Citation Nr: 22027770 Decision Date: 05/11/22 Archive Date: 05/11/22 DOCKET NO. 17-33 476 DATE: May 11, 2022 ORDER Entitlement to an increased disability rating for hypertension, presently rated as noncompensable prior to July 26, 2019, and as 10 percent disabling thereafter, is denied. Entitlement to an increased disability rating for headaches, presently rated noncompensable prior to June 17, 2019, as 30 percent disabling from June 17, 2019, to February 22, 2021, is denied. Entitlement to a 50 percent rating, but no higher, for headaches, effective February 22, 2021, is granted. Entitlement to an increased disability rating for status-post right ankle fracture with degenerative arthritis, presently rated as 10 percent disabling prior to October 14, 2021, and as 30 percent disabling thereafter, is denied. Entitlement to a compensable disability rating for status-post left little finger fracture is denied. Entitlement to a disability rating in excess of 10 percent for left knee chondromalacia, based on limitation of motion, is denied. Entitlement to a disability rating in excess of 10 percent for right knee chondromalacia, based on limitation of motion, is denied. Entitlement to a separate 10 percent rating for right knee chondromalacia, based on slight lateral instability, effective December 23, 2021, is granted. Entitlement to a disability rating in excess of 10 percent for gastroesophageal reflux disease (GERD) is denied. REMANDED Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. FINDINGS OF FACT 1. Prior to June 17, 2019, the Veteran's hypertension required medication to control, but did not show diastolic pressure predominantly 100 or more or systolic pressure predominantly 160 or more; thereafter, his hypertension did not result in diastolic pressure predominantly 110 or more, or; systolic pressure predominantly 200 or more. 2. Prior to June 17, 2019, the Veteran's headaches occurred no more than one to two times per week, and were not prostrating in nature; from June 17, 2019, to February 22, 2021, the Veteran's headaches increased in severity, resulting in characteristic prostrating attacks occurring on average once per month. 3. On February 22, 2021, the Veteran reported to a medical provider that his headache pain was increasing significantly in severity; on October 14, 2021, a VA examination confirmed that the Veteran's headaches had increased to include very frequent and prostrating attacks capable of severe economic inadaptability. 4. Prior to October 14, 2021, the Veteran's right ankle showed moderate, but not marked, limitation of motion. Thereafter, his condition has manifested with ankylosis in dorsiflexion of 10 degrees and plantar flexion of 30 degrees, without evidence of abduction, adduction, inversion or eversion deformity. 5. The Veteran is in receipt of the maximum schedular rating for status-post left little finger fracture; his symptoms are contemplated by the diagnostic criteria and have not resulted in interference with employment or frequent hospitalization. 6. For the period on appeal, the Veteran's right and left knee chondromalacia have been manifested by painful motion which has not resulted in limitation of either extension or flexion. 7. From December 23, 2021, the Veteran's right knee chondromalacia has shown objective evidence of slight lateral instability. 8. The Veteran has two or more symptoms of GERD which do not result in considerable or severe impairment of health, and to date are of less severity that those anticipated by the 30 percent rating, CONCLUSIONS OF LAW 1. The criteria for a compensable rating for hypertension prior to June 17, 2019, and in excess of 10 percent thereafter, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1-4.7, 4.21, 4.104, Diagnostic Code (DC) 7101. 2. Prior to June 17, 2019, the criteria for a compensable rating for headaches have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.124a, DC 8100. 3. From June 17, 2019, to February 22, 2021, the criteria for a rating in excess of 30 percent for headaches have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.124a, DC 8100. 4. From February 22, 2021, the criteria for a 50 percent rating, but no higher, for headaches have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.124a, DC 8100. 5. The criteria for a rating in excess of 10 percent for a right ankle disability prior to October 14, 2021, and in excess of 30 percent thereafter, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, DCs 5270, 5271. 6. The criteria for a compensable rating for status-post left little finger fracture have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.7, 4.71a, DCs 5227, 5230. 7. The criteria for a rating in excess of 10 percent for left knee chondromalacia, based on limitation of motion, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.45, 4.71a, DCs 5260, 5261. 8. The criteria for a rating in excess of 10 percent for right knee chondromalacia, based on limitation of motion, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.45, 4.71a, DCs 5260, 5261. 9. The criteria for a separate rating in of 10 percent for right knee chondromalacia, based on slight lateral instability have been met from December 23, 2021. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, DC 5257. 10. The criteria for a disability rating in excess of 10 percent for service-connected GERD have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1-4.7, 4.21, 4.114, DC 7346. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from August 199 to August 2003, and from April 2005 to July 2011. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a June 2015 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). As a matter of procedural background, this appeal has previously come before the Board in March 2019 and September 2021, at which time the Board remanded these claims for further development. The Board notes that in its September 2021 remand, the Board characterized several of the claims addressed herein as claims for increased initial ratings. However, this characterization was made in error. With the exception of the Veteran's hypertension, which has been granted service connection since August 2003, the remaining issues on appeal were all granted service connection in an April 2012 rating decision and initial ratings were assigned therein. The Veteran did not appeal that rating decision nor did he submit any additional evidence to suggest the ratings assigned were incorrect. As such, that rating decision and the initial ratings assigned therein became final. The Veteran filed a claim for an increased rating for all issues addressed herein on December 10, 2014. As this is the date of the claim on appeal, the issues do not deal with the initial rating of any of the disabilities, and the Board will consider the appeals based on the date of the claim. To date, this appeal has not included a claim of entitlement to TDIU. The Court of Appeals for Veterans Claims (Court) has held that entitlement to TDIU is part and parcel of any increased rating claim when reasonably raised by the record. Based on the below decision, and the Veteran's medical records which imply he became unemployable in April 2019 due to increased disability, the Board finds that TDIU is now part of this appeal. Rice v. Shinseki, 22 Vet. App. 447 (2009). Increased Ratings Disability ratings are determined by the application of a schedule of ratings, which is based on the average impairment of earning capacity. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. The Veteran's entire history is reviewed when making disability evaluations. See generally, Schafrath v. Derwinski, 1 Vet. App. 589 (1991); 38 C.F.R. § 4.1. Where, as in the case of the claims on appeal, entitlement to compensation has already been established and an increase in the assigned evaluation is at issue, it is the present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Consideration of the medical evidence since the date of the claim for increase and consideration of the appropriateness of staged ratings are required. See Fenderson v. West, 12 Vet. App. 119 (1999). "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. Otherwise, the lower rating will be assigned." 38 C.F.R. § 4.7. 1. Entitlement to an increased rating for hypertension The Veteran's hypertension is presently rated as noncompensable from the date of the claim for an increased rating to June 17, 2019, and as 10 percent disabling thereafter. He seeks higher ratings for his hypertension. The Board finds that the claim should be denied. The Veteran's hypertension is rated pursuant to Diagnostic Code (DC) 7101, which rates specifically for hypertensive vascular disease, to include hypertension. Under the applicable rating criteria, a compensable 10 percent rating requires a showing of diastolic pressure predominantly 100 or more, or; systolic pressure 160 or more, or; minimum evaluation for an individual with a history of diastolic pressure predominantly 100 or more who requires continuous medication to control. 38 C.F.R. § 4.104, Diagnostic Code (DC) 7101. For a rating in excess of 10 percent, diastolic pressure must be shown to be predominantly 110 or more, or ; systolic pressure must be shown to be predominantly 200 or more. Id. Hypertension or isolated systolic hypertension must be confirmed by readings taken two or more times on at least three different days. The term hypertension means that the diastolic blood pressure is predominantly 90mm. or greater, and isolated systolic hypertension means that the systolic blood pressure is predominantly 160mm. or greater with a diastolic blood pressure of less than 90mm. Id., Note (1). The Veteran filed a claim for an increased rating for hypertension in December 2014. In the year prior to that, there are no associated medical records which the Board finds would speak to the severity of his hypertension. Nonetheless, the Board notes that an April 2012 VA examination found blood pressure of 120/80 with medication. For example, in November 2014, the Veteran's blood pressure was 146/93 and found to be well controlled. At that time he denied any symptoms of hypertension and reported home readings at approximately 120/70. It is further noted that VA service treatment records from the Veteran's various periods of active service generally show diastolic pressure below 100. In March 2015, the Veteran's blood pressure was 147/84. The Veteran was afforded a VA hypertension examination in April 2015. At that time his diagnosis of hypertension was confirmed. His treatment plan included continuous medication to control. He did not have a history of diastolic blood pressure predominantly 100 or more. Average blood pressure readings at that examination were systolic of 140 and diastolic of 90. Functionally, the examiner determined that his hypertension had no effect on his ability to work. In May 2016, the Veteran's blood pressure was 136/84. In December 2016, the Veteran's blood pressure was 148/98. In May 2017, the Veteran's blood pressure was 159/75. On August 28, 2017, the Veteran's blood pressure was noted to be 171/110. Between August 31, 2017, and September 19, 2017, the Veteran reported the following blood pressure readings: 144/95, 148/98, 152/99, 149/88. 152/101, 127/89, and 132/90. On January 1, 2018, the Veteran's blood pressure was recorded as 165/101. On December 27, 2018, his blood pressure was 145/91. On June 17, 2019, the Veteran was afforded a new VA examination in connection with his claim. At that time, the examiner noted that the Veteran's hypertension was reasonable under control, with home blood pressure checks in the 150/90 range. Current blood pressure readings were 160/94, 164/97, and 165/96. The average reading was 163/95. No other physical findings or complications were reported. Functionally, the condition did not affect his ability to work. In September 2020, the Veteran was seen at a VA facility for rectal bleeding and pain. At that time, his blood pressure was recorded as 155/114 and 168/113. In December 2020, a new VA examination was conducted. Blood pressure readings at that time were 140/100, 138/99, and 193/101. An addendum opinion given after that examination found his readings at his December 2020 examination to be more indicative of the severity of his hypertension than the September 2020 emergency treatment records. In support of this, the examiner noted that the Veteran has a chronic condition, which has existed since service. While he does require medication to control his condition, the increased blood pressure shown in September 2020 was certainly also a manifestation of his chronic condition plus his pain associated with the rectal bleeding condition. In December 2021, the Veteran was afforded a new VA examination. At that time, blood pressure readings were 125/60, 123/79, and 125/80. He treated his blood pressure with medication. Functionally, the condition resulted in 0-1 weeks of lost work time in the prior 12 months, noting that it may cause dizziness, fatigue, and tiredness due to his medication, and that it slowed the Veteran's ability to focus on work tasks. Based on the above evidence, the Board does not find that the Veteran's hypertension should be afforded a compensable rating prior to June 17, 2019. In this regard, while he did treat his hypertension with medication, there is no evidence of a sustained diastolic pressure averaging over 100 or a sustained systolic pressure averaging over 160. While several blood pressure readings do show levels elevated beyond these parameters, those were isolated incidents and the Veteran's blood pressure returned to levels below those set by the diagnostic criteria. In short, there is simply no evidence prior to that date that the Veteran's hypertension met the criteria for a compensable rating. Additionally, the Board recognizes that the Veteran's hypertension has been rated 10 percent disabling from June 17, 2019. The Board does not find that his hypertension should be granted a rating in excess of that 10 percent for that period. At no point has he been shown to have diastolic pressure predominantly 110 or more, or systolic pressure predominantly 200 or more. Indeed, many of his blood pressure readings during that period are more closely aligned with a noncompensable rating. Although in September 2020, he was shown to have several readings of diastolic pressure above 110, the Board notes that a VA examiner has attributed that spike to non-hypertensive pain, and therefore those readings are not indicative of his hypertension alone. At most, his hypertension has resulted in some systolic readings above 160 and some diastolic readings above 100. As such, a 10 percent rating is supported by the diagnostic criteria, and a rating in excess thereof is not for application at this time. In sum, the Board has reviewed the Veteran's available medical history and has determined that prior to June 17, 2019, the Veteran's hypertension has not been manifested by a diastolic pressure predominantly higher than 100 or a systolic pressure predominantly 160 or more. Although he did control his hypertension with medication, absent a history of sustained diastolic pressure of 100 or more, he does not qualify for a compensable rating. Likewise, from June 17, 2019, the Veteran's hypertension has not been shown to result in diastolic pressure predominantly 110 or more or systolic pressure predominantly 200 or more. As such a compensable rating prior to June 17, 2019, and a rating in excess of 10 percent thereafter is not supported. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine; however, because the evidence is against the claim, that doctrine does not apply. See 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 C.F.R. § 3.102. 2. Entitlement to an increased rating for headaches The Veteran's headache disorder is presently rated as noncompensable from the date of the claim for an increased rating to June 17, 2019. From June 17, 2019, to October 14, 2021, his headaches are rated as 30 percent disabling. From October 14, 2021, his headaches are rated as 50 percent disabling. He seeks higher ratings for his headaches. The Board finds that the claim should be prior to February 22, 2021, but that from that date forward, the maximum 50 percent rating should be assigned. At no point thereafter should a rating in excess of the maximum 50 percent be granted. The Veteran's headaches are rated pursuant to DC 8100, which rates for migraine headaches. Under the applicable rating criteria a maximum 50 percent rating is assigned for very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. A 30 percent rating is assigned for characteristic prostrating attacks occurring on average once a month over the last several months. A 10 percent rating is assigned for characteristic prostrating attacks averaging one in two months over the last several months. Finally, a noncompensable rating is assigned for less frequent attacks. 38 C.F.R. § 4.124a, DC 8100. The medical evidence available for the year prior to the Veteran's claim for an increased rating note a history of chronic headaches, but do not speak to the nature of those headaches, nor do they discuss frequency or severity. In connection with his increased rating claim, the Veteran was afforded a VA examination in April 2015. At that time the Veteran's diagnosis was given as migraine including migraine variant headaches. Symptoms included pulsating or throbbing pain; pain localized to the side of the head; sensitivity to light; and sensory changes. Sensory changes tended to last less than one day. The examiner determined that the Veteran's headache attacks were not prostrating in nature. The Veteran reported at that time that his headaches occurred one to two times per week with a 7/10 severity, and lasting a couple of hours as most. For the majority of his headaches, he was able to continue functioning and "fight through it." He denied that his headaches were incapacitating. In March 2016, the Veteran was seen in a walk-in clinic for a headache, which was determined to be secondary to tooth pain. On June 17, 2019, the Veteran was afforded a new VA examination in connection with his claim. At that time, he was found to have symptoms which included constant head pain and pain affecting both sides of the head. Typical duration of head pain lasted less than one day. No non-headache symptoms were reported. Prostrating attacks did occur, but occurred once every month, at most. The examiner concluded that the Veteran's attacks were not "very prostrating and prolonged" nor were they productive of severe economic inadaptability. He treated his headaches with over the counter medication. The examiner concluded that his headaches did not impact his ability to work. For his part, the Veteran reported headache pain occurring two times per week, starting on the right and spreading to the entire head. He described the pain as "squeezing" in nature. He reported that a severe headache would cause him to miss work only occasionally. On February 22, 2021, the Veteran reported to a VA treatment provider that he had been experiencing increased episodes of migraine headaches, despite taking medication for that condition. Because of this notation, the Board remanded the claim in September 2021, so that a new VA examination could be conducted. On October 14, 2021, the Veteran was afforded a new VA examination. At that time, the Veteran reported increased migraine headaches with blurry vision. Headaches occurred twice a week and interfered with his ability to concentrate. He took medication for his condition. Symptoms included pulsating or throbbing head pain; pain localized to one side of the head; pain worsening with physical activity; nausea; sensitivity to light; and sensitivity to sound. Head pain lasted 1-2 days. Characteristic prostrating attacks occurred once every month, and were described as completely prostrating and prolonged and productive of severe economic inadaptability. No other pertinent findings were listed. The examiner stated that the Veteran's headaches resulted in an inability to focus, concentrate, or comprehend, and could require him to take time off work during such an attack. Turning to the question of the rating for the Veteran's headaches, the Board notes that the Veteran's headaches have been granted the maximum rating allowable under the diagnostic criteria from October 14, 2021. His symptoms from that date forward are within the diagnostic purview of the rating criteria, and he has not asserted any symptoms which are not considered by the rating criteria. Neither has he asserted significant interference with daily life such as frequent hospitalizations, due to his migraine headaches. As such, the Board cannot grant a rating in excess of the 50 percent already assigned for that condition, nor does it find that referral for extraschedular consideration in the first instance is appropriate at this time. However, the Board does not that as early as February 22, 2021, the Veteran reported a significant increase in his headache symptoms, which prompted the Board to remand this claim for the new examination that confirmed such significant symptoms in October 2021. Affording the Veteran the benefit of the doubt, the Board will grant a maximum 50 percent rating from the date of the medical note which implied an increase in headache symptoms, February 22, 2021. Looking at the period prior to that grant, the Board notes that from June 17, 2019, to February 22, 2021, the Veteran's headaches, while prostrating in nature, were not very frequently completely prostrating or prolonged in nature. Neither were they productive of severe economic inadaptability. At most, prostrating attacks occurred once per month and the Veteran remained able to work. As such, the Board does not find that a rating in excess of 30 percent is supported during that period. Finally, for the period prior to June 17, 2019, while the Veteran did report headache pain, occurring several times per week, he denied that the condition significantly affected his ability to function. Indeed, his symptoms and headache attacks were not deemed to be "prostrating" in nature. Because no prostrating attacks of headache pain were found during this period, the Board cannot grant a compensable rating, as that is a key criteria for such a rating under the diagnostic code. In sum, the Board finds that the Veteran's headaches should not be granted a compensable rating prior to June 17, 2019. From that date, through February 22, 2021, a rating in excess of 30 percent is not supported. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine; however, because the evidence is against the claim, that doctrine does not apply. See 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 C.F.R. § 3.102. Finally, from February 22, 2021, the Board will afford the benefit of the doubt and grant a 50 percent rating for his headaches; to this limited extent, the appeal is granted. However, as this grant represents the maximum rating allowable under the diagnostic code, a rating in excess of 50 percent is not supported thereafter. 3. Entitlement to an increased rating for status-post right ankle fracture with degenerative arthritis The Veteran's right ankle disability is presently rated as 10 percent disabling from the date of the claim for an increased rating to October 14, 2021, and 30 percent disabling thereafter. He seeks a higher rating for his right ankle fracture. The Board finds that the claim should be denied. The Veteran's right ankle disability is presently rated pursuant to DC 5271-5270. Hyphenated Diagnostic Codes are used when a rating under one code requires use of an additional diagnostic code to identify the basis for the evaluation assigned. 38 C.F.R. § 4.27. In this matter, DC 5271 refers to limited motion of the ankle, and DC 5270 implies evidence of ankylosis or fixation of the joint. Under the applicable rating criteria limitation of motion of the ankle is afforded a 10 percent rating when there is evidence of "moderate" limitation of motion. "Marked" limitation of motion is afforded a maximum 20 percent rating. 38 C.F.R. § 4.71a, DC 5271. Terms such as "moderate," and "marked" are not traditionally defined by the rating schedule; rather than applying a mechanical formula, VA must evaluate all the evidence to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6. However, during the pendency of this appeal, the schedular criteria for evaluating the ankle were amended. Specifically, DC 5271 was amended effective February 7, 2021. See 85 Fed. Reg. 76,453 (November 30, 2020). Where a law or regulation changes during the pendency of a claim for increased rating, the Board should first determine whether application of the revised version would produce retroactive results. In particular, a new rule may not extinguish any rights or benefits the claimant had prior to enactment of the new rule. VAOPGCPREC 07-03 (November 19, 2003). However, if the revised version of the regulation is more favorable, the implementation of that regulation under 38 U.S.C. § 5110(g) can be no earlier than the effective date of that change. If the former version is more favorable, VA can apply the earlier version of the regulation for the period prior to, and from, the effective date of the change. 38 U.S.C. § 5110; Karnas v. Derwinski, 1 Vet. App. 308, 313 (1991), overruled in part, Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). As the Veteran's claim was received prior to the effective date of the regulation changes, the Board must consider the Veteran's right ankle disability under both the old and the revised rating criteria and must apply the old rating criteria if the result is more favorable to the Veteran. Id. In this case, the Board notes that the rating criteria for limitation of motion of the ankle was amended to include descriptions of the terms "moderate" and "marked." Under the amended criteria, "moderate" limited motion is described as "less than 15 degrees dorsiflexion or less than 30 degrees plantar flexion." "Marked" limited motion is described as "less than 5 degrees dorsiflexion or less than 10 degrees plantar flexion." 38 C.F.R. § 4.71a, DC 5271. Under DC 5270, ankylosis or other fixation of the ankle joint is granted a 20 percent rating for an ankle in plantar fixation of less than 30 degrees. Plantar flexion, between 30 degrees and 40 degrees, or in dorsiflexion, between 0 degrees and 10 degrees is afforded a 30 percent rating. When the ankle is fixed in plantar flexion at more than 40 degrees, or in dorsiflexion at more than 10 degrees or with abduction, adduction, inversion or eversion deformity, a maximum 40 percent rating is assigned. 38 C.F.R. § 4.71a, DC 5270. It is noted that these diagnostic criteria were not amended during the appeal period. A disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance. Functional loss may be due to the absence or deformity of structures or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior in undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. § 4.40 With respect to joints, in particular, the factors of disability reside in reductions of normal excursion of movements in different planes. Inquiry will be directed to more or less than normal movement, weakened movement, excess fatigability, incoordination, pain on movement, swelling, deformity or atrophy of disuse. 38 C.F.R. § 4.45. Although pain may cause functional loss, pain itself does not constitute functional loss. Rather, pain must affect some aspect of "the normal working movements of the body," such as "excursion, strength, speed, coordination, and endurance," in order to constitute functional loss. Mitchell v. Shinseki, 25 Vet. App. 32, 38-43 (2011) (quoting 38 C.F.R. § 4.40 ); see also DeLuca v. Brown, 8 Vet. App. 202, 206-207 (1995). In March 2015, a VA treatment records notes that the Veteran reported having pain to the right ankle, he "rates pain as a 4 on scale of 0-10." The Veteran was afforded a VA examination in June 2015 in connection with his initial increased rating claim. He was diagnosed with traumatic arthritis of the ankle. He complained of pain to the medial right ankle rated at 4-5/10, rising to 10/10. No locking or stiffness was reported. He had occasional swelling, increased warmth and redness. He denied clicking or popping. He had feelings of occasional giving way, but no falling. He used a cam walker, hinged AFO, and/or an ankle wrap about 4-5 times per week. Activities of daily living were not limited. His job was not limited, although he avoided prolonged walking. Walking was limited to about 600-700 meters; standing limited to 10-15 minutes. Flare-ups of increased pain caused him to rest the ankle, take medication and use ice, occurring 1-2 times per month. Dorsiflexion was to 5 degrees; plantar flexion was to 25 degrees. Pain was noted, but did not cause functional loss. There was evidence of pain with weight bearing. There was evidence of localized tenderness to palpation at the medial ankle. No crepitus was identified. No additional loss was noted on repetitive use testing. the examination was neither medically consistent nor inconsistent with the Veteran's statements describing functional loss during a flare-up. Muscle strength was normal. He had no muscle atrophy. No ankylosis was diagnosed, and the examiner did not identify any fixation of the ankle joint. Instability or dislocation was suspected, although drawer test and talar tilt test results were normal. He had required arthroscopic surgery in 2010. No other pertinent findings were identified. Functionally, the examiner did not find that the condition affected his ability to perform any type of occupational task. In August 2016, a VA treatment record noted subjective pain to the ankles 6/10 in severity. He had no visible swelling or deformity to knees, he was able to flex and extend without difficulty, no crepitus was felt or heard, and he exhibited slightly limited range of motion to the right ankle only, with no visible swelling noted. In August 2017, VA treatment records noted the right ankle was painful on flexion and extension, there was no swelling but it was tender to touch. In June 2019, the Veteran was afforded a new VA examination of his ankle. He reported a history of chronic ankle pain with weight bearing after a half hour. He stated he could not run, and the ankle became stiff when resting. He also periodically used an ankle brace. He denied flare-ups of the ankle. Dorsiflexion was to 10 degrees; plantar flexion was to 30 degrees. Pain was noted on examination but did not result in functional loss. No additional loss was identified on repetitive use testing. The examination was medically consistent with his report of loss of use over time. Increased pain resulted in disturbance of locomotion. Muscle strength was normal. He had no signs of ankylosis or fixation of the joint. Joint stability testing was normal and no dislocation was suspected. Functionally, the examiner stated that walking should be limited 1 hour at a time, or 6 hours per day. Treatment records in February 2020 noted difficulty navigating stairs and distant walks. Lifting and bending due to minimal weight bearing on the ankle would be almost impossible. Treatment records from July 2020 note that the ankle has very limited range of motion in both dorsi and plantar flexion, and he had pain with inversion and eversion. Low strength was also noted, and he was only able to do 2+ dorsiflexion and plantar flexion. There was swelling in the lateral ankle. Unfortunately, specific range of motion findings were nor reported at this time. The examiner noted that he would likely have trouble using pedals on a large motor vehicle or operating heavy machinery due to his ankle. He could not stand for long period of time. In November 2020, a VA treatment record noted pain created difficulty walking and limited his mobility. It could make it easier for him to stumble or fall at times. In April 2021, the Veteran reported right ankle pain after falling the prior week while walking up the stairs. Objectively, the ankle showed some swelling and tenderness. Range of motion was limited, which the Veteran reported was due to "fusion of bones," although x-rays of the ankle showed no acute changes. He was diagnosed with a contusion of the right foot and ankle due to the injury sustained the week earlier. In May 2021, he was noted ot have significant dorsal spurring in the ankles bilaterally, in addition to hardware form his prior right ankle surgery. Pain was noted especially in dorsiflexion of the ankles. He reported decreased edema and more pain when he does not wear an ankle brace. No range of motion findings were offered. On October 14, 2021, the Veteran was afforded a new VA examination. Current symptoms included pain throughout the ankle and lower leg and bone spurs. He used a brace, cane, and prescription medicine. Functionally, the condition hindered mobility and punctuality. Flare-ups occurred almost daily with severe pain lasting 2-3 days and sometimes longer. Flares were precipitated by movement throughout the day, standing, weather, and brace over-time. Flares were alleviated by time. He was unable to stand or walk more than a few minutes. No history of instability was noted. Dorsiflexion was limited to 10 degrees; plantar flexion to 30 degrees. No additional loss was noted on repetitive use testing, although with repetitive use over time, plantar flexion was limited to 25 degrees and dorsiflexion to 5 degrees. during a period of flare, plantar flexion was anticipated to be limited to 20 degrees. no muscle atrophy was noted. The examiner stated that ankylosis was present in plantar flexion less than 30 degrees and dorsiflexion more than 10 degrees. There was no evidence of an adduction, abduction, inversion, or eversion deformity. Ankylosis of the subastragalar joint was in poor weight-bearing position. He showed a positive anterior drawer test, but a negative talar tilt test. He constantly used a brace and cane to ambulate. Functionally, the Veteran was independent in terms of most activities of daily living, but was not able to climb stairs, a ramp, ladder, rope, or scaffold. He would be expected to have difficulty with narrow, slippery or erratic surfaces, as well as standing or walking on level terrain. He was not able to kneel, crouch, or bend both legs and his spine, or crawl frequently. He could do light desk work, or sedentary work without any specific restrictions. Based on the above, the Board finds that prior to October 14, 2021, the Veteran did not meet the criteria for a rating in excess of 10 percent. During this period, the Veteran's ankle did not show subjective evidence of ankylosis or fixation of the joint. While some passing private and VA treatment records note stiffness and at least one notes bone fusion, those appear to be objective reports from the Veteran. Indeed, while the Veteran reported "fusion of the bones" in his ankle in April 2021, x-rays showed an ankle with no significant changes, and ankylosis was not diagnosed at that time. Turning to the available evidence regarding the Veteran's range of motion during that period, the Veteran was generally able to accomplish 5 or more degrees of dorsiflexion, and 10 or more degrees of plantar flexion. While he experienced pain in his ankle, and complained of some instability, no actual instability has been demonstrated on examination. As such, the Board finds, that even considering the Veteran's reports and description of symptoms during periods of flare, the criteria for a rating in excess of 10 percent for his right ankle, prior to October 14, 2021, have not been met. From October 14, 2021, the Veteran is diagnosed with ankylosis resulting in 10 degrees (but not more) dorsiflexion, and 30 degrees (but not more) plantar flexion. He has not been found to have any evidence of abduction, adduction, inversion or eversion deformity. Even during periods of flare, while the Board recognizes that his symptoms are quite significant, his fixation of the joint had not exceeded the parameters set for a 30 percent rating under DC 5270 (indeed, the nature of ankylosis is fixation of the joint, so additional movement beyond those degrees noted on examination would not be likely even during a period of flare). Based on this, the Board is satisfied that a rating in excess of 30 percent is not supported. In sum, prior to October 14, 2021, the Veteran's right ankle showed moderate, but not marked, limitation of motion. Thereafter, his condition has manifested with ankylosis in dorsiflexion of 10 degrees and plantar flexion of 30 degrees, without evidence of abduction, adduction, inversion or eversion deformity. As such, ratings in excess of 10 percent prior to October 14, 2021, and in excess of 30 percent, thereafter, are not supported, and the appeal is denied. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine; however, because the evidence is against the claim, that doctrine does not apply. See 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 C.F.R. § 3.102. 4. Entitlement to an initial compensable rating for status-post left little finger fracture The Veteran's left little finger disability is presently rated as noncompensable for the entire period on appeal. He seeks a higher rating. the Board finds that the claim should be denied. The Veteran's left little finger, status-post fracture/dislocation, healed with extension lag (decreased range of motion) is rated pursuant to DC 5230, which evaluates limitation of motion of a single ring or little finger. Under the diagnostic criteria, a noncompensable rating is assigned for any limitation of motion of the little finger, regardless of whether ot is on the major or minor hand. 38 C.F.R. § 4.71a, DC 5230. The Board notes that DC 5227 may also be applicable in this matter. That Diagnostic Code provides for a noncompensable rating for unfavorable or favorable ankylosis of the ring or little finger. Id., DC 5227. A disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance. Functional loss may be due to the absence or deformity of structures or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior in undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. § 4.40 With respect to joints, in particular, the factors of disability reside in reductions of normal excursion of movements in different planes. Inquiry will be directed to more or less than normal movement, weakened movement, excess fatigability, incoordination, pain on movement, swelling, deformity or atrophy of disuse. 38 C.F.R. § 4.45. Although pain may cause functional loss, pain itself does not constitute functional loss. Rather, pain must affect some aspect of "the normal working movements of the body," such as "excursion, strength, speed, coordination, and endurance," in order to constitute functional loss. Mitchell v. Shinseki, 25 Vet. App. 32, 38-43 (2011) (quoting 38 C.F.R. § 4.40 ); see also DeLuca v. Brown, 8 Vet. App. 202, 206-207 (1995). Under the applicable rating criteria for disabilities of the little finger, the Veteran is already in receipt of the maximum rating for such a disability, which in this matter is noncompensable in nature. Accordingly, the Board cannot assign a higher rating based on the schedular criteria. To the extent that he has asserted that he is entitled to a higher rating than the maximum allowable rating for that disability, the Board finds that the issue of whether referral for an extraschedular rating is raised in this matter, but finds that such referral is not warranted. Ratings shall be based as far as practicable upon the average impairments of earning capacity, with the additional proviso that the Secretary shall from time to time readjust this schedule of ratings in accordance with experience. To accord justice, therefore, to the exceptional case where the schedular ratings are found to be inadequate, the Under Secretary for Benefits or the Director, Compensation and Pension Service, upon field station submission, is authorized to approve on the basis of the criteria set forth in this paragraph an extraschedular rating commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities. The governing norm in these exceptional cases is: a finding that the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards. 38 C.F.R. § 3.321 (b)(1). The Court of Appeals for Veterans Claims (Court) has clarified that there is a three-step inquiry for determining whether a veteran is entitled to an extraschedular rating. Thun v. Peake, 22 Vet. App. 111, 115 (2008). Initially, the Board must determine whether the evidence presents such an exceptional disability picture that the available schedular ratings for the service-connected disability are inadequate. See Yancy v. McDonald, 27 Vet. App. 484 (2016); Doucette v. Shulkin, 28 Vet. App. 366 (2017) (holding that either the veteran must assert that a schedular rating is inadequate or the evidence must present exceptional or unusual circumstances); Sowers v. McDonald, 27 Vet. App. 472, 478 (2016) ("[t]he rating schedule must be deemed inadequate before extraschedular consideration is warranted"). Second, if the schedular rating does not contemplate the veteran's level of disability and symptomatology and is found inadequate, the Board must determine whether the veteran's disability picture exhibits other related factors such as marked interference with employment and frequent periods of hospitalization. Thun, 22 Vet. App. at 116. Third, if the first two Thun elements have been satisfied, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the veteran's disability picture requires the assignment of an extraschedular rating. Thun, 22 Vet. App. at 116. In other words, the first element of Thun compares a veteran's symptoms to the rating criteria, while the second element considers the resulting effects of those symptoms; if either prong is not met, then referral for extraschedular consideration is not appropriate. Yancy, 27 Vet. App. at 494-95. In this case, the Board finds that neither the first nor the second prong have been met. For example, in a June 2015 VA examination the Veteran reported that his finger does "ok" other than being able to fully extend the PIP joint. He denied pain except during cold weather. He denied locking of the joint or stiffness. He did not have clicking or popping. There was no swelling, heat or redness. He denied flare-ups of the joint. He denied general functional loss. He had some mild tenderness to palpation of the PIP joint. Although he did show some mild limitation of range of motion, there was no fixation of the joint. He did not have muscle atrophy or weakness. Imaging did not reveal any abnormalities. Functionally, the condition did not impact his employment status. Likewise in June 2019, a new examination was conducted. At that time he continued to have limitation of extension at the PIP joint with mild pain on repetitive movement of the finger. He denied flare-ups. Range of motion was normal with the exception of 10 degrees o extension in the PIP joint. No evidence of tenderness or pain was noted. Pain was not observed on examination. No change was noted with repetitive use. Muscle strength was normal and he had no atrophy. No ankylosis or fixation was identified. Functionally, the condition did not impact the Veteran's ability to work or perform occupational tasks. Finally, in December 2021, a new VA examination was conducted. At that time there was no active treatment plan for his condition. He reported continued pain in the finger with an inability to extend the finger completely. Pain was mild, increasing with gripping motion. He used topical pain reducer and Tylenol to treat his pain. He denied flare-ups. The examiner noted limited range of motion, but then reported generally normal findings. There was tenderness n palpation of the finger. The same was identified on repetitive use testing. Grip strength showed active movement against some resistance. No ankylosis or fixation of the joint was identified. No other pertinent findings were identified. Functionally, his condition had resulted in less than one week of lost work in the prior 12 months, with movement causing pain to increase. X-rays showed well preserved joint spaces and a lack of arthritis. There appeared to be a deformity in the soft tissue area of the injury. The Veteran has not testified as to any additional symptoms those reported in the various examination reports, which are specifically accommodated under the applicable diagnostic criteria. Further, although he has indicated that his condition causes pain him his finger, he has not testified that his disability has resulted in interference with employment as a whole (for example, resulting in significant missed work), nor has it resulted in frequent periods of hospitalization. As such, referral for extraschedular consideration is not appropriate in this matter. In sum, the Board finds that the Veteran is already in receipt of the maximum allowable schedular rating based on his diagnosis of a status-post fracture of the left little finger with limitation of motion, and cannot be assigned a compensable rating for his disability. Therefore, the Board must deny the increased rating claim based on schedular analysis. Neither is referral for an extraschedular rating appropriate in this matter. See 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 C.F.R. § 3.102. 5. Entitlement to an increased rating for left knee chondromalacia 6. Entitlement to an increased rating for right knee chondromalacia The Veteran's right and left knee disabilities are presently rated as 10 percent disabling from the date of the claim for an increased disability rating to the present. He seeks higher ratings for both knee disabilities. The Board finds that the claims should be denied. The Veteran's bilateral knee disabilities are both presently rated under DC 5260, which rate for knee disabilities manifested by limitation of flexion. Under the applicable rating criteria, a 10 percent rating is assigned when evidence showed flexion is limited to 45 degrees or less. For a rating in excess of 10 percent, flexion must be shown to be limited to 30 degrees or less. 38 C.F.R. § 4.71a, DC 5260. When rating based on limitation of motion, a separate rating may be assigned for knee disabilities based on limitation of flexion as well as limitation of extension of the knee if both pathologies exist. Likewise, separate ratings may be assigned based on limitation of motion, as well as instability or subluxation, if found. See VAOPGCPREC 23-97 (Multiple Ratings for Knee Disability). Limitation of extension is afforded a compensable rating when extension is limited to 10 degrees or more. 38 C.F.R. § 4.71a, DC 5261. With regard to instability or subluxation, it should be noted that, during the course of this appeal, the schedular criteria for evaluating the knee have been amended. Specifically, the criteria pertaining to (1) knee instability and (2) impairment of the tibia and fibula under 38 C.F.R. § 4.71a, DCs 5257 and 5262 respectively, was amended effective February 7, 2021. See 85 Fed. Reg. 76,453 (November 30, 2020). Where a law or regulation changes during the pendency of a claim for increased rating, the Board should first determine whether application of the revised version would produce retroactive results. In particular, a new rule may not extinguish any rights or benefits the claimant had prior to enactment of the new rule. VAOPGCPREC 07-03 (November 19, 2003). VA's Office of General Counsel has determined that the amended rating criteria can be applied only for the period from and after the effective date of the regulatory change. The Board can apply only the former regulation to rate the disability for periods preceding the effective date of the regulatory change. However, the former rating criteria may be applied prospectively, beyond the effective date of the new regulation. See VAOPGCPREC 3-2000. As the Veteran's claim was received prior to the effective date of the regulation changes, the Board must consider the Veteran's right knee disability under both the old and the revised rating criteria and must apply the old rating criteria if the result is more favorable to the Veteran. Id. However, in this case, the Board finds that the original criteria are more favorable, as they do not limit recurrent subluxation or lateral instability to conditions caused by a ligament tear or a diagnosed condition of the patellofemoral complex. As such, the Board will focus its analysis on the original rating criteria. Under the rating criteria for recurrent subluxation or lateral instability, in effect prior to February 2021, a 10 percent rating is assigned based on slight symptoms. A 20 percent rating is assigned for moderate symptoms. Finally, a 30 percent rating is assigned for severe symptoms. 38 C.F.R. § 4.71a, DC 5257 (prior to February 7, 2021). Terms such as "mild," "moderate," and "severe" are not defined by the rating schedule; rather than applying a mechanical formula, VA must evaluate all the evidence to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6. A disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance. Functional loss may be due to the absence or deformity of structures or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior in undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. § 4.40 With respect to joints, in particular, the factors of disability reside in reductions of normal excursion of movements in different planes. Inquiry will be directed to more or less than normal movement, weakened movement, excess fatigability, incoordination, pain on movement, swelling, deformity or atrophy of disuse. 38 C.F.R. § 4.45. Although pain may cause functional loss, pain itself does not constitute functional loss. Rather, pain must affect some aspect of "the normal working movements of the body," such as "excursion, strength, speed, coordination, and endurance," in order to constitute functional loss. Mitchell v. Shinseki, 25 Vet. App. 32, 38-43 (2011) (quoting 38 C.F.R. § 4.40 ); see also DeLuca v. Brown, 8 Vet. App. 202, 206-207 (1995). Other rating criteria applicable to the knee includes ankylosis (DC 5256); dislocation of the semilunar cartilage with episodes of locking, pain and effusion (DC 5258); removal of the semilunar cartilage (DC 5259); impairment of the tibia or fibula (DC 5262); and genu recurvatum (DC 5263). As such pathology is not shown in this matter, those rating criteria are not for consideration in this appeal. The Board has searched the Veteran's available medical records, but finds nothing in the year prior to his claim to imply that his bilateral knee conditions could warrant a higher rating under any rating criteria. The Veteran was afforded a VA examination in June 2015 in connection with his claim. At that time, the Veteran's bilateral patellar chondromalacia was confirmed as a diagnosis. He reported pain as 2-3/10, rising to 7-9/10. He had not pain with stairs, although he did have a grinding sensation in both knees. He had painless clicking and popping. He denied locking or stiffness. He had not required surgery. He reported feeling that he had buckling or giving way without falling. He occasionally used a knee sleeve. Activities of daily living were not limited. He denied flare-ups at the present, although he endorsed them in the distant past. He had some mild swelling in the right knee with occasional redness but no warmth. Bilateral range of motion was normal with pain noted on flexion. No evidence of pain with weight bearing. There was some bilateral patellar grind and mild peripatellar tenderness to palpation. Crepitus was observed. No additional loss was observed with repetitive use over time. No flare-ups were reported. He did not have fixation of the joints or ankylosis. Joint stability was normal upon all tests. He had no patellar dislocation, shin splints, stress fractures, compartment syndrome or tibial or fibular impairment. He did not have a meniscal condition. The knees were stable without heat, redness or swelling. He was positive for bilateral patellar crepitus with range of motion testing. Functionally, the examiner concluded that the Veteran's current condition did not impact his ability to perform any kind of occupational task. In August 2016, a VA treatment record found "no visible swelling or deformity to knees," and that he was "able to flex and extend [without] difficulty, no crepitus felt or heard." He reported pain at 7/10 in his knees. In June 2019, the Veteran was afforded a new VA examination of his knees. At that time he reported pain in both knees, the right worse than the left. He had pain beneath his patella with weight bearing, squatting and stairs. There was crepitation but no instability. He denied flare-ups. Pain was reported with squatting and prolonged walking. Range of motion was normal bilaterally with evidence of pain noted on flexion and mild patellar grind resulting in tenderness to palpation. No evidence of pain with weight bearing was noted. There was noted evidence of crepitus. No additional loss of function was found on repetitive use testing, and the examination was medically consistent with the Veteran's statements describing functional loss with repetitive use over time. No additional factors contributed to his disability. He did not have fixation of the knee or any diagnosis of ankylosis. Joint stability testing was normal bilaterally on all tests. He had never had a patellar condition such as dislocation. He did not have a meniscal condition. He had not required surgery. He denied using an assistive device to ambulate. The examiner concluded that the condition did impact his ability to work in that he needed to avoid frequent squatting or stairs. A notation from July 2019 noted a long history of bilateral knee pain. June 2020 x-rays of the right knee showed a normal right knee. A physical examination note from July 2020 noted fully strength in the lower extremities with normal range of motion, but slight painful motion. Pain was aching and sharp in nature. The examiner noted the June 2020 x-ray showed a normal knee, but reported the Veteran's assertion of a limitation in his ability to bend, kneel, crawl, stoop and walk long distances, making a workplace environment difficult. In December 2021, the Veteran was afforded a new VA examination. His diagnosis of bilateral patellar chondromalacia was confirmed. He reported constant pain in his knees 5-6/10, achy and stiff at rest or sitting. Movement increased pain to 6-10/10/ there was grinding in the knee. The knee was aggravated by standing, walking, motion of the knee, climbing, kneeling, or squatting, He avoided activity that will aggravate his knees. He used knee pads on the anterior knee to kneel. Flare-ups were reported based on activity, occurring 1-2 times per week, and lasting at least 24 hours. Flare-ups resulted in throbbing and grinding pain. He used a topical pain reducer, elevated, applied ice and rested to give the knees time to reduce in pain. During a flare, he had constant pain in the knees, although he did not indicate any limitation during such a period. The examiner stated that functionally, during a flare, he would not be able to work a traditional physical job. He had no history of recurrent subluxation or instability in either knee. His knees could swell with rest or activity. Range of motion was normal bilaterally. He had pain on flexion and extension. Pain was noted on active, passive, weight bearing and non-weight bearing motion. Evidence of crepitus and localized tenderness were identified int eh anterior knee. No additional loss was observed on repetitive use testing. The examiner anticipated no additional loss of range of motion with repeated use over time or during a period of flare. No muscle atrophy was noted. No surgery was required. No ankylosis or fixation of the joint was diagnosed. Stability testing was normal in the left knee, but showed 0-5 millimeters of medial and lateral instability in the right knee. He did not have a ligament tear. There was no evidence of patellar dislocation, shin splints, tibial or fibular impairment, or stress fractures. He had not required surgery. He regularly used a cane to ambulate. Functionally, his condition caused him to lose 0-1 weeks of work in the prior 12 months. The Veteran's flare-ups would likely result in him being away from work at least two days per week, resulting in his inability to work a traditional job. Based on the above, the Board finds that the Veteran's left knee should not be granted a rating in excess of the 10 percent already assigned for any period on appeal. In this regard, the Board recognizes pain with movement in the knee. However, the Veteran's left knee has generally been shown to have complete range of motion, and even accounting for pain, range of motion has not been limited. Even accounting for periods of flare, as reported in the December 2021, as described by the Veteran, there is no evidence that his extension has been limited, and to the extent that he has pain on movement such as kneeling or squatting, there is no indication that he cannot complete such movement, just that it causes additional pain. Generally speaking, when the evidence shows painful motion but without any actual functional limitation, a single 10 percent rating is for application. 38 C.F.R. §§ 4.40, 4.45, 4.71a, DC 5003 (explaining that when the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 pct is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under diagnostic code 5003, which applies to non-post-traumatic arthritis). As such, the Board does not find that a rating in excess of 10 percent is supported for the left knee. However, concerning the right knee, the Board similarly finds that a rating based on limitation of motion in excess of 10 percent is not supported, but that from December 23, 2021, the date of his most recent VA examination, a separate rating for slight lateral instability of the right knee should be granted. Here, the Board again notes that the Veteran's right knee has been manifested by pain with movement. However, the Veteran's right knee has generally been shown to have complete range of motion, and even accounting for pain, range of motion has not been limited. Even accounting for periods of flare, as reported in the December 2021, as described by the Veteran, there is no evidence that his extension has been limited, and to the extent that he has pain on movement such as kneeling or squatting, there is no indication that he cannot complete such movement, just that it causes additional pain. Generally speaking, when the evidence shows painful motion but without any actual functional limitation, a single 10 percent rating is for application. 38 C.F.R. §§ 4.40, 4.45, 4.71a, DC 5003. Therefore, to the extent that pain is noted on both extension and flexion in the most recent examination, and only on flexion in all prior records, a rating based on limitation of motion in excess of 10 percent is not supported. To this limited extent, the right knee claim is denied. Nonetheless, in the December 2021 examination report, the Veteran was found to have medial and lateral instability in the right knee of 1+ (0-5 millimeters). This is the most minor level of instability found on examination, and there is no evidence of the Veteran actually experiencing falls or giving way of the knee due to such instability. As such, the Board is satisfied that the Veteran's right knee has shown objective evidence of instability from December 23, 2021, and will grant a separate 10 percent rating for lateral instability from that date forward. Prior to this date the Board does not find any evidence of instability. Indeed, the Veteran generally has denied instability of the knee joint, with the exception of some feeling of buckling or giving way in the 2015 examination, although the Veteran denied any actual instability such as falling, and no objective evidence of instability was found on objective testing of the knee. As such, the Board finds that the earliest date it can grant a separate rating for instability of the right knee is December 23, 2021. To this limited extent the appeal is granted. In sum, the Board finds that both the right and left knee have been manifested by painful motion but no actual functional loss. As such, neither should be granted a rating in excess of 10 percent based on limitation of motion for the appeal period. To this extent the appeal is denied. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine; however, because the evidence is against the claim, that doctrine does not apply. See 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 C.F.R. § 3.102. However, the Board will grant a separate 10 percent rating for the right knee based on objective evidence of slight lateral instability of the knee effective December 23, 2021. To this limited extent the appeal is granted. 7. Entitlement to an increased rating for GERD The Veteran's GERD is presently rated as 10 percent disabling from the date of the claim for an increased disability rating to the present. He seeks a higher rating for that disability. The Board finds that the claim should be denied. The Veteran's GERD is rated under DC 7399-7346. Hyphenated Diagnostic Codes are used when a rating under one code requires use of an additional diagnostic code to identify the basis for the evaluation assigned. 38 C.F.R. § 4.27. In this matter, GERD is not specifically addressed by the diagnostic code. However, DC 7399 refers to a disability of the digestive system, and DC 7346 rates by analogy to symptoms associated with a hiatal hernia. Based on the symptoms reported in the record, this is the most appropriate rating criteria allowable under the diagnostic criteria. Under the applicable rating criteria, a 60 percent rating is assigned for symptoms of pain, vomiting, material weight loss and hematemesis or melena with moderate anemia; or other symptoms productive of severe impairment of health. A 30 percent rating is assigned for persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health. A 10 percent rating is assigned for two or more symptoms of the 30 percent evaluation of less severity. 38 C.F.R. § 4.114, DC 7346. Terms such as "considerable," and "severe" are not defined by the rating schedule; rather than applying a mechanical formula, VA must evaluate all the evidence to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6. There is no specific evidence identified in the record in the year prior to the Veteran's claim for an increase which would speak to the Veteran's GERD warranting a higher rating. In May 2015, the Veteran was afforded a VA examination in connection with his claim. Symptoms included pyrosis, reflux and regurgitation. No other pertinent physical findings were identified. Functionally, the Veteran's GERD did not impact his ability to work. A December 2018 VA treatment record indicates he treated his GERD with medication to good control. He denied dysphagia and heartburn. There was no abdominal pain. In June 2019, a new VA examination was conducted. At that time he was noted ot have daily substernal heartburn, but no dysphagia. Symptoms reported at that time were pyrosis and reflux exclusively. He had not esophageal stricture, spasm or diverticula. No other pertinent complications were identified. The condition did not affect his ability to work, and he did not require follow up with a primary care provider. A June 2021 treatment note indicated some episodic rectal bleeding in relation to GERD flare-ups, but that there was no current active bleeding. In December 2021, a new VA examination was conducted. He reported that his GERD was worsening. He used over the counter medication in addition to prescription medication to control his symptoms, with symptoms remaining. He had noted blood in his stool. Symptoms included pyrosis, reflux, substernal pain, sleep disturbance four or more times per week, and lasting less than one day. no esophageal stricture, spasm or diverticulum was identified. No other significant findings or test results were reported. The condition did affect his ability to work in that he had lost less than one week of work in the prior 12 months due to delayed or interrupted sleep, and stomach pain interfering with focus, resulting in efficiency at traditional jobs. In light of the above, the Board finds that a rating in excess of 10 percent is not supported for GERD for any period on appeal. Prior to December 2021, the Veteran has shown symptoms of GERD, but there has been no evidence that the symptoms have resulted in any considerable or severe impairment of health. Indeed, at most, his symptoms appeared to fluctuate, but responded well to treatment. While symptoms were shown to have increased in the December 2021 examination report, the Board still does not find that these symptoms are productive of a considerable impairment of health. He has not required hospitalization or surgical treatment due to his condition. While there is some substernal pain noted, it has not affected his shoulder or arm, and those flares last less than a day, at most. functionally, his condition has affected his ability to work less than one total week over the prior year. While his condition does result in some fatigue due to sleep disturbance, the Board finds that this is not indicative of "considerable" impairment of health. In sum, the Board finds that the Veteran has two or more symptoms of GERD which do not result in considerable or severe impairment of health, and to date are of less severity that those anticipated by the 30 percent rating. As such, the Board finds that a rating in excess of 10 percent for GERD is not supported. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine; however, because the evidence is against the claim, that doctrine does not apply. See 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 C.F.R. § 3.102. REASONS FOR REMAND Inasmuch as the Board regrets further delay in the adjudication of this appeal, a remand is necessary to complete additional development warranted based on the above decision. 8. Entitlement to TDIU The Board notes that the Veteran has not explicitly claimed entitlement to TDIU. Nonetheless, the medical evidence in the record suggests he left his full-time employment in approximately April 2019 due to an increasing disability picture. As such, the Board is satisfied that the claim of entitlement to TDIU is raised as part and parcel of the increased rating claims on appeal. Rice v. Shinseki, 22 Vet. App. 447 (2009). The Veteran has a combined disability rating of 90 percent with at least one disability rated 50 percent from July 26, 2018. From October 14, 2021, the Veteran's combined disability picture has been 100 percent; the Board recognizes that its grant of a 50 percent rating for a headache disorder will likely move the effective date of the combined 100 percent rating to February 22, 2021. To the extent that the question of the Veteran's employability between April 2019 and February 2021 could result in a grant of TDIU, the Board notes that the records is undeveloped. The Veteran's medical records imply that he left employment at that time, however, the Veteran has not personally asserted this fact. Neither is there adequate evidence in the record to speak to the Veteran's educational and occupational background. As such, on remand, the Veteran should be given the opportunity to furnish such evidence in support of a possible grant of TDIU from his last date of employment. Regarding the period after the Veteran's disability picture resulted in a combined 100 percent disability rating, while a 100 percent rating in theory precludes a grant of TDIU, VA has a duty to maximize benefits to a claimant. Particularly, this implies that VA has a duty to consider whether any combination of disabilities establishes entitlement to special monthly compensation (SMC) under 38 U.S.C. § 1114(s). Buie v. Shinseki, 24 Vet. App. 242, 249-250 (2010). Housebound benefits based on a combined rating are not available to a Veteran whose 100 percent disability is based on multiple disabilities, none of which is rated a 100 percent disabling. Guerra v. Shinseki, 642 F.3d 1046 (Fed. Cir. 2011). However, a total disability rating based on TDIU satisfies the total (100 percent) rating requirement for housebound status, if the TDIU was, or can be, predicated upon a single disability, and there exists additional disability or a combination of additional disabilities which are independently ratable as 60 percent or more. Bradley v. Peake, 22 Vet. App. 28, 293 (2008). As TDIU could feasibly be granted based on a single disability, particularly the Veteran's headaches which have been shown to result in severe economic inadaptability from February 22, 2021, the Board finds that TDIU during this period is also for consideration based on a single disability on an extraschedular basis. Therefore, on remand, the Veteran should be afforded the opportunity to report his occupational and educational history, as well as submit any additional evidence in support of total disability. Thereafter, the question of entitlement to TDIU, either on a schedular (prior to February 22, 2021) or extraschedular basis (based on a single disability after February 22, 2021) should be adjudicated in the first instance by the RO. The appeal is REMANDED for the following action: 1. Invite the Veteran to submit any additional evidence in support of his appeal. Specifically, request that the Veteran submit a VA Form 21-8940 (Application for Increased Compensation Based on Unemployability), as well as any additional evidence which speaks to his employability during the period on appeal. 2. Adjudicate the issue of entitlement to TDIU. B.T. KNOPE Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Pryce, Counsel