Citation Nr: 23014792 Decision Date: 03/10/23 Archive Date: 03/10/23 DOCKET NO. 18-28 049 DATE: March 10, 2023 ORDER Entitlement to a disability rating in excess of 10 percent disabling for a service-connected lumbosacral strain prior to January 20, 2021, and in excess of 40 percent disabling thereafter is denied. Entitlement to a disability rating in excess of 10 percent disabling for a service-connected cervical strain prior to January 20, 2021, and in excess of 20 percent thereafter is denied. Entitlement to a disability rating in excess of 10 percent for a service-connected right knee disability is denied. Entitlement to a disability rating in excess of 10 percent disabling for a service-connected left knee disability prior to January 20, 2021, and in excess of 20 percent thereafter is denied. Entitlement to service connection for acne is denied. REMANDED Entitlement to service connection for a right ankle disability, to include as secondary to service-connected lumbosacral strain is remanded. Entitlement to service connection for a left ankle disability, to include as secondary to service-connected lumbosacral strain is remanded. FINDINGS OF FACT 1. Prior to January 20, 2021, the probative medical evidence shows that the Veteran's lumbosacral strain did not result in forward flexion limited to 60 degrees or less or a combined range of motion of 120 degrees or less, even in contemplation of functional loss due to symptoms such as pain, fatigue, weakness, lack of endurance, or incoordination, or as a result of repetitive motion and/or flare-ups, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal contour, ankylosis, intervertebral disc syndrome (IVDS), or associated objective neurological abnormalities other than radiculopathy. 2. After January 20, 2021, the Veteran's service-connected lumbosacral strain was not manifested by unfavorable ankylosis or its functional equivalent. 3. Prior to January 20, 2021, the Veteran's service-connected cervical strain was not manifested by forward flexion less than 30 degrees or combined range of motion greater than 170 degrees, or guarding or muscle spasm resulting in an abnormal gait or abnormal spinal contour. 4. After January 20, 2021, the Veteran's service-connected cervical strain was not manifested by forward flexion to 15 degrees or less, and no ankylosis was present. 5. The Veteran's right knee disability was not manifested by limitation of flexion to 30 degrees, limitation of extension to 15 degrees, or ankylosis even when considering her complaints of pain with and without weight bearing and resistance in passive and active range of motion as well as during flare-ups. 6. Prior to January 20, 2021, the Veteran's left knee disability was not manifested by was not manifested by limitation of flexion to 30 degrees, limitation of extension to 15 degrees, or ankylosis even when considering her complaints of pain with and without weight bearing and resistance in passive and active range of motion as well as during flare-ups. 7. After January 20, 2021, the Veteran's left knee range of motion did not have limitation of flexion to 15 degrees or less. 8. The Veteran does not suffer from a skin disability, including acne, that began during service, was aggravated by service, or is otherwise related to an in-service injury or disease or to a service-connected disability. CONCLUSIONS OF LAW 1. The criteria for entitlement to a disability rating in excess of 10 percent disabling for a service-connected lumbosacral strain prior to January 20, 2021, and in excess of 40 percent disabling thereafter have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.7, 4.71a, Diagnostic Code (DC) 5242. 2. The criteria for entitlement to a disability rating in excess of 10 percent disabling for a service-connected cervical strain prior to January 20, 2021, and in excess of 20 percent thereafter have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.7, 4.71a, DC 5242. 3. The criteria for entitlement to a disability rating in excess of 10 percent for a service-connected right knee disability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, DC 5003-5260 4. The criteria for entitlement to a disability rating in excess of 10 percent disabling for a service-connected left knee disability prior to January 20, 2021, and in excess of 20 percent thereafter have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, DC 5260 5. The criteria for entitlement to service connection for acne have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Air Force from January 2003 to May 2007. This matter was previously before the Board in November 2019, at which time the Board remanded it to the Department of Veterans Affairs (VA) Regional Office (RO) for further development. The RO most recently readjudicated the appeal in May 2021 supplemental statement of the case. The Board finds that VA has substantially complied with the November 2019 Board remand, with the exception of the issues of entitlement to service connection for a left and right ankle disability, which are discusses further below. Stegall v. West, 11 Vet. App. 268, 271 (1998). The remaining issues are appropriate for appellate decision at this time. The Board also notes that the Veteran is currently in receipt of a combined 100 percent disability rating from May 1, 2018. INCREASED RATING Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule). 38 C.F.R. Part 4. The Rating Schedule is primarily a guide in the evaluation of a disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. See 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Separate Diagnostic Codes (DCs) identify the various disabilities. Where there is a question as to which of two evaluations to apply, the higher rating is assigned if the disability picture more nearly approximates the criteria required for that evaluation. 38 C.F.R. § 4.7. Otherwise, the lower rating is assigned. Id. Separate evaluations may be assigned for separate periods of time based on the facts found. In other words, the evaluations may be "staged." Hart v. Mansfield, 21 Vet. App. 505 (2007) (staged ratings are appropriate when the factual findings show distinct periods where the service- connected disability exhibits symptoms that would warrant different ratings). Where entitlement to compensation has already been established, as is the case here, and an increase in the disability rating is at issue, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). The Board has assessed the credibility and weight of all evidence, including the medical evidence, to determine its probative value, accounting for evidence that it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. Equal weight is not accorded to each piece of evidence contained in the record. Not every item of evidence has the same probative value. 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). In Correia v. McDonald, 28 Vet. App. 158 (2016), the Court held that the final sentence of 38 C.F.R. § 4.59 requires that the examiner record the results of range of motion testing "for pain on both active and passive motion [and] in weight-bearing and non-weight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint." The spine has no opposite joint. In Sharp v. Shulkin, 29 Vet. App. 26 (2017), the Court held that VA examiners must obtain information about the severity, frequency, duration, precipitating and alleviating factors, and extent of functional impairment of flares from the veterans themselves, when a flare-up is not observable at the time of examination. 1. Entitlement to a disability rating in excess of 10 percent disabling for a service-connected lumbosacral strain prior to January 20, 2021, and in excess of 40 percent disabling thereafter The Veteran is service-connected for a lumbosacral strain and was assigned a disability rating of 10 percent disabling from May 7, 2007, until January 20, 2021, at which point the evaluation was increased to 40 percent disabling under diagnostic code 5237. However, since this increase did not constitute a full grant of the benefit sought, the issue remains in appellate status. AB v. Brown, 6 Vet. App. 35, 39 (1993). Disabilities of the spine are rated under a General Rating Formula for Diseases and Injuries of the Spine (General Rating Formula), encompassing Diagnostic Codes 5235 to 5243, unless evaluated under DC 5243 based on the Formula for Rating Intervertebral Disc Syndrome (IVDS) Based on Incapacitating Episodes. Under the General Rating Formula for Diseases and Injuries of the Spine, a 20 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine. A 40 percent rating is warranted for forward flexion of the thoracolumbar spine 30 degrees or less; or favorable ankylosis of the entire thoracolumbar spine. Id. A 50 percent rating is warranted for unfavorable ankylosis of the entire thoracolumbar spine. Id. A 100 percent rating is warranted for unfavorable ankylosis of the entire spine. Id. Unfavorable ankylosis is defined as "a condition in which the entire cervical spine, the entire thoracolumbar spine, or the entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurological symptoms due to nerve root stretching." Id. at Note 5. Additionally, fixation of a spinal segment in neutral position (zero degrees) is "always considered favorable ankylosis. Id. 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; 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). Any associated objective neurologic abnormalities, including but not limited to bowel or bladder impairment, are to be evaluated separately under the appropriate diagnostic codes. 38 C.F.R. § 4.71a, Note (1). Prior to January 20, 2021 The Board finds that the evidence is persuasively against a rating in excess of 10 percent for the Veteran's lumbosacral sprain prior to January 20, 2021. Even considering these lay reports of symptoms and noted functional loss, the degree of additional limitation reflected by the statements would not result in limitation of motion more nearly approximating forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees or the combined range of motion of the thoracolumbar spine not greater than 120 degrees. Additionally, the Veteran did not have muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. The Veteran was afforded a VA examination of the thoracolumbar spine in March 2015. She was diagnosed with a low back strain. The Veteran reported sharp intermittent lower pain with increased activity and while in bed. Examination however revealed full flexion without objective evidence of pain. The examiner did note that the Veteran had radiculopathy manifested by moderate intermittent pain in the left and right lower extremities. The examiner found no incapacitating episodes gibbus, kyphosis, lumbar lordosis, lumbar flattening, reverse lordosis, list, scoliosis, or ankylosis. The examiner found no spasm, atrophy, guarding, pain with motion, tenderness, or weakness. The examiner found normal reflex and sensory testing. Finally, the examiner found that the Veteran does not have IVDS of the thoracolumbar spine. At a March 2018 examination of the back the examiner found no objective evidence of a back condition or radiculopathy on examination, only subjective complaints of pain. Magnetic resonance imaging was normal. The Veteran was observed sitting, standing, and arising quickly and easily and was noted to display suboptimal exertion during examination. At a subsequent April 2019 VA examination, the examiner again found full range of motion. Moreover, the examiner noted that there was very inconsistent performance on the examination and that the range of motion findings were unreliable, showing as decreased when testing but full when evaluating other body parts. The examiner noted submaximal effort during the examination. The Veteran submitted a private disability benefit questionnaire (DBQ) for the back also dated April 2019. The examiner found forward flexion to 50 degrees, extension to 15 degrees, lateral flexion to 15 degrees bilaterally and lateral rotation to 10 degrees bilaterally. After repetitive use testing the range of motion decreased with forward flexion to 540 degrees, extension to 10 degrees, lateral flexion to 10 degrees bilaterally and lateral rotation to 5 degrees bilaterally. The examiner found muscle spasms, an abnormal gait, and an abnormal spinal contour due to guarding and spasms. The examiner found strength of 2/5 in all areas. The examiner did not note atrophy or ankylosis. Lower extremity radiculopathy was found to be severe bilaterally. Moreover, the examiner found that the Veteran suffers from intervertebral disc syndrome IVDS with incapacitating episodes of at least six weeks in the prior year. A detailed review of the report provides many questions as to how the conclusions were reached based on the objective medical evidence and significant inconsistencies with other VA examinations and available treatment records. Overall, the Board finds that the opinion, particularly considering the objective medical evidence, is entitled to limited probative value. The Veteran underwent a VA thoracolumbar examination in January 2021. The Veteran informed the examiner that she experienced back pain going through the buttock to her feet. He reported flare-ups with increased pain that is palpable to touch in the back area. Range of motion testing showed forward flexion to 30 degrees, and extension to 20 degrees. Right lateral flexion and left lateral flexion were 30 degrees. Right lateral rotation was 25 degrees and left lateral rotation was 20 degrees. Neither the range of motion nor pain contributed to a functional loss. There was no evidence of pain on weightbearing. The Veteran was able to perform repetitive use testing with at least 3 repetitions, without additional loss of function or range of motion. The examiner noted that during a flare-up, pain and lack of endurance would limit functional ability, although without a change in range of motion testing. There was no guarding or muscle spasm, loss of strength, atrophy, sensory deficits, radiculopathy or ankylosis. The Veteran had no neurologic abnormalities or findings related to her back disability, to include bower or bladder problems or pathologic reflexes. The Veteran did not have IVDS of the thoracolumbar spine. The Veteran occasionally used a brace when pain flared up. Imaging studies revealed arthritis. For the period prior to January 20, 2021, the Veteran's, there is no evidence that shows that the Veteran's back disability manifested by forward flexion greater than 30 degrees but not greater than 60 degrees; a combined range of motion of 120 degrees or less; or muscle spasms or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. The Board finds that the symptoms detailed in the April 2019 private opinions are inconsistent with the remainder of the evidence of record and affords low probative value to this private opinion. Caluza v. Brown, 7 Vet. App. 498, 510-11 (1995), aff'd per curium, 78 F.3d 604 (Fed. Cir. 1996). For the period subsequent to January 20, 2021, the Board finds that a disability rating in excess of 40 percent is not warranted. In order to warrant a 50 percent rating, the Veteran would need to show that she experienced unfavorable ankylosis of the entire thoracolumbar spine. The record does not show ankylosis of any kind. The January 2021 VA examination found no ankylosis. Further, lay statements and VA treatment records show that, while the Veteran has difficulty sitting, standing, or walking for prolonged periods and lifting heavy objects, she is still able to move her thoracolumbar spine. As the Veteran has some range of motion, although significantly limited due to pain, she does not exhibit unfavorable ankylosis or the functional equivalent of the entire thoracolumbar spine. In so finding, the Board acknowledges that the Court recently clarified that ankylosis of the spine can also mean the "functional equivalent" of ankylosis. Chavis v. McDonough, 34 Vet. App. 1 (2021). However, even when taking such into consideration, the Board finds that there was no functional limitation that more nearly approximates ankylosis. Even when considering the effects of flareups and repeated use over time, the evidence shows that the Veteran retained spinal movement sufficient to participate in range of motion testing upon examination. This is not consistent with an immobile or consolidated joint or one that is fixed or frozen in one position. Therefore, the Board finds that the symptoms experienced from after January 2021 most closely approximate the criteria for the assigned 40 percent rating and a higher rating is not warranted. Accordingly, the Board finds that the evidence is persuasively against the assignment of a rating higher than 10 percent prior to January 20, 2021, and in excess of 40 percent disabling after January 20, 2021, for the Veteran's service-connected back disability and the claim is be denied. The benefit of the doubt rule does not change the outcome of this determination based on the persuasive weight of the evidence . 38 U.S.C. § 5107(b). 2. Entitlement to a disability rating in excess of 10 percent disabling for a service-connected cervical strain prior to January 20, 2021, and in excess of 20 percent thereafter The Veteran's service-connected cervical strain is currently rated pursuant to 38 C.F.R. § 4.71a, Diagnostic Code 5237. Under the General Rating Formula, a disability rating of 10 percent is assigned for forward flexion of the cervical spine greater than 30 degrees but less than 40 degrees; or combined range of motion of the cervical spine greater than 170 degrees but less than 335 degrees; or muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or vertebral body fracture with loss of 50 percent or more of the height. 38 C.F.R. § 4.71a, Diagnostic Code 5237. A 20 percent evaluation is provided for forward flexion of the cervical spine greater than 15 degrees but less than 30 degrees; or combined range of motion of the cervical spine not greater than 170 degrees; or muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. Id. A 30 percent disability rating is assigned when forward flexion of the cervical spine is measured at 15 degrees or less; or when the evidence shows favorable ankylosis of the entire cervical spine. Id. A 40 percent evaluation is provided when the evidence shows unfavorable ankylosis of the entire cervical spine. Id. For VA compensation purposes, normal forward flexion of the cervical spine is zero to 45 degrees, extension is zero to 45 degrees, left and right lateral flexion are zero to 45 degrees, and left and right lateral rotation are zero to 80 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion of the cervical spine is 340 degrees. The normal ranges of motion for each component of spinal motion provided in this note are the maximum that can be used for calculation of the combined range of motion. 38 C.F.R. § 4.71a, General Formula, Note 2; see also Plate V. Unfavorable ankylosis is a condition in which the entire cervical spine, the entire thoracolumbar spine, or the entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision, restricted opening of the mouth and chewing, breathing limited to diaphragmatic respiration, gastrointestinal symptoms due to pressure of the costal margin on the abdomen, dyspnea or dysphagia, atlantoaxial or cervical subluxation or dislocation, or neurologic symptoms due to nerve root stretching. Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. 38 C.F.R. § 4.71a, General Formula, Note 5. After a review of the evidence of record, the Board finds that prior to January 20, 2021, the signs and symptoms associated with the Veteran's recurrent cervical recurrent cervical strain best approximated forward flexion of the cervical spine greater than 30 degrees but not greater than 40 degrees, entitling her to a disability rating of 10 percent and no higher. The Board also finds that from January 20, 2021, onward, the signs and symptoms associated with the Veteran's recurrent cervical strain best approximated forward flexion of the cervical spine greater than 15 degrees but not greater than 30 degrees, entitling her to a disability rating of 20 percent and no higher. A March 2015 examination of the neck found no observed medical evidence of a neck condition and the Veteran showed full range of motion on exam. At an April 2019 examination of the neck, the Veteran reported pain and limited mobility. On examination, however, the Veteran had a full range of motion, full strength and there were no objective evidence of pain or tenderness to palpation. The The Veteran submitted a private disability benefit questionnaire (DBQ) dated April 2019 and completed by Dr. C.B. Cervical spine initial range of motion testing revealed forward flexion to 20 degrees, extension to 15 degrees, right lateral flexion to 20 degrees, left lateral flexion to 20 degrees, right lateral rotation to 15 degrees and left lateral rotation to 15 degrees. The examiner checked "no" as to whether the Veteran had intervertebral disc syndrome or incapacitating episodes over the last 12 months but then checked the box for "at least 6 weeks" as to the duration of incapacitating episodes in the past 12 months. A detailed review of the report provides many questions as to how the conclusions were reached based on the objective medical evidence and significant inconsistencies with other VA examinations and available treatment records. Overall, the Board finds that the opinion, particularly considering the objective medical evidence, is entitled to very limited probative value. Following the November 2019 Board remand, the Veteran was afforded another VA cervical spine condition examination in April 2021. The examiner diagnosed the Veteran with a cervical strain. The Veteran reported that her condition had worsened and that she experienced flare-ups consisting of more intense pain. On examination, the Veteran's range of motion revealed flexion to 20 degrees, extension to 20 degrees, left lateral flexion to 20 degrees, left lateral flexion to 30 degrees, right lateral rotation to 25 degrees and left lateral rotation to 30 degrees. No pain was noted on exam and there was no objective evidence of localized tenderness. Repeated use over time and flare-ups would limit the Veteran's functioning due to pain, fatigue, weakness, and lack of endurance but without any additional loss of range of motion. The Veteran had full strength. There was no evidence of ankylosis and no IVDS of the cervical spine. For the period prior to January 20, 2021, the evidence is persuasively against the application of an initial disability rating in excess of 10 percent for the Veteran's service-connected cervical strain, even when considering the functional loss as outlined in 38 C.F.R. § §§ 4.40 and 4.45. The next higher rating of 20 percent requires flexion greater than 15 degrees but less than 30 degrees. Alternatively, the Veteran could demonstrate combined range of motion less than 170 degrees, or muscle spasm or guarding severe enough to result in an abnormal gait or spinal contour. However, the Board finds no evidence to suggest that the Veteran experienced this degree of restriction in his neck prior to January 20, 2021. The Board considers whether a separate evaluation may be warranted for any associated objective neurological abnormalities, including, but not limited to, bowel or bladder impairment, under Diagnostic Code 5237. 38 C.F.R. §§ 4.71a, Note 1. The Board notes that no neurological abnormalities associated with the Veteran's cervical strain were noted during the appeal period. For the period after January 20, 2021, the evidence is also persuasively against finding that a rating in excess of 20 percent for the Veteran's service-connected cervical strain. The requirements for the next higher rating of 30 percent, the criteria require forward flexion of the cervical spine is measured at 15 degrees or less; or when the evidence shows favorable ankylosis of the entire cervical spine. The Board finds no evidence to suggest this degree of restriction in his neck from January 20, 2021. During the January 2021 VA examination, the Veteran's forward flexion measured, at worst, to 20 degrees; and an objective finding of ankylosis was explicitly denied by the examiner. Accordingly, the Board finds that the evidence is persuasively against the assignment of a rating higher than 10 percent prior to January 20, 2021, and in excess of 40 percent disabling after January 20, 2021, for the Veteran's service-connected cervical disability and the claim is denied. During the pendency of the appeal, the rating criteria for evaluating musculoskeletal disabilities under 38 C.F.R. § 4.71a were amended effective February 7, 2021. 85 Fed. Reg. 230 (Nov. 30, 2020). The amendments, however, do not effect the back symptoms or criteria involved in this case. As the evidence of record persuasively weighs against the increased rating claims, the benefit-of-the-doubt rule does not apply. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 4.3, 4.7; Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021). 3. Entitlement to an initial disability rating in excess of 10 percent for a service-connected right knee disability 4. Entitlement to a disability rating in excess of 10 percent disabling for a service-connected left knee disability prior to January 20, 2021, and in excess of 20 percent thereafter An April 2015 rating decision granted the Veteran service connection for a right knee disability and a left knee disability and awarded the Veteran initial noncompensable ratings under diagnostic code 5257 effective December 11, 2014. That rating decision also granted service connection for a left knee disability and A May 2018 rating decision increased the Veteran's right and left knee evaluation to 10 percent disabling effective December 11, 2014, under diagnostic code 5260. Most recently, following the November 2019 Board remand, a May 2021 rating decision increased the Veteran's left knee disability to 20 percent disabling effective January 20, 2021. The Veteran has maintained, generally, that she is entitled to higher disability ratings. As noted earlier, during the pendency of the appeal, the rating criteria for evaluating musculoskeletal disabilities under 38 C.F.R. § 4.71a were amended effective February 7, 2021. These amendments revised select diagnostic codes "to ensure that this portion of the rating schedule uses current medical terminology and provides detailed and updated criteria for the evaluation of musculoskeletal disabilities." Id. When a law or regulation changes during the course of a claim or an appeal, the version more favorable to the Veteran applies, to the extent permitted by any stated effective date in the amendment in question. 38 U.S.C. § 5110(g). When 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. Prior to February 7, 2021, Diagnostic Code 5257 provided that a 10 percent rating was warranted for slight recurrent subluxation or lateral instability; a 20 percent rating was warranted for moderate recurrent subluxation or lateral instability; and a 30 percent rating was warranted for severe recurrent subluxation or lateral instability. 38 C.F.R. § 4.71a, DC 5257. As of February 7, 2021, under the amended criteria, Diagnostic Code 5257 provides that a 10 percent rating is warranted for a 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. 38 C.F.R. § 4.71a, Diagnostic Code 5257. A 20 percent rating is warranted for (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. Id. A 30 percent rating is warranted for severe 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. Id. In addition to the above, the amended rating criteria under Diagnostic Code 5257 also provides ratings specific to patellar instability, a diagnosed condition involving the patellofemoral complex with recurrent instability. A 10 percent rating is warranted for patellar 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 patellar instability after surgical repair that requires a prescription by a medical provider for one of the following: A brace, cane, or walker. A 30 percent rating is warranted for patellar instability after surgical repair that requires a prescription by a medical provider for a brace and either a cane or a walker. Id. For patellar instability, the patellofemoral complex consists of the quadriceps tendon, the patella, and the patellar tendon. Id. at Note 1. Under Diagnostic Code 5260, a noncompensable rating is assigned when flexion of the knee is limited to 60 degrees; a 10 percent rating is assigned when flexion is limited to 45 degrees; a 20 percent rating is assigned when flexion is limited to 30 degrees; and a 30 percent rating is assigned when flexion is limited to 15 degrees. Separate ratings under Diagnostic Code 5260 for limitation of flexion of the leg and Diagnostic Code 5261 for limitation of extension of the leg may be assigned for disability of the same joint. VAOPGCPREC 09-04. Under Diagnostic Code 5261, a noncompensable rating is assigned when extension of the knee is limited to 5 degrees; a 10 percent rating is assigned when extension is limited to 10 degrees; a 20 percent rating is assigned when extension is limited to 15 degrees; a 30 percent rating is assigned when extension is limited to 20 degrees; a 40 percent rating is assigned when extension is limited to 30 degrees; and a 50 percent rating is assigned when extension is limited to 50 degrees. Notably, Diagnostic Code 5260 was not affected by the February 7, 2021, musculoskeletal rating criteria changes. A separate compensable rating may also be assigned for meniscal pathology under DC 5258 or 5259. Lyles v. Shulkin, 29 Vet. App. 107 (2017). Full range of motion of the knee is from 0 degrees to 140 degrees in extension and flexion. See 38 C.F.R. § 4.71, Plate II. 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). In Correia v. McDonald, 28 Vet. App. 158 (2016), the Court held that the final sentence of 38 C.F.R. § 4.59 requires that the examiner record the results of range of motion testing "for pain on both active and passive motion [and] in weight-bearing and non-weight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint." In Sharp v. Shulkin, 29 Vet. App. 26 (2017), the Court held that VA examiners must obtain information about the severity, frequency, duration, precipitating and alleviating factors, and extent of functional impairment of flares from the veterans themselves, when a flare-up is not observable at the time of examination. The Veteran was provided with a VA examination of her knees in March 2015. The examiner diagnosed the Veteran with a bilateral knee strain. The Veteran reported sharp pain with prolonged standing and use which she treated with over-the-counter medication. The Veteran was afforded a VA examination of her knees in April 2019. The examiner found no objective evidence of a knee condition on examination today, only subjective complaints of pain. The Veteran submitted a private disability benefit questionnaire (DBQ) dated April 2019 and completed by Dr. C.B. The private examiner noted the Veteran's range of motion consisted of right knee flexion to 90 degrees and extension to 20 degrees, and left knee flexion to 90 degrees and extension to 20 degrees. Dr. C.B. noted several contributing factors for the left and right knee disabilities; however, he did not check which side was affected. Strength was found to be 3/5 on both flexion and extension bilaterally. The examiner noted a history of slight recurrent subluxation bilaterally and slight history of lateral instability bilaterally. On joint stability testing, the Veteran exhibited instability consisting of anterior instability, posterior instability, medical instability, and lateral instability of 2+ (5-10 millimeters) bilaterally. He also noted the Veteran used a cane and walker but failed to indicate the frequency of use and did not specify the condition for which each assistive device was used A detailed review of the report provides many questions as to how the conclusions were reached based on the objective medical evidence and significant inconsistencies with other VA examinations and available treatment records. Overall, the Board finds that the opinion, particularly considering the objective medical evidence, is entitled to limited probative value. The Veteran was afforded another VA examination of her right knee in January 2021. The examiner diagnosed the Veteran with bilateral knee strain and bilateral osteoarthritis. On examination, the Veteran's right knee was limited to 40 degrees flexion and 0 degrees extension. Flexion in the Veteran's left knee was to 30 degrees and extension to 0 degrees. The examiner noted evidence of pain with weight bearing bilaterally, but no tenderness or crepitus. The Veteran reported regular use of a walker and occasional use of a cane. The examiner opined that the Veteran was unable to stand, sit or walk for a prolonged period of time. The Veteran was able to perform repetitive-use testing of the knees without additional loss of function or range of motion after three repetitions. There was no ankylosis bilaterally. Joint stability testing found no instability bilaterally. The Veteran did not have recurrent patellar dislocation, stress fractures, chronic exertional compartment syndrome or any other tibial or fibular impairment. The Board finds that the private physician's opinion has less probative value than the VA examination evidence because it is inconsistent with and outweighed by treatment records and the rest of the medical evidence of record, including the March 2015, April 2019, and January 2021 VA examinations. See Bloom v. West, 12 Vet. App. 185, 187 (1999) (the value of a physician's statement is dependent, in part, upon the extent to which it reflects "clinical data or other rationale to support his opinion"); see also Miller v. West, 11 Vet. App. 345, 348 (1998) (a bare conclusion, even one reached by a health care professional, is not probative without a factual predicate in the record). After a review of the evidence the Board finds that a rating in excess of 10 percent for the right knee is not warranted. As noted above, the Veteran's right knee limitation of flexion with painful motion has been evaluated under diagnostic code 5260. Significantly, right knee range of motion and stability were tested multiple times throughout the appellate period, including during VA examinations in March 2015, April 2019, and January 2021. Right knee flexion was limited, at worst, to 40 degrees and extension was full. Prior to January 20, 2021, the evidence is persuasively against a rating in excess of 10 percent disabling for the Veteran's left knee disability. The Board finds that even when considering functional limitations due to pain with and without weight bearing and resistance in passive and active range of motion as well as during flare-ups, and when considering the appellant's competent reports of his observable adverse symptomatology, his functional losses do not equate to the criteria required for at least a 20 percent rating because flexion of the left and right knee is not limited to 30 degrees or less. As noted earlier, the January 20, 2021, examination is the first adequate examination showing a limitation of flexion to 30 degrees. In order for a disability evaluation in excess of 20 percent be assigned under Diagnostic Code 5260, flexion of the knee must be limited to 15 degrees or more. 38 C.F.R. § 4.71a, Diagnostic Code 5260. Here, the Board finds no basis for assigning a rating in excess of 20 percent under Diagnostic Code 5260 since the evidence shows that there has not been flexion limited to 15 degrees or more. As noted by the January 2021 VA examiner, pain on flexion was at 30 degrees. There was no indication in the record of flexion to 15 degrees that would warrant an increased rating to 30 percent, to include additional functional loss due to pain. Disability rating in excess of 20 percent is not warranted for the left knee disability. Flexion has not been limited to 15 degrees, as would warrant the next higher evaluation of 30 percent. Additionally, as the Veteran's extension was not limited to a compensable degree during this period, separate compensable ratings under DC 5261 are not warranted. Regarding a separate rating under DC 5257, the January 2021 VA examination and all prior VA examinations were negative for any recurrent subluxation, persistent instability, or other impairment resulting from a ligament tear or other disability of the left knee. Thus, an increased rating under the former or revised version of DC 5257 is also not warranted at any time during the pendency of this appeal. In considering the applicability of other Diagnostic Codes, the Board finds that DCs 5256 (ankylosis of the knee), 5258 (dislocated semilunar cartilage), 5262 (tibia and fibula impairment), and 5263 (genu recurvatum) are not applicable in this instance, as the medical evidence does not show that the Veteran has any of those conditions. 38 C.F.R. § 4.71a, Diagnostic Codes 5256, 5257, 5258, 5262, 5263. While the Veteran clearly has problems with her knees, the Board finds the medical evidence of record to be highly probative as to the current nature, extent, and severity of the Veteran's right and left knee disorders. The medical reports were based on physical examination and provided sufficient information to allow the Board to apply the schedular criteria. Thus, although the Veteran's competent and credible reports of symptoms have been considered and are probative, the Board attaches greater probative weight to the clinical findings of skilled, unbiased professionals. In conclusion, the Board finds that the evidence of record persuasively weighs against the Veteran's claim for a rating in excess of 10 percent for a left knee disability prior to January 20, 2021, and in excess of 20 percent thereafter and against the Veteran's claim for an initial rating in excess of 10 percent disabling for a right knee disability. As the evidence of record persuasively weighs against the increased rating claims, the benefit-of-the-doubt rule does not apply. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 4.3, 4.7; Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021). SERVICE CONNECTION Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (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. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). Certain chronic diseases are presumed related to service if they were shown as chronic in service; or, if they manifested to a compensable degree within a presumptive period following separation from service; or, if they were noted in service, with continuity of symptomatology since service that is attributable to the chronic disease. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.303, 3.307, 3.309; Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2013). 1. Entitlement to service connection for acne The Veteran contends, generally, that she suffers from acne that is originally related to her active duty service. The Board concludes that, while the Veteran clearly has a current acne diagnosis, and serious symptoms associated with the same, the evidence is persuasively against finding that this condition began during active service or is otherwise related to an in-service injury, event, or disease. Treatment records and an April 2021 VA examination indicate that the Veteran has been diagnosed with acne. The Veteran has maintained that she was treated for an active rash on her body during active duty service in approximately 2003 or 2004. Service treatment records show that in March 2005 she sought treatment for eczema and complained of an allergic reaction to a new soap in October 2005. The Veteran was provided with a VA skin conditions examination in April 2021. The examiner diagnosed the Veteran with acne manifested by several significant acne blotches on her face, back and chest which she treats with clindamycin solution. However, the examiner opined that it was less likely than not that the Veteran's current acne condition is etiologically related to service, to include consideration of the Veteran's in-service reports of eczema. The examiner explained that the Veteran had no evidence of eczema at the April 2021 examination. Further, the examiner also noted post-service treatment records which did not mention acne. Here, there is no competent and credible evidence of a nexus between the Veteran's current skin disorder and service. The only evidence of record in support of such a nexus is the Veteran's lay opinion that her current acne problems are due to service. The Veteran is certainly competent to report as to the observable symptoms she experiences and their history, but she cannot diagnose a skin disorder because of the medically complex nature of such a diagnosis. See Jandreau, 492 F.3d at 1377, n. 4. The Veteran has not been shown to possess specialized training sufficient to render such an opinion. Accordingly, the Veteran's assertions as to a relationship between her acne complaints, initially noted many years after service, and service are of little probative value. Additionally, to the extent the Veteran is asserting continuity of symptomatology from service, the Board finds such statements inconsistent with the overall record. Particularly, the service treatment records that fail to support her contentions. Accordingly, the evidence is persuasively against the claim. As there is not an approximate balance of positive and negative evidence, the benefit-of-the-doubt doctrine is not applicable and service connection for acne is not warranted. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. REASONS FOR REMAND 1. Entitlement to service connection for a right ankle disability, to include as secondary to service-connected lumbosacral strain is remanded. 2. Entitlement to service connection for a left ankle disability, to include as secondary to service-connected lumbosacral strain is remanded. The November 2019 Board remand requested that an examination of the Veteran's ankles was necessary and requested opinions as to whether it was at least as likely as not that: (1) any current left or right ankle disabilities arose during service or was otherwise related to service, (2) any left or right ankle disabilities were caused by a service-connected disability and (3) whether any left or right ankle disability were aggravated or worsened beyond their natural progression by her service-connected disabilities. A contract medical examiner completed medical opinion reports in April and May 2021 that addressed the Veteran's claims regarding her ankles. While the examiner provided an opinion as to direct service connection, the opinions provided regarding service connection are inconsistent and not responsive to the November 2019 remand instructions. The examiner's opinion as to the issue of aggravation is also inadequate. While the examiner was asked to determine whether the ankle conditions were aggravated beyond their natural progression by any service-connected disabilities, the opinions provided instead indicate that the Veteran's service-connected conditions would not "cause" left and right ankle disabilities. The examiner used an incorrect standard for aggravation and did not provide adequate rationale as to the requested proximate causation question. The United States Court of Appeals for Veteran Claims (Court) has held that for secondary service connection claims, the standard for aggravation is any increase in disability, not permanent worsening beyond normal progression. See Ward v. Wilkie, 31 Vet. App. 233 (2019). When VA provides an examination or obtains an opinion, the examination or opinion must be adequate. Barr v. Nicholson, 21 Vet. App. 303 (2007). There must be a reasoned medical explanation that connects clear conclusions to supporting data. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). In these regards, further consideration is necessary before the Board may properly adjudicate the ankle issues. Although the Board sincerely regrets the additional delay, it is necessary to ensure that there is a complete record upon which to decide the Veteran's claim so that she is afforded every possible consideration. The matters are REMANDED for the following action: 1. Schedule the Veteran fora VA ankle examination with a different provider to determine the nature of her bilateral ankle disabilities and to obtain an opinion as to whether such are possibly related to service or to a service-connected disability. The claims file should be reviewed by the examiner in conjunction with the examination. All necessary tests should be conducted, and the results reported. 2. Following review of the claims file and examination of the Veteran, the examiner should provide an opinion as to the following: (a.) is it at least as likely as not (nearly approximately balanced likelihood) that the Veteran's left and/or right ankle disabilities were caused by a service-connected disability? Please explain why or why not, to include addressing the September 2019 medical opinion from Dr. C.B. (b.) Is it at least as likely as not that the Veteran's left and/or right ankle disabilities were worsened beyond their natural progression (aggravated) by her service-connected disabilities? Please explain why or why not, to include addressing the September 2019 medical opinion from Dr. C.B. 3. Then, readjudicate the issues on appeal. If the decision is adverse to the Veteran, issue a supplemental statement of the case, allow appropriate time for response, and return the case to the Board. RAY BARTO SLABBEKORN, JR. Veterans Law Judge Board of Veterans' Appeals Attorney for the Board V. Woehlke 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.