that had its onset during active service and that such has continued since that time. STRs and medical evidence tend to support the Veteran's reports. Of record are relevant STRs, which reflected complaints and treatment related to the Veteran's claimed GI disability. The Veteran's entrance June 1983 Report of Medical History form included the Veteran's denial of ever having or having now frequent indigestion or "[s]tomach, liver, or intestinal trouble." A November 1984 STR noted a chief complaint of acid indigestion, a complaint of "burning pain after eating" and noted an assessment of gastritis. A November 1988 STR noted a complaint of substernal chest pain, noted that the Veteran "states [history of] 'heartburn'" and noted an assessment of esophagitis. On a July 1989 Report of Medical History form, the Veteran reported ever having or having now frequent indigestion. On the July 1992 separation Report of Medical History form, the Veteran reported ever having or having now frequent indigestion and "[s]tomach, liver, or intestinal trouble." In the section of the form completed by a medical professional, it was noted "[f]requent indigestion heartburn." Electronic VA treatment records of record date to 1998. The earliest record of record, dated in July 1998, stated that the Veteran "is in OPT at PCC X GERD." While not entirely clear, this record suggested that the Veteran was receiving treatment for GERD at that time. The earliest primary care VA treatment record of record, from January 2000, listed GERD as a problem. Private medical records from 2003 noted a diagnosis of GERD with esophagitis. In this regard, the earliest record of record was from April 2003 and noted a history and diagnosis of GERD. In addition, May 2003 test results (an upper GI series) noted an impression of GERD with esophagitis and gastritis. On the September 2009 VA Form 21-526, the Veteran stated that "[t]his problem (GERD) was made worse by MREs and went untreated until VA found it." During the appeal period, the Veteran was afforded three relevant VA exams. First, an October 2009 VA Esophagus and Hiatal Hernia examination was completed. Under the medical history section, it was stated that the Veteran was "with history of acid reflux that he consider began while on service...Reports that he has been under treatment by VA [Medical Center (VAMC)] since 1997." A diagnosis was noted of GERD. Second, an August 2010 VA Esophagus and Hiatal Hernia examination was completed. The exam report stated that "the Veteran mentions that since his military service he has been experiencing chronic symptoms related to [GERD]." The course since onset was noted as "[i]ntermittent w[ith] remissions." The examiner noted that "there is no evidence of Barret[t]'s Esophagus in this exam" and also noted diagnoses of GERD and esophagitis. Third, the Veteran was afforded a VA examination in November 2020 following the March 2018 Board remand and two DBQs were completed. A November 2020 Stomach and Duodenal Conditions DBQ noted a diagnosis of gastritis, with a date of diagnosis noted of 1984. A date of onset was noted of 1984 and the details were noted as "unable to tolerate MRE, which led to gastritis symptoms." The course since onset was noted as "[p]rogressed/[w]orsened." In addition, an Esophageal Conditions DBQ was completed and such noted a diagnosis of GERD, with a date of diagnosis noted of 1984. A date of onset was noted of 1984 and the details were noted as "unable to tolerate MRE, which led to reflux symptoms." The course since onset was noted as "[p]rogressed/[w]orsened." Current symptoms were noted on both DBQs as "burning epigastric pain." As outlined, the Veteran has reported the onset of GI symptoms during his active service and, essentially, that such have continued since that time. STRs, VA treatment records and private medical records tend to support the Veteran's reports. On the other hand, following the March 2018 Board remand, a negative direct service connection opinion was obtained in November 2020 following the VA examination discussed above. The opinion stated that "GERD and gastritis are the only GI conditions for which the Veteran is treated, and the only GI conditions for which he has symptoms." The opinion also noted that it was "unlikely" that these disabilities were "related to the Veteran's service/to include the GI complaints noted therein." The provided rationale was that "STR is silent for chronic reflux-like and gastritis-like symptoms during active duty years." Upon review, the Board finds the November 2020 VA opinion inadequate, for multiple reasons. First, the Board finds this opinion inadequate because it did not substantially comply with the March 2018 Board remand directives. See Stegall v. West, 11 Vet. App. 268 (1998). In this regard, as noted, the March 2018 Board remand requested an opinion "specifically indicating whether" a GI disability "is related to the Veteran's service/to include the GI complaints noted therein." The provided rationale did not "specifically" address whether the Veteran's GI disabilities were related to the GI complaints noted during service, as such complaints were not clearly discussed or addressed in the rationale. Second, the November 2020 VA opinion was based on an inaccurate factual premise. See Reonal v. Brown, 5 Vet. App. 458, 461 (1993) ("An opinion based upon an inaccurate factual premise has no probative value"). Specifically, the rationale stated that "STR is silent for chronic reflux-like and gastritis-like symptoms," whereas the Veteran's STRs included a November 1984 assessment of gastritis, a November 1988 report of a history of heartburn and an assessment of gastritis, a July 1989 Report of Medical History form with a report of frequent indigestion and a July 1992 separation Report of Medical History form, which noted the Veteran's report of frequent indigestion and "[s]tomach, liver, or intestinal trouble" and contained a notation in the section of the form completed by a medical professional of "[f]requent indigestion heartburn." Third, the opinion appeared to impermissibly ignore the Veteran's lay report of the onset of symptoms being during active service. See Dalton v. Nicholson, 21 Vet. App. 23, 39 (2007) ("it appears that the medical examiner impermissibly ignored the appellant's lay assertions"); Miller v. Wilkie, 32 Vet. App. 249, 260 (2020) ("The examiner must address the veteran's lay statements to provide the Board with an adequate medical opinion"). In this regard, the rationale only addressed STRs as being "silent," without any discussion of the Veteran's lay reports relating the onset of his GI symptoms to his active service, as was previously discussed. The Board notes that the negative November 2020 VA opinion is the only competent opinion of record that specifically addressed the issue of direct service connection with respect to the Veteran's GI disabilities. As explained, the Board finds this opinion to be inadequate. As such, remand would be warranted to obtain an adequate opinion. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) ("Once [VA] undertakes the effort to provide an examination when developing a service-connection claim...[VA] must provide an adequate one"). In light of the Veteran's competent reports as to experiencing the onset of GI symptoms during and since active service, along with STRs, VA treatment records and private medical records that tend to support such reports, and the diagnoses of GERD, gastritis and esophagitis upon VA examination during the appeal period related to the Veteran's reported GI symptoms, the Board will, however, resolve reasonable doubt in the Veteran's favor and find that there is currently sufficient evidence to determine that the Veteran's GI disabilities are related to his active service. See 38 C.F.R. § 3.304(c) ("The development of evidence in connection with claims for service connection will be accomplished when deemed necessary but it should not be undertaken when evidence present is sufficient for this determination"); see also Mariano v. Principi, 17 Vet. App. 305, 312 (2003) ("it would not be permissible for VA to undertake...additional development if a purpose was to obtain evidence against an appellant's case"). (Continued on the next page) In sum, the Board finds that the Veteran's GERD, gastritis and esophagitis are related to his active service. As such, the Board concludes that the criteria for entitlement to service connection for GERD, gastritis and esophagitis were met. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. The Board notes that it has separately characterized the claims being granted because such more clearly and precisely explains the decision reached by the Board. K.A. KENNERLY Veterans Law Judge Board of Veterans' Appeals Attorney for the Board S. Hoopengardner, 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.