Citation Nr: 18146435 Decision Date: 10/31/18 Archive Date: 10/31/18 DOCKET NO. 16-21 932 DATE: October 31, 2018 ORDER Entitlement to service connection for a left knee disability is denied. New and material evidence has been received to reopen the Veteran’s claim for service connection for a right hip disability; to this extent only, the appeal is granted. Entitlement to a rating in excess of 30 percent for other impairment of the right knee due to subluxation or lateral instability is denied. Entitlement to a rating in excess of 10 percent for limitation of flexion of the right knee is denied. Entitlement to a separate 20 percent rating for dislocation of the semilunar cartilage of the right knee is granted. Entitlement to an effective date prior to December 6, 2011 for a separate evaluation for other impairment of the right knee is denied. Entitlement to an effective date prior to December 6, 2011 for a separate evaluation for limitation of flexion of the right knee is denied. Entitlement to a 20 percent rating for radiculopathy of the right lower extremity is granted. Entitlement to an effective date prior to March 3, 2011 for a rating for radiculopathy of the right lower extremity is denied. The appeal to revise the October 20, 2009 rating decision that discontinued entitlement to a total rating based on individual unemployability (TDIU) due to clear and unmistakable error (CUE) is denied. Entitlement to TDIU is denied. REMANDED The claim for service connection for diabetes mellitus is remanded. The claim for service connection for a right hip disability to include as secondary to a service connected right knee disability on a de novo basis is remanded. FINDINGS OF FACT 1. The Veteran does not have a current diagnosis of a left knee disability, and there is no evidence of a functional impairment of earning capacity due to a left knee disability. 2. Entitlement to service connection for a right hip disability was initially denied in a November 1989 rating decision on the basis that there was no evidence of a current right knee disability; the Veteran did not submit a notice of disagreement with this decision or submit new and material evidence within the one-year appeal period. 3. Evidence received since the most recent final denial of the Veteran’s claim for service connection for a right hip disability in July 2009 raises the possibility the Veteran now has a current right hip disability; this information was not previously before the decision makers and addresses the basis for the original denial. 4. The Veteran is evaluated as having severe impairment of the right knee due to recurrent subluxation or lateral instability; this is the highest schedular evaluation available under the appropriate rating criteria. 5. The Veteran’s right knee has limitation of flexion to 100 degrees; there is no additional limitation due to pain, weakness, incoordination or other factors due to repetitive use or flare-ups. 6. The Veteran has a history of meniscal tear, with frequent episodes of locking, pain, and effusion into the joint; these symptoms are not duplicative or overlapping with the symptoms listed in the rating criteria for impairment of the knee due to subluxation or lateral instability or limitation of flexion. 7. The earliest communication that can be construed as a claim for an increased rating for the Veteran’s right knee disability was received on December 6, 2011, and it was not factually ascertainable that an increase in disability occurred during the one year prior to receipt of this claim. 8. The Veteran’s radiculopathy of the right lower extremity is productive of moderate incomplete paralysis. 9. The earliest communication that can be construed as a claim for an increased rating for the Veteran’s lumbosacral strain was received on March 3, 2011; the separate rating for radiculopathy of the right lower extremity was established in conjunction with this claim, and it was not factually ascertainable that an increase in disability manifested by radiculopathy occurred during the one year prior to receipt of this claim. 10. Entitlement to TDIU was discontinued in an October 20, 2009 rating decision; the Veteran did not submit a notice of disagreement with this decision or submit new and material evidence within the one-year appeal period. 11. The Veteran has not identified a clear and unmistakable error in the October 20, 2009 rating decision with any specificity; her argument is a disagreement with how the facts were evaluated; there is no indication that the facts before the October 20, 2009 decisionmakers were inaccurate or that the regulations then in effect were applied incorrectly. 12. The Veteran meets the schedular criteria for consideration of TDIU, but her service connected disabilities do not preclude her from obtaining and maintaining gainful employment. CONCLUSIONS OF LAW 1. The criteria for service connection for a left knee disability have not been met. 38 U.S.C. §§ 1110, 5107(b) (2012); 38 C.F.R. §§ 3.303(a), 3.310 (2017). 2. The November 1989 rating decision that initially denied entitlement to service connection for a right hip disability is final. 38 U.S.C. § 7105 (2012); 38 C.F.R. §§ 3.105(a), 3.156(b) (2017). 3. New and material evidence has been received since the most recent final denial, and the claim for service connection for a right hip disability as secondary to a service connected right knee disability is reopened. 38 C.F.R. § 3.156(a) (2017). 4. The criteria for a rating in excess of 30 percent for other impairment of the right knee due to subluxation or lateral instability have not been met. 38 U.S.C. §§ 1155, 5107(b) (2012); 38 C.F.R. §§ 4.7, 4.10, 4.21, 4.40, 4.45, 4.71a, Code 5257 (2017). 5. The criteria for a rating in excess of 10 percent for limitation of flexion of the right knee have not been met. 38 U.S.C. §§ 1155, 5107(b) (2012); 38 C.F.R. §§ 4.7, 4.10, 4.21, 4.40, 4.45, 4.71a, Code 5260 (2017). 6. The criteria for a separate 20 percent rating for dislocation of the semilunar cartilage of the right knee have been met. 38 U.S.C. §§ 1155, 5107(b) (2012); 38 C.F.R. §§ 4.7, 4.10, 4.21, 4.40, 4.45, 4.71a, Code 5258 (2017). 7. The criteria for an effective date prior to December 6, 2011 for a 30 percent rating for other impairment of the right knee due to subluxation or lateral instability have not been met. 38 C.F.R. § 3.400 (o)(2) (2017). 8. The criteria for an effective date prior to December 6, 2011 for a 10 percent rating for limitation of flexion of the right knee have not been met. 38 C.F.R. § 3.400(o)(2) (2017). 9. The criteria for a 20 percent rating for radiculopathy of the right lower extremity have been met; the criteria for a rating in excess of 20 percent have not been met. 38 U.S.C. §§ 1155, 5107(b) (2012); 38 C.F.R. §§ 4.7, 4.10, 4.21, 4.124a, Code 8520 (2017). 10. The criteria for an effective date prior to March 3, 2011 for a separate rating for radiculopathy of the right lower extremity have not been met. 38 C.F.R. § 3.400(o)(2) (2017). 11. The October 20, 2009 rating decision that discontinued entitlement to a total rating based on individual unemployability due to service connected disabilities is final; and does not contain clear and unmistakable error. 38 U.S.C. § 7105 (2012); 38 C.F.R. §§ 3.105(e), 3.343(c), 4.16(a) (2009); 38 C.F.R. §§ 3.105(a), 3.156(b) (2017). 12. The criteria for a total rating based on individual unemployability due to service connected disabilities have not been met. 38 C.F.R. §§ 3.341, 4.16, 4.19 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from September 1979 to April 1983. The Veteran withdrew her request for a hearing before a Veterans Law Judge in November 2016. During this appeal, the effective dates for the awards of a separate 30 percent rating based on other impairment of the right knee due to subluxation or lateral instability, and a 10 percent rating based on limitation of flexion were changed to the earlier date of December 6, 2011 by an April 2016 rating decision. Similarly, an August 2016 rating decision awarded an effective date of March 3, 2011 for a separate evaluation for radiculopathy of the right lower extremity. A veteran is generally presumed to be seeking the maximum benefit allowed by law and regulation, and a claim remains in controversy where less than the maximum available benefit is awarded. AB v. Brown, 6 Vet. App. 35, 38 (1993). Therefore, as the Veteran has not expressed satisfaction with the new effective dates, these issues remain on appeal. Service Connection The Veteran contends that a left knee disability and a right hip disability have developed secondary to her service connected right knee disability. Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active military service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Establishing service connection generally requires (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); 38 C.F.R. § 3.303. Consistent with this framework, service connection is warranted for a disease first diagnosed after discharge when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303 (d). Under 38 C.F.R. § 3.303 (b), an alternative method of establishing the second and third Shedden/Caluza element is through a demonstration of continuity of symptomatology. However, this method may be used only for the chronic diseases listed in 38 C.F.R. § 3.309. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Regulations provide that service connection is warranted for a disability which is aggravated by, proximately due to, or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Further, a disability which is aggravated by a service-connected disorder may be service connected to the degree that the aggravation is shown. Allen v. Brown, 7 Vet. App. 439, 449 (1995); 38 C.F.R. § 3.310(b). To establish entitlement to secondary service connection, there must be (1) evidence of a current disability; (2) evidence of a service-connected disability; (3) medical evidence establishing a nexus between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). In relevant part, 38 U.S.C. § 1154(a) (2012) requires that VA give "due consideration" to "all pertinent medical and lay evidence" in evaluating a claim for disability benefits. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). The Federal Circuit has held that "[l]ay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional." Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); see also Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) ("[T]he Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence"). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107(b). 1. Entitlement to service connection for a left knee disability. VA X-ray studies conducted in June 1989 and March 2001 show that the left knee was normal. A July 2008 magnetic resonance imaging (MRI) study said to be of the left knee states that the Veteran has a history of pain and swelling with multiple knee surgeries. The findings were that the cartilage surface was preserved, and there was no evidence of derangement. However, as there is no evidence that the left knee has undergone surgery and ample evidence that the right knee has undergone multiple surgeries, the accuracy of the description of the MRI as being for the left knee is questionable. The Veteran was afforded a VA examination of her disabilities in October 2008. She was noted to have a history of internal derangement of the right knee, and to have undergone five surgeries. No left knee symptoms were noted. On examination, the left knee did not show signs of edema, effusion, weakness, tenderness, redness, heat, subluxation or guarding of movement. There was no locking or crepitus. The range of motion was normal, without additional limitation due to pain, weakness, fatigue, or lack of endurance after repetitive use. The ligaments were stable, and the meniscus tests were normal. The Veteran was afforded a VA examination of the knee and lower legs in January 2014. The left knee had a normal range of motion that was unchanged after repetitive motion. No pain or other functional loss of the left knee was noted, and muscle strength testing was normal. Stability testing was normal, and there was no patellar subluxation or dislocation of the left knee. The left knee did not have any symptoms relating to a meniscus condition. The right knee had a history of multiple surgeries but the left knee did not. There was no evidence of traumatic arthritis or patellar subluxation on X-ray study. The examination did not conclude with any diagnosis of a left knee disability. In an October 2014 Notice of Disagreement with many of the issues now on appeal, the Veteran said that although there had been mentions of issues with her left knee being aggravated as secondary to her service connected right knee, she had never claimed service connection for the left knee. The Board concludes that entitlement to service connection for a left knee disability is not warranted. Every theory of entitlement requires competent evidence of a current disability. In this case, there is simply no evidence of a diagnosis of a left knee disability during the appeal period. Furthermore, as every examination shows that the Veteran has a full range of motion and normal stability of the left knee that does not change with repetitive motion or demonstrate objective evidence of pain, there is no evidence of a functional impairment of earning capacity due to a left knee disability. The initial requirement to establish service connection has not been met, and the Veteran’s appeal must be denied. 38 C.F.R. §§ 3.303, 3.310; Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018). New and Material Evidence 1. Entitlement to service connection for a right hip disability. The Veteran contends that she has developed a right hip disability secondary to her service connected right knee disability. She states that her right knee disability has altered her gait, which strains her right hip, resulting in a chronic disability. The record shows that entitlement to service connection for a right hip disability was initially denied in a November 1989 rating decision. The basis for this denial was that there was no evidence to show that the Veteran had a right hip disability. The Veteran was notified of this decision and provided her appellate rights in a January 1990 letter. She did not appeal this decision by submitting a notice of disagreement and new and material evidence was not received prior to the expiration of the period in which to appeal. Therefore, the November 1989 rating decision is final and is not subject to revision on the same factual basis. 38 U.S.C. § 7105; 38 C.F.R. §§ 3.105(a), 3.156(b). A veteran may reopen a finally adjudicated claim by submitting new and material evidence. New evidence is defined as existing evidence not previously submitted to the VA, and material evidence is defined as existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). The newly presented evidence is presumed to be credible for purposes of determining whether it is new and material. Savage v. Gober, 10 Vet. App. 488 (1997). The question of whether to reopen a claim should be considered under the standard of 38 C.F.R. § 3.159(c)(4)(iii), consistent with McLendon v. Nicholson, 20 Vet. App. 79 (2006), for determining whether a VA examination is necessary. VA is 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). The threshold for finding a link between current disability and service is low. Locklear v. Nicholson, 20 Vet. App. 410 (2006); McLendon, 20 Vet. App. at 83. If the McLendon standard is met, the claim should be reopened. See Shade v. Shinseki, 24 Vet. App. 110 (2010). The Veteran’s claim for service connection for a right hip disability was most recently considered in a December 2008 rating decision. After the receipt of additional medical records, her claim was again considered in a July 2009 rating decision, which determined that new and material evidence had not been submitted. She was notified of this decision in a July 2009 letter, but did not submit a notice of disagreement or additional evidence within the appeal period. The July 2009 decision is final, and as it is the most recent final determination on any basis, the Board will consider the evidence received since July 2009 to determine if any is new and material. Evans v. Brown, 9 Vet. App. 273, 285 (1996). The evidence received since July 2009 includes the report of an February 2012 VA examination of the hips and thighs. The examiner found that the Veteran has never had a diagnosis of a hip or thigh condition. The Veteran reported chronic right hip pain since 1987, and there was a history of steroid injections into the hip in 1992. On examination, the range of motion of the right hip was normal, with no objective evidence of pain. There was no change following repetitive motion. Muscle strength testing was normal. Imaging studies were negative for evidence of degenerative or traumatic arthritis. However, VA treatment records from September 2012 show that the Veteran was seen with complaints of right hip and lower back pain. She described her right hip pain as a burning and grinding sensation. She had experienced previous episodes of hip pain which were helped by cortisone injections. On examination, there was tenderness over the lateral right hip, with pain with all range of motion but able to flex and extend to 45 degrees. An X-ray study of the hip was normal. The Board finds that the September 2012 VA treatment records constitutes new and material evidence. These records and the information they purport to show were not previously before the Board, which makes the evidence new. The basis of the original denial was the lack of evidence of a current disability. There continues to be a lack of a current disability in the February 2012 VA examination. However, the September 2012 VA records show that the Veteran was seen with complaints of tenderness and pain of the right hip with all range of motion, but able to flex and extend to 45 degrees. The Board observes that normal range of motion of the hip is from zero to 125 degrees, and that the Veteran could achieve full range of motion only seven months earlier at the February 2012 examination. 38 C.F.R. § 4.71a, Plate II. This limitation of motion at least raises the question as to whether the Veteran has a functional impairment of her right hip and, therefore, a current disability. Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018). As there is evidence that the Veteran may have a current disability, the evidence is material, and her claim can is reopened. Moreover, given her service-connected right knee disability, the question as to whether any potential current right hip disability is the result of the right knee disability is also raised, which meets the McLendon standard. The Veteran should be afforded a new examination to confirm whether or not she now has a chronic disability of the right hip and, if so, whether or not it is related to her service connected right knee disability. The issue of entitlement to service connection for a right hip disability secondary to the service connected right knee disability on a de novo basis will be addressed in the remand section. Increased Ratings and Effective Dates The Veteran contends that the evaluations assigned to her right knee laxity, right knee limitation of flexion, and radiculopathy of the right lower extremity are inadequate to reflect the impairment produced by these disabilities. She also believes that she is entitled to effective dates prior to December 6, 2011 for her knee evaluations, and prior to March 3, 2011 for the radiculopathy of the right lower extremity. In her notice of disagreement, she expresses her belief that her claims for increased ratings for the right knee were submitted in March 2011. The evaluation of service-connected disabilities is based on the average impairment of earning capacity they produce, as determined by considering current symptomatology in the light of appropriate rating criteria. 38 U.S.C. § 1155. Consideration is given to the potential application of the various provisions of 38 C.F.R. Parts 3 and 4, whether or not they are raised by the veteran, as required by Schafrath v. Derwinski, 1 Vet. App. 589 (1991). In addition, the entire history of the veteran's disability is also considered. Consideration must be given to the ability of the veteran to function under the ordinary conditions of daily life. 38 C.F.R. § 4.10. If there is a question as to which of two evaluations should apply, the higher rating is assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is assigned. 38 C.F.R. § 4.7. In view of the number of atypical instances it is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified. Findings sufficiently characteristic to identify the disease and the disability therefrom, and above all, coordination of rating with impairment of function will, however, be expected in all instances. 38 C.F.R. § 4.21. Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Although a rating specialist is directed to review the recorded history of a disability in order to make a more accurate evaluation, see 38 C.F.R. § 4.2, the regulations do not give past medical reports precedence over current findings. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, the Board will consider whether a staged rating is appropriate for the period on appeal. Hart v. Mansfield, 21 Vet. App. 505 509-10 (2007). In general, the effective date of an evaluation and award of pension, compensation or dependency and indemnity compensation based on an original claim, a claim reopened after final disallowance, or a claim for increase will be the date of receipt of the claim or the date entitlement arose, whichever is the later. 38 C.F.R. § 3.400. For increases, the effective date will be the date of receipt of the claim or date entitlement arose, whichever is later. 38 C.F.R. § 3.400(o). The effective date of an increase in disability compensation is the earliest date as of which it is factually ascertainable that an increase in disability had occurred if the claim is received within one year from such date. Otherwise, the effective date is the date of receipt of the claim. 38 C.F.R. § 3.400(o)(2). If an increase in disability occurred within one year prior to the claim, the increase is effective as of the date the increase was "factually ascertainable." If the increase occurred more than one year prior to the claim, the increase is effective the date of claim. If the increase occurred after the date of claim, the effective date is the date of increase. 38 U.S.C. § 5110(b)(2); Harper v. Brown, 10 Vet. App. 125 (1997); 38 C.F.R. § 3.400(o)(1)(2); VAOPGCPREC 12-98 (1998). 1. A rating in excess of 30 percent for other impairment of the right knee due to subluxation or lateral instability. 2. A rating in excess of 10 percent for limitation of flexion of the right knee. 3. An effective date prior to 12/6/11 for a separate evaluation for other impairment of the right knee. 4. An effective date prior to 12/6/11 for a separate evaluation for limitation of flexion of the right knee. Entitlement to service connection for a right knee disability was granted in a July 1983 rating decision. A 10 percent rating for was initially assigned under the rating criteria for other impairment of the knee due to subluxation or lateral instability. This was increased to 30 percent on March 30, 1994. Effective December 6, 2011, a separate 10 percent rating was assigned for limitation of motion of the right knee. Although the diagnosis of the right knee disability was recharacterized from right knee strain with laxity and scar to right knee meniscus derangement with patellofemoral pain syndrome, the 30 percent rating assigned under the rating criteria for other impairment of the knee due to subluxation or lateral instability was continued. The rating criteria for other impairment of the knee due to recurrent subluxation or lateral instability provide a 30 percent rating for severe impairment; a 20 percent rating for moderate impairment; and a 10 percent rating for slight impairment. 38 C.F.R. § 4.71a, Code 5257. Flexion of the knee that is limited to 15 degrees is evaluated as 30 percent disabling. Limitation of flexion to 30 degrees merits a 20 percent evaluation. Limitation of flexion to 45 degrees warrants a 10 percent evaluation. Limitation of flexion to 60 degrees is evaluated as zero percent disabling. 38 C.F.R. § 4.71a, Code 5260. The rating code for limitation of extension of the knee may also be for consideration. This provides that limitation of extension to 45 degrees is evaluated as 50 percent disabling. Limitation of extension to 30 degrees receives a 40 percent evaluation. 20 degrees of extension is evaluated as 30 percent disabling. Limitation of extension to 15 degrees merits a 20 percent evaluation. Limitation of extension to 10 degrees is evaluated as 10 percent disabling. Limitation of extension to 5 degrees is evaluated as 0 percent disabling. 38 C.F.R. § 4.71a, Code 5261. When evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use and, therefore, not be reflected on range-of-motion testing. 38 C.F.R. § 4.45 requires consideration also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Nonetheless, even when the background factors listed in § 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a (musculoskeletal system) or § 4.73 (muscle injury); a separate or higher rating under § 4.40 or 4.45 itself is not appropriate. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016) (“[I]t is clear that the guidance of § 4.40 is intended to be used in understanding the nature of the veteran’s disability, after which a rating is determined based on the § 4.71a [or 4.73] criteria.”). The evidence includes VA treatment records dated September 2012. These state that the Veteran has a history of five surgeries of the right knee for dislocation. The knee was still lax, and she was seen with reports of right knee pain that had spread to the right hip. The Veteran underwent a VA examination of her knees in January 2014. She reported the daily use of pain medication and the constant use of a brace. She was unable to use stairs, kneel, or squat. The Veteran also reported flare-ups, which she described as increased subluxation during cold weather, or when walking on uneven or slick surfaces, standing for extended periods of time, kneeling, or using the stairs. Flexion was to 100 degrees, at which point there was objective evidence of painful motion. Extension was a normal zero degrees without pain. The Veteran completed repetitive-use testing, which did not result in additional limitation of motion. Her functional loss of the right knee was characterized as less movement than normal and pain on movement, but did not include weakened movement, excess fatigability, or incoordination. Muscle strength testing was normal, and there was no instability. Slight patellar subluxation was demonstrated. There was a history of meniscal tear, with frequent episodes of locking, pain, and effusion. The Veteran reported multiple surgeries, and continued to report pain and swelling of the right knee. She used a brace on a constant basis and regularly used a cane. On X-ray study, there was no documentation of arthritis or patellar subluxation. The examiner concluded that the Veteran’s disability limited her ability to kneel, stoop, squat, climb, carry a load, stand for long periods of time, climb stairs or move laterally. There were no contributing factors of weakness, fatigability, incoordination or pain during flare-ups or repeated use that resulted in additional limitation of function. Regarding the Veteran’s evaluation under the rating criteria for other impairment of the knee due to recurrent subluxation or instability, the current 30 percent rating is the highest provided under the rating criteria. Therefore, no further discussion is required. See 38 C.F.R. § 4.71a, Codes 5257; Johnston v. Brown, 10 Vet. App. 80, 85 (1995). Furthermore, the Board finds that the evidence does not support entitlement to a rating higher than the current 10 percent based on limitation of flexion. Flexion must be limited to 30 degrees or less to warrant a rating higher than 10 percent. However, the January 2014 examination found that the Veteran had 100 degrees of flexion before she displayed objective evidence of pain. She could complete repetitive motion testing, but this did not result in further limitation of motion. The Veteran reported flare-ups but described these symptoms as an increase in subluxation, and not limitation of motion. The examiner found there were no contributing factors of weakness, fatigability, incoordination or pain during flare-ups or repeated use that resulted in additional limitation of function. The Board concludes that entitlement to a rating higher than 10 percent based on limitation of flexion is not supported by the evidence. 38 C.F.R. §§ 4.40, 4.45, 4.71a, Code 5260. The Board has also considered entitlement to an evaluation based on limitation of extension, but limitation of extension was not shown on the January 2014 examination even on flare-ups or after repetitive testing. Therefore, there is no basis for an evaluation under this code instead of the code for limitation of flexion, and no basis for separate evaluations based on limitation of both flexion and extension. 38 C.F.R. §§ 4.40, 4.45, 4.71a, Code 5260; VAOPGCPREC 9-04. However, the Board will find that the Veteran is entitled to a separate 20 percent rating for dislocation of the semilunar cartilage. The rating criteria of 38 C.F.R. § 4.71a, Code 5258 provide for a 20 percent rating for dislocation of the semilunar cartilage when there is frequent episodes of locking, pain, and effusion into the joint. The January 2014 VA examination notes her history of meniscal tears, and states that her symptoms include frequent locking, pain, and effusion into the joint. None of these symptoms are duplicative or overlapping of the symptoms outlined in the rating criteria for either other impairment of the knee due to recurrent subluxation or lateral instability, or of limitation of flexion. It follows that a separate 20 percent rating is warranted under the rating criteria for dislocation of the semilunar cartilage. See 38 C.F.R. § 4.71a, Codes 5257, 5258, 5260; VAOPGCPREC 23-97; Esteban v. Brown, 6 Vet. App. 259, 261-262 (1994). Turning to the Veteran’s claims for earlier effective dates, the Board finds that there is no basis for an effective date prior to December 6, 2011 for either the 30 percent rating for other impairment of the right knee or the separate 10 percent rating for limitation of flexion. A previous claim from the Veteran for an increased rating for her right knee disability was denied in a July 2009 rating decision. As previously noted in the discussion of her right hip, she was notified of this decision in a July 2009 letter, but did not submit a notice of disagreement or additional evidence within the appeal period. The July 2009 decision is final, including the denial therein for a rating higher than 30 percent for a right knee disability. 38 U.S.C. § 7105; 38 C.F.R. §§ 3.105(a), 3.156(b). An earlier effective date based on the actions within this rating decision can only be awarded on the basis of clear and unmistakable error, which has not been raised by the Veteran. A free-standing claim for an earlier effective date based on this decision may not be addressed. Rudd v. Nicholson, 20 Vet. App. 296, 299-300 (2006). The record confirms that a VA Form 21-526 was received from the Veteran on March 4, 2011. However, while this form includes claims pertaining to her low back, diabetes, and a genitourinary disability, it makes no mention of her service connected right knee disability. Thereafter, the Veteran submitted a VA Form 21-4138 that was received on December 6, 2011. Although she did not specifically claim an increased rating for her right knee disability, she did discuss this disability in the context of how it affects her other claims. The Regional Office (RO) accepted this as a claim for an increased rating for her knee disability. The Board notes that no other communication dated between the July 2009 rating decision and this submission can be construed as a claim for an increased rating for the right knee disability. Furthermore, a review of the medical records does not show a VA examination, hospitalization, or other treatment for the right knee between July 2009 and December 6, 2011 that could be accepted as a claim for an increased rating under the regulations in effect at that time. See 38 C.F.R. § 3.157 (2011). The Board finds that the earliest document that can be interpreted as a claim for an increased rating for the right knee was the form received on December 6, 2011, and accepts this document as the Veteran’s current claim. The Board must next review the record to ascertain whether or not it is factually ascertainable that the Veteran became eligible for an increased rating within one year prior to the receipt of the December 6, 2011 claim. After completion of this review, the Board’s is unable to identify any medical records or other competent evidence that shows it was factually ascertainable the Veteran became eligible for an increased rating in the year prior to receipt of the December 6, 2011 claim. The evidence for this period includes the report of a May 2011 VA general medical examination, but this did not include an examination of the right knee. VA treatment records from this period note her history of previous knee surgeries, but do not include any treatment or findings for the right knee. Private chiropractic records and other private medical records do not show treatment of the right knee. There is no evidence to confirm both limitation of flexion and impairment of the knee due to subluxation or instability during this year that would support a separate rating. The Board concludes that it was not factually ascertainable that the Veteran was eligible for an increased rating for her right knee disability within one year prior to receipt of the claim on December 6, 2011, and the proper effective date is the December 6, 2011 date that is currently assigned for both the 30 percent rating based on impairment due to subluxation or instability, and the separate 10 percent rating based on limitation of flexion of the right knee. 38 C.F.R. § 3.400(o)(2). 5. A rating in excess of 10 percent for radiculopathy of the right lower extremity. 6. An effective date prior to 3/3/11 for a separate rating for radiculopathy of the right lower extremity. In a March 2014 rating decision, it was determined that the Veteran was entitled to a separate 10 percent rating for radiculopathy of the right lower extremity. This was noted to be related to her service connected lumbosacral strain. An effective date of October 11, 2012 was first assigned for this disability. However, an August 2016 rating decision changed the effective date to the current date of March 3, 2011. The Veteran’s radiculopathy of the right lower extremity is evaluated under the rating criteria for paralysis of the sciatic nerve. Complete paralysis of the sciatic nerve exists when the foot dangles and drops, there is no active movement possible of muscles below the knee, and flexion of the knee is weakened or (very rarely) lost. This is evaluated as 80 percent disabling. Severe incomplete paralysis with marked muscular atrophy is evaluated as 60 percent disabling. Moderately severe paralysis is evaluated as 40 percent disabling. Moderate paralysis is evaluated as 20 percent disabling, and mild paralysis merits continuation of the 10 percent rating currently in effect. 38 C.F.R. § 4.124a, Code 8520. The term “incomplete paralysis,” with this and other peripheral nerve injuries, indicates a degree of lost or impaired function substantially less than the type picture 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 should be for the mild, or at most, the moderate degree. 38 C.F.R. § 4.124a. VA policy indicates, as a guide, that moderate incomplete paralysis will likely be described by the Veteran and medically graded as significantly disabling and may be demonstrated by 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. In Miller v. Shulkin, the United States Court of Appeals for Veterans Claims (Court) held that “[a]lthough the note preceding § 4.124a directs the claims adjudicator to award no more than a 20 percent disability rating for incomplete paralysis of a peripheral nerve where the condition is productive of wholly sensory manifestations, it does not logically follow that any claimant who also exhibits non-sensory manifestations must necessarily be rated at a higher level.” 28 Vet. App. 376, 380 (2017). The evidence includes the report of a May 2011 VA general medical examination. The Veteran’s lumbosacral strain was said to be productive of pain that traveled to the right buttocks and right leg. She described the pain as moderate in intensity. The Veteran underwent a VA examination of her back in January 2014. She reported shooting pain down her legs. However, the examination report states that the Veteran did not have radicular pain or any other signs or symptoms due to radiculopathy. The examiner checked the “None” box for all possible radicular symptoms listed, and added that the Veteran did not have any other radicular symptoms. In June 2016, the Veteran was afforded a VA fee basis examination of the peripheral nerves. Her symptoms included severe pain of the right lower extremity. She also reported moderate paresthesias and severe numbness. The sensory examination showed there was decreased sensation of the right thigh, knee, lower leg, and ankles. Muscle strength testing and reflexes were normal. There were no trophic changes. The examiner concluded that the affected nerve was the right sciatic, and opined that there was moderate incomplete paralysis. The diagnosis was sciatica. The Board finds that the evidence supports entitlement to a 20 percent rating for radiculopathy of the right lower extremity. The June 2016 examiner opined that the Veteran has moderate incomplete paralysis. There is no contradictory evidence or opinion dating on or after June 2016. The rating criteria provides a 20 percent rating for moderate incomplete paralysis, and the Board concludes the 20 percent evaluation is proper. 38 C.F.R. § 4.124a, Code 8520. The Board has also considered entitlement to a rating in excess of 20 percent but this is not supported by the rating criteria. The June 2016 VA examination did not include evidence of symptoms such as muscle weakness or loss of reflexes. Instead, it shows that the Veteran’s symptoms are wholly sensory, in which case the disability cannot be rated as worse than moderate. See 38 C.F.R. § 4.124a. As noted, the rating criteria for radiculopathy of the sciatic nerve provides for a 20 percent rating for moderate incomplete paralysis, and it follows that, given the Veteran’s current symptomatology, this is the maximum evaluation that can be assigned. 38 C.F.R. § 4.124a, Code 8520. Turning to the question of the proper effective date for the separate evaluation for the Veteran’s radiculopathy of the right lower extremity, the Board observes that the August 2016 rating decision that first assigned this evaluation indicates that it is associated with her service connected lumbosacral strain. The rating criteria for that disability state that any associated objective neurologic abnormalities are to be evaluated separately under the appropriate diagnostic code. 38 C.F.R. § 4.71a, Code 5237 (2017). The record shows that the same July 2009 rating decision that denied her claim for an increased rating for her right knee disabilities also denied a claim for an increased rating for her service connected lumbosacral strain. As discussed in the context of the Veteran’s claims for her right hip and right knee, she did not appeal this decision or submit new and material evidence within the appeal period, and it is final. 38 U.S.C. § 7105; 38 C.F.R. §§ 3.105(a), 3.156(b). Thereafter, the Veteran submitted a new claim for an increased rating for her back disability that was received on March 3, 2011. A review of the record does not show any earlier communication received after July 2009 that can be construed as a claim for an increased rating for a back disability or requesting compensation for radiculopathy, nor were there any examinations or treatment records that can be accepted as a claim for increased compensation under the regulations then in effect. See 38 C.F.R. § 3.157 (2011). Finally, a review of the evidence for the year prior to March 3, 2011 fails to show that it was factually ascertainable that the Veteran was eligible for an increased rating for her back disability on the basis of radiculopathy within one year prior to receipt of the claim on March 3, 2011. The Board concludes that the effective date currently assigned, March 3, 2011, is correct. TDIU 1. Whether the October 20, 2009 rating decision that discontinued the Veteran’s entitlement to TDIU contains CUE. The Veteran contends that she should remain entitled to TDIU. She argues that although she has been employed full time for most of the period in question, her disabilities caused her to miss significant time, which resulted in lost income. The Veteran also states that in 2011 to 2012 it took her approximately eight months to find a new job, which she states was the result of difficulty in finding an employer who would accommodate her disabilities. The record shows that entitlement to TDIU was granted in a September 1994 rating decision, and effective from January 12, 1994. In August 2009, a rating decision proposed to discontinue TDIU on the grounds the Veteran was able to secure and follow a gainful occupation. An October 20, 2009 rating decision discontinued entitlement to TDIU effective from October 31, 2009. She was notified of this decision and provided her appellate rights in a November 2009 decision. The Veteran did not submit a notice of disagreement with this decision, and new and material evidence was not received within the one-year period provided to initiate an appeal. The decision is final. 38 U.S.C. § 7105; 38 C.F.R. §§ 3.105(a), 3.156(b). Under the provisions of 38 C.F.R. § 3.105(a), previous determinations that are final and binding will be accepted as correct in the absence of CUE. However, if the evidence establishes CUE, the prior decision will be reversed and amended. A finding of CUE has the same effect as if the corrected decision had been made on the date of the reversed decision. At this juncture, the Board observes that an October 2012 rating decision determined that the October 20, 2009 rating decision contained CUE to the extent that it made October 31, 2009 the effective date of termination of TDIU. This decision found that the effective date violated 38 C.F.R. § 3.105(e) (2009), and found that the correct effective date of termination is February 1, 2010. The appeal that is now before the Board does not concern the effective date of termination, but whether or not the October 20, 2009 rating decision contained CUE regarding whether or not the termination itself was proper. A motion for revision on the basis of CUE is a collateral attack on a final RO or Board decision. Disabled Am. Veterans v. Gober, 234 F.3d 682, 696-98 (Fed. Cir. 2000). CUE is established when the following conditions are met: First, either (1) the correct facts in the record were not before the adjudicator, or (2) the existing statutory or regulatory provisions were incorrectly applied. Damrel v. Brown, 6 Vet. App. 242, 245 (1994). Second, the alleged error must be "undebatable," not merely "a disagreement as to how the facts were weighed or evaluated." Russell v. Principi, 3 Vet. App. 310, 313-14 (1992) (en banc). Finally, the commission of the alleged error must, at the time that decision was rendered, have "manifestly changed the outcome" of the decision. Id.; see Bustos v. West, 179 F.3d 1378, 1380 (Fed. Cir. 1999) (expressly adopting "manifestly changed the outcome" language in Russell); see also King v. Shinseki, 26 Vet. App. 433, 442 (2014) (citing Russell, 3 Vet. App. at 313-14) ("Whether it is reasonable to conclude that the outcome would have been different is not the standard that must be met for a motion alleging [CUE] to succeed. The governing law requires that the error be 'undebatable' and that the commission of the alleged error must have 'manifestly changed the outcome' of the decision."). In order to determine whether or not a decision contains CUE, the laws and regulations in effect at the time of the decision in question are for consideration. In this case, the regulations have not changed since October 2009. Then, as now, TDIU may be assigned, when the disabled person is, in the judgment of the rating agency, unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities, provided that, if there is only one such disability, this disability shall be ratable at 60 percent or more, and that, if there are two or more disabilities, there shall be at least one disability ratable at 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent or more. Marginal employment shall not be considered substantially gainful employment. 38 C.F.R. § 4.16(a) (2009). Once the rating criteria are met, the remaining question concerns whether the Veteran is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities. 38 C.F.R. § 4.16(a). Under 38 C.F.R. § 3.343(c)(1) (2009), in reducing a rating of 100 percent based on individual unemployability, the provisions of 38 C.F.R. § 3.105(e) (2009) are for application. A reduction of a rating of 100 percent service-connected disability based on individual unemployability must be based on a determination that actual employability is established by clear and convincing evidence. Furthermore, if a Veteran with TDIU begins to engage in a substantially gainful occupation, the rating may not be reduced solely on the basis of having secured and followed a gainful occupation unless the Veteran maintains the occupation for a period of 12 consecutive months. 38 C.F.R. § 3.343(c)(2) (2009). In this case, the evidence clearly shows that the Veteran met the schedular criteria for TDIU at the time of termination. Her service connected urinary tract infection with kidney atrophy and incontinence has been evaluated as 60 percent disabling since July 22, 1993, and she has had a combined evaluation of at least 70 percent since that time. Her combined evaluation was 80 percent at the time of the October 20, 2009 rating decision. Therefore, the Veteran’s basic schedular entitlement to TDIU under § 4.16(a) was not at issue. Instead, the question that was addressed in the October 20, 2009 rating decision was whether the Veteran’s service connected disabilities rendered her unable to obtain and maintain gainful employment. The evidence considered by this decision consisted of a VA Form 21-4140 Employment Questionnaire in August 2009. This states that she had been employed working 40 hours a week at an office job since September 2008. She had missed 109 hours of work due to illness, and earned has highest gross earnings of $2,701 a month. She submitted a second VA Form 21-4140 in October 2009. On this occasion, she states that she was working 40 hours a week in accounting. She had lost 326 hours due to illness, and earned has highest gross earnings of $2,685 a month. She also submitted a statement arguing that because of her absences, her job did not constitute substantially gainful employment. She notes that her wages were reduced due to her lost time. Based on this evidence, the October 20, 2009 decision determined that after the 326 hours of lost work were factored in, the Veteran had earned $26,850 over the past year (based on 10 months of work). The decision noted that this was well over the 2008 poverty level for one person of $11,201. It further noted that the Veteran had maintained her occupation for a period of 12 consecutive months. The Board finds that the October 20, 2009 rating decision does not contain CUE. The Veteran has not identified the alleged CUE with any specificity. Instead, she merely argues that the decision incorrectly found that she was able to be gainfully employed. This, in essence, is merely a disagreement with how the facts were weighed or evaluated, and not a CUE argument. The Veteran does not contend that the factual evidence considered by the October 20, 2009 rating decision was incorrect. In fact, the key evidence was the VA Form 21-4140’s that were completed and submitted by the Veteran herself. There is also no indication that the regulatory provisions were incorrectly applied. A rating with the proposed reduction was provided to the Veteran in August 2009 and, after the appropriate period had passed, the October 2009 rating decision finalized the termination in accordance with 38 C.F.R. § 3.105(e) (2009). Although this decision assigned an effective date that did not comport with 38 C.F.R. § 3.105(e) (2009), it was corrected prior to the current appeal in an October 2012 rating decision, and the Veteran has not argued that the assigment of the effective date contains CUE. Finally, the reduction did not occur until the Veteran had been employed for 12 months. See 38 C.F.R. § 3.343(c)(2) (2009). Although the rating decision did not discuss whether employability had been established by clear and convincing evidence, the Board is unable to find that the failure to explicitly articulate the standard of proof manifestly changed the outcome of this rating decision. See 38 C.F.R. § 3.343(c)(1) (2009). It further observes that one year of constant employability would likely be clear and convincing evidence of actual employability. In sum, the Board finds that the October 20, 2009 rating decision does not contain CUE. 2. Entitlement to TDIU. The Board recognizes that a claim for an increased rating encompasses a claim for TDIU if raised by the record or the Veteran. Rice v. Shinseki, 22 Vet. App. 447, 453-54 (2009). Given that the Veteran contends she is unable to maintain gainful employment, the matter is clearly raised. With consideration of the increased ratings assigned by the current decision, the record shows the Veteran’s service connected disabilities include a urinary tract infection with kidney atrophy and incontinence, evaluated as 60 percent disabling from July 22, 1993; a right knee disability manifest by subluxation and instability; evaluated as 30 percent disabling; a right knee disability with dislocation of the semilunar cartilage, evaluated as 20 percent disabling; a scar of the right knee, evaluated as 20 percent disabling; lumbosacral strain, evaluated as 20 percent disabling; radiculopathy of the right lower extremity, evaluated as 20 percent disabling; a right knee disability manifested by limitation of flexion, evaluated as 10 percent disabling; a right wrist disability; evaluated as 10 percent disabling; and hemorrhoids and a second right knee scar, both evaluated as noncompensable. A combined 80 percent evaluation has been in effect from March 30, 1994, and a 90 percent evaluation has been in effect from December 6, 2011. The Veteran has clearly met the criteria for schedular consideration of TDIU for the entire appeal period. 38 C.F.R. § 4.16(a). Once the rating criteria are met, the remaining question concerns whether the Veteran is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities. 38 C.F.R. § 4.16(a). The fact that a veteran is unemployed or has difficulty finding employment does not warrant assignment of a TDIU alone as a high rating itself establishes that their disability makes it difficult for him to obtain and maintain employment. See Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). Rather, the evidence must show that he or she is incapable “of performing the physical and mental acts required” to be employed. See Van Hoose, 4 Vet. App. at 363. Thus, the central question is “whether the [V]eteran’s service connected disabilities alone are of sufficient severity to produce unemployability,” and not whether the Veteran could find employment. Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). Consideration may be given to a veteran’s education, training, and special work experience, but not to his or her age or to impairment caused by nonservice-connected disabilities. See 38 C.F.R. §§ 3.341, 4.16, 4.19. The Board finds that entitlement to TDIU is not established. As noted, the Veteran’s October 2009 VA Form 21-4140 Employment Questionnaire shows that she worked 40 hours a week as an accountant. She submitted a statement with this form in which she points out she missed 326 hours of work over the previous year due to her illnesses, and that her wages were below the average salary for an accountant with her qualifications. The Veteran’s October 2014 notice of disagreement states that she was unemployed from October 2011 to July 2012. She states that this is due to the inability to obtain employment with a firm that was willing to accommodate her disabilities. An August 2012 VA treatment record shows that she was now working as a medical administrative assistant at a VA laboratory. A March 2014 letter from the Veteran’s former employer states that she had been employed from January 2006 to October 2011. She consistently missed work time due to illnesses but was not in jeopardy of losing her job due to her health issues. VA treatment records from February 2013 show that the Veteran was working for the VA as an administrative assistant. She was also going to school online to learn medical coding. June 2013 records showing treatment for a non-service connected cardiac disability state the Veteran felt tired but was able to work an eight-hour day. August 2013 VA treatment records show that the Veteran was now working at a medical laboratory. April 2015 VA treatment records show that the Veteran was scheduled to undergo surgery. She requested a letter to give to her employer to validate her sick leave. Based on this evidence, the Board finds that the preponderance of the evidence shows that the Veteran is not precluded from obtaining and maintaining gainful employment. She has been employed on a full-time basis in various professional positions for most of the appeal period. Her employment as an accountant and an administrative assistant at a VA medical laboratory cannot be considered marginal employment. The Board is sympathetic to her contention that her disabilities have resulted in reduced wages. However, it must also be noted that the purpose of the compensation she already receives for her combined service connected disabilities is to replace those reduced wages. 38 C.F.R. § 4.1 (2017). Furthermore, the medical records indicate that the Veteran’s most recent absences have often been the result of non-service connected disabilities, such as her cardiac disability. The effects of those disabilities are not for consideration in determining her employability. As the totality of the evidence reflects that the Veteran is not precluded from obtaining and maintaining gainful employment by her service connected disabilities, entitlement to TDIU is not warranted. REASONS FOR REMAND 1. Entitlement to service connection for diabetes mellitus. The Veteran contends that she was diagnosed with hypoglycemia during service. She believes that this condition was a precursor to diabetes mellitus, and that it eventually developed into her current diabetes mellitus. The February 1983 service treatment records confirm that the Veteran was diagnosed with hypoglycemia. Private medical records demonstrate that the Veteran was first diagnosed with diabetes mellitus in June 2010. The Veteran was afforded a VA examination for diabetes mellitus in February 2012. The examiner found that while the Veteran had previously been diagnosed with diabetes mellitus, she did not currently meet the criteria for a diagnosis as her A1C was within normal limits. Consequently, no opinions were provided as to whether diabetes mellitus was incurred due to active service, to include the hypoglycemia noted in service. The examiner also noted that the Veteran had diabetic neuropathy, but did not explain how this was possible without a diagnosis of diabetes mellitus. However, both private and VA treatment records dated after the March 2011 claim include diagnoses of diabetes mellitus. More recent VA treatment records from May 2016 now include an assessment of Type 2 diabetes mellitus, uncontrolled with oral medication. Once VA undertakes the effort to provide an examination, it must provide one that is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). Therefore, the Veteran should be scheduled for a new VA examination of her diabetes mellitus to determine whether it is related to the hypoglycemia diagnosed in service or otherwise related to active service. 2. Service connection for a right hip disability on a de novo basis As noted above, new and material evidence has been submitted to reopen the Veteran’s claim for service connection for a right hip disability to include as secondary to a service connected right knee disability. The McLendon standard has also been met, and the Veteran should be afforded a new VA examination. The matter is REMANDED for the following actions: 1. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of her diabetes mellitus. The examiner is to provide an opinion with a comprehensive rationale whether it is at least as likely as not related to an in-service injury, event, or disease, including hypoglycemia. The examiner should opine whether it at least as likely as not that the diabetes mellitus (1) began during active service, (2) manifested within one year after discharge from service, or (3) was noted during service with continuity of the same symptomatology since service. 2. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any right hip disability. Following examination, the examiner should state whether the Veteran has a current disability of the right hip that is manifested by functional impairment. In addition to an orthopedic disability, the examiner should consider the possibility of a muscular or neurological disability of the right hip. For any disability that is found to be currently diagnosed, the examiner is to provide an opinion with a comprehensive rationale whether it is at least as likely as not related to an in-service injury, event, or disease. For any disability that is found not to be related to active service, the examiner is to provide an opinion whether it is at least as likely as not (1) proximately due to the service-connected right knee disability, or (2) aggravated beyond its natural progression by the service connected right knee disability. If aggravation is held to have occurred, can a baseline disability prior to aggravation be determined? If so, what was this baseline? Paul Sorisio Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD J. L. Prichard, Counsel