Citation Nr: 18145040 Decision Date: 10/26/18 Archive Date: 10/25/18 DOCKET NO. 11-18 492A DATE: October 26, 2018 ORDER New and material evidence having been received, entitlement to service connection for a left wrist disability, claimed a secondary to service-connected bilateral knee disabilities, is reopened. Entitlement to a disability rating in excess of 20 percent for a right knee disability is denied. Entitlement to a disability rating in excess of 10 percent for a left knee disability is denied. REMANDED Entitlement to service connection for a left wrist disability is remanded. Entitlement to service connection for a back disability is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) due to service-connected disabilities is remanded. FINDINGS OF FACT 1. Evidence received since the February 2005 rating decision is new and material regarding the issue of service connection for a left wrist disability, as it contains evidence not previously considered that has some tendency to establish that a left wrist disability may be related to the service-connected bilateral knee disabilities. 2. The preponderance of the evidence does not show limitation of flexion of the right knee to 60 degrees or extension limited to 5 degrees; or recurrent subluxation or lateral instability; or dislocation of the semilunar cartilage accompanied by frequent episodes of "locking," or effusion into the joints. 3. The preponderance of the evidence does not show limitation of flexion of the left knee to 60 degrees or extension limited to 5 degrees; or recurrent subluxation or lateral instability; or dislocation of the semilunar cartilage accompanied by frequent episodes of "locking," pain or effusion into the joints. CONCLUSIONS OF LAW 1. The criteria for reopening the Veteran's previously denied claim of service connection for a left wrist disability have been met. 38 U.S.C. § 5108 (2012); 38 C.F.R. § 3.156 (2017). 2. The criteria for a rating higher than 20 percent for the Veteran's right knee disability have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §3.102, 3.159, 4.1-4.14, 4.40-4.45, 4.59, 4.71a, Diagnostic Codes 5010, 5260, 5261, 5257 (2017). 3. The criteria for a rating higher than 10 percent for the Veteran's left knee disability have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §3.102, 3.159, 4.1-4.14, 4.40-4.45, 4.59, 4.71a, Diagnostic Codes 5010, 5260, 5261, 5257 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran, who is the appellant in this case, had active service from May 1991 to October 1992. These matters come to the Board of Veterans' Appeals (Board) on appeal from an April 2010 decision of the Regional Office (RO) in Los Angeles, California. In August 2014, the claims were remanded to provide the Veteran with a hearing. In August 2015, the Veteran testified at a Board hearing before the undersigned Veterans Law Judge (VLJ); a transcript of the hearing is associated with the electronic claims file. In January 2017, the claim was remanded for additional development. Specifically, the Board ordered the AOJ to provide appropriate notice for the Veteran’s TDIU claim, obtain the Veteran’s Social Security Administration (SSA) records, and to provide the Veteran with a VA examination for the service-connected bilateral knee disability. On remand, the requested actions were completed by the AOJ; therefore, the case is once again before the Board for appellate consideration of the issue on appeal. Stegall v. West, 11 Vet. App. 268 (1998). Neither the Veteran nor his representative have raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 69-70 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). 1. New and Material Evidence Sufficient to Reopen the Claim for Service Connection for a Left Wrist Disability. The Veteran seeks to reopen the previously denied claim of service connection for a left wrist disability. Generally, a claim which has been denied in a final unappealed rating decision, or a rating decision that was appealed but was not perfected, may not thereafter be reopened and allowed. 38 U.S.C. § 7105(c), (d)(3); 38 C.F.R. § 20.1103. If "new and material" evidence is presented or secured with respect to a claim which has been disallowed, VA shall reopen the claim and review the former disposition of the claim. 38 U.S.C. § 5108; 38 C.F.R. § 3.156(a). "[N]ew evidence" means evidence not previously submitted to agency decision makers which is neither cumulative nor redundant of the evidence of record at the time of the last prior final denial. 38 C.F.R. § 3.156(a). Materiality has two components, first, that the new evidence pertains to the reason(s) for the prior final denial, and second, that the new evidence, combined with VA assistance and considering the other evidence of record, raises a reasonable possibility of substantiating the claim. Shade v. Shinseki, 24 Vet. App. 110, 117 (2010). When making a determination whether the submitted evidence meets the definition of new and material evidence, the Board should take cognizance of whether that evidence could, if the claim were reopened, reasonably result in substantiation of the claim, applying concepts derived from the duty to assist. Id. at 118. The Veteran seeks to reopen the previously denied claims of service connection for a left wrist disability. The claim was initially considered and denied by the RO in a February 2005 rating decision. The Veteran did not initiate an appeal of the decision denying service connection for a left wrist disability, and he also did not submit any new and material evidence with respect to this claim within the applicable one-year period. See 38 C.F.R. § 3.156(b); Jennings v. Mansfield, 509 F.3d 1362, 1368 (Fed. Cir. 2007). As such, the decision became final as to the evidence then of record, and is not subject to revision on the same factual basis. 38 U.S.C. § 7105 (b); 38 C.F.R. §§ 3.104, 20.302, 20.1103. The Veteran then filed to reopen a claim for service connection for a left wrist disability in August 2009. The claim was subsequently considered and denied in an April 2010 rating decision. The Veteran perfected the appeal and it is now before the Board. Since the February 2005 rating decision, additional evidence has been received in the form of VA treatment records and lay testimony from the Veteran. The VA treatment records and lay testimony are new because they have not been previously submitted. This evidence is also material because it pertains to the basis for the prior denial, that is, a basis to relate any current left wrist disability to the Veteran's service-connected bilateral knee disabilities, and raises a reasonable possibility of substantiating the claim. Specifically, the Veteran testified about the events surrounding his left wrist injury and the possibility that it was caused by his service-connected knee disabilities. For these reasons, the Board finds that new and material evidence has been received to reopen service connection for a left wrist disability. See 38 C.F.R. § 3.156(a). When making determinations as to whether new and material evidence has been presented, the credibility of the evidence is generally presumed. Justus v. Principi, 3 Vet. App. 510, 513 (1992); Duran v. Brown, 7 Vet. App. 216 (1995). This new evidence raises a reasonable possibility of substantiating the claim; thus, this evidence is new and material and the requirements to reopen the claim under 38 C.F.R. § 3.15 (a) have been satisfied. Accordingly, the Board has determined that new and material evidence has been received to reopen service connection for a left wrist disability. Increased Rating Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities. The percentage ratings are based on the average impairment of earning capacity and individual disabilities are assigned separate diagnostic codes. 38 U.S.C. § 1155; 38 C.F.R. § 4.1 (2017). If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Any reasonable doubt regarding a degree of disability will be resolved in favor of the veteran. 38 C.F.R. § 4.3. Where entitlement to compensation has already been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Consistent with the facts found, the rating may be higher or lower for segments of the time under review on appeal, i.e., the rating may be "staged." See Fenderson v. West, 12 Vet. App. 119 (1999). In rendering a decision on appeal the Board must also analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify."). 2. Increased Rating for Bilateral Knee Disabilities. The Veteran contends that the bilateral knee disabilities warrant a higher rating evaluation. The Veteran's right knee disability has been rated under Diagnostic Codes 5257-5010. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the assigned rating; the additional code is shown after the hyphen. Here, the first four digits 5257 represent recurrent subluxation or lateral instability. The second four digits, 5010, represent the diagnostic used to rate traumatic arthritis. The Veteran's left knee disability has been rated under Diagnostic Codes 5099-5010. The use of the "99" series (5099) and hyphenated DCs reflects that there is no specific DC applicable to the disability, and it must be rated by analogy. 38 C.F.R. § 4.20 (2017). The second four digits, 5010, represent the diagnostic used to rate traumatic arthritis. Traumatic arthritis is rated as degenerative arthritis. 38 C.F.R. § 4.71a, Diagnostic Code 5010. Degenerative arthritis established by x-ray findings will be rated on the basis of limitation of motion for the specific joint or joints involved. When, however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under Diagnostic Code 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. 38 C.F.R. § 4.71a, Diagnostic Code 5003. The normal range of motion of the knee is from 0 degrees extension to 140 degrees flexion. 38 C.F.R. § 4.71, Plate II. Diagnostic Code 5260 concerns limitation of leg flexion. A noncompensable evaluation is assigned where flexion is limited to 60 degrees. A 10 percent rating is warranted where flexion is limited to 45 degrees. A 20 percent evaluation is for application where flexion is limited to 30 degrees. Finally, a 30 percent rating applies where flexion is limited to 15 degrees. 38 C.F.R. § 4.71a. Additional diagnostic codes are potentially applicable to the claim. Diagnostic Code 5261 pertains to limitation of leg extension, and provides a noncompensable evaluation where extension is limited to 5 degrees. A 10 percent rating is warranted where extension is limited to 10 degrees. A 20 percent evaluation is for application where extension is limited to 15 degrees. A 30 percent rating applies where extension is limited to 20 degrees. A 40 percent rating is warranted where extension is limited to 30 degrees. Finally, a 50 percent evaluation is warranted where extension is limited to 45 degrees. Id. Diagnostic Code 5257 provides for assignment of a 10 percent rating when there is slight recurrent subluxation or lateral instability, a 20 percent rating when there is moderate recurrent subluxation or lateral instability, or a 30 percent evaluation for severe knee impairment with recurrent subluxation or lateral instability. Id. Precedent opinions of the 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)). VA regulations, set forth at 38 C.F.R. §§ 4.40, 4.45, 4.59 provide for consideration of functional impairment due to pain on motion when evaluating the severity of a musculoskeletal disability. The Court has held that a higher rating can be based on "greater limitation of motion due to pain on use." DeLuca v. Brown, 8 Vet. App. 202, 206 (1995). Any such functional loss must be "supported by adequate pathology and evidenced by the visible behavior of the claimant." See 38 C.F.R. § 4.40. In Burton v. Shinseki, 25 Vet. App. 1 (2011), the Court held that consideration of 38 C.F.R. § 4.59 is not limited to cases involving arthritis, thereby providing for the possibility of a rating based on painful motion of a joint, regardless of whether the painful motion stemmed from joint or periarticular pathology. The Court held that pain must affect some aspect of the normal working movements of the body such as excursion, strength, speed, coordination and endurance to constitute functional loss. Mitchell v. Shinseki, 24 Vet. App. 32, 33, 43 (2011). Although pain may cause functional loss, pain, itself, does not constitute functional loss and is just one factor to be considered when evaluating functional impairment. Id. The Court explained in Mitchell 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 (38 C.F.R. §§ 4.40), 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 (38 C.F.R. § 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. Consequently, in rating the severity of a joint disability, VA must determine the overall functional impairment due to these factors. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011). The Board notes, however, that the Court has held that 38 C.F.R. § 4.40 does not require a separate rating for pain but rather provides guidance for determining ratings under other diagnostic codes assessing musculoskeletal function. See Spurgeon v. Brown, 10 Vet. App. 194 (1997). In April 2010, the Veteran underwent a VA examination to determine the severity of the service-connected right knee. The Veteran reported weakness, stiffness, swelling, giving way, lack of endurance, fatiguability, tenderness, and pain. He denied locking, deformity, drainage, effusion, subluxation, or dislocation. The Veteran also reported flare-ups of a 10 on a scale of 1-to-10 that were precipitated by physical activity that he treated with ibuprofen. The Veteran reported that during a flare-up he had difficulty walking and felt like his knee was going to crack and give out. On examination, range of motion testing in the bilateral knees revealed flexion of 60 degrees with pain at 60 degrees and extension of 0 degrees with pain at -20 degrees. Range of motion was unchanged after repetitive testing. Medial and lateral collateral ligament stability testing was normal bilaterally. The VA examiner diagnosed the Veteran with scars, status post arthroscopic surgery, with arthritis, bilateral knees. An April 2010 rating decision continued the right knee evaluation at 20 percent disabling and the left knee evaluation at 10 percent disabling. The Veteran filed a timely notice of disagreement and this appeal followed. In January 2011, the Veteran underwent an additional VA examination to determine the severity of the service-connected bilateral knee disability. The Veteran reported weakness, giving way, lack of endurance, fatiguability, tenderness, tenderness, pain and feelings of looseness. He denied stiffness, swelling, heat, locking, effusion, subluxation, or dislocation. The Veteran also reported flare-ups two times a week that were a 10 on a scale of 1-to-10 and were precipitated by physical activity that he treated with ibuprofen. The Veteran reported that during a flare-up he had difficulty walking and significant pain. On examination, range of motion testing in the bilateral knees revealed flexion of 140 degrees and extension of 0 degrees. Pain in the right knee was noted at 120 degrees. Range of motion was unchanged after repetitive testing. Joint function was not additionally limited by pain, fatigue, weakness, lack of endurance, or coordination after repetitive use. Medial and lateral collateral ligament stability testing was normal bilaterally. The VA examiner diagnosed the Veteran with bilateral knee chondromalacia and degenerative joint disease, bilaterally. In April 2014, the Veteran underwent an additional VA examination to determine the severity of the service-connected bilateral knee disability. The Veteran reported daily pain in the knees that he treated with Naproxen. He also reported flare-ups that impacted standing, using stairs, and squatting. On examination, range of motion testing in the right knee revealed flexion of 115 degrees with pain at 115 degrees and extension of 0 degrees with no objective evidence of painful motion. Range of motion testing in the left knee revealed flexion of 95 degree with pain at 95 degrees and extension of 0 degrees with no objective evidence os painful motion. The Veteran’s range of motion was unchanged with repetitive testing. Strength and instability testing (posterior and medial-lateral) was normal, bilaterally. There was no evidence of recurrent patellar subluxation or dislocation. The VA examiner diagnosed the Veteran with bilateral knee chondromalacia and degenerative joint disease, bilaterally, with a tear of the right knee lateral meniscus. In August 2015, the Veteran provided testimony in support of his claim. The Veteran reported the service-connected knees were stiff in the morning and required stretching. He further reported pain throughout the day that affected standing, walking long distances, and manipulating stairs. In March 2018, the Veteran underwent an additional VA examination to determine the severity of the service-connected bilateral knee disability. The Veteran reported flare-ups that impacted standing, walking, repetitive kneeling, squatting, climbing stairs, and running. On examination, range of motion testing in the right knee revealed flexion of 120 degrees with pain at 115 degrees and extension of 0 degrees. The VA examiner noted objective evidence of localized tenderness with evidence of pain on weight bearing in the right knee. Range of motion testing in the left knee revealed flexion of 140 degree with pain at 95 degrees and extension of 0 degrees. Crepitus was noted bilaterally. After repetitive testing, flexion in the right knee was 105 degrees and extension was 0 degrees and extension in the left knee was 125 degrees with extension of 0 degrees. Additional repetitive testing limited the Veteran’s flexion to 90 degrees in the right knee and 110 degrees in the left knee while extension remained 0 degrees, bilaterally. Pain and lack of endurance was noted bilaterally. Strength testing was normal bilaterally. There was no evidence of muscle atrophy, ankylosis, recurrent subluxation, lateral instability, or recurrent effusion, bilaterally. Joint stability testing was normal in both knees. The examination was not conducted during a flare-up. The VA examiner indicated that without speculation limitations to the Veteran’s range of motion during a flare-up could not be calculated. The rationale provided was that prior familiarity and the ability to make comparisons would be necessary to formulate such an opinion. VA treatment records throughout the appeal period are consistent with the January 2011, April 2014, and March 2018 VA examinations. The April 2010 VA examination is discussed above and is not supported by the VA treatment records throughout the appeal period. Right Knee As noted above, the Veteran is currently rated at 20 percent for the right knee disability under diagnostic code 5257-5010. A higher rating under Diagnostic Code 5257 would require recurrent subluxation or lateral instability which is severe. Although the Veteran contends that he experiences “giving way” of the knee, the VA examination reports do not reveal any objective evidence of instability of the right knee and joint stability testing has consistently been normal. Thus, the Board finds the objective findings on examination of stable knee joints to be more probative than the Veteran’s lay assertions of instability. He is competent to describe the sensation of feeling unsteady due to his knees, but not to provide a diagnosis of subluxation, which can only be made with clinical testing performed by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372 (2007) (a Veteran may be competent to provide a diagnosis of a simple condition such as a broken leg, but not competent to provide evidence as to more complex medical questions). Thus, a separate rating based on recurrent subluxation or lateral instability of the right knee under Diagnostic Code 5257 is not warranted. The Board also finds that a rating greater than 20 percent for the service-connected right knee disability is not warranted under either Diagnostic Code 5260 or Diagnostic Code 5261. Diagnostic Code 5260 pertains to limitation of leg flexion, and requires flexion is limited to 15 degrees for an evaluation of 30 percent. During the appeal period, the Veteran’s right knee flexion was, 60 degrees in April 2010, 120 degrees in January 2011, 115 degrees in April 2014, and 105 degrees in March 2017. The Board notes the April 2010 finding of 60 degrees, but based on the following three examinations during the appeal period it appears to be an episodic anomaly because the closest reading to it over the next eight years is more than 50 degrees greater. Based on the evidence of record, the Veteran’s right knee does not warrant a separate rating for limitation of flexion. As previously stated, Diagnostic Code 5261 pertains to limitation of leg extension, and provides a noncompensable evaluation where extension is limited to 5 degrees. 38 C.F.R. § 4.71a, Diagnostic Codes 5260. The Veteran had had normal extension of the right knee on examination in January 2011, April 2014and March 2018. The Board again notes the April 2010 VA examination and again finds it less probative because its findings are inconsistent with three other examinations of record that span the following eight years after it was conducted. The Board therefore concludes these readings were likely episodic in nature and are not consistent with the majority of the assigned range of motion recordings. As there has never been any evidence of ankylosis or tibia and fibula impairment, consideration of Diagnostic Code 5256 is not appropriate. There is no evidence of dislocated semilunar cartilage, and the Veteran has not asserted that he experiences symptoms of dislocated semilunar cartilage such as "popping" and "locking" of the knee. Thus, a higher evaluation is not warranted under Diagnostic Code 5258. The Board has also considered the Veteran's statements that describe his pain and discomfort. The Board finds those statements to be competent and credible; however, the medical evidence does not reflect that the Veteran's subjective reports of knee pain and weakness caused functional loss sufficient to warrant a disability rating in excess of 20 percent. See 38 C.F.R. § 4.40; DeLuca, supra. Although the Board is sympathetic to the Veteran's credible account of pain and limitation of activities, his symptoms are already contemplated by the 20 percent ratings presently assigned. In summary, the Board finds that an evaluation in excess of 20 percent is not warranted for the right knee at any time during the course of the appeal. Left Knee As noted above, the Veteran is currently rated at 10 percent for the left knee disability under diagnostic code 5099-5010. The Board first finds that a separate rating for the service-connected left knee disability is not warranted under Diagnostic Codes 5260. As previously stated, Diagnostic Code5260 pertains to limitation of leg flexion, and provides a noncompensable evaluation where extension is limited to 60 degrees. 38 C.F.R. § 4.71a, Diagnostic Codes 5260. Flexion of the Veteran’s left knee was 60 degrees in April 2010, 140 degrees in January 2011, 95 degrees in April 2014, and 95 degrees in March 2018. Again, the Board notes the April 2010 finding of 60 degrees, but based on the subsequent three examinations during the appeal period it appears to be an episodic anomaly because the closest reading to it over the following eight years is more than 30 degrees greater. Based on the evidence of record, the Veteran’s left knee does not warrant a separate rating for limitation of flexion. Next, the Board finds that a separate rating is not warranted under Diagnostic Code 5261. As previously stated, Diagnostic Code 5261 pertains to limitation of leg extension, and provides a noncompensable evaluation where extension is limited to 5 degrees. 38 C.F.R. § 4.71a, Diagnostic Codes 5260. The Veteran had had normal extension of the left knee on examination in January 2011, April 2014, and March 2018. The Board again notes the April 2010 VA examination and finds it less probative because its findings are inconsistent with three other examinations of record that span the following eight years after it was conducted. The Board therefore concludes these readings were likely episodic in nature and are not consistent with the majority of the assigned range of motion recordings. The Board has considered whether a higher disability rating is warranted based on functional loss due to pain or weakness, fatigability, incoordination, or pain on movement of a joint. See 38 C.F.R. §§ 4.40, 4.45, 4.59; see also Mitchell, Burton, and DeLuca. However, Diagnostic Codes 5060 and 5061 contemplate the effects of any complaints of pain, fatigue, swelling, weakness, or lack of endurance. Additionally, VA examiners specifically performed repetitive testing and considered the effects of pain. In other words, even factoring the effect of pain and repetitive motion, the functional limitation does not more nearly approximate limitation of flexion or extension to warrant a higher rating. Accordingly, consideration of other factors of functional limitation does not support the grant of a higher rating than the 10 percent ratings already assigned. See 38 C.F.R. §§ 4.40, 4.45; DeLuca, supra. The Veteran reported no instability in the left knee during the appeal period. Thus, a separate rating based on recurrent subluxation or lateral instability of the left knee under Diagnostic Code 5257 is not warranted. Similarly, the Veteran has reported no "popping" or "locking" sensation in the left knee. Further, there have been no objective findings of effusion in the left knee. Diagnostic Code 5258 requires a clinical finding of dislocated semilunar cartilage "with frequent episodes of 'locking' pain, and effusion into the joint." 38 C.F.R. § 4.71a, Diagnostic Code 5258 (emphasis added). As noted, no evidence of dislocated semilunar cartilage was found upon physical examination or x-ray imaging. Effusion and pain without dislocated semilunar cartilage does not meet the criteria for a higher evaluation under Diagnostic Code 5258. As there has never been any evidence of ankylosis, cartilage removal, or tibia and fibula impairment, consideration of Diagnostic Codes 5256 and 5259 is not appropriate. In sum, the medical evidence does not reflect that the Veteran's subjective reports of knee pain caused functional loss sufficient to warrant a disability rating in excess of 10 percent in left knee. See 38 C.F.R. § 4.40; DeLuca, supra. The Veteran's subjective complaints of pain are adequately addressed by the 10 percent rating presently assigned and the Veteran’s current level of disability in the left knee. Therefore, the Board finds that an initial evaluation in excess of 10 percent is not warranted for the left knee at any time during the course of the appeal. REASONS FOR REMAND 1. Entitlement to Service Connection for a Low Back Disability and Left Wrist Disability is Remanded. The Veteran contends that service connection is warranted for a back disability and left wrist disability, claimed as secondary to the service-connected bilateral knee disabilities. Specifically, the Veteran contends his service-connected knee caused a fall that injured the left wrist and that he has a current back disability due to the service-connected knees. Under the VCAA, VA is obliged to provide an examination when the record contains competent evidence that the claimant has a current disability or signs and symptoms of a current disability, the record indicates that the disability or signs and symptoms of disability may be associated with active service; and the record does not contain sufficient information to make a decision on the claim. 38 U.S.C. § 5103A(d) (2012); McLendon v. Nicholson, 20 Vet. App. 79 (2006). To date, the Veteran has not been afforded VA examinations for either the claimed back disability or the left wrist disability. As such, remand for VA examinations is necessary. The Veteran's claim for entitlement to a TDIU is inextricably intertwined with the issues of entitlement to service connection for a back disability and left wrist disability, which are being remanded for further adjudication. Therefore, a final decision on the issue of entitlement to a TDIU cannot be rendered at this time. See Harris v. Derwinski, 1 Vet. App. 180 (1991) (two issues are "inextricably intertwined" when they are so closely tied together that a final decision on one issue cannot be rendered until a decision on the other issue has been rendered). The matters are REMANDED for the following action: 1. Associate all VA treatment records since April 10, 2018 with the electronic claims file. 2. After completion of the above-requested development. Schedule the Veteran for a VA orthopedic examination to determine the etiology of any current back disability. The examiner is asked to provide the following opinions: a) Is it at least as likely as not that any current back disability was incurred during the Veteran’s active military service? b) Is it at least as likely as not (50 percent probability or greater) that any current back disability is caused by the Veteran’s service-connected bilateral knee disabilities? c) If not caused by the service-connected disabilities, is it at least as likely as not (50 percent probability or greater) that any back disability is aggravated (worsened in severity beyond the natural progression of the disease) by the Veteran’s bilateral knee disabilities? If the VA examiner opines that any back disability is aggravated by the bilateral knee disabilities, he/she should indicate the degree of disability before aggravation and the current degree of disability. A rationale should be given for all opinions and conclusions rendered. 3. Schedule the Veteran for a VA orthopedic examination to determine the etiology of any left wrist disability. The examiner is asked to provide the following opinions: a) Is it at least as likely as not that any current left wrist disability was incurred during the Veteran’s active military service? b) Is it at least as likely as not (50 percent probability or greater) that any current left wrist disability is caused by the Veteran’s service-connected bilateral knee disabilities? The VA examiner must specifically comment on the Veteran’s contentions that his service-connected knees caused him to fall and injure the left wrist. c) If not caused by the service-connected disabilities, is it at least as likely as not (50 percent probability or greater) that any left wrist disability is aggravated (worsened in severity beyond the natural progression of the disease) by the Veteran’s bilateral knee disabilities? If the VA examiner opines that any left wrist disability is aggravated by the bilateral knee disabilities, he/she should indicate the degree of disability before aggravation and the current degree of disability. (Continued on the next page)   A rationale should be given for all opinions and conclusions rendered. H. SEESEL Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD C. Teague, Associate Counsel