Citation Nr: 18147302 Decision Date: 11/02/18 Archive Date: 11/02/18 DOCKET NO. 16-12 248 DATE: November 2, 2018 ORDER Entitlement to an increased disability rating in excess of 10 percent prior to February 9, 2018, for hallux valgus, first metatarsophalangeal, with degenerative joint disease of 2nd through 4th toes of the left foot is denied. Entitlement to an increased disability rating in excess of 10 percent from June 1, 2018, for hallux valgus, first metatarsophalangeal, with degenerative joint disease of 2nd through 4th toes of the left foot is denied. A separate 10 percent rating for a scar associated with hallux valgus, first metatarsophalangeal, with degenerative joint disease of 2nd through 4th toes of the left foot is granted. Entitlement to a compensable disability rating for dysuria is denied. REMANDED Entitlement to service connection for a left knee disorder is remanded. Entitlement to service connection for a right knee disorder is remanded. Entitlement to an increased disability rating in excess of 10 percent for arthritis of the lumbar spine is remanded. Entitlement to an initial disability rating in excess of 70 percent for an anxiety disorder is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. FINDINGS OF FACT 1. Prior to February 9, 2018, the Veteran is in receipt of the maximum 10 percent rating for his hallux valgus, first metatarsophalangeal, with degenerative joint disease of 2nd through 4th toes of the left foot. 2. From June 1, 2018, the Veteran is in receipt of the maximum 10 percent rating for his hallux valgus, first metatarsophalangeal, with degenerative joint disease of 2nd through 4th toes of the left foot. 3. The Veteran has one surgical scar associated with the service-connected hallux valgus, first metatarsophalangeal, with degenerative joint disease of 2nd through 4th toes of the left foot that is linear and painful. 4. Throughout the period of appeal, the Veteran’s dysuria was not manifested by voiding dysfunction, urinary frequency or obstructed voiding. CONCLUSIONS OF LAW 1. Prior to February 9, 2018, the criteria are not met for an increased disability rating in excess of 10 percent for hallux valgus, first metatarsophalangeal, with degenerative joint disease of 2nd through 4th toes of the left foot. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 4.1-4.14, 4.21, 4.71a, Diagnostic Code 5280 (2018). 2. From June 1, 2018, the criteria are not met for an increased disability rating in excess of 10 percent for hallux valgus, first metatarsophalangeal, with degenerative joint disease of 2nd through 4th toes of the left foot. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 4.1-4.14, 4.21, 4.71a, Diagnostic Code 5280 (2018). 3. The criteria for a separate 10 percent rating for a scar associated with hallux valgus, first metatarsophalangeal, with degenerative joint disease of 2nd through 4th toes of the left foot have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1-4.16, 4.25, 4.26, 4.118, Diagnostic Code 7804 (2018). 4. The criteria for a compensable rating for dysuria have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. § 4.115b, Diagnostic Code 7518 (2018). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from August 1975 to August 1995. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. In an April 2018 rating decision, the RO assigned a temporary total (100 percent) rating for surgical treatment of the left foot hallux valgus that required convalescence, effective from February 9, 2018, and 10 percent from June 1, 2018. Veteran was therefore in receipt of a temporary 100 percent rating for his left foot hallux valgus from February 9, 2018, through May 31, 2018. Because the 100 percent rating for that portion of the appeal constitutes a full grant of that portion of the benefit sought, that period is no longer on appeal. AB v. Brown, 6 Vet. App. 35, 39 (1993). The issues of entitlement to service connection for a right knee and left knee disorder, entitlement to an increased disability rating in excess of 10 percent for arthritis of the lumbar spine, entitlement to an initial disability rating in excess of 70 percent for an anxiety disorder, and TDIU are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). Increased Rating Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Schedule), found in 38 C.F.R. Part 4 (2018). The Schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1 (2018). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2018). When reasonable doubt arises as to the degree of disability, such doubt will be resolved in the Veteran’s favor. 38 C.F.R. § 4.3 (2018). In considering the severity of a disability, it is essential to trace the medical history of the Veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41 (2018). Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of any disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Although the regulations do not give past medical reports precedence over current findings, the Board is to consider the Veteran’s medical history in determining the applicability of a higher rating for the entire period in which the appeal has been pending. Powell v. West, 13 Vet. App. 31, 34 (1999). Where entitlement to compensation has been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Where an appeal is based on an initial rating for a disability, however, evidence contemporaneous with the claim and the initial rating decision are most probative of the degree of disability existing when the initial rating was assigned and should be the evidence “used to decide whether an original rating on appeal was erroneous.” Fenderson v. West, 12 Vet. App. 119, 126 (1999). In either case, if later evidence indicates that the degree of disability increased or decreased following the assignment of the initial rating, staged ratings may be assigned for separate periods of time. Fenderson, 12 Vet. App. at 126; Hart v. Mansfield, 21 Vet. App. 505 (2007) (noting that staged ratings are appropriate whenever the factual findings show distinct time periods in which a disability exhibits symptoms that warrant different ratings). When adjudicating an increased rating claim, the relevant time period for consideration is the time period one year before the claim was filed. Hart, 21 Vet. App. at 509. 1. Entitlement to an increased disability rating in excess of 10 percent for hallux valgus, first metatarsophalangeal, with degenerative joint disease of 2nd through 4th toes of the left foot Evaluation of a disability involving a joint rated on limitation of motion requires adequate consideration of functional loss due to pain, weakness, fatigability, incoordination, or pain on movement. 38 C.F.R. §§ 4.40, 4.45. See, in general, DeLuca v. Brown, 8 Vet. App. 202 (1995). However, pain itself does not constitute functional loss. In order to constitute functional loss, pain must affect some aspect of “the normal working movements of the body” such as “excursion, strength, speed, coordination, and endurance.” Mitchell v. Shinseki, 25 Vet. App. 32, 38-43 (2011) (quoting 38 C.F.R. § 4.40). Joints that are actually painful, unstable, or malaligned due to healed injury are entitled to at least the minimum compensable rating. 38 C.F.R. § 4.59; Burton v. Shinseki, 25 Vet. App. 1 (2011). The Veteran’s left foot disability was rated 10 percent disabling prior to February 9, 2018, and from June 1, 2018. The Veteran’s left foot hallux valgus is rated under 38 C.F.R. § 4.71a, Diagnostic Code 5280. This diagnostic code assigns a 10 percent rating for unilateral hallux valgus that was either (1) operated on, with resection of metatarsal head, or (2) severe, if equivalent to amputation of great toe. This is the highest rating available. A separate 10 percent rating may be warranted under Diagnostic Code 7804 with one or two scars that are unstable or painful. In order to warrant a 20 percent rating under Diagnostic Code 7804, the evidence must show three or four scars that are unstable or painful. The Veteran was afforded a VA examination in March 2012 where the diagnoses of hallux valgus, hammer toes, and hallux rigidus were confirmed. It was noted that the Veteran underwent a left bunionectomy and fusion of 3rd-5th hammer toes in 1978. The Veteran reported recurring hallux valgus, pain on the ball and bottom of the foot and toes which affected his gait. He stated he currently used inserts and was recently prescribed new inserts. He denied new injuries, injections, or new surgeries. The Veteran’s symptoms of hallux valgus on the left foot were mild or moderate in severity. There was no evidence of weak foot. The Veteran had a scar related to his condition but it was not painful and/or unstable, or the total area greater than 39 square cm. There was pain on palpation on the left hallux valgus with limited motion. He did not use any assistive devices. The VA examiner determined the Veteran’s left foot hallux valgus did not produce functional impairment such that no effective function remained other than that which would be equally well served by an amputation with prosthesis. Imaging studies revealed degenerative or traumatic arthritis of the left foot. A May 2015 VA examination was conducted. The diagnosis of hallux valgus and arthritis was confirmed. He reported pain and flare-ups. The symptoms of the Veteran’s hallux valgus were mild or moderate. The reported indicated the Veteran had underwent a resection of the metatarsal head. Pain was not reported on physical examination. There was weakened movement and pain on weight-bearing. The fatigue and pain caused lack of endurance when the Veteran walked or stood for a prolonged period. No scar or other pertinent physical findings, complications, conditions, signs or symptoms related to the hallux valgus were noted. The Veteran did not use any assistive devices as a normal mode of locomotion. The VA examiner determined the Veteran’s left foot hallux valgus did not produce functional impairment such that no effective function remained other than that which would be equally well served by an amputation with prosthesis. Imaging studies showed moderate left hallux valgus with some cystic change on the head of the left first metatarsal and mild joint space narrowing of the left first metatarsophalangeal joint. There was also mild narrowing of the first metatarsophalangeal joints on the left 2nd and 4th toes. The functional impact of the Veteran’s disability was described as pain and fatigue from walking or standing greater than 30 minutes on hard ground/surfaces in the left foot at all times. In September 2015, the Veteran testified at the Decision Review Officer (DRO) hearing his foot disability has become worse. He reported daily pain, swelling, and muscle spasms. According to a July 2018 VA examination of his left foot, diagnoses of hallux valgus, hallux rigidus, and acquired pes cavus were confirmed. He reported pain in the left foot especially when walking. An examination of the left foot revealed mild or moderate symptoms of the hallux valgus. There was pain on the left foot on weight-bearing and disturbances of locomotion. There was also limping and pain with walking due to pain on the left foot contributing to his limitation of motion. The scar on the left foot was identified related to his hallux valgus was not painful and unstable. It was measured at 7.5 cm. In August 2018, the Veteran was afforded another VA examination where the diagnoses of left foot hallux valgus and hallux rigidus were confirmed. The Veteran reported constant pain and numbness to his big toe since his bunionectomy in 1977. The Veteran did not report flare-ups but did have functional loss as he could not climb stairs, run or walk barefoot. A physical examination of the left foot hallux valgus was mild or moderate symptoms. There was interference with standing due to his disability. There was no presence of pain, weakness, fatigability, or incoordination that significantly limited functional ability during flare-ups or when the foot was used repeatedly over a period of time. The Veteran did not use any assistive devices as a normal mode of locomotion. The left foot disability did not impact his ability to perform any type of occupational task. This VA examination revealed the Veteran’s left foot had a scar that were painful or unstable. Given the finding of a scar, the Veteran was afforded another VA examination for his scar the same month where the VA examiner identified a scar on the dorsal foot resulting from surgeries in 1977 and 2018. The scar was painful but not unstable. It was a linear scar measured at 8.5 cm and was tender to palpation. After carefully reviewing the evidence of record, the Board finds that a rating in excess of 10 percent is not warranted at any point that is contemplated by this appeal. The 10 percent rating is the maximum rating available under Diagnostic Code 5280. A 20 percent maximum evaluation, however, is available for degenerative joint disease. 38 C.F.R. § 4.71a, Diagnostic Codes 5003, 5010. But the evidence of record does not demonstrate X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups, with occasional incapacitating exacerbations. No other diagnostic code is for consideration. See Copeland v. McDonald, 27 Vet. App. 333 (2015); Suttman v. Brown, 5 Vet. App. 127, 134 (1993) (providing that “[a]n analogous rating... may be assigned only where the service-connected condition is ‘unlisted.’”). As the Veteran’s hallux valgus is a listed condition under Diagnostic Code 5280, VA has a duty to apply that diagnostic code to his disability and determine the appropriate disability rating. The Board has considered whether separate ratings are warranted. Esteban v. Brown, 6 Vet. App. 259 (1994); 38 C.F.R. § 4.14. The March 2012 and May 2015 and July 2018 VA examination reports did not reveal a that scar was painful or unstable. However, the August 2018 VA examination reports of the foot and scar revealed the surgical scar to be painful and tender but not unstable. It was also linear. It was measured at 8.5 cm at the August 2018 scar examination. Given the foregoing, the Board finds that the painful scar associated with the postoperative bunionectomy warrant a separate 10 percent rating pursuant to 38 C.F.R. § 4.118, Diagnostic Code 7804. A higher rating is not warranted under Diagnostic Code 7804 because the Veteran does not have more than one painful scar associated with the hallux valgus of the left foot. Additionally, the scar disabilities described by Diagnostic Codes 7800 (burn scars), 7801 (deep and nonlinear scars), and 7802 (superficial and nonlinear scars) do not match the Veteran’s scar disability; therefore, those codes are not for application. In reaching the foregoing determination, the Board has also carefully considered the Veteran’s contentions with respect to the nature of his service-connected left hallux valgus and notes that his lay testimony is competent to describe certain symptoms associated with such disability, to include pain and swelling, because this requires only personal knowledge as it comes to him through his senses. See Layno v. Brown, 6 Vet. App. 465, 470 (1994). He is not, however, competent to identify a specific level of disability relating to his left foot hallux valgus to the appropriate diagnostic codes. The March 2012 VA examiner found the Veteran’s symptoms of hallux valgus on the left foot were mild or moderate in severity and did not produce functional impairment such that no effective function remained other than that which would be equally well served by an amputation with prosthesis. A May 2015 VA examiner determined that the VA examiner determined the Veteran’s left foot hallux valgus did not produce functional impairment such that no effective function remained other than that which would be equally well served by an amputation with prosthesis. The functional impact of the Veteran’s disability was described as pain and fatigue from walking or standing greater than 30 minutes on hard ground/surfaces in the left foot at all times. The July 2018 VA examiner found mild or moderate symptoms of the hallux valgus. An August 2018 VA examiner determined that the Veteran did not report flare-ups but did have functional loss as he could not climb stairs, run or walk barefoot, with mild or moderate symptoms. The examiner found no presence of pain, weakness, fatigability, or incoordination that significantly limited functional ability during flare-ups or when the foot was used repeatedly over a period of time. These finding, despite the Veteran’s competent and credible reports of symptoms, do not demonstrate additional functional loss. The Board has considered the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, the claim is not in equipoise. See 38 U.S.C. § 5107 (b); 38 C.F.R. §§ 3.102, 4.3; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). Accordingly, entitlement to ratings in excess of 10 percent are not warranted. Finally, neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 369-70 (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). 2. Entitlement to a compensable disability rating for dysuria The Veteran’s dysuria, also claimed as UTI, has been rated under Diagnostic Code 7518 which contemplates urethra stricture. The diagnostic criteria indicates that the condition is to be rated as voiding dysfunction. 38 C.F.R. § 4.115b, Diagnostic Code 7518 (2018). Voiding dysfunction is rated based on urine leakage, frequency, or obstructed voiding. For urinary leakage, a 20 percent rating contemplates leakage requiring the wearing of absorbent materials, which must be changed less than 2 times per day. When there is leakage requiring the wearing of absorbent materials, which must be changed 2 to 4 times per day, a 40 percent disability rating is warranted. When these factors require the use of an appliance or the wearing of absorbent materials which must be changed more than 4 times per day, a 60 percent evaluation is warranted. 38 C.F.R. § 4.115a. For urinary frequency, a 10 percent evaluation is warranted for daytime voiding interval between two and three hours or awakening to void two times per night. A 20 percent rating is warranted for daytime voiding interval between one and two hours or awakening to void three to four times per night warrants. A 40 percent rating is warranted for daytime voiding interval less than one hour or; awakening to void five or more times per night. Id. For obstructed voiding, a noncompensable rating contemplates obstructive symptomatology with or without stricture disease requiring dilatation 1 to 2 times per year. A 10 percent rating contemplates marked obstructive symptomatology (hesitancy, slow or weak stream, decreased force of stream) with any one or combination of the following: (1) post-void residuals greater than 150 cubic centimeters (cc’s); (2) uroflowmetry; markedly diminished peak flow rate (less than 10 cc’s per second); (3) recurrent urinary tract infections secondary to obstruction; (4) stricture disease requiring periodic dilatation every 2 to 3 months. A 30 percent rating contemplates urinary retention requiring intermittent or continuous catheterization. Id. Turning to the evidence of record, the Veteran was afforded a VA examination in March 2012 where it was noted that he was diagnosed with UTI in 1982. The Veteran reported he still had penile discharge and occasional pain on urination. The VA examination report indicated the Veteran did not have voiding dysfunction; a history of urethral or bladder calculi; bladder or urethral infection; bladder or urethral fistula, stricture, neurogenic bladder, bladder injury, or other bladder surgery; benign or malignant neoplasm or metastases, or scars (surgical or otherwise) related to his disability. There was also no evidence the Veteran’s disability impacted his ability to work or activities of daily living. The Veteran testified in a DRO hearing where he stated his symptoms flared up “once in a while” but otherwise it was “pretty much stable… it could be gone, I don’t know, it all depends… I haven’t seen it now in about two and half years.” Furthermore, VA treatment records during the period of appeal reflect negative findings for dysuria and voiding frequency. The Board finds that the preponderance of the evidence of record is against a compensable rating for the Veteran’s service-connected dysuria, also claimed as UTI. The VA examination and VA treatment records do not disclose any evidence of voiding dysfunction, urinary frequency, or obstructed voiding. Furthermore, the Veteran did not claim the he experienced voiding dysfunctions such as leakage, frequency, obstructed voiding or worsening of his symptomatology. Accordingly, a compensable rating for dysuria, also claimed as UTI, is not warranted based on voiding dysfunction. 38 C.F.R. § 4.115b, Diagnostic Code 7518. The Board has considered the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, the claim is not in equipoise. See 38 U.S.C. § 5107 (b); 38 C.F.R. §§ 3.102, 4.3; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). Accordingly, entitlement to a compensable rating for the Veteran’s service-connected dysuria, also claimed as UTI, are not warranted Finally, neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 369-70 (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). REASONS FOR REMAND 1. Entitlement to service connection for left and right knee disorders Where VA provides the veteran with an examination in a service connection claim, the examination must be adequate. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). The Veteran was afforded a VA examination of the knees in March 2012 where the Veteran stated there had no issues with either knee at that time. Currently, however, the Veteran contends he injured his knees during service as an infantry soldier. He testified at the September 2015 DRO hearing that low crawling, jumping, and running impacted his knees. At the DRO hearing, the Veteran reported flare-ups and that he wore a brace. Furthermore, according to the VA treatment records since the March 2012 VA examination, left knee degenerative joint disease has been diagnosed. The Board finds a new VA examination is warranted. 2. Entitlement to an increased disability rating in excess of 10 percent for arthritis of the lumbar spine Remand is required to afford the Veteran a current VA examination. When a claimant asserts, or the evidence shows, that the severity of a disability has increased since the most recent rating examination, an additional examination is appropriate. VAOPGCPREC 11-95 (April 7, 1995); Snuffer v. Gober, 10 Vet. App. 400 (1997). VA last examined the Veteran with respect to his lumbar spine in May 2014 where there was no evidence of the Veteran being bedridden. At his September 2015 DRO hearing the Veteran indicated that he has been bedridden three to four times a year. Therefore, as there is evidence of possible worsening, a new VA examination was warranted. Remand is also required to obtain an adequate examination. In examinations regarding joint disabilities, “[t]he joints involved should be tested for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with the range of the opposite undamaged joint.” Correia v. McDonald, 28 Vet. App. 158 (2016) (citing to 38 C.F.R. § 4.59). An examination must address the necessary findings to evaluate functional loss during flare-ups, or clearly explain why the required testing cannot be completed or is not necessary. Correia, 28 Vet. App. 158. In increased evaluation claims, a VA examination report is not adequate without an explanation for an examiner’s failure to evaluate the functional effects of a flare-up. Sharp v. Shulkin, 29 Vet. App. 26 (2017). The Board may accept a VA examiner’s statement that he or she cannot offer an opinion in that regard without resorting to speculation, but only after determining that this is not based on the absence of procurable information or on a particular examiner’s shortcomings or general aversion to offering an opinion on issues not directly observed. Although not binding on VA examiners, the VA Clinician’s Guide instructs examiners when evaluating certain musculoskeletal conditions to obtain information about the severity, frequency, duration, precipitating and alleviating factors, and extent of functional impairment of flares from the veterans themselves. Sharp, 29 Vet. App. at 34-35, citing VA CLINICIAN’S GUIDE, ch. 11. The examinations on record do not address these required items. Accordingly, the Veteran should be afforded another VA spine examination. 3. Entitlement to an initial disability rating in excess of 70 percent for an anxiety disorder Remand is required for a current VA examination. When a claimant asserts, or the evidence shows, that the severity of a disability has increased since the most recent rating examination, an additional examination is appropriate. VAOPGCPREC 11-95 (April 7, 1995); Snuffer v. Gober, 10 Vet. App. 400 (1997). The Veteran most recently underwent a VA examination in May 2014 to determine the severity of his service-connected psychiatric disabilities. At the September 2015 DRO hearing, the Veteran testified that his symptoms were worsening as he could not get along with people, felt isolated, had suicidal thoughts, and some memory loss. As the examination is over four years old and the DRO hearing testimony indicates a worsening of symptoms, a remand is required for another examination. 4. Entitlement to TDIU With regard to the claim for entitlement to TDIU, such claim is “inextricably intertwined” with the issues of service connection and increased rating being remanded and the disposition of the TDIU claim must be deferred pending resolving this preliminary matter. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (holding that issues are inextricably intertwined and must be considered together when a decision concerning one could have a significant impact on the other). The matters are REMANDED for the following action: 1. Contact the appropriate VA Medical Center and obtain and associate with the claims file all outstanding records of treatment. If any requested records are not available, or the search for any such records otherwise yields negative results, that fact must clearly be documented in the claims file. Efforts to obtain these records must continue until it is determined that they do not exist or that further attempts to obtain them would be futile. The non-existence or unavailability of such records must be verified and this should be documented for the record. Required notice must be provided to the Veteran and his attorney. 2. Contact the Veteran and afford him the opportunity to identify by name, address and dates of treatment or examination any relevant medical records. Subsequently, and after securing the proper authorizations where necessary, make arrangements to obtain all the records of treatment or examination from all the sources listed by the Veteran which are not already on file. All information obtained must be made part of the file. All attempts to secure this evidence must be documented in the claims file, and if, after making reasonable efforts to obtain named records, they are not able to be secured, provide the required notice and opportunity to respond to the Veteran. 3. After any additional records are associated with the claims file, provide the Veteran with an appropriate examination to determine the clarify the diagnosis and etiology of his bilateral knee disabilities. The entire claims file must be made available to and be reviewed by the examiner. Any indicated tests and studies must be accomplished and all clinical findings must be reported in detail and correlated to a specific diagnosis. An explanation for all opinions expressed must be provided. The examiner must determine the presence of right and left knee disabilities or left and right knee functional impairment of earning capacity. The examiner must provide an opinion regarding whether it is at least as likely as not (50 percent or greater probability) that the bilateral knee disabilities had onset in, or were otherwise related to, active military service. The examiner must specifically address the Veteran’s assertions of an in-service occurrence, namely stress on his knees during training, and continuity of symptomatology. Relevant treatment records, including the March 2012 VA examination report, should be considered and discussed. 4. After any additional records are associated with the claims file, provide the Veteran with an examination to determine the severity of the service-connected arthritis of the lumbar spine. The entire claims file must be made available to and be reviewed by the examiner. Any indicated tests and studies must be accomplished and all clinical findings must be reported in detail and correlated to a specific diagnosis. An explanation for all opinions expressed must be provided. The examiner must utilize the appropriate Disability Benefits Questionnaires (DBQ). The examiner is also asked to indicate the point during range of motion testing that motion is limited by pain. The examiner must test the range of motion and pain of the left knee in active motion, passive motion, weight-bearing, and non-weight-bearing. If the examiner is unable to conduct the required testing or concludes that the required testing is not necessary in this case, he or she should clearly explain why that is so. Describe any functional limitation due to pain, weakened movement, excess fatigability, pain with use, or incoordination. Additional limitation of motion during flare-ups and following repetitive use due to limited motion, excess motion, fatigability, weakened motion, incoordination, or painful motion must also be noted. If the Veteran describes flare-ups of pain, the examiner must offer an opinion as to whether there would be additional limits on functional ability during flare-ups. All losses of function due to problems such as pain should be equated to additional degrees of limitation of flexion and extension beyond that shown clinically. Should the examiner state that he or she is unable to offer such an opinion without resorting to speculation based on the fact that the examination was not performed during a flare, the examiner is directed to do all that reasonably can be done to become informed before such a conclusion, to include ascertaining adequate information-i.e. frequency, duration, characteristics, severity, or functional loss-regarding his flares by alternative means. 5. After any additional records are associated with the claims file, provide the Veteran a VA psychiatric examination to determine the current severity of his anxiety disorder. The entire claims file should be made available to and be reviewed by the examiner. Any indicated tests and studies must be accomplished and all clinical findings must be reported in detail and correlated to a specific diagnosis. An explanation for all opinions expressed must be provided. The examiner must report all signs and symptoms necessary for rating the Veteran’s service-connected psychiatric disabilities under the rating criteria, utilizing the appropriate DBQ. 6. After the above development has been completed, obtain an opinion regarding the Veteran’s employment functioning. The entire claims file must be made available to and be reviewed by the examiner. If an examination is deemed necessary, it shall be provided. An explanation for all opinions expressed must be provided. The examiner must comment regarding each service-connected disability’s effects on employment. 7. Notify the Veteran that it is his responsibility to report for any scheduled examination and to cooperate in the development of the claims, and that the consequences for failure to report for a VA examination without good cause may include denial of the claims. 38 C.F.R. §§ 3.158, 3.655 (2018). In the event that the Veteran does not report for any scheduled examination, documentation must be obtained which shows that notice scheduling the examination was sent to the last known address. It must also be indicated whether any notice that was sent was returned as undeliverable. K. MILLIKAN Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD H. Yoo, Counsel