Citation Nr: 18143509 Decision Date: 10/19/18 Archive Date: 10/19/18 DOCKET NO. 16-10 927 DATE: October 19, 2018 ORDER Entitlement to restoration of a 40 percent disability rating for the service-connected postoperative left knee patellofemoral syndrome is denied; the reduction to 10 percent, effective October 26, 2012, was proper. REMANDED Entitlement to service connection for degenerative disc disease of the cervical spine with cervical radiculopathy, to include as secondary to service-connected postoperative left knee patellofemoral syndrome, is remanded. Entitlement to an initial increased rating for a left patellar subluxation disability (Diagnostic Code 5257), associated with postoperative left knee patellofemoral syndrome, in excess of 20 percent, is remanded. Entitlement to an initial increased rating for a postoperative left knee patellofemoral syndrome disability (Diagnostic Codes 6260, 5261) in excess of 10 percent is remanded. Entitlement to a total rating based on individual unemployability (TDIU) due to service-connected disability is remanded. FINDING OF FACT The evidence shows improvement in the Veteran’s ability to function under the ordinary conditions of life and work with respect to his service-connected postoperative left knee patellofemoral syndrome disability since October 26, 2012, which is commensurate with a reduced disability rating from 40 percent to 10 percent. CONCLUSION OF LAW The criteria for entitlement to restoration of a 40 percent disability rating for the service-connected postoperative left knee patellofemoral syndrome was not met; the reduction to 10 percent, effective October 26, 2012, was proper. 38 U.S.C. §§1155, 5107; 38 C.F.R. §§ 3.102, 3.105(e), 3.159, 4.1, 4.2, 4.10, 4.71a, Diagnostic Codes 5257, 5261, 5260. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from March 1987 to July 1991. This case is before the Board of Veterans’ Appeals (Board) on appeal from a February 2013 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). In the February 2013 rating decision, the RO reduced the previously assigned rating disability for the service-connected postoperative left knee patellofemoral syndrome from 40 percent to 10 percent, effective from October 26, 2012. The Veteran timely appealed the reduction and asserted that full restoration to 40 percent for her postoperative left knee patellofemoral syndrome was warranted. Thus, the issue is characterized as an entitlement to restoration of the 40 percent rating, to include whether the reduction to 10 percent for the postoperative left knee patellofemoral syndrome was proper. In August 2018, the Veteran also appealed the reduction of her right patellar subluxation disability, associated with right knee patellofemoral syndrome, from 20 percent to 10 percent effective July 8, 2015. The Board has not yet certified the appeal. Therefore, this issue is not currently within the Board’s jurisdiction. 1. Entitlement to restoration of a 40 percent disability rating for the service-connected postoperative left knee patellofemoral syndrome, to include whether the reduction to 10 percent, effective October 26, 2012, was proper. In a rating reduction, not only must it be determined that an improvement in a disability has actually occurred, but also that the improvement actually reflects an improvement in a Veteran’s ability to function under the ordinary conditions of life and work. Brown v. Brown, 5 Vet. App. 413, 420-21 (1993); Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). The provisions of 38 C.F.R. §§ 4.1, 4.2, and 4.10 require that a reduction in rating be based upon review of the entire history of a veteran’s disability. VA must then ascertain whether the evidence reflects an actual change in the disability and whether the examination reports reflecting such change are based on thorough examinations. Faust v. West, 13 Vet. App. 342 (2000). VA is not limited, however, to medical indicators of improvement. Rather, VA may rely on non-medical indicators of improvement to show that a Veteran is capable of more than marginal employment. Id. The examination reports on which the reduction are based must be adequate. See Tucker v. Derwinski, 2 Vet. App. 201 (1992) (holding that the failure of the examiner in that case to review the claims file rendered the reduction decision void ab initio). In addressing whether improvement is shown, the comparison point generally is the last examination on which the rating at issue was assigned or continued. See Hohol v. Derwinski, 2 Vet. App. 169 (1992). Where, however, the rating was continued in order to see if improvement was in fact shown, the comparison point could include prior examinations as well. Collier v. Derwinski, 2 Vet. App. 247 (1992). Specific requirements must be met in order for VA to reduce certain ratings assigned for service-connected disabilities. See 38 C.F.R. § 3.344 ; see also Dofflemyer v. Derwinski, 2 Vet. App. 277 (1992). The requirements for reduction of ratings in effect for five years or more are set forth at 38 C.F.R. § 3.344 (a) and (b), which prescribe that only evidence of sustained material improvement under the ordinary conditions of life, as shown by full and complete examinations, can justify a reduction; these provisions prohibit a reduction on the basis of a single examination. See Brown, 5 Vet. App. at 417-18. Where a rating reduction was made without observance of law, the reduction must be vacated and the prior rating restored. Schafrath, 1 Vet. App. at 595. In this case, the 40 percent rating for the postoperative left knee patellofemoral syndrome disability was in effect for less than five years at the time of the reduction. Accordingly, the provisions of 38 C.F.R. § 3.344 (a) and (b) do not apply to this rating. Under the provisions of 38 C.F.R. § 3.344 (c), when a disability rating has been in effect for less than five years, a reexamination that shows improvement in a disability warrants a reduction in disability benefits. Specifically, it is necessary to ascertain, based upon a review of the entire recorded history of the condition, whether the evidence reflects an actual change in disability and whether examination reports reflecting change are based upon thorough examinations. In addition, it must be determined that an improvement in a disability has actually occurred and that such improvement actually reflects an improvement in the Veteran’s ability to function under the ordinary conditions of life and work. See Brown v. Brown, 5 Vet. App. 413, 421 (1993); 38 C.F.R. §§ 4.2, 4.10. When reducing a disability rating based on the severity of a Veteran’s condition, the burden falls on VA to show “material improvement” in the Veteran’s condition from the time of the previous rating examination that assigned the Veteran’s rating. Ternus v. Brown, 6 Vet. App. 370, 376 (1994). In determining whether the reduction was proper in this case, the Board must focus upon the evidence available to the RO at the time the reduction was effectuated, although post-reduction medical evidence may be considered in the context of evaluating whether the disability had actually improved. Cf. Dofflemyer v. Derwinski, 2 Vet. App. 277, 281-282. Such after-the-fact evidence may not be used to justify an improper reduction. Disability ratings are determined by the application of a schedule of ratings which is based on average impairment of earning capacity. 38 U.S.C. § 1155 ; 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. 38 C.F.R. §§ 4.3, 4.7. In specific regard to rating disabilities of the knee, precedent opinions of VA’s General Counsel have held that dual ratings may be given for a knee disorder, with one rating for instability (Diagnostic Code 5257) and one rating for arthritis with limitation of motion (Diagnostic Codes 5003 and 5010). VAOPGCPREC 9-98 (63 Fed. Reg. 56,704 (1998)) and 23-97 (62 Fed. Reg. 63,604 (1997)). Another such opinion held that separate ratings under Diagnostic Code 5260 (leg, limitation of flexion) and Diagnostic Code 5261 (leg, limitation of extension) may be assigned for disability of the same joint. VAOPGCPREC 9-2004 (69 Fed. Reg. 59988 (2004)). Diagnostic code 5261, under which the Veteran received disability ratings for left knee patellofemoral syndrome, provides ratings for limitation of extension with the following ratings assigned: 0 percent for extension limited to 5 degrees, 10 percent for extension limited to 10 degrees, 20 percent for extension limited to 15 degrees, 30 percent for extension limited to 20 degrees, 40 percent for extension limited to 30 degrees, and 50 percent for extension limited to 45 degrees. 38 C.F.R. § 4.71a. Under diagnostic code 5260, a noncompensable rating will be assigned for limitation of flexion of the leg to 60 degrees; a 10 percent rating will be assigned for limitation of flexion of the leg to 45 degrees; a 20 percent rating will be assigned for limitation of flexion of the leg to 30 degrees; and a 30 percent rating will be assigned for limitation of flexion of the leg to 15 degrees. 38 C.F.R. § 4.71a. For rating purposes, normal range of motion of the knee is to zero degrees extension and to 140 degrees flexion. See 38 C.F.R. § 4.71a, Plate II. In evaluating joint disabilities, VA must consider higher ratings in cases in which functional loss due to pain, weakness, excess fatigability, or incoordination is demonstrated, and those factors are not contemplated in the relevant rating criteria. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202 (1995). 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). Instead, 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. Thus, 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. In this case, the Veteran was originally granted service connection for postoperative left knee patellofemoral syndrome disability in an August 1991 rating decision. An initial 10 percent disability rating was assigned for the left knee, under Diagnostic Code 5260, effective from July 1991. In an August 2011 rating decision, the disability rating for the Veteran’s postoperative left knee patellofemoral syndrome was increased to 40 percent from July 2011. In a February 2013 rating decision, the RO decreased the disability rating for the Veteran’s left knee patellofemoral syndrome to 10 percent from October 2012. Therefore, the Board is only deciding the issue of whether the reduction of the left knee rating for patellofemoral syndrome disability was warranted. As such, the Board’s sole concern is whether actual improvement was shown in the left knee patellofemoral syndrome. In making this determination, the Board will have to consider all painful limitation of motion, to include both flexion and extension, as well as whether there was functional impairment beyond the level of actual limitation of flexion and/or extension. At the time of the August 2011 rating decision that increased the Veteran’s disability rating for postoperative left knee patellofemoral syndrome to 40 percent, the RO relied on findings from a July 2011 VA examination, which indicated that the Veteran had constant pain in both her knees under the patella area and behind both knees, and experienced flare ups with any activity requiring her to go up and down steps, walk more than 100 feet, stand more than 5 minutes, and sit in one position for more than 20 minutes. The Veteran also reported that she wore bilateral knee braces for stability regularly and occasionally used a cane. In terms of functional loss, the examiner noted the following contributing factors: less movement than normal, weakened movement, excess fatigability, pain on motion, disturbance of locomotion, swelling, and interference with sitting and standing. Stability was noted as normal. Extension of the left knee was limited to 20 degrees, and flexion was limited to 115 degrees. Pain on motion had its onset at 20 degrees on extension. The extension of the Veteran’s knee was limited to 35 degrees following repetitive range of motion testing. Weakened muscle strength in the left knee was noted. Joint stability was recorded as normal. The examiner also reported that the Veteran’s knee pain made her late for work at least two times per week, and prevented her from using the stairs between the floors at her school forcing her to rely on the elevator. Essentially, the RO increased the Veteran’s disability rating from 10 percent to 40 percent because the extension of the Veteran’s knee was limited to 35 degrees following repetitive range of motion testing. The RO noted in its decision that the evidence did not establish that the level of severity of the Veteran’s disability, at the time of the increased rating, was permanent. In a February 2013 rating decision, the RO reduced the Veteran’s disability rating from 40 percent to 10 percent for the service-connected postoperative left knee patellofemoral syndrome, effective October 2012. The RO concluded that, based on the most recent VA examination in October 2012, the Veteran’s knee symptoms did not meet the criteria for more than a 10 percent rating because she could flex her left knee to 110 degrees and there was no limitation of extension of the left knee. The results for flexion and extension of the left knee were the same following range of motion testing. The Veteran reported that her left knee had been giving out more frequently, the pain and grinding in both her knees had increased, both knees flare up with overuse and bending lasting up to four hours and that during the flare ups she had increased difficulty walking. The examination showed that the Veteran had an antalgic gait and walked stiffly with a wide based gait due to bilateral knee pain but also due to wearing bilateral knee braces. The examiner also reported that the Veteran wore braces on both her knees regularly. In relation to functional loss, the examiner provided the following contributing factors: less movement than normal, incoordination, impaired ability to execute skilled movements smoothly, disturbance of locomotion and pain on movement. Stability was noted as normal. The Veteran was provided with three additional VA examinations since the RO reduced her disability rating for left knee patellofemoral syndrome in February 2013. The October 2013 VA examination showed that the Veteran could flex her left knee to 110 degrees, with painful motion beginning at 90 degrees, and there was no limitation of extension of the left knee. The VA examination also tested for range of motion after repetition and the results for flexion and extension of the left knee were the same. The examiner noted a reduction in muscle strength on extension. The examiner noted that the Veteran’s disability resulted in functional loss due to less movement than normal, weakened movement, pain on movement, disturbance of locomotion, and interference with sitting, standing and weight bearing. Stability tests showed normal results. The Veteran reported daily pain, which increased when using stairs. She reported trouble with prolonged standing and walking. She described waking up at night with grinding pain and reported a lot of achiness in her left knee. The Veteran also reported using knee braces regularly. The July 2015 VA examination showed that the Veteran could flex her left knee to 110 degrees and there was no limitation of extension of the left knee. The symptoms reported by the Veteran were the same as the symptoms noted in the July 2015 VA examination, including reduction in muscle strength on extension. The examiner also noted the following contributing factors to the Veteran’s left knee patellofemoral syndrome disability: less movement than normal, instability of station, disturbance of locomotion, and interference with sitting and standing. No joint instability was noted on examination. However, the examiner noted a reduction in muscle strength on extension. The Veteran reported that she continued to use knee braces regularly. The Veteran had a VA examination in June 2018 in connection to her right patellar subluxation. While the focus of the examination was the Veteran’s right knee, certain tests were also performed on the left knee. As it related to left knee, the June 2018 VA examination showed that the Veteran could flex her left knee to 100 degrees and there was no limitation of extension. The results for flexion and extension of the left knee after repetition were the same. The Veteran reported that “not a whole lot has changed” in the condition of her knees since the July 2015 VA examination. She continued to report constant pain in her left knee, which was aggravated by stair climbing and walking. She also reported grinding pain when walking and that she regularly used a knee brace. No joint instability was reported. A review of the medical evidence in the Veteran’s claims file prior to the July 2011 VA examination reflects that during a May 2010 examination at a VA orthopedic surgery clinic, the physician noted that the Veteran had “some isolated patellofemoral degenerative changes in [the left] knee but not bad enough probably to warrant patellofemoral joint replacement.” On the physician’s recommendation, the Veteran was administered repeat viscosupplementation to relieve the pain in the left knee, including 6 rounds of Euflexxa injections in November 2009 and June 2010. In June 2010, the Veteran was diagnosed with bilateral patellofemoral joint osteoarthritis. During an October 2010 examination at the CMH Orthopedic Service, LLC, the Veteran complained of pain in the left knee at rest, instability and occasional giving way of the knee. The physician recommended a lateral release procedure in the left knee. On December 2010, the Veteran underwent an arthroscopy of the left knee with lateral retinacular release, and an excision of medial plica from the left knee. The purpose of the lateral release surgical procedure was to realign the kneecap, and the excision of the medial plica (a fold of synovial membrane) was to relieve the pain in the left knee, as the medial plica can cause pain when it becomes irritated, enlarged or enflamed. There is no evidence that the examiners were not competent or credible, and as their opinions were based on the medical evidence and physician evaluations of the Veteran, the Board finds they are entitled to significant probative weight as to the severity of the Veteran’s left knee patellofemoral syndrome at the time of the examination. Nieves-Rodriguez, 22 Vet. App. 295. In November 2010, the Veteran stated that she experienced increased pain and discomfort in her left knee, which made it difficult to perform her duties as a teacher, wife and mother. She described her symptoms as giving way of knees, instability, tenderness and pain with active motion, stiffness, weakness, incoordination, decreased speed, joint clicking, weekly flare ups that last one to two days, episodes of locking of the knees several times per year. She reported tenderness and pain with active motion and described the pain as constant, worsening at the end of the day and keeping her from sleeping at night. The Veteran explained that she was unable to escort students up and down stairs and unable to stand for more than 15-30 minutes at a time. During an examination at the CMH Orthopedic Service, LLC in September 2011, the Veteran reported that “her left knee gave way on her and she fell down 8 steps.” The Veteran also reported that she stopped working as a teacher since her fall in September 2011 and has since remained unemployed. The Veteran is competent to report on observable symptomatology of her left knee disability, including pain in her left knee and its impact on her ability to function on a day-to-day basis. Barr v. Nicholson, 21 Vet. App. 303, 307-08 (2007). Therefore, the Board finds the Veteran’s testimony credible. The October 2012 VA examination, as well as the subsequent VA examinations, show an improvement in in the Veteran’s range of motion of her left knee during flexion and extension. In fact, all the VA examinations since October 2012 show that the limitation of the Veteran’s range of motion of the left knee does not amount to a compensable rating. This signifies a material improvement in the Veteran’s postoperative left knee patellofemoral syndrome disability. The improvement in the range of motion of the Veteran’s postoperative left knee patellofemoral syndrome disability also reflects an improvement in the Veteran’s ability to function under the ordinary conditions of life and work. The contributing factors to functional loss listed in the October 2012 VA examination decreased in comparison to those listed in the July 2011 VA examination. Specifically, while the July 2011 VA examination listed less movement than normal; weakened movement; excess fatigability; pain on movement; disturbance of locomotion; swelling; and interference with sitting; standing, and weight bearing, the October 2012 VA examination only listed the following factors as contributing to functional loss: less movement than normal, incoordination, impaired ability to execute skilled movements smoothly; disturbance of locomotion; and pain on movement. In subsequent VA examinations, the factors contributing to the Veteran’s functional loss have essentially remained constant. Additionally, during the July 2011 VA examination, the Veteran was using both a cane and knee braces to assist in her movement. By the October 2012 examination, the Veteran was only using knee brace, which reflects an improvement in the Veteran’s stability and motion. During medical examinations, including the October 2012 VA examination, the Veteran had the same symptoms that she reported prior to the July 2011 VA examination, including pain and grinding in both her knees, flare ups in both knees with overuse and bending, difficulty walking, inability to sit or stand for long periods squatting and climbing stairs, and buckling of the left knee. Also, joint stability continued to be recorded as normal since the July 2011 VA examination. Moreover, while the Veteran underwent several treatments, including viscosupplementation injections in November 2009 and June 2010, and an arthroscopy of the left knee with lateral retinacular release, and an excision of medial plica from the left knee in December 2010, the Veteran has not required any surgical procedures to alleviate the pain in the left knee since December 2010. Also, increased pain or functional loss to the left knee was not reported following the Veteran’s fall. The Board notes that the Veteran indicated, as part of her October 2013 Notice of Disagreement, that the disability rating for her left knee patellofemoral syndrome should be increased to 40 percent because the arthritic conditions of the left knee led to a recommendation for knee replacement surgery. However, the medical evidence shows that the Veteran only had a discussions in 2010 about knee replacement surgery, and that at least two physicians recommended alternate treatment methods in lieu of a knee replacement surgery because the condition of the Veteran’s left knee was not severe enough to warrant patellofemoral joint replacement. In summary, the Veteran’s postoperative left knee patellofemoral syndrome disability did not deteriorate from July 2011 to October 2012 to the extent of requiring a knee replacement surgery. In fact, no deterioration was reported and the recommendation to undergo knee replacement surgery was only made in July 2015. The evidence shows that the Veteran stopped working in September 2011, but there is nothing to suggest that the worsening of the Veteran’s left knee disability prevented her from continuing to work. Rather, the Veteran’s statements suggest that her mental disorders as well as cervical spine disability have contributed to her inability to continue working as a teacher. Therefore, based on the aforementioned evidence showing an improvement in the Veteran’s condition in October 2012, the Board finds that the reduction in the Veteran’s disability rating from 40 percent to 10 percent effective October 26, 2012 was proper. The preponderance of the evidence is against the restoration of the 40 percent rating. As such, the benefit-of-the-doubt doctrine is inapplicable. 38 C.F.R. § 4.3. REASONS FOR REMAND 1. Entitlement to service connection for degenerative disc disease of the cervical spine with cervical radiculopathy, to include as secondary to service-connected postoperative left knee patellofemoral syndrome is remanded. The Veteran has stated in documentation submitted to the RO and to the Board, as well as during medical examinations, that she injured her cervical spine in September 2011 when her left knee buckled causing her to fall down a flight of stairs. In an October 2012 VA examination, the examiner was asked to provide a medical opinion addressing whether the Veteran’s cervical herniated disc was at least as likely as not (50 percent or greater probability) proximately due to or the result of her left knee conditions. The examiner opined that it is less likely as not that the Veteran’s cervical herniated disc was proximately due to left knee postoperative patellofemoral syndrome with subluxation. The examiner’s rationale was based on the fact that the symptom of a knee giving way, otherwise referred to as instability, is most often due to a ligament tear and the VA examinations did not show that the Veteran had instability in the left knee. Pursuant to Barr v. Nicholson, if VA provides an examination that examination must be adequate. 21 Vet. App. 303, 311 (2007). However, the October 2012 medical opinion was inadequate for a number of reasons. First, the question presented to the examiner was overly narrow and should have encompassed an assessment of both of the Veteran’s knees. Secondly, the examiner’s rationale focused on ligament instability as a possible cause of the left knee giving way because it was considered the “the most common cause” but the examiner did not assess other less common causes of knee instability, such as patellar subluxation, which is defined as “a temporary, partial dislocation of the kneecap from its normal position in the groove in the end of the thigh bone (femur).” This is in particular significant because the Veteran has been service connected for patellar subluxation of both the left and right knees. Thirdly, the examiner was incorrect in concluding that there was no evidence that the Veteran suffered from instability of the left knee. In fact, the October 2012 VA examination shows that the Veteran has a history of moderate recurrent subluxation/dislocation of the left knee, which is a type of patellar instability. A symptom of knee subluxation includes the knee suddenly buckling, which was the sensation described by the Veteran prior to her fall. In the July 2011 VA examination, approximately two months prior to the Veteran’s fall, the examiner reported that the Veteran had moderate recurrent subluxation/dislocation in both her left and right knees. Also, during an October 2011 medical appointment, the Veteran complained of her left knee giving away. During an October 2010 private medical examination, x-rays of the Veteran’s bilateral knees showed “subluxation of the patella laterally in the sunrise views”. During the same examination, the Veteran reported that the pain in her left knee was continuous and that “there is also associated instability in the knee with occasional giving way.” Finally, during an October 2009 VA examination, the Veteran reported symptoms of instability, weakness, and “giving away” of both her knee joints. Therefore, the medical evidence shows that prior to and shortly after the Veteran’s fall, she experienced instability and buckling of her left knee. As such, the Board is required to remand this issue and obtain a VA examination with a more adequate medical opinion that addresses whether the Veteran’s bilateral knee disabilities caused or contributed to the Veteran’s fall. 2. Entitlement to an increased rating for a left patellar subluxation disability associated with postoperative left knee patellofemoral syndrome is remanded. The Veteran seeks an increased rating for a left patellar subluxation disability which is secondary to postoperative left knee patellofemoral syndrome. The Veteran claims that her service connected postoperative left knee patellofemoral syndrome causes instability in her left kneecap, which takes the form of a left patellar subluxation disability. As such, the Veteran’s claim for an increased rating for left patellar subluxation is inextricably linked with her postoperative left knee patellofemoral syndrome disability. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (claims “are inextricably linked together” where a favorable decision on one “could have a significant impact” on the other). Therefore, in order to assess the severity of the Veteran’s left patellar subluxation disability to determine if an increased rating is warranted, the Board must first assess the severity of the Veteran’s postoperative left knee patellofemoral syndrome disability. Also, while the record contains a contemporaneous VA examination, dated July 2015, regarding the Veteran’s left patellar subluxation disability, the examination does not comply with the requirements in Correia v. McDonald, 28 Vet. App. 158, 168 (2016). The examination does not contain passive range of motion measurements/pain on weight-bearing testing. The examination also does not comply with the requirements in Sharp v. Shulkin, 29 Vet. App. 26, 34-36 (2017), because the examiner did not attempt to elicit relevant information regarding the description of the Veteran’s flare-ups and any additional functional loss suffered during flare-ups. Additionally, the most recent VA examination from June 2018, that complies with the requirement of Correia and Sharp, pertains to the Veteran’s right patellar subluxation disability as opposed to her left patellar subluxation disability. Therefore, a new VA examination is required so that the Board can conduct further development into the Veteran’s claim for an increased rating for a left patellar subluxation disability. 3. Entitlement to an increased rating for postoperative left knee patellofemoral syndrome disability is remanded. While the record contains a contemporaneous VA examination, dated July 2015, regarding the Veteran’s postoperative left knee patellofemoral syndrome disability, the examination does not comply with the requirements in Correia, 28 Vet. App. 158, 168 (2016). The examination does not contain passive range of motion measurements/pain on weight-bearing testing. The VA examination also does not comply with the requirements in Sharp, 29 Vet. App. 26, 34-36 (2017) because the examiner did not attempt to elicit relevant information regarding the description of the Veteran’s flare-ups and any additional functional loss suffered during flare-ups. Additionally, the most recent VA examination that complies with the requirements of Correia and Sharp, dated June 2018, pertains to the Veteran’s right patellar subluxation disability as opposed to her left knee patellofemoral syndrome disability. Therefore, a new VA examination is required so that the Board can conduct further development into the Veteran’s claim for an increased rating for a left patellar subluxation disability. 4. Entitlement to a total rating based on individual unemployability (TDIU) due to service-connected disability is remanded. The Board notes that the issue of entitlement to a TDIU is inextricably intertwined with the other claims on appeal. Harris v. Derwinski, 1 Vet. App. 180 (1991) (finding that a TDIU claim is part and parcel of an increase rating claim, and it can be reasonably raised or inferred by the evidence and the Veteran’s statements). The determination of the TDIU will, in part, be based on whether the Board will grant the Veteran’s service connection claim for degenerative disc disease of the cervical spine with cervical radiculopathy and the extent of the severity of the Veteran’s left patellar subluxation disability and postoperative left knee patellofemoral syndrome noted in the examination to be accomplished upon remand. Therefore, the Board cannot adjudicate the Veteran’s TDIU claim until the development requested for the increased rating claims and the service connection claim is completed. Thus, the Board defers consideration of TDIU until further development is complete. The matters are REMANDED for the following action: 1. Obtain any outstanding VA and private treatment records to be associated with the Veteran’s claims file. 2. Direct the Veteran’s claims file to the same examiner who conducted the Veteran’s October 2012 VA examination relating to her herniated cervical disc and ask the examiner to address the questions below. If the examiner who conducted the Veteran’s October 2012 VA examination is no longer available, an appropriate clinician should be directed to provide the addendum opinion with a response to the those questions. The questions posed are as follows: But for the Veteran’s service connected knee disabilities, to include postoperative left knee patellofemoral syndrome, left knee patellar subluxation, right knee patellofemoral syndrome, and right knee patellar subluxation, is it unlikely that the Veteran would have fallen down the stairs injuring his cervical disc? In responding to the question and assessing the correlation between the Veteran’s bilateral knee disabilities and her fall, the addendum opinion must use the following language: the Veteran’s fall is as least as likely as not related to/proximately due to her service-connected bilateral knee disabilities, or aggravated beyond its natural progression by her service-connected bilateral knee disabilities. If a new VA examination is required for the new clinician to provide an addendum opinion, a new VA examination should be scheduled. 3. Schedule the Veteran for an examination of the current severity of her service-connected postoperative left knee patellofemoral syndrome and left patellar subluxation disabilities. The examiner must test the Veteran’s active motion, passive motion, and pain with weight-bearing and without weight-bearing. The examiner must also attempt to elicit information regarding the severity, frequency, and duration of any flare-ups, and the degree of functional loss during flare-ups. To the extent possible, the examiner should identify any symptoms and functional impairments due to service-connected postoperative left knee patellofemoral syndrome and left patellar subluxation disabilities alone and discuss the effect of the Veteran’s service-connected postoperative left knee patellofemoral syndrome and left patellar subluxation disabilities on any occupational functioning and activities of daily living. If it is not possible to provide a specific measurement, or an opinion regarding flare-ups, symptoms, or functional impairment without speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). (Continued on the next page)   4. Thereafter, complete any other development deemed necessary and then readjudicate the Veteran’s increased rating and service connection claims. If a complete grant of the benefits requested is not awarded, issue a supplemental statement of the case to the Veteran and his representative, and provide them an opportunity to respond before returning the case to the Board. MICHAEL A. PAPPAS Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD A. White, Associate Counsel