Citation Nr: A25041288
Decision Date: 05/06/25	Archive Date: 05/06/25

DOCKET NO. 230703-359144
DATE: May 6, 2025

ORDER

The claim for a rating in excess of 10 percent for tenosynovitis with degenerative arthritis/trigger finger and gamekeeper's thumb is dismissed. 

An initial rating in excess of 70 percent for posttraumatic stress disorder (PTSD) is denied. 

An effective date of August 1, 2018, but no earlier, for a total disability rating based on individual unemployability (TDIU) is granted, subject to the laws and regulations governing the award of monetary benefits. 

An effective date of August 1, 2018, but no earlier, for the award of basic eligibility to Dependents' Educational Assistance (DEA) benefits is granted, subject to the laws and regulations governing the assignment of monetary benefits.

An effective date of July 14, 2021, but no earlier, for the award of service connection for erectile dysfunction (ED) is granted, subject to the laws and regulations governing the award of monetary benefits. 

An effective date of July 14, 2021, but no earlier, for the award of special monthly compensation based on loss of use of a creative organ (SMC) is granted, subject to the laws and regulations governing the assignment of monetary benefits.

An initial compensable rating for ED is denied. 

An initial rating of 20 percent, but no more, for left knee lateral instability associated with left knee degenerative arthritis with synovitis and chondromalacia (left knee lateral instability) is granted, subject to the laws and regulations governing the assignment of monetary benefits.   

A rating in excess of 20 percent for the period from July 14, 2021 to December 22, 2022 for left knee lateral instability is denied. 

A rating of 10 percent, but no more, for left knee meniscal impairment is granted. 

A rating in excess of 20 percent from November 18, 2018 and in excess of 30 percent from July 14, 2021 for left knee degenerative arthritis with synovitis and chondromalacia/medial meniscus tear is denied. 

An effective date earlier than March 16, 2015 for service connection for left knee scars is denied. 

An effective date of March 16, 2015, but no earlier, for service connection for painful scars is granted, subject to the laws and regulations governing the assignment of monetary benefits.  

A compensable rating for a right thumb scar is denied. 

An initial compensable rating for left knee scars is denied.  

A 20 percent rating for painful scars for the period from March 16, 2015 to August 11, 2022 is granted, subject to the laws and regulations governing the assignment of monetary benefits.  

An effective date of March 20, 2012, but no earlier, for service connection for degenerative arthritis of the spine with degenerative disc disease (a back condition) is granted, subject to the laws and regulations governing the assignment of monetary benefits.  

An effective date of March 20, 2012, but no earlier, for service connection for right lower extremity sciatic nerve radiculopathy is granted, subject to the laws and regulations governing the assignment of monetary benefits. 

An effective date earlier than March 24, 2020 for service connection for left lower extremity sciatic nerve radiculopathy is denied. 

An effective date earlier than August 31, 2021 for service connection for right lower extremity femoral nerve radiculopathy is denied. 

An effective date earlier than August 31, 2021 for service connection for left lower extremity femoral nerve radiculopathy is denied. 

A rating in excess of 20 percent for a back condition for the period from March 16, 2015 to August 12, 2022 is denied.

A rating in excess of 20 percent for right lower extremity sciatic nerve radiculopathy for the period from July 14, 2021 to December 22, 2022 is denied.

An initial rating in excess of 20 percent for left lower extremity sciatic nerve radiculopathy is denied. 

An initial rating in excess of 20 percent for right lower extremity femoral nerve radiculopathy is denied. 

An initial rating in excess of 20 percent for left lower extremity femoral nerve radiculopathy is denied. 

Service connection for voiding dysfunction is granted. 

FINDINGS OF FACT

1. The Veteran's claim for an increased rating for his service-connected tenosynovitis with degenerative arthritis/trigger finger and gamekeeper's thumb was appealed in another appeal stream. The Board issued a decision in January 2025. 

2. During the period on appeal, the symptoms and overall impairment caused by the Veteran's PTSD have not nearly approximated total occupational and total social impairment.

3. As of August 1, 2018, the Veteran's service-connected disabilities precluded him from securing or following substantially gainful employment.

4. Eligibility for DEA benefits is an ancillary benefit that is awarded as of the date on which a permanent and total disability is established.

5. VA received a notice of Intent to File on July 14, 2021 followed by an October 8, 2021 claim for service connection for ED. In a July 2022 rating decision, the agency of original jurisdiction (AOJ) granted his claim for ED and granted SMC based on loss of use of a creative organ. 

6. During the period on appeal, the Veteran's ED did not manifest in penile deformity. 

7. During the periods on appeal, the Veteran's left knee disability was manifested by recurrent instability, which required the prescribed use of a brace for ambulation but did not require the prescription of an assistive device (e.g., cane(s), crutch(es), or walker). 

8. During the period on appeal, the Veteran experienced symptoms of swelling following left knee surgery to remove damaged cartilage.  

9. For the period from November 18, 2018 to July 13, 2021, at its worst, the Veteran's left knee extension was limited to 15 degrees. For the period from July 14, 2021, at its worst, left knee extension was limited to 20 degrees. 

10. The Veteran filed a claim for service connection for a left knee disability on March 16, 2015. 

11. During the period on appeal, the Veteran's right thumb scar measured at 1 sq. cm., and his left knee scars measured at 0.2 sq. cm. and 0.6 sq. cm., respectively.

12. During the period on appeal, the Veteran's scars were shown to be painful.

13. On March 20, 2012, the Veteran filed a claim for service connection for a back condition and continuously pursued service connection thereafter. 

14. March 24, 2020 is the earliest date in which it is factually ascertainable that the Veteran was diagnosed with left lower extremity sciatic nerve radiculopathy. 

15. August 31, 2021 is the earliest date in which it is factually ascertainable that the Veteran was diagnosed with bilateral lower extremity femoral nerve radiculopathy.

16. During the period on appeal, despite pain, at its worst, the Veteran's forward flexion in his back was limited to 50 degrees with a combined ROM of 145 degrees. 

17. During the respective periods on appeal, the Veteran's radiculopathy symptoms were wholly sensory in nature.

18. The Veteran's voiding dysfunction is proximately due to his service-connected back condition.  

CONCLUSIONS OF LAW

1. The criteria for dismissal have been met. 38 U.S.C. § 7105. 

2. The criteria for a rating in excess of 70 percent for PTSD have not been met. 38 C.F.R. § 4.130, Diagnostic Code (DC) 9411.

3. The criteria for an earlier effective date of August 1, 2018 for a TDIU have been met. 38 U.S.C. § 5110; 38 C.F.R. §§ 3.400, 4.16.

4. The criteria for basic eligibility to DEA benefits from August 1, 2018 have been met. 38 U.S.C. § 3501; 38 C.F.R. § 3.807.

5. The criteria for an earlier effective date of July 14, 2021 for service connection for ED have been met. 38 U.S.C. § 5110; 38 C.F.R. § 3.400.

6. The criteria for an earlier effective date of July 14, 2021 for the award of SMC based on loss of use of a creative organ have been met. 38 U.S.C. § 1114; 38 C.F.R. § 3.350.

7. The criteria for an initial compensable rating for ED have not been met. 38 C.F.R. § 4.115b, DC 7522.

8. The criteria for an initial 20 percent rating for left knee lateral instability have been met. 38 C.F.R. § 4.71a, DC 5003-5257.

9. The criteria for a rating in excess of 20 percent for left knee lateral instability for the period from July 14, 2021 to December 22, 2022 have not been met. 38 C.F.R. § 4.71a, DC 5003-5257.

10. The criteria for a 10 percent rating for left knee meniscal impairment have been met. 38 C.F.R. § 4.71a, DC 5259.

11. The criteria for a rating in excess of 20 percent from November 18, 2018 and in excess of 30 percent from July 14, 2021 for left knee degenerative arthritis with synovitis and chondromalacia/medial meniscus tear have not been met. 38 C.F.R. § 4.71a, DCs 5003-5261, 5256, 5258, 5260, 5262, 5263.

12. The criteria for an earlier effective date for service connection for left knee scars have not been met. 38 U.S.C. § 5110; 38 C.F.R. § 3.400.

13. The criteria for an earlier effective date of March 16, 2015 for service connection for painful scars have been met. 38 U.S.C. § 5110; 38 C.F.R. § 3.400.

14. The criteria for a compensable rating for a right thumb scar have not been met. 38 C.F.R. § 4.118, DCs 7800-7805.

15. The criteria for a compensable rating for left knee scars have not been met. 38 C.F.R. § 4.118, DCs 7800-7805.

16. The criteria for a 20 percent rating for painful scars have been met. 38 C.F.R. § 4.118, DC 7804.

17. The criteria for an earlier effective date of March 20, 2012 for service connection for a back condition have been met. 38 U.S.C. § 5110; 38 C.F.R. § 3.400.

18. The criteria for an earlier effective date of March 20, 2012 for service connection for right lower extremity sciatic nerve radiculopathy have been met. 38 U.S.C. § 5110; 38 C.F.R. § 3.400.

19. The criteria for an earlier effective date for service connection for left lower extremity sciatic nerve radiculopathy have not been met. 38 U.S.C. § 5110; 38 C.F.R. § 3.400.

20. The criteria for an earlier effective date for service connection for right lower extremity femoral nerve radiculopathy have not been met. 38 U.S.C. § 5110; 38 C.F.R. § 3.400.

21. The criteria for an earlier effective date for service connection for left lower extremity femoral nerve radiculopathy have not been met. 38 U.S.C. § 5110; 38 C.F.R. § 3.400.

22. The criteria for a rating in excess of 20 percent for a back condition for the period from March 16, 2015 to August 12, 2022 have not been met. 38 C.F.R. 4.71a, DC 5242.

23. The criteria for a rating in excess of 20 percent for right lower extremity sciatic nerve radiculopathy for the period from July 14, 2021 to December 22, 2022 have not been met. 38 C.F.R. § 4.124a, DC 8520.

24. The criteria for an initial rating in excess of 20 percent for left lower extremity sciatic nerve radiculopathy have not been met. 38 C.F.R. § 4.124a, DC 8520.

25. The criteria for an initial rating in excess of 20 percent for right lower extremity femoral nerve radiculopathy have not been met. 38 C.F.R. § 4.124a, DC 8526.

26. The criteria for an initial rating in excess of 20 percent for left lower extremity femoral nerve radiculopathy have not been met. 38 C.F.R. § 4.124a, DC 8526.

27. The criteria for service connection for voiding dysfunction as secondary to a service-connected back condition have been met. 38 U.S.C. § 1110; 38 C.F.R. § 3.310.

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran served on active duty from June 12, 1989 to December 9, 1994 and from December 10, 1994 to June 4, 1998. According to a November 2012 VA administrative decision, the second period of service from December 1994 to June 1998 for which the Veteran was discharged for other than honorable conditions, was dishonorable for VA purposes, and as such, is a bar to payment of VA benefits for disabilities deriving from that period of service. See 38 C.F.R. § 3.12. 

In the July 2023 VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement), the Veteran elected the Direct Review docket.

Therefore, the Board may only consider the evidence of record at the time of the July 2022, August 2022, and December 2022 AOJ decisions on appeal. 38 C.F.R. § 20.301. Any evidence submitted after the AOJ decisions on appeal cannot be considered by the Board. 38 C.F.R. §§ 20.300, 20.301, 20.801. 

If the Veteran would like VA to consider any evidence that was submitted that the Board could not consider, the Veteran may file a Supplemental Claim (VA Form 20-0995) and submit or identify this evidence. 38 C.F.R. § 3.2501. If the evidence is new and relevant, VA will issue another decision on the claim[s], considering the new evidence in addition to the evidence previously considered. Id. Specific instructions for filing a Supplemental Claim are included with this decision. 

Preliminarily, the Board acknowledges and accepts the Veteran's July 2023 waiver of any further notice/assistance from VA, or error therefrom, under 38 U.S.C. §§ 5103 (a) (1) and 5103A. Specifically, the Veteran has requested that, should the Board find that additional development is needed, the Board should not remand the matter. Rather, the Board should decide the claims based on the current evidence of record. This waiver was made with the assistance of counsel, and with the acknowledgement that the Veteran understood his rights.

The Board further acknowledges that in a July 2023 brief, the Veteran generally requested increased ratings for "all periods on appeal" for his service connected 1) PTSD, 2) ED, 3) left knee degenerative arthritis with synovitis and chondromalacia, 4) left knee lateral instability, 5) painful scars, 6) tenosynovitis with degenerative arthritis (trigger finger and gamekeeper's thumb), 7) right thumb scar, 8) degenerative arthritis of the spine with degenerative disc disease, 9) left knee scars, 10) right lower extremity sciatic nerve radiculopathy, 11) right lower extremity femoral nerve radiculopathy, 12) left lower extremity femoral nerve radiculopathy, 13) left lower extremity radiculopathy, and 14) left lower extremity sciatic nerve radiculopathy. 

Notably, the last two conditions are the same.  To provide context, the AOJ initially granted service connection for "left, radiculopathy lower extremity" in an August 2020 rating decision (also referred to as "left lower extremity radiculopathy" in subsequent records). However, in the December 2020 rating decision, it was recharacterized as "left lower extremity sciatic nerve radiculopathy."  To avoid confusion, the Board has treated the two as one condition and will refer to it as "left lower extremity sciatic nerve radiculopathy."  Thus, in total, the Veteran requested increased ratings, for all periods, for 13 disabilities. 

Additionally, the Veteran requested entitlement to earlier effective dates for service connection for his 1) ED, 2) left knee scar, 3) painful scars, 4) degenerative arthritis of the spine with degenerative disc disease, 5) right lower extremity sciatic nerve radiculopathy, 6) left lower extremity sciatic nerve radiculopathy, 7) right lower extremity femoral nerve radiculopathy, and 8) left lower extremity femoral nerve radiculopathy. Finally, he requested earlier effective dates for entitlement to 9) TDIU, 10) basic eligibility to DEA, and 11) SMC. In total, the Veteran requested earlier effective dates for 11 disabilities/claims. 

1. The claim for a rating in excess of 10 percent for tenosynovitis with degenerative arthritis/trigger finger and gamekeeper's thumb is dismissed. 

The Board may dismiss any appeal which fails to allege specific error of fact or law in the determination being appealed. 38 U.S.C. § 7105 (d). Here, the Board notes that, prior to the July 2023 Notice of Disagreement, the Veteran filed a February 2023 Notice of Disagreement for the same claim. The matter was adjudicated, and the Board issued a January 2025 decision.  Accordingly, there remain no allegations of errors of fact or law for appellate consideration. Therefore, the Board does not have jurisdiction to review the appeal, and it is dismissed.

2. An initial rating in excess of 70 percent for PTSD is denied. 

The Veteran is seeking an initial rating in excess of 70 percent for his service-connected PTSD. The period on appeal begins February 12, 2015, the date his claim was received by VA. 

The Veteran's PTSD is rated under 38 C.F.R. § 4.130, Diagnostic Code 9411, General Rating Formula for Mental Disorders. The provisions pertinent to this case are as follows:

A 70 percent rating is assigned when a psychiatric disability causes occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); and inability to establish and maintain effective relationships. Id.

A 100 percent rating is assigned when a psychiatric disability causes total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of close relatives, own occupation, or own name. Id.

Evaluation under § 4.130 is symptom-driven, meaning that symptomatology should be the fact-finder's primary focus when deciding entitlement to a given disability rating under that regulation. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 116-17 (Fed. Cir. 2013). In Vazquez-Claudio, the United States Court of Appeals for the Federal Circuit explained that the frequency, severity, and duration of the symptoms also play an important role in determining the rating. Id. at 117. Significantly, however, the list of symptoms under the rating criteria are meant to be examples of symptoms that would warrant the rating, but are not meant to be exhaustive, and the Board need not find all or even some of the symptoms to award a specific rating. 38 C.F.R. § 4.21; Mauerhan v. Principi, 16 Vet. App. 436, 442-43 (2002). If the evidence shows that the Veteran suffers symptoms listed in the rating criteria or symptoms of similar severity, frequency, and duration that cause occupational or social impairment equivalent to what would be caused by the symptoms listed in the criteria for a particular rating, the appropriate equivalent rating will be assigned. Mauerhan, 16 Vet. App. at 443; Vazquez-Claudio, 713 F.3d at 117.

During the relevant period, VA Medical Center (VAMC) records reflect that the Veteran attended numerous appointments for mental health treatment. The Board will summarize some of those records below.

A February 2020 VAMC mental health note indicates that the Veteran had continued to sleepwalk/patrol nightly without realizing his actions. His wife reported screaming and fighting at night and constant agitation and anger during the day. During his appointment, the Veteran was observed to be appropriately dressed and well-groomed, but vigilant and looking behind and over his shoulder. He was restless and agitated, but he eventually calmed down. He was noted as alert and "oriented x3" with good attention span, recall, and judgement. There was no evidence of a thinking disorder, and his thought content was devoid of delusions, hallucinations, and suicidal or homicidal intent. However, he did experience significant guilt and cognitive distortions. His mood was anxious and depressed and his affect was full, congruent, and at some point, tearful.

An April 2020 VAMC psychiatry note describes the Veteran as pleasant, open, and spontaneous with good rapport. During his appointment, he was alert, oriented, and his speech was clear, logical, and coherent. There was no evidence of delusions, hallucinations, or suicidal or homicidal ideation.  His mood was euthymic with congruent affect.

May 2020 VAMC records indicate that the Veteran attended a telephonic initial mental health assessment. Prior to beginning the assessment, the psychiatrist noted symptoms of paranoia regarding the doctor's affiliation with VA. After some discussion, he was observed to be "debating with himself" for a period of time prior to proceeding with the interview. Further, he shared that he was "very observant" and noted that during visits with his previous provider, he had shared observations regarding the air pressure in that person's tires. The doctor noted this as concerning for stalking behavior; however, he emphasized that the Veteran had not made any threats toward the provider or others.

The clinician noted the following PTSD symptoms as present and clinically significant: distressing memories of an in-service traumatic event; recurrent nightmares (with content not clearly connected with identified trauma); dissociative reactions (not directly related to past trauma); intense or prolonged psychological distress at exposure to cues that symbolize or resemble an aspect of the traumatic event; marked physiological reactions to cues that symbolize or resemble an aspect of the traumatic event; avoidance; persistent and exaggerated negative beliefs or expectations about oneself, others, or the world; persistent, distorted cognitions about the cause or consequences of the traumatic event; persistent negative emotional state; markedly diminished interest or participation in significant activities; feelings of detachment/estrangement from others; persistent inability to experience positive emotions; irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects; reckless or self-destructive behavior; hypervigilance; exaggerated startle response; and sleep disturbance. Symptoms of lesser clinical significance included problems with concentration. The clinician also noted dissociative symptoms; specifically, depersonalization and derealization. The Veteran denied suicidal plans, means, or intent, but he endorsed a history of passive suicidal ideation in 1990. He also denied aggressive ideation, but noted that during his last trip to the hardware store several months prior, the police were called due to verbal aggression.

Regarding education and work history, the Veteran reported that he obtained his bachelor's degree in adult education and worked for the state department and the department for military affairs. He was fired from both jobs. He last worked in August 2018 and was fired because, as he reported, "I thought the director was inferior and full of it and a ----- and I felt the need to let him know." He reported doing "odds and ends things with carpentry," and his wife always came up with projects for him. For example, he recently built barn doors for a friend. He noted that his wife was his primary financial support, and he remarked, "maybe she married me to take care of me."

A mental status examination revealed that he was alert, oriented in all spheres, and able to establish rapport. His speech was fluent and angry in tone with normal rate and rhythm. His affect was "irritable, reactive, congruent, increased range." His thought processes were logical, linear, and goal oriented. Regarding thought content, the Veteran endorsed paranoia, but he denied specific paranoid delusions or ongoing audiovisual hallucinations. He also denied suicidal and homicidal ideation, and there was no evidence of self-injurious behavior. His insight, judgement, and impulse control were noted as "limited-fair," and his cognition was grossly intact in terms of immediate, recent, and remote memory functioning. Also, his attention/concentration was normal during the interview, and his fund of knowledge was age appropriate.

During a July 2020 VAMC mental health appointment, the Veteran was observed to be alert, "oriented x 3" with good attention span, recall, and judgment. His thought process was normal in rate, and he was coherent and logical with no loosening of associations. His thought content was devoid of delusions, hallucinations, and suicidal or homicidal intent. His mood was dysthymic and dysphoric with full and congruent affect.

In a September 2020 VAMC psychiatry note, the Veteran's clinician noted that he liked the "direction" he was going in but was still interrupted with vigilance and agitation, and he was noted to be prone to anger. He reported going out to lunch with his wife for the first time in two years, but he had to cut the date short due to loud construction noises which agitated him. He appreciated her support and help but noted that he did not want her to be his "medical provider." Notably, the clinician indicated that the Veteran had catastrophic and distorted suspicious thinking with significant impairment to functioning and relationships. He also noted that the Veteran "stays at home" and had difficulty trusting his wife. During the appointment, he was more relaxed, open, and verbalized trust and hopefulness. He was alert, oriented, and had good attention span, recall, and judgment. His thought process was normal in rate and volume of speech. Also, he was noted as coherent, logical, and there was no evidence of a thinking disorder. His thought content was devoid of delusions, suspiciousness, hallucinations, and suicidal or homicidal intent. Further, his mood was euthymic with full and congruent affect.

Notably, subsequent mental health treatment reports are consistent with the above. 

During the period on appeal, the Veteran also attended multiple VA examinations. In February 2016, he was diagnosed with situational phobia. He reported that, after separating from active service, he went back to school and earned his bachelor's degree in adult education. He first worked in the prison system but transitioned to working with youth. He worked for the state for six years and noted that he had not "called in sick once." 

Regarding his social life, he denied socializing outside of work and only enjoyed fishing as a hobby. At the time of the examination, he had been married for approximately one year; however, he had been in a relationship with his wife for about ten years before marriage. He did not have any children. Regarding other family, he reported that his grandparents raised him, but they had passed away, and he did not speak to his biological mother. He also denied having a relationship with his half-siblings.

The examiner noted symptoms of anxiety, panic attacks occurring weekly or less often, and chronic sleep impairment. During the examination, the Veteran was observed to be euthymic in mood with congruent affect. His thought processes were logical to the course of conversation, goal-directed, and linear with no evidence of a psychotic process. His thought content was free of suicidal or homicidal ideation or intent, and the examiner opined that the Veteran was capable of managing his own financial affairs.

In March 2020, the Veteran attended a second VA examination at which he was diagnosed with PTSD. He reported being married to his second wife for approximately five years with no children. Regarding work, he stated that he had been fired from "many" jobs since separating from active military service. He worked at his last job for approximately four years and had not secured employment since August 2018.

His PTSD symptoms were noted as follows: recurrent distressing dreams related to an in-service traumatic event, avoidance, markedly diminished interest or participation in significant activities, feelings of detachment or estrangement from others, irritable behavior, and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects, hypervigilance, and sleep disturbance. Notably, the examiner opined that his PTSD symptoms caused clinically significant distress or impairment in social, occupational, or other important areas of functioning. Additional symptoms included depressed mood, anxiety, chronic sleep impairment, difficulty in establishing and maintaining effective work and social relationships, social avoidance, and exaggerated startle response.

During the examination, the Veteran was observed to be neatly dressed and groomed and fully oriented. He maintained eye contact, his memory was grossly intact, his speech was of normal rate and tone, and his thoughts were organized and coherent. The Veteran denied hallucinations and delusions as well as suicidal, homicidal, and self-harm ideation. His mood appeared anxious with congruent affect. The examiner opined that he was capable of managing his financial affairs.

The Veteran attended a third VA examination in September 2021. During the examination, he reported that he last worked in 2018. Regarding his wood working, he reported that he did not leave his home, as he easily got angered. For example, he stopped going to the hardware store to pick up wood because he would get into arguments with staff and patrons.  He further reported that he could "never complete a wood-working project" as he had difficulty with concentration. He noted feeling guilty all the time. Regarding his social life, he reported that he tended to isolate in his garage working on various projects. He denied doing things as a couple with his wife, and he denied wanting friends. 

His PTSD symptoms were noted as follows: recurrent distressing dreams related to an in-service traumatic event; intense or prolonged psychological distress at exposure to cues that symbolize or resemble an aspect of the traumatic event; marked physiological reactions to cues that symbolize or resemble an aspect of the traumatic event; avoidance; persistent and exaggerated negative beliefs or expectations about oneself, others, or the world; persistent negative emotional state; markedly diminished interest or participation in significant activities; feelings of detachment or estrangement from others; persistent inability to experience positive emotions; irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects; reckless or self-destructive behavior; hypervigilance; exaggerated startle response; problems with concentration; and sleep disturbance. The examiner opined that his PTSD symptoms caused clinically significant distress or impairment in social, occupational, or other important areas of functioning. Additional symptoms included depressed mood; anxiety; suspiciousness; near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively; chronic sleep impairment; disturbances of motivation and mood; difficulty in adapting to stressful circumstances, including work or a work like setting; and inability to establish and maintain effective relationships.

During the examination, the Veteran mentioned that the noises outside the office had made him irritable. He was also seen to be "fidgety." He presented with a dry sense of humor, irritable mood, and appropriate affect. He made eye contact, was fully oriented, and casually dressed. He denied suicidal ideation, intent, or plan, but noted that if he died of an accident or illness, he would be "okay with it." He was noted as capable of managing his financial affairs.

After a careful review of the Veteran's symptomology, the Board finds that the evidence of record does not reflect him to have gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; disorientation to time or place; memory loss for names of close relatives, own occupation, or own name; or symptoms of similar severity, frequency, or duration. That is, symptoms consistent with a 100 percent rating. The Board acknowledges the Veteran's attorneys' argument that he is unable to perform activities of daily living; however, that argument was made in relation to his service-connected physical disabilities (e.g., his finger/thumb, knee, and back disabilities). The record does not reasonably suggest that the Veteran's PTSD rendered him incapable of performing activities of daily living. 

The Board notes that a total disability rating requires total occupational and total social impairment. Here, while the record reflects an eventual cessation of employment during the period on appeal as well as difficulty with socialization, the record does not reflect total social impairment. Rather, the record shows that the Veteran has maintained a relationship with his wife for more than 15 years. Although he had difficulty trusting her, he also described her as supportive and helpful. In an August 2021 statement, he noted she kept him grounded and he avoided talking to anyone other than his wife. These facts suggest that the Veteran is not totally socially impaired. Such a conclusion is not meant to minimize the Veteran's disorder and the symptoms he experiences, but rather to show that the evidence of record does not warrant a rating in excess of 70 percent.  To this end, the 70 percent rating that is assigned contemplates the inability to establish and maintain effective relationships.  

Although not dispositive, it is worth noting that neither the Veteran nor his attorney have offered an argument to advance this claim. In an August 2021 brief, the attorney explicitly stated, "Once VA appropriately considers the full record and the Veteran's specific circumstances, it should determine that his service-connected PTSD causes a level of occupational and social impairment consistent with the 70 percent rating criteria." The attorney went on to request a 70 percent rating effective from at least March 2015. After the AOJ granted this request in July 2022, the attorney did not submit any additional argument for an increased rating. 

In light of the foregoing, the Board finds that a rating in excess of 70 percent is not warranted, and the claim is denied. 

3. An effective date of August 1, 2018, but no earlier, for a TDIU is granted.

4. An effective date of August 1, 2018, but no earlier, for the award of basic eligibility to DEA benefits is granted.

The Veteran contends that he is entitled to an August 2018 earlier effective date for his TDIU claim. The Board agrees. 

Generally, the effective date of an evaluation and award of pension, compensation, or dependency and indemnity compensation based on an initial claim or supplemental claim will be the date of receipt of the claim or the date entitlement arose, whichever is later. 38 U.S.C. § 5110 (a)(1); 38 C.F.R. § 3.400.

For increased rating claims, including TDIU claims, an effective date may be granted up to one year prior to the date of claim, but only if it is factually ascertainable that the increase in disability had occurred within that year. 38 U.S.C. § 5110 (b) (2); 38 C.F.R. § 3.400 (o) (1) and (2).

In Rice v. Shinseki, 22 Vet. App. 447 (2009), the Court of Appeals for Veteran's Claims held that a request for TDIU, whether expressly raised by a veteran or reasonably raised by the record, is not a separate claim for benefits, but rather involves an attempt to obtain an appropriate rating for a disability or disabilities, either as part of the initial adjudication of a claim or, if a disability upon which entitlement to TDIU is based has already been found to be service connected, as part of a claim for increased compensation. Id. at 453-54. 

Here, the Board finds that the Veteran raised TDIU as part and parcel of his March 16, 2015 increased rating claim for his service-connected right thumb/trigger finger disability. It has already been found by the AOJ that his service-connected disabilities, including his right thumb/trigger finger disability, contributed to his TDIU. Also, the Veteran met the schedular criteria for a TDIU as of February 12, 2015. 38 C.F.R. § 4.16. Finally, the record shows that he last worked in a substantially gainful capacity in August 2018. Accordingly, an earlier effective date of August 1, 2018 is warranted and is granted.

DEA under 38 U.S.C. Chapter 35 is an ancillary benefit for the eligible dependents of veterans who are considered totally and permanently disabled. 38 U.S.C. § 3501; 38 C.F.R. § 3.807 (a). As such, the issue of an earlier effective date for DEA benefits is linked to the assignment of the TDIU. Accordingly, an earlier effective date of August 1, 2018 for DEA benefits is granted.

5. An effective date of July 14, 2021, but no earlier, for service connection for ED is granted. 

6. An effective date of July 14, 2021, but no earlier, for the award of SMC is granted.

7. An initial compensable rating for ED is denied. 

The Veteran is seeking earlier effective dates for his ED and SMC. He is also seeking an initial increased rating for his service-connected ED. In a July 2023 brief, his attorney requested an earlier effective date from 2020 but no later than July 2021. 

The record demonstrates that VA received a notice of Intent to File on July 14, 2021 followed by an October 8, 2021 claim for service connection for ED. Later, during a November 2021 VA examination, the Veteran was diagnosed with ED. The examiner noted that his condition began in 2020. 

The Veteran's attorney asserts that because his ED is a complication of his PTSD, it was encompassed in his February 2015 service connection claim. The Board finds this argument unpersuasive. The Veteran's February 2015 claim for PTSD did not reasonably raise a claim for ED as he had not been diagnosed with this condition nor had he reported any related symptoms. In fact, the first mention of an ED diagnosis in the record is in the November 2021 VA examination report where the Veteran stated that his symptoms began the year prior when his PTSD medication was increased. Thus, while the date entitlement arose was in 2020, because he filed his claim on July 14, 2021, the latter date is the appropriate effective date. Accordingly, an earlier effective date of July 14, 2021 is granted. See 38 U.S.C. § 5110 (a)(1); 38 C.F.R. § 3.400.

The Veteran also contends that he is entitled to an earlier effective date for his SMC. In the July 2022 rating decision, the AOJ granted SMC under 38 U.S.C. § 1114 (k) and 38 C.F.R. § 3.350 (a) indicating that the grant was based on the Veteran's loss of use of a creative organ. The effective date chosen, October 8, 2021, was based on the date VA received the Veteran's claim for service connection for ED. However, as explained above, VA initially received a notice of Intent to File on July 14, 2021. Due to the earlier effective date for the Veteran's ED granted in this decision, he is now entitled to the same effective date for his SMC. Accordingly, July 14, 2021 is assigned for the award of SMC.

The Board will now address the Veteran's increased rating claim. 

On November 14, 2021, VA adopted new regulations for evaluating genitourinary system disabilities under 38 C.F.R. § 4.115b. However, "the case law is clear that a regulation is not to be applied retroactively unless the regulation is intended to be retroactive." Ervin v. Shinseki, 24 Vet. App. 318, 322 (2011) (citing Kuzma v. Principi, 341 F.3d 1327, 1328 (Fed. Cir. 2003)). Therefore, the Board will consider the Veteran's claim under the criteria in effect prior to November 14, 2021, and both the old and new rating criteria from November 14, 2021, and the criteria that is more favorable to the Veteran will be applied. 

The Veteran's ED is rated under DC 7522. Under the version of DC 7522 in effect when the claim was received, a 20 percent rating is warranted for deformity of the penis with loss of erectile power. No other evaluation was provided. The Board notes that, in every instance where the schedule does not provide a zero percent rating for a DC, a zero percent evaluation shall be assigned when the requirements for a compensable rating are not met. 38 C.F.R. § 4.31.

Under the amended version of DC 7522, a noncompensable rating is assigned for ED with or without penile deformity. Because the amended criteria only provides a noncompensable evaluation, whereas the old criteria provides a 20 percent evaluation, the Board finds that the old criteria is more favorable to the Veteran. Thus, an analysis under the old criteria will be undertaken.

Two requirements must be met before a 20 percent evaluation can be assigned: (1) the deformity must be evident; and (2) the deformity must be accompanied by loss of erectile power. Simply stated, the condition is not compensable in the absence of penile deformity. Note, however, as is the case here, SMC is still permitted for loss of use of a creative organ.

As indicated above, the Veteran attended a November 2021 VA examination at which he was diagnosed with ED. Notably, per his request, he was not physically examined. However, the examiner noted the Veteran's report of "normal anatomy with no penile deformity or abnormality." The Board accepts the Veteran at his word. As such, an initial compensable rating is not warranted as "deformity of the penis" is required in order to assign a compensable rating. Accordingly, the claim in denied. 

8. An initial rating of 20 percent, but no more, for left knee lateral instability is granted.

9. A rating in excess of 20 percent for left knee instability for the period from July 14, 2021 to December 22, 2022 is denied.

10. A rating of 10 percent, but no more, for left knee meniscal impairment is granted. 

11. A rating in excess of 20 percent from November 18, 2018 and in excess of 30 percent from July 14, 2021 for left knee degenerative arthritis with synovitis and chondromalacia is denied.  

The Veteran is seeking increased ratings for his service-connected left knee. The AOJ granted service connection for instability and "left knee degenerative arthritis with synovitis and chondromalacia (medial meniscus tear)." As granted herein, the Board has assigned a separate rating for meniscal impairment. Therefore, to avoid confusion, the Board has recharacterized the Veteran's degenerative arthritis claim as shown above. 

The Veteran's left knee disabilities are rated under DC 5003-5257 for instability and DC 5003-5261 for limited extension. Note, hyphenated DCs are used when a rating under one DC requires use of an additional DC to identify the basis for the evaluation assigned; the additional code is shown after the hyphen. 38 C.F.R. § 4.27. Here, DCs 5257 and 5261 provide for rating the service-connected disabilities based on limitation of motion of the affected body part, which in this case is the Veteran's left knee, as arthritis under DC 5003.

The rating criteria for evaluating musculoskeletal disabilities under 38 C.F.R. § 4.71a was amended effective February 7, 2021. As noted above, when a law or regulation changes during the pendency of an appeal, the version most favorable to the Veteran applies, absent congressional intent to the contrary. Notably, DC 5257 was revised while DCs 5259 and 5261 remained unchanged. 

DC 5257 evaluates recurrent subluxation or instability of the knee. Prior to February 7, 2021, a 10 percent rating was assigned for slight recurrent subluxation or lateral instability, a 20 percent rating was assigned for moderate recurrent subluxation or lateral instability, and a 30 percent rating was assigned for severe recurrent subluxation or lateral instability.

The words "slight," "moderate" and "severe" as used in the various diagnostic codes are not defined in the VA Schedule for Rating Disabilities. Rather than applying a mechanical formula, the Board must evaluate all of the evidence, to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6. It should also be noted that use of terminology such as "severe" by VA examiners and others, although an element of evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6.

According to Merriam Webster's Collegiate Dictionary (11th Ed. 2007), "slight" means small of its kind or in amount. "Moderate" means limited in scope or effect. "Severe" means very painful or harmful, or of a great degree. See Merriam-Webster Dictionary Online (https://www.merriam-webster.com). On February 7, 2021, VA amended those criteria, "to ensure that this portion of the rating schedule uses current medical terminology and provides detailed and updated criteria." See 85 Fed. Reg. 76453 (Nov. 30, 2020).

As noted, prior to February 7, 2021, the regulations did not define "slight," "moderate," or "severe" with regard to instability, and the Board has provided the dictionary definitions of those words above. However, the Court of Appeals for Veterans Claims has continuously reminded the Board to define the terms in DC 5257 as part of its role as finder of fact; and VA regulations provide that the Board definition will be given deference as long as it is equitable and just. While revised regulations cannot have retroactive effect, there is nothing preventing the Board from using the new instability ratings as a proxy for slight, moderate, and severe instability, and to give meaning to those terms, as the revisions were the result of extensive study and analysis of the regulations and intended to provide clearer guidelines for rating instability and subluxation in the knee. As such, the Board will adopt the meanings of "slight," "moderate," and "severe" subluxation or lateral instability as found in the 10, 20, and 30 percent ratings in the revised regulations under DC 5257.

Turing to the revised regulations, as of February 7, 2021, DC 5257 contains two sections for rating other impairment of the knee. The first is for recurrent subluxation or instability. The second is for patellar instability. 

Regarding recurrent subluxation or instability, a 10 percent rating is assigned 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, DC 5257. A 20 percent rating is assigned with one of the following: (a) sprain, incomplete ligament tear, or repaired complete ligament tear causing persistent instability, and a medical provider prescribes a brace and/or assistive device for ambulation; or (b) unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribes either an assistive device or bracing for ambulation. Id. A 30 percent rating is assigned for unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribes both an assistive device and bracing for ambulation. Id. 

Regarding patellar instability, a 10 percent rating is assigned for a diagnosed condition involving the patellofemoral complex with recurrent instability (with or without history of surgical repair) that does not require a prescription from a medical provider for a brace, cane, or walker. 38 C.F.R. § 4.71a, DC 5257.  A 20 percent rating is assigned for a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for one of the following: a brace, cane, or walker. Id. A 30 percent rating is assigned for a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for a brace and either a cane or a walker. Id. Note 1 provides that for patellar instability, the patellofemoral complex consists of the quadriceps tendon, the patella, and the patellar tendon. Id. Note 2 provides that a surgical procedure that does not involve repair of one or more patellofemoral components that contribute to the underlying instability shall not qualify as surgical repair for patellar instability (including, but not limited to, arthroscopy to remove loose bodies and joint aspiration). Id.

"Persistent" is defined as "continuing or inclined to persist in a course" with "continuing" defined as "constant" and "persist" defined as "to continue to exist." See Merriam-Webster Dictionary Online (https://www.merriam-webster.com/dictionary).

DC 5260 provides a noncompensable rating for flexion limited to 60 degrees, a 10 percent rating for flexion limited to 45 degrees, a 20 percent rating for flexion limited to 30 degrees, and a maximum 30 percent rating for flexion limited to 15 degrees. 38 C.F.R. § 4.71a, DC 5260.

DC 5261 provides a noncompensable rating for extension limited to 5 degrees, a 10 percent rating for extension limited to 10 degrees, a 20 percent rating for extension limited to 15 degrees, a 30 percent rating for extension limited to 20 degrees, a 40 percent rating for extension limited to 30 degrees, and a maximum 50 percent rating for extension limited to 45 degrees. 38 C.F.R. § 4.71a, DC 5261.

Note, the normal range of motion (ROM) for the knee is from 0 to 140 for flexion and from 140 to 0 degrees for extension. 38 C.F.R. § 4.71a, Plate II.

DC 5258 provides a 20 percent rating for dislocated semilunar cartilage with frequent episodes of "locking," pain, and effusion into the joint while DC 5259 provides a 10 percent rating for removal of semilunar cartilage and current residual symptoms. 38 C.F.R. § 4.71a, DCs 5258, 5259.

Separate ratings may also be assigned for ankylosis of the knee under DC 5256, impairment of the tibia and fibula under DC 5262, and genu recurvatum under DC 5263. 

When evaluating joint disabilities rated on the basis of limitation of motion, VA must consider granting a higher rating in cases in which functional loss due to pain, weakness, excess fatigability, or incoordination is demonstrated, and those factors are not contemplated by the relevant rating criteria. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202 (1995). The Court has clarified that although pain may be a cause or manifestation of functional loss, limitation of motion due to pain is not necessarily rated at the same level as functional loss where motion is impeded. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011); cf. Powell v. West, 13 Vet. App. 31, 34 (1999); Hicks v. Brown, 8 Vet. App. 417, 421 (1995); Schafrath v. Derwinski, 1 Vet. App. 589, 592 (1991).

The Mitchell Court explained that pursuant to 38 C.F.R. §§ 4.40 and 4.45, the possible manifestations of functional loss include decreased or abnormal excursion, strength, speed, coordination, or endurance, as well as less or more movement than is normal, weakened movement, excess fatigability, and pain on movement (as well as swelling, deformity, and atrophy) that affects stability, standing, and weight-bearing. See 38 C.F.R. §§ 4.40, 4.45.  Functional loss caused by pain must be rated at the same level as if the functional loss were caused by any of the other factors cited above. In evaluating the severity of a joint disability, VA must determine the overall functional impairment due to these factors.

The Board will now discuss the relevant evidence of record during the period on appeal. 

The Veteran attended a November 2018 VAMC orthopedic consult regarding his left knee pain. He reported increased pain with activity and stairs and stated that his brace did not help. However, the clinician noted that his brace did not appear to fit properly and actually increased the force on the lateral compartment of his knee. The clinician also noted a history of "foot drop." An examination revealed a slow gait with minimal limp and no foot drop gait. ROM was "0 - 120" with no effusion and no instability. The clinician indicated that the Veteran had degenerative joint disease (DJD).  His treatment plan included use of a lateral unloader brace. 

Subsequent VAMC treatment records show that the Veteran continued to complain of left knee pain due to osteoarthritis with minimal relief from steroid injections. 

The Veteran attended a March 2020 VA examination to assess his left knee condition. He reported injuring his left knee in May 1992 which resulted in surgery the same year. The examiner noted that this surgery was to "remove damaged cartilage." After this, he had two additional surgeries in 1997 and 2014 for meniscus repair and cleanup of DJD and chondromalacia and synovitis. Since onset, he reported continued left knee pain and flare-ups of "worsening pain." Regarding functional loss, the Veteran stated that he experienced difficulty running, walking/standing for long periods of time, and climbing ladders/stairs. 

Initial ROM testing for the Veteran's left knee was abnormal, but the examiner noted that this did not contribute to functional loss. For active and passive ROM, flexion was limited to 120 degrees and extension was limited to 15 degrees. Pain was noted in both ranges, but there was no evidence of pain in weight bearing or non-weight bearing. The Veteran was able to perform repetitive use testing with no additional loss of function or ROM. Although not immediately examined after repeated use over time or during a flare-up, the examiner opined that pain would limit functional ability. Estimated in ROM, the Veteran's flexion would be limited to 120 degrees, and his extension would be limited to 15 degrees.  

Additional factors that contributed to the Veteran's disability were less movement than normal and swelling.  When given an opportunity to elaborate, the examiner stated that "DJD and chondromalacia and synovitis and lateral meniscal tear lead to these issues."

The examination also revealed no evidence of muscle atrophy or ankylosis. There was also no history of recurrent subluxation, recurrent lateral instability, or recurrent effusion. Joint stability testing showed medial and lateral instability measured at 1+ (0-5 millimeters). 

With respect to meniscus (semilunar cartilage) conditions and surgeries, the examiner noted that the Veteran underwent three surgeries to repair a lateral meniscal tear and DJD. Despite this, at the time of the examination, he continued to experience frequent episodes of joint pain and effusion. To ambulate, the Veteran regularly used a knee brace.

The Veteran attended a second VA examination in August 2021 at which he reported current symptoms of left knee pain and limited ROM. He denied flare ups, but reported functional loss due to difficulty running, walking/standing for long periods of time, and climbing ladders/stairs. The Veteran also reported buckling (instability) due to over usage and swelling (effusion). 

Initial ROM testing for the Veteran's left knee was abnormal. For active and passive ROM testing, flexion was limited to 120 degrees and extension was limited to 20 degrees. Pain was noted in both ranges as well as weight-bearing, however, pain did not result in/cause functional loss. The Veteran was able to perform repetitive use testing with no additional loss of function or ROM. The Veteran was not immediately examined after repeated use over time; however, the examiner opined that neither pain, fatigability, weakness, lack of endurance, or incoordination would significantly limit functional ability. 

Additional factors that contributed to the Veteran's disability were less movement than normal and swelling. When given an opportunity to elaborate, the examiner stated that "DJD and chondromalacia and synovitis and lateral meniscal tear lead to these issues." There was no evidence of muscle atrophy, ankylosis, or tibial or fibular impairment; however, the examiner indicated "yes" for recurrent subluxation or persistent instability. Regarding meniscus (semilunar cartilage) conditions, consistent with his prior examination, the examiner noted that the Veteran had a meniscal tear repaired but continued to experience pain and swelling. The examiner also noted that he continued to regularly use a brace due to pain and instability.                                                                                                                                                                                                                                                                                                                                                                                                                                                   

Having carefully considered the above, the Board finds that an initial 20 percent rating under DC 5257 is warranted for the Veteran's left knee instability. Collectively, the evidence indicates that he underwent three surgeries to repair a meniscus tear. Despite this, he continued to experience pain, and his November 2018 treatment plan included use of a lateral unloader brace for ambulation. Also, VA examination reports indicate that he continued to regularly use a brace due to instability. Accordingly, an initial 20 percent rating is granted. 

Conversely, a rating in excess of 20 percent under DC 5257 is denied for all periods on appeal. At no time has the evidence shown that the Veteran was prescribed both an assistive device and bracing for ambulation. 

The Board also finds that the criteria for a separate rating under DC 5259 have been met as the evidence of record shows that the Veteran underwent surgery in 1992 to remove damaged cartilage and continued to experience swelling. Accordingly, the claim is granted. Note, a 10 percent rating is the only rating available for this DC. 

The Board finds that a separate rating under DC 5258 is not appropriate. While the evidence shows that the Veteran experienced frequent episodes of pain and effusion, there is no evidence to suggest he experienced episodes of frequent joint locking. Note, use of the conjunction "and" in the DC indicates that all three conditions must be present in order to grant service connection.   

With respect to DC 5261, the Board finds that increased ratings are not warranted. For the period from November 18, 2018, at its worst, the Veteran's left knee extension was limited to 15 degrees (this is consistent with a 20 percent rating). For the period from July 14, 2021, at its worst, his left knee extension was limited to 20 degrees (this is consistent with a 30 percent rating). Accordingly, the claim is denied. 

Finally, the Board considered whether ratings under any other DCs for the Veteran's left knee disability are warranted but find that none are appropriate. At no time during the periods on appeal has the record shown evidence of ankylosis (DC 5256), limitation of flexion to at least 60 degrees for assignment of a noncompensable rating (DC 5260), impairment of the tibia and fibula (DC 5262), or genu recurvatum (DC 5263). 

12. An effective date earlier than March 16, 2015 for service connection for left knee scars is denied. 

13. An effective date of March 16, 2015, but no earlier, for service connection for painful scars is granted. 

14. A compensable rating for a right thumb scar is denied. 

15. An initial compensable rating for left knee scars is denied.  

16. A 20 percent rating for painful scars for the period from March 16, 2015 to August 11, 2022 is granted. 

The Veteran is seeking increased ratings for his service-connected scars. The Board notes the following, relevant procedural history. 

On March 16, 2015, the Veteran filed a claim for service connection for his left knee and an increased rating claim for his service-connected trigger finger/right thumb disability. 

In an October 2017 rating decision, the Veteran was granted service connection for a right thumb scar, effective October 13, 2017 under DC 7805. He did not appeal this decision, and it became final. 

In an August 2020 rating decision, the AOJ granted service connection for his left knee scars, effective March 16, 2015. This disability was also rated under DC 7805.

In August 2021, the Veteran timely filed a Supplemental Claim in which he requested an earlier effective date and increased rating for his left knee scars.  However, the Veteran's attorney did not offer any argument to support his claims. 

In July 2022, the AOJ issued a rating decision in response to the Veteran's August 2021 Supplemental Claim. Therein, it granted service connection for painful scars under DC 7804, effective July 14, 2021; a 20 percent rating was assigned. Notably, while the August 2021 Supplemental Claim did not include a request for an increased rating for the Veteran's right thumb scar, the AOJ's July 2022 rating decision effectively provided increased ratings for all of his service-connected scars. The AOJ also changed the DCs previously assigned for the Veteran's scars from 7805 to 7802, and under DC 7802, it denied compensable ratings for both disabilities. The Board notes that the AOJ failed to address the Veteran's claim for an earlier effective date for his left knee scars. 

In August 2022, the AOJ issued a second rating decision in response to the Veteran's August 2021 Supplemental Claim in which it continued its denial for a compensable rating for his left knee scars under DC 7802.

Finally, in the December 2022 rating decision, the AOJ denied the Veteran's claim for an earlier effective date for service connection of his left knee scars under DC 7802.

In July 2023, the Veteran filed a timely Notice of Disagreement.

To begin, the Board will address the Veteran's claims for earlier effective dates for his left knee scars and painful scars under DCs 7802 and 7804, respectively.  

Regarding his left knee scars under DC 7802, the Board finds that an earlier effective date is not appropriate. The Veteran filed a claim for service connection for his left knee disability on March 16, 2015. Service connection for his left knee scars was later granted as related to his service-connected left knee disability. As detailed above, the Veteran's scars are due to surgeries that occurred prior to his March 2015 date of claim. Therefore, because entitlement arose prior to his date of claim, the latter date of March 16, 2015 is the appropriate effective date. Accordingly, the claim is denied. See 38 U.S.C. § 5110 (a)(1); 38 C.F.R. § 3.400.

With respect to service connection for painful scars under DC 7804, the Board finds that an earlier effective date is warranted. As previously noted, the Veteran underwent three left knee surgeries. However, the VA examination reports of record, dated March 2020 and August 2021, provide conflicting narratives regarding the quantity and characteristics of the Veteran's scars. Having weighed the reports, the Board finds more credible the August 2021 report. 

In the August 2021 report, the examiner documented three scars that were incurred in 1992 and 2014. As detailed below, the Veteran reported that each scar had been painful since onset. In light of the examiner's notations and the Veteran's credible statements, the Board finds that he is entitled to a March 16, 2015 effective date under DC 7804 for painful scars as this date coincides with the Veteran's date of claim for service connection for his left knee disability. Accordingly, the claim is granted. 

The Board will now address the Veteran's claims for increased ratings. 

Note, the Veteran's right thumb scar was not the subject of the August 2021 Supplemental Claim. That notwithstanding, the AOJ issued a July 2022 rating decision which included this disability. Accordingly, the period on appeal before the Board begins August 10, 2020, one year prior to the date VA received the August 2021 Supplemental Claim. See Gaston v. Shinseki, 605 F.3d 979 (Fed. Cir. 2010). However, a rating can only be assigned in the year prior to August 2021 if it is factually ascertainable that the Veteran's right thumb scar met the criteria for a higher rating during that time. 

With respect to the Veteran's service-connected left knee scars, the Board notes that he has continuously pursued a higher rating since service connection was granted in August 2020. Thus, the period on appeal is from March 16, 2015 to August 11, 2022.

Under the General Rating Formula for Skin, scars are typically rated under DCs 7800-7805. 38 C.F.R. §§ 4.118. It is noted that on August 13, 2018, during the course of the appeal period, revisions to the Schedule for Rating Disabilities that address the General Rating Formula for the Skin went into effect. However, the amendments to the rating schedule do not have any retroactive application. Therefore, the Board will consider the Veteran's claim under the criteria in effect prior to August 13, 2018, and both the old and new rating criteria from August 13, 2018, and the criteria that is more favorable to the Veteran will be applied. 

DC 7800 contemplates scars of the head, face, or neck. As the Veteran's scars do not involve his head, face, or neck, analysis under this DC is not appropriate and will not be addressed any further.

Prior to August 13, 2018, DC 7801 contemplated ratings for scars other than the head, face or neck that were deep and nonlinear. A 10 percent rating was assigned for an area or areas of at least 6 square inches (39 sq. cm.) but less than 12 square inches (77 sq. cm.). A 20 percent rating was assigned for an area or areas of at least 12 square inches (77 sq. cm.) but less than 72 square inches (465 sq. cm.). A 30 percent rating was assigned for an area or areas of at least 72 square inches (465 sq. cm.) but less than 144 square inches (929 sq. cm.). The maximum 40 percent rating was assigned for an area or areas of 144 square inches (929 sq. cm.) or greater.

The revised DC 7801 contemplates ratings for scars other than the head, face or neck that are associated with underlying soft tissue damage. A 10 percent rating is assigned for an area or areas of at least 6 square inches (39 sq. cm.) but less than 12 square inches (77 sq. cm.). A 20 percent rating is assigned for an area or areas of at least 12 square inches (77 sq. cm.) but less than 72 square inches (465 sq. cm.). A 30 percent rating is assigned for an area or areas of at least 72 square inches (465 sq. cm.) but less than 144 square inches (929 sq. cm.). The maximum 40 percent rating is assigned for an area or areas of 144 square inches (929 sq. cm.) or greater.

Prior to August 13, 2018, DC 7802 contemplated ratings for scars other than on the head, face, or neck that are superficial and non-linear. A maximum 10 percent rating was assigned for an area or areas of 144 square inches (929 sq. cm.) or greater.

The revised DC 7802 contemplates ratings for scars other than on the head, face, or neck that are not associated with underlying soft tissue damage. A maximum 10 percent rating is assigned for an area or areas of 144 square inches (929 sq. cm.) or greater.

DC 7803 was removed from the regulations, effective October 23, 2008 (prior to the litigation). 

DC 7804 remained unchanged and contemplates scars that are unstable or painful. A 10 percent rating is assigned for one or two scars that are unstable or painful. A 20 percent rating is assigned for three or four scars that are unstable or painful. The maximum 30 percent rating is assigned for five or more scars that are unstable or painful. Note 1 provides that an unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar.

DC 7805 remained unchanged and provides that any other scars (including linear) and other disabling effects of scars should be evaluated even if not considered in a rating provided under DCs 7800-04 under an appropriate DC. In other words, DC 7805 is a "catchall" code providing for other scars and/or other affects beyond those covered by the aforementioned DCs.

The Board will now summarize the relevant evidence of record. Note, the March 2020 VA examination referenced above will not be summarized below as the Board has already found this report to be less competent with respect to the assessment of the Veteran's left knee scars. 

The Veteran attended a December 2020 VA examination at which his right thumb scar was measured at 4 cm. in length and 0.25 cm. in width (1 sq. cm.). His scar was not noted to be painful or unstable.

During the August 2021 VA examination, the Veteran was diagnosed with a right thumb and left knee lateral scars from 1992 as well as a left knee anterior scar from 2014. As noted above, the Veteran reported that his left knee scars had stayed the same since onset; specifically, the anterior knee scar ached when pushed on, and the lateral knee scar burned all the time. He also stated that, since onset, his right thumb scar ached and burned. Neither scar was observed to be unstable.

The Veteran's right thumb scar measured at 4 cm. in length and 0.25 cm. in width (1 sq. cm.).  His first left knee scar measured at 1 cm. in length and 0.2 cm. in width (0.2 sq. cm.), and his second scar measured at 3 cm. in length and 0.2 cm. in width (0.6 sq. cm.).  All three scars were noted to be tender to palpation, but none had underlying tissue damage. In sum, the examiner noted that the approximate combined total area for each affected anatomical region was 1 sq. cm. for the right upper extremity and 0.8 sq. cm. for the left lower extremity. No other pertinent findings were noted. Regarding functional impact, the examiner opined that neither scar resulted in limitation of function or impacted the Veteran's ability to work. 

VA treatment records do not provide for any findings of greater significance than those found in the above VA examinations. Notably, the records do not contain measurements or complaints related to the Veteran's scars. 

To begin, the Board will address the Veteran's right thumb increased rating claim. Because the rating criteria was amended in August 2018, the Board will only consider the new criteria with respect to this claim. Having considered the evidence of record, the Board finds that compensable ratings under DCs 7801 and 7802 are inapplicable because the Veteran's scar would need to measure at least 39 sq. cm. and 144 sq. cm., respectively. Also, a compensable rating under DC 7805 is not warranted because the Veteran has not asserted, and the record does not reflect, that he experienced any disabling effects not considered under DCs 7800-04. The Board will address DC 7804 in more detail below. 

With respect to the Veteran's service-connected left knee scars, the Board finds that increased ratings are not warranted under DCs 7801, 7802, or 7805. At no point were his scars larger than 0.6 sq. cm. (combined total 0.8 sq. cm.). Thus, compensable ratings under DCs 7801 and 7802 are inapplicable under the old and new rating criteria because the Veteran's scars would need to measure at least 39 sq. cm. and 144 sq. cm., respectively. Also, a compensable rating under 7805 is not warranted because the Veteran has not asserted, and the record does not reflect, that he experienced any disabling effects not considered under DCs 7800-04. 

With respect to DC 7804, for the period from March 16, 2015 to August 11, 2022, the Board finds there is sufficient evidence to grant a 20 percent rating for painful scars. In this regard, the evidence shows that all three scars had been painful since onset (onset for each scar pre-dates the beginning of the appeal period). Of note, the Board acknowledges that this grant of entitlement to a 20 percent rating, effective March 16, 2015, entitles the Veteran to an increased rating for his right thumb scar prior to the period on appeal indicated above. However, because the AOJ included the Veteran's right thumb as part of its rationale for a 20 percent rating under DC 7804 (see the July 2022 rating decision), and because the Veteran credibly reported that his right thumb scar had been painful since onset, the Board finds that a 20 percent rating for all three scars for the entire appeal period is appropriate. Accordingly, the claim is granted.

A rating in excess of 20 percent is not warranted because, to achieve a higher rating, the Veteran would need more painful scars. Here, the evidence shows that he only has three painful scars which is consistent with a 20 percent rating. Accordingly, a rating in excess of 20 percent is denied. 

17. An effective date of March 20, 2012, but no earlier, for service connection for a back condition is granted.

18. An effective date of March 20, 2012, but no earlier, for service connection for right lower extremity sciatic nerve radiculopathy is granted. 

19. An effective date earlier than March 24, 2020 for service connection for left lower extremity sciatic nerve radiculopathy is denied. 

20. An effective date earlier than August 31, 2021 for service connection for right lower extremity femoral nerve radiculopathy is denied. 

21. An effective date earlier than August 31, 2021 for the award of service connection for left lower extremity femoral nerve radiculopathy is denied. 

22. A rating in excess of 20 percent for a back condition for the period from March 16, 2015 to August 12, 2022 is denied.

23. A rating in excess of 20 percent for right lower extremity sciatic nerve radiculopathy for the period from July 14, 2021 to December 22, 2022 is denied.

24. An initial rating in excess of 20 percent for left lower extremity sciatic nerve radiculopathy is denied. 

25. An initial rating in excess of 20 percent for right lower extremity femoral nerve radiculopathy is denied. 

26. An initial rating in excess of 20 percent for left lower extremity femoral nerve radiculopathy is denied. 

27. Service connection for voiding dysfunction is granted. 

The Veteran is seeking increased ratings and earlier effective dates for his service-connected back disabilities. The Board notes the following relevant procedural history. 

On March 20, 2012, VA received the Veteran's informal claim for service connection for a back condition. This claim was denied in an August 2013 rating decision. 

The Veteran filed a timely Notice of Disagreement in January 2014, but he also filed a second claim for service connection on March 16, 2015. 

In September 2015, the AOJ issued a Statement of the Case (SOC) in response to the Veteran's January 2014 Notice of Disagreement. Thereafter, the Veteran continued to pursue service connection. 

In an August 2020 rating decision, the AOJ granted service connection for the Veteran's back claim, effective March 16, 2015, finding that he had continuously pursued his claim since this date. The AOJ also granted service connection for lower left extremity radiculopathy (now recharacterized as lower left extremity sciatic nerve radiculopathy), effective March 24, 2020. The AOJ assigned a 20 percent rating under DC 5242 for the Veteran's back condition, and a separate 20 percent rating under DC 8520 for his radiculopathy. 

The Veteran timely filed an August 2020 Supplemental Claim seeking increased ratings and earlier effective dates for his disabilities. In July 2022 and August 2022 rating decisions, the AOJ denied his claims for increased ratings. The Board notes that his claims for earlier effective dates were not addressed. 

In December 2022, the AOJ issued a rating decision notifying the Veteran that it had made clear and unmistakable errors with respect to his back disability claims. As a result, the AOJ granted separate ratings for right lower extremity sciatic nerve radiculopathy, left lower extremity femoral nerve radiculopathy, and right lower extremity femoral nerve radiculopathy. Each condition was evaluated as 20 percent disabling. The AOJ denied the Veteran's claims for earlier effective dates for his service-connected back condition and left lower extremity sciatic nerve radiculopathy. 

In July 2023, the Veteran filed a timely Notice of Disagreement.

Preliminarily, the Board finds that the Veteran effectively preserved his March 20, 2012 effective date. In making this determination, the Board notes that while the AOJ issued a September 2015 SOC in response to the January 2014 Notice of Disagreement, it also considered the Veteran's March 2015 claim continuously pursued. This claim was filed prior to the SOC which means that the AOJ did not consider the Veteran's failure to file a VA Form 9 (appeal to the Board) necessary to preserve his March 2015 claim date. Using this logic, it stands to reason that his initial March 2012 claim, which resulted in the August 2013 rating decision that precipitated the timely filing of the January 2014 Notice of Disagreement, should also be considered preserved. Accordingly, the appropriate effective date for the Veteran's back condition is March 20, 2012, the date of his initial claim for service connection. 

The Veteran's back condition is rated under DC 5242. 38 C.F.R. § 4.71a. Disabilities of the spine are evaluated under the General Rating Formula for Diseases and Injuries of the Spine (General Formula) or the Intervertebral Disc Syndrome (IVDS) Based on Incapacitating Episodes (IVDS Formula), whichever is more favorable to the Veteran, provided the criteria for both evaluations are met. 38 C.F.R. § 4.71a, DC 5235-43. In this case, however, the evidence of record fails to show or suggest that the Veteran was diagnosed with IVDS at any time during the period on appeal.

This leaves the Board with the evaluation of the Veteran's back disability under the General Formula. As noted above, the VA schedule for rating musculoskeletal disabilities was amended. DC 5242 was revised to "Degenerative arthritis, degenerative disc disease other than intervertebral disc syndrome (also, see either DC 5003 or 5010)." That aside, the regulatory changes to the rating criteria for evaluating musculoskeletal disabilities under 38 C.F.R. § 4.71a, as amended effective February 7, 2021, 85 Fed. Reg. 230 (Nov 30, 2020), do not impact the rating of the Veteran's disability under the General Rating Formula.

Under the General Formula, 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. Id.

A 40 percent rating is warranted for forward flexion of the thoracolumbar spine to 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 evaluation is warranted for unfavorable ankylosis of the entire spine. Id.

Note 1 to the rating formula specifies that any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, should be separately evaluated under an appropriate DC. Radiculopathy is not specifically listed in the schedule for rating neurologic abnormalities and thus is rated by analogy to the complete or incomplete paralysis of the affected nerves, namely, the sciatic and femoral nerves, evaluated under the criteria set forth in 38 C.F.R. § 4.124a, DC 8520 and 8526, respectively. See 38 C.F.R. § 4.20. 

Note 2 states that, for VA compensation purposes, normal forward flexion of the thoracolumbar spine is zero to 90 degrees, extension is zero to 30 degrees, left and right lateral flexion are zero to 30 degrees, and left and right lateral rotation are zero to 30 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 thoracolumbar spine is 240 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.

Note 4 instructs raters to round each range of motion measurement to the nearest five degrees.

The Veteran's lower right and left extremity sciatic nerve radiculopathy conditions are rated under DC 8520 while his lower right and left extremity femoral nerve radiculopathy conditions are rated under DC 8526.

Under DC 8520, mild incomplete paralysis of the sciatic nerve is rated at 10 percent disabling. 38 C.F.R. § 4.124a, DC 8520. Moderate incomplete paralysis is rated as 20 percent disabling. Id. Moderately severe incomplete paralysis is rated as 40 percent disabling. Id. Severe incomplete paralysis with marked muscular atrophy is rated as 60 percent disabling. Id. Complete paralysis, with the foot dangles and drops, no possible active movement of muscles below the knee, flexion of knee weakened or (very rarely) lost is rated as 80 percent disabling. Id.

Under DC 8526, mild incomplete paralysis of the femoral nerve is rated at 10 percent disabling. 38 C.F.R. § 4.124a, DC 8526. Moderate incomplete paralysis is rated as 20 percent disabling. Id. Severe incomplete paralysis is rated as 30 percent disabling. Id. Complete paralysis of the quadriceps extensor muscles is rated as 40 percent disabling. Id. 

The words "mild," "moderate," and "severe" as used in the DCs are not defined in the Rating Schedule. Regulations provide that ratings for peripheral neurological disorders are to be assigned based on the relative impairment of motor function, trophic changes, or sensory disturbance. 38 C.F.R. § 4.120. Consideration is also given for loss of reflexes, pain, and muscle atrophy. See 38 C.F.R. §§ 4.123, 4.124.

The term "incomplete paralysis" indicates a degree of lost or impaired function substantially less than the type pictured for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating is for the mild, or at most, the moderate degree. The disability ratings for the peripheral nerves are for unilateral involvement; when bilateral, the ratings combine with application of the bilateral factor. 38 C.F.R. § 4.124a, Note at "Diseases of the Peripheral Nerves." The Note to 38 C.F.R. § 4.124a establishes a maximum disability rating for conditions that are wholly sensory, as opposed to a minimum disability rating for conditions that are more than wholly sensory. See Miller v. Shulkin, 28 Vet. App. 376 (2017).

As noted above, the terms in the DCs are not defined. The Court in Chavis v. McDonough, found that benchmarks established by VA must be discussed in addressing the subjective terms of these regulations. See Chavis v. McDonough, 34 Vet. App. 1 (2021) ("Without established benchmarks for those subjective terms, the Court is left without standards upon which to review the Board's decision." (citing Johnson v. Wilkie, 30 Vet. App. 245, 255 (2018); Buczynski v. Shinseki, 24 Vet. App. 221, 224 (2011)). Thus, the Board will provide the required definitions below.

"Mild" corresponds to slight symptoms sufficient to support the diagnosis, generally characterized by less persistent sensory deficits, or those affecting a small area, and or very minimal reflex or motor abnormalities.

The Board considers "moderate" to correspond to the maximum evaluation available for sensory-only impairment, characterized by symptoms described by a veteran and considered significantly disabling medically, and/or involving a larger area in nerve distribution. Notably, moderate can also correspond to combinations of significant sensory changes and reflex or motor changes of a lower degree, or motor and/or reflex impairment such as weakness or diminished or hyperactive reflexes with or without sensory impairment, graded as medically moderate.

"Severe" is characterized by motor and/or reflex impairment (for example, atrophy, weakness, or diminished or hyperactive reflexes) at a grade reflecting a very high level of limitation or disability. Trophic changes may be seen in severe longstanding neuropathy cases. Although severe incomplete paralysis cases should show findings substantially less than those for complete impairment of the nerve, the disability picture for severe incomplete paralysis may contain signs or symptoms that resemble some of those expected in cases of complete paralysis of the nerve.

Thus, "moderately severe," by extension, lies somewhere in the middle of "moderate" and "severe" and is characterized by motor and/or reflex impairment (for example, weakness or diminished or hyperactive reflexes) at a grade reflecting a high level of limitation or disability.

The regulations further set forth the specific limits for assigning rating percentages. For example, neuritis characterized by loss of reflexes, muscle atrophy, sensory disturbances, and constant pain, at times excruciating, is to be rated at no higher than for the severe, incomplete paralysis. Of note is a regulatory language using conjunction "and," which means that all listed criteria, to include loss of reflexes, muscle atrophy, sensory disturbances, and constant pain must be present to constitute neuritis of severe degree.  In cases, where neuritis with sciatic nerve involvement is not characterized by organic changes, the maximum rating may not be any higher than for the moderately severe degree. See 38 C.F.R. § 4.123. From the unequivocal regulatory language, it is further apparent that the regulations set forth an upper limit for determining a degree of severity, which neither means nor implies a mandate to automatically find such a degree of severity.

In contrast to neuritis, neuralgia characterized usually by dull and intermittent pain is rated on the same scale from mild to severe, with a maximum evaluation not to exceed moderate incomplete paralysis. 38 C.F.R. § 4.124. Likewise, in cases, where the neurologic abnormality is wholly sensory, the rating may not be higher than for the moderate degree. See 38 C.F.R. § 4.124a, Note at "Diseases of the Peripheral Nerves."  As such, while not specifically defining several key terms, the regulations read as a whole do set forth clear parameters for determining rating percentages.

The Board will now discuss the relevant evidence of record.

In an April 2012 statement, the Veteran reported that he developed a back condition while attending Basic Parachute School in Thailand. He noted that he treated with a specialist in 1993 to 1994 who advised that he would have life-long back issues. 

The Veteran attended a June 2012 VA examination at which he was diagnosed with a back strain with right sided L5 radiculopathy. He reported back pain four to five times a year as well as a "sensation of weakness and loss of feeling" in his right leg. The examiner noted that this feeling went down the back of his right buttock into the right posterior thigh, posterior calf, and into the dorsal foot on the second digit. He reported experiencing flare-ups of low back pain, weakness, and decreased sensation.

Initial ROM testing was normal with pain noted on extension and lateral rotation. The Veteran was able to perform repetitive use testing with no additional functional loss or limitation. The examination revealed evidence of localized tenderness; however, it did not result in an abnormal gait or spinal contour; there was also no evidence of vertebral body fracture. 

Muscle strength testing revealed active movement against some resistance in his right great toe; all other testing was normal, and there was no evidence of muscle atrophy. Also, reflex and sensory testing were normal.

The examiner noted the following radiculopathy symptomology with respect to the Veteran's right lower extremity sciatic nerve: moderate, intermittent pain (usually dull); moderate paresthesias and/or dysesthesias; and moderate numbness. 

No other pertinent findings were noted. Regarding functional impact, the examiner opined that the Veteran's condition impacted his ability to lift heavy objects and bend over. 

The Veteran attended a second March 2020 VA examination at which he was diagnosed with degenerative arthritis of the spine, degenerative disc disease (DDD), and left lumbar radiculopathy. He reported current symptoms of back pain and left leg radiculopathy as well as flare-ups of "worsening" back pain. Regarding functional impairment, the Veteran stated that he had difficulty running, walking/standing for long periods of time, climbing ladders/stairs, sitting for long periods of time, sleeping (due to pain), bending, lifting, and carrying objects.

Initial ROM testing was abnormal, but the examiner opined that this did not contribute to functional loss. Forward flexion was shown to be limited to 60 degrees, and the Veteran had a combined ROM of 160 degrees (this is consistent with a 20 percent rating). The examiner noted pain in flexion and extension, however, he opined that this did not result in or cause functional loss. There was no evidence of pain in weight bearing or non-weight bearing. Passive ROM testing could not be performed. 

The Veteran was able to perform repetitive use testing with no additional loss of function or ROM. Although not immediately examined after repeated use over time or during a flare up, the examiner opined that pain would limit functional ability. Estimated in ROM, forward flexion would be limited to 60 degrees, and his combined ROM would be 160 degrees.

The examination also revealed evidence of muscle spasms due to the Veteran's DDD and DJD; however, the examiner noted that this did not result in abnormal gait or abnormal spinal contour. The examiner also noted that DDD and DJD resulted in less movement than normal. 

Muscle strength testing showed active movement against some resistance on the Veteran's left side, but there was no evidence of muscle atrophy. Reflex testing was normal, but sensory testing revealed decreased sensation to light touch in his upper anterior thigh, thigh/knee, lower leg/ankle, and foot/toes. Straight leg testing was negative for his right side but positive for his left side. 

With respect to radiculopathy symptomology, the examiner noted the following for the Veteran's lower left extremity: mild, constant pain (may be excruciating at times); moderate, intermittent pain (usually dull); moderate paresthesias and/or dysesthesias; and moderate numbness. The aforementioned symptoms were all associated with his sciatic nerve roots, and the examiner noted that the Veteran's symptoms were wholly sensory and moderate in nature. No symptoms were reported with respect to his right lower extremities.

The examination revealed no evidence of or diagnosis for ankylosis, IVDS, or other neurologic abnormalities. However, the examiner noted that the Veteran regularly used a brace due to his DDD and DJD. 

The Veteran attended a third VA examination in August 2021. In addition to his previous diagnoses, he was also diagnosed with bilateral lower extremity radiculopathy. The Veteran reported current symptoms of back pain with radiation down both legs to his feet.  He noted that his left side symptomology was more severe than his right. He denied flare-ups. Regarding functional loss, the Veteran statements were consistent with his previous examination.

Initial ROM testing was abnormal, but the examiner noted that this did not contribute to a functional loss. Forward flexion was shown to be limited to 50 degrees, and the Veteran had a combined ROM  of 145 degrees (this is consistent with a 20 percent rating). Pain was noted in all motions. The examiner also noted pain in weight-bearing but stated that this did not result in or cause functional loss. Passive ROM testing was not performed as it was medically contraindicated.

The Veteran was able to perform repetitive use testing with no additional loss of function. He was not examined immediately after repetitive use over time; however, the examiner opined that neither pain, fatigability, weakness, lack of endurance, nor incoordination would significantly limit functional ability.

Consistent with his previous examination, the examiner noted that the Veteran had muscle spasms, but the spasms did not result in abnormal gait or abnormal spinal contour. The examiner also noted that the Veteran's DDD and DJD continued to cause less movement than normal. 

Muscle strength testing showed active movement against some resistance on the Veteran's left side, but there was no evidence of muscle atrophy. Reflex testing was normal, but sensory testing revealed decreased sensation to light touch bilaterally (upper anterior thighs, thighs/knees, lower legs/ankles, and feet/toes). Also, straight leg testing was positive for both legs. 

Regarding radiculopathy symptomology, the Veteran's symptoms were noted as mild intermittent pain (usually dull) in the right lower extremity and moderate in the left lower extremity; mild paresthesias and/or dysesthesias in the right lower extremity and moderate in the left lower extremity; and mild numbness in the right lower extremity with moderate numbness in the left lower extremity. The preceding symptomology was associated with the sciatic and femoral nerve roots. 

In addition to the aforementioned neurologic abnormalities, the examiner also diagnosed the Veteran with urinary incontinence (voiding dysfunction) secondary to DDD and DJD of the lumbar spine. In a separate report, the examiner stated that the Veteran's condition began in 2020 due to nerve root impingement caused by his DDD and DJD. No other pertinent findings were noted. 

The Veteran attended a fourth VA examination in November 2022 to assess the severity of his conditions. Critically, testing revealed that his ROM had decreased since August 2021. Specifically, forward flexion was shown to be limited to 45 degrees. With each motion rounded to the nearest five degrees, his combined ROM was 120 (the aforementioned ranges are consistent with a 20 percent rating). The examiner opined that his abnormal ROM did not contribute to functional loss. Also, the examiner noted pain for active motion and weight-bearing, but he opined that neither caused functional loss. Passive ROM testing could not be performed as it was contraindicated. 

The Veteran was able to perform repetitive use testing with no additional loss of function or ROM. He was not examined immediately after repetitive use over time; however, the examiner opined that neither pain, fatigability, weakness, lack of endurance, nor incoordination would significantly limit functional ability. The remainder of the examiner's findings were consistent with the August 2021 examination report. 

VA treatment records do not provide for any findings of greater significance than those found in the above VA examinations. Notably, the records do not contain ROM measurements or reports of radicular symptomology. 

The Board will now address the remainder of the Veteran's earlier effective date claims. 

In light of the Veteran's right lower extremity sciatic nerve radiculopathy diagnosis during the June 2012 VA examination, the Board finds that the appropriate effective date for this disability is March 20, 2012 (the date of claim for service connection for the Veteran's back condition). Giving credit to the Veteran's statements that he had experienced a sensation of weakness, loss of feeling in his right leg, and flare-ups of weakness and decreased sensation, along with the fact that he was examined less than three months after he filed his claim, the Board finds that it is more likely than not that his radiculopathy symptomology existed prior to March 20, 2012. Accordingly, the Board finds that this date (being the latter date), is an appropriate effective date for his claim. 

Conversely, with respect to his left lower extremity sciatic nerve radiculopathy (effective March 24, 2020) and his right and left lower extremity femoral nerve radiculopathy (effective August 31, 2021), the Board finds the currently assigned effective dates appropriate. In this regard, the Board notes that the medical evidence of record in this case is very limited. The dates assigned are the earliest dates in which it was factually ascertainable that the Veteran was diagnosed with  these conditions. Having occurred after the Veteran's date of claim, March 24, 2020 and August 31, 2021 are the appropriate effective dates, respectively. Accordingly, the claims are denied.

The Board will now address the Veteran's increased rating claims. 

For the period from March 16, 2015 to August  12, 2022 (the only period on appeal), the Board finds that an initial rating in excess of 20 percent for his back condition is not warranted. Higher ratings are warranted where there is evidence of forward flexion limited to 30 degrees or less, favorable ankylosis of the entire thoracolumbar spine, unfavorable ankylosis of the entire thoracolumbar spine, or unfavorable ankylosis of the entire spine. Notably, neither circumstance has been shown at any point during the period on appeal. Instead, the evidence shows that, despite pain, at its worst, forward flexion was limited to 45 degrees with a combined ROM of 120 degrees; this is consistent with a 20 percent rating. Note, even when the factors listed in §§ 4.40 or 4.45 are present, such as pain or less movement than normal, the rating is based on the extent to which motion is limited under 38 C.F.R. § 4.71a. Thus, a higher or separate rating under 38 C.F.R. §§ 4.40 or 4.45 itself is not appropriate. Accordingly, the claim for a higher rating for this period is denied. 

With respect to the Veteran's radiculopathy increased rating claims, the periods on appeal are as follows: July 14, 2021 to December 22, 2022 for right lower extremity sciatic nerve radiculopathy;  March 24, 2020 to August 12, 2022 for left lower extremity sciatic nerve radiculopathy; and August 31, 2021 to December 22, 2022 for right and left lower extremity femoral nerve radiculopathy. During each respective period, the Veteran's radiculopathy symptoms were wholly sensory in nature (e.g., pain, paresthesias and/or dysesthesias, and numbness).  The Veteran did not report, and the examiner did not observe, symptomology consistent with a higher rating such as weakness, diminished or hyperactive reflexes, or atrophy. As noted above, moderate (20 percent) is the maximum evaluation available for sensory-only impairment. Accordingly, ratings in excess of 20 percent for either claim is denied. 

The Board further considered whether ratings under any other DCs for the Veteran's back condition are warranted but find that none are appropriate.

Finally, in light of the August 2021 VA examiner's opinion that the Veteran's voiding dysfunction was secondary to his back condition, the Board finds that service connection for voiding dysfunction is warranted and is granted. 38 C.F.R. § 3.310 (a). 

 

MATTHEW W. BLACKWELDER

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	K. Graison-McBride, Associate Counsel

The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.