Citation Nr: 18150867 Decision Date: 11/16/18 Archive Date: 11/15/18 DOCKET NO. 13-00 453 DATE: November 16, 2018 ORDER Entitlement to service connection for a left knee disability, claimed as secondary to service-connected right and left foot disabilities, is granted. Entitlement to service connection for a cervical spine disability, claimed as secondary to right and left foot disabilities, is granted. Entitlement to service connection for headaches, claimed as secondary to cervical spine disability, is granted. Entitlement to service connection for erectile dysfunction, claimed as secondary to service-connected herpes progenital, is denied. Entitlement to an initial 50 percent rating, but no higher, for service-connected right knee degenerative joint disease (DJD) from the date of service connection is granted. Entitlement to a separate 20 percent rating for service-connected meniscal tear of the right knee is granted. REMANDED Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD) and depressive disorder, not otherwise specified (NOS), is remanded. FINDINGS OF FACT 1. The Veteran’s currently diagnosed left knee disability, status-post total knee arthroplasty, is as likely as not proximately caused by his service-connected right and left foot disabilities. 2. The Veteran’s currently diagnosed cervical spine disability is as likely as not proximately caused by his service-connected right and left foot disabilities. 3. The Veteran’s currently diagnosed chronic cephalgia, claimed as headaches, is as likely as not proximately caused by his service-connected cervical spine disability. 4. The Veteran does not have erectile dysfunction that is proximately due to or aggravated beyond its natural progression by his service-connected herpes progenital. 5. From the date of service connection, the Veteran’s service-connected strain and degenerative arthritis of the right knee has been manifested by flexion limited to no less than 75 degrees with pain, and extension to 45 degrees; there is no evidence of recurrent subluxation or lateral instability. 6. The Veteran’s service-connected right knee disability is also manifested by a meniscal tear with frequent episodes of stiffness, pain, crepitus, and effusion into the joint, and these symptoms are sufficiently distinct from painful limitation of motion to warrant a separate rating. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for a left knee disability, status-post left total knee arthroplasty, are met. 38 U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2017). 2. The criteria for entitlement to service connection for a cervical spine disability are met. 38 U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2017). 3. The criteria for entitlement to service connection for chronic cephalgia are met. 38 U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2017). 4. The criteria for entitlement to service connection for erectile dysfunction are not met. 38 U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2017). 5. The criteria for a disability rating of 50 percent, but no higher, for strain and degenerative arthritis of the right knee have been met from the date of service connection. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.40, 4.45, 4.59, 4.71, 4.71a, Diagnostic Codes (DC) 5003, 5260, 5261 (2017). 6. The criteria for a separate rating of 20 percent for meniscal injury of the right knee with frequent episodes of stiffness, pain, and effusion into the joint are met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.159, 3.321, 4.1, 4.3, 4.27, 4.71a, DC 5258 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from July 1972 to July 1974. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from rating decisions dated May 2010 and October 2013 of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. In a December 2015 decision, the Board remanded the claim of entitlement to service connection for erectile dysfunction for further evidentiary development. The decision also remanded the claims of entitlement to service connection for a left knee disability, a cervical spine disability, headaches, and PTSD, as well as entitlement to a higher initial rating for service-connected right knee disability for the issuance of a statement of the case (SOC). Pursuant to the Board Remand, the RO issued an SOC in March 2017, and the Veteran perfected his appeal of the claims in April 2017. A supplemental statement of the case (SSOC) was issued in November 2017. The Veteran’s VA claims file has been returned to the Board for further appellate proceedings. The December 2015 Board decision also denied entitlement to a total disability rating based upon individual unemployability (TDIU) due to service-connected disabilities. The Veteran appealed to the United States Court of Appeals for Veterans Claims (Court). In an August 2016 Order, granting a July 2016 Joint Motion for Remand, the Court partially vacated the Board’s December 2015 decision and remanded the matter of entitlement to a TDIU for further development in compliance with the directives specified in the Joint Motion. In a September 2016 decision, the Board remanded the matter of entitlement to a TDIU to the RO for further evidentiary development. In a September 2018 rating decision, the RO granted entitlement to a TDIU from February 8, 2012. To the Board’s knowledge, the Veteran has not disagreed with that decision; that matter has accordingly been resolved. See, e.g., Grantham v. Brown, 114 F.3d 1136 (Fed. Cir. 1997). Service Connection In order to establish direct service connection for the claimed disorder, generally, there must be competent and credible evidence of (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the current disability. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006); Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Lay evidence can be competent and sufficient to establish the elements of service connection 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. See Jandreau, 492 F.3d at 1377. Service connection may be granted for a disability that is proximately due to, the result of, or aggravated by a service-connected disability. See 38 C.F.R. § 3.310(a); see also Harder v. Brown, 5 Vet. App. 183, 187 (1993). Additional disability resulting from the aggravation of a nonservice-connected condition by a service-connected condition is also compensable under 38 C.F.R. § 3.310(a). See Allen v. Brown, 7 Vet. App. 439, 448 (1995). The Board notes that there has been an amendment to the provisions of 38 C.F.R. § 3.310. See 71 Fed. Reg. 52,744 -47 (Sept. 7, 2006). The amendment sets a standard by which a claim based on aggravation of a non-service-connected disability by a service-connected one is judged. 1. Entitlement to service connection for a left knee disability, claimed as secondary to service-connected right and left foot disabilities. Here, the Veteran asserts that he suffers from a left knee disability, which is due to his service-connected right and left foot disabilities. See the Veteran’s claim dated August 2014. The Board has reviewed the record and concludes that the evidence supports an award of service connection for currently diagnosed left knee disability, status-post left total knee replacement. The Board initially notes that the Veteran is service-connected for left foot hallux valgus with callosities status-post bunionectomy, right hallux valgus status-post bunionectomy, osteomyelitis of the right foot, and residuals of surgical scar status-post right bunionectomy associated with right hallux valgus. As indicated above, the Veteran served on active duty from July 1972 to July 1974. His service treatment records do not document any disabilities of the left knee. Private treatment records dated in July 2006 indicated that the Veteran’s left knee was sore. It was further noted that a radiological report showed that the Veteran “is getting progressive narrowing in the medial and lateral compartments.” See the private treatment records dated July 2006. Treatment records dated in May 2008 indicated that the Veteran has a “history of job related left knee injury in 2001 after a heavy jackhammer fell on his left knee, resulting in left knee torn ligaments.” It was reported that the Veteran has undergone three knee surgeries. Significantly, the Veteran’s treatment provider further noted that “[r]eview of limited medical records shows an x-ray report of the left knee from 1998 with evidence of mild osteoarthritis of the left knee.” A diagnosis of osteoarthritis of the left knee was indicated. See the private treatment records dated May2008. VA treatment records dated in February 2011 noted the Veteran’s report of knee pain, status-post left knee replacement. In support of his claim, the Veteran submitted a January 2012 report from Dr. P.Y., who noted that the Veteran began experiencing left knee pain following surgery on his right foot. Dr. P.Y. indicated that the Veteran underwent a total joint replacement of the left knee in approximately January 2011. Dr. P.Y. diagnosed the Veteran with “degenerative joint disease (DJD) of the left knee complicated by sub-optimal surgical result.” He explained, “[i]t is more likely than not that the aforementioned is directly and causally related to chronic and constant bio-mechanical compensation, and adaption due to altered gait, and weight-shifting relating to his pedal (foot) imbalance.” Dr. P.Y. further stated, “[i]t is more likely than not that same is directly and causally related to [the Veteran’s] military service.” The Veteran has not been afforded a VA medical opinion in this matter. However, given the evidence in favor of secondary service connection before the Board, a remand for an examination or opinion could be construed as obtaining additional evidence for the sole purpose of denying a claim, which is impermissible. See Mariano v. Principi, 17 Vet. App. 305, 312 (2003) (VA may not order additional development for the sole purpose of obtaining evidence unfavorable to a claimant); 38 C.F.R. § 3.304(c) (“The development of evidence in connection with claims for service connection will be accomplished when deemed necessary but it should not be undertaken when evidence present is sufficient for this determination”). Overall, the Board finds that the record supports the award of service connection for a left knee disability. It is undisputed that the Veteran is diagnosed with DJD of the left knee, status-post knee replacement, and has thus met the current disability requirement. Moreover, given the positive nexus opinion from Dr. P.Y. and the credible lay statements of the Veteran, the evidence is at least evenly balanced as to whether the current left knee disability is caused by his service-connected right and left foot disabilities. As the reasonable doubt created by this relative equipoise in the evidence must be resolved in favor of the Veteran, entitlement to service connection for a left knee disability is warranted. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. 2. Entitlement to service connection for a cervical spine disability, claimed as secondary to a foot disability. Here, the Veteran asserts that he suffers from a cervical spine disability, which is due to his service-connected right and left foot disabilities. See the Veteran’s notice of disagreement (NOD) dated December 2013. The Board has reviewed the record and concludes that the evidence supports an award of service connection for currently diagnosed cervical spine disability. The Veteran’s service treatment records do not document any neck-related abnormalities or complaints. In support of his claim, the Veteran submitted a January 2012 private examination from Dr. P.Y. who indicated that the Veteran is diagnosed with DJD and spondylosis of the cervical spine. Dr. P.Y. stated that “[s]ince development of right foot pain and surgery along with other spine pain . . . [the Veteran] developed cervical and cervicothoracic pain which is constant in varying degrees along with chronic cephalgia.” Dr. P.Y. opined, “[i]t is more likely than not that the aforementioned is directly and causally related to chronic and constant bio-mechanical compensation, and adaption due to altered gait, and weight-shifting relating to his pedal (foot) imbalance.” Dr. P.Y. continued, “[i]t is more likely than not that same is directly and causally related to [the Veteran’s] military service. This is a permanent and progressive condition.” An August 2013 VA examination indicated that the Veteran was diagnosed with degenerative disc disease (DDD) of the cervical spine. The examiner stated, “[n]o injury to the neck, but strain associated with the low back pain, right knee pain, and right foot pain.” However, the examiner then stated that the Veteran’s claimed cervical spine disability was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury. The examiner explained that the Veteran had an initial complaint of neck injury in February 1974. He was noted to have degenerative changes and spondylosis of the cervical spine in 2012. The examiner then opined, “[t]he claimed condition is less likely than not (less than 50 percent probability) proximately due to or the result of the Veteran’s service-connected condition.” The examiner explained, “[t]he Veteran with right hallux valgus and status-post bunionectomy which is claimed to cause an altered gait. An x-ray of the cervical spine in August 2013 revealed moderate to severe degenerative changes. An altered gait does not progress to arthritis of cervical spine.” In this matter, there is conflicting evidence of record as to whether the currently diagnosed cervical spine disability is caused or aggravated by the Veteran’s service-connected right and left foot disabilities. To this end, the Board notes that the August 2013 VA examiner rendered a somewhat contradictory negative nexus opinion and, significantly, the examiner failed to address whether the Veteran’s cervical spine disability has been aggravated by his service-connected right and left foot disabilities. The examiner also provided little rationale to support his conclusion. In contrast, the Board finds the January 2012 opinion from Dr. P.Y. particularly probative as to the question of etiology, as the opinion was based upon a thorough review of the record and thoughtful analysis of the Veteran’s entire history. See Bloom, 12 Vet. App. at 187 (the probative value of a physician’s statement is dependent, in part, upon the extent to which it reflects “clinical data or other rationale to support his opinion”). Significantly, after reviewing the Veteran’s medical history, Dr. P.Y. concluded that the Veteran’s diagnosed cervical spine disability is etiologically related to altered gait and weight-shifting caused by his right and left foot disabilities. Overall, the Board finds that the record supports the award of service connection for a cervical spine disability. It is undisputed that the Veteran is diagnosed with DJD and DDD of the cervical spine and has thus met the current disability requirement. Moreover, given the positive nexus opinion from Dr. P.Y. and the credible lay statements of the Veteran, the evidence is at least evenly balanced as to whether the current cervical spine disability is caused by the Veteran’s service-connected right and left foot disabilities. As the reasonable doubt created by this relative equipoise in the evidence must be resolved in favor of the Veteran, entitlement to service connection for a cervical spine disability is warranted. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. 3. Entitlement to service connection for headaches, claimed as secondary to cervical spine disability. Here, the Veteran asserts that he developed headaches as a result of his cervical spine disability. See, e.g., the NOD dated December 2013. As the Board has herein granted service connection for DJD and DDD of the cervical spine, the evidence now supports an award of service connection for the currently diagnosed chronic cephalgia. In a January 2012 report, Dr. P.Y. reported that, “[c]oncomitant with cervical and cervicothoracic pain . . . [the Veteran] developed chronic cephalgia which presents as greater occipital neuralgia/cephalgia.” Dr. P.Y. noted that the Veteran’s chronic cephalgia is manifested by at least two episodes of headaches per week, which last from a period of several hours to an entire day. Dr. P.Y. stated, “[i]t is more likely than not that this symptomatology of cephalgia is directly and causally related to alteration of the cervical spine.” Dr. P.Y. then confirmed a diagnosis of chronic cephalgia secondary to cervical spine spondylosis. The August 2013 VA examiner noted the Veteran’s report that he suffers with daily headaches since the onset of his neck pain years ago. The examiner then stated that the Veteran no history of head trauma. The examiner additionally opined, “[a]rthritis of the neck does not cause headaches.” The examiner provided no additional rationale to support his opinion. In addition, the examiner failed to address whether the Veteran’s chronic headaches are aggravated by his now service-connected cervical spine disability. The Board finds the January 2012 opinion from Dr. P.Y. particularly probative as to the question of etiology, as the opinion was based upon a thorough review of the record and thoughtful analysis of the Veteran’s entire history. See Bloom, 12 Vet. App. at 187 (the probative value of a physician’s statement is dependent, in part, upon the extent to which it reflects “clinical data or other rationale to support his opinion”). Significantly, after reviewing the Veteran’s medical history, Dr. P.Y. concluded that the Veteran’s diagnosed chronic cephalgia secondary to his cervical spine disability. In sum, the Board finds that the record supports the award of service connection for chronic cephalgia. The evidence is at least evenly balanced as to whether the current chronic cephalgia is caused by the Veteran’s service-connected cervical spine disability. As the reasonable doubt created by this relative equipoise in the evidence must be resolved in favor of the Veteran, entitlement to service connection for chronic cephalgia is warranted. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. 4. Entitlement to service connection for erectile dysfunction, claimed as secondary to service-connected herpes progenital. The Veteran has asserted entitlement to service connection for erectile dysfunction, which he contends is secondary to his service-connected herpes progenital. For the reasons set forth below, the Board concludes that service connection is not warranted. Initially, it is undisputed that the Veteran is service-connected for herpes progenital. See the rating decision dated October 1974. With respect to the claimed disability, the Veteran was afforded a VA examination in April 2010 at which time he reported that “he gets erections but notes for the past year he sometimes does not get an erection at all and sometimes partial erections.” The examiner stated that the Veteran’s claimed erectile dysfunction is less likely as not (less than 50/50 probability) caused by or a result of herpes progenitalis. The examiner explained, “herpes is not a known cause of erectile dysfunction.” In a February 2013 opinion, Ms. T.K., a certified nurse practitioner, stated “in my opinion, his erectile dysfunction is as likely as not associated with herpes progenital which is service-related.” Pursuant to the December 2015 Board Remand, the Veteran was afforded a VA medical opinion in September 2016. The examiner reviewed the Veteran’s medical history and stated that the Veteran’s treatment records show “no complaints of any on-going scrotal pain or swelling. Typically, swelling and pain [are] due to infection or trauma. There is no pattern of chronicity from the complaints of swollen and painful testicles in June 1974; therefore, making this an acute self-limited problem.” The examiner concluded, “[i]t is less likely as not that the erectile dysfunction was permanently worsened beyond normal progression by his service-connected herpes progenital.” The examiner explained, “[h]erpes does not directly or indirectly cause erectile dysfunction. Herpes is a STD that can reoccur and be treated.” The examiner continued, “Veteran states he may get partial erection or none at all and this could occur whether he had a herpes outbreak or not . . . He has multiple common risk factors for erectile dysfunction including age (64), obesity (BMI of 36.67), which could have worsened erectile dysfunction over time.” Crucially, the competent and probative evidence of record shows that the currently diagnosed erectile dysfunction is not proximately caused or aggravated by his service-connected herpes progenital. Significantly, although Ms. T.K. reported that the Veteran’s erectile dysfunction is caused by his service-connected herpes progenital, she provided no rationale to support her conclusion. The Board therefore finds this opinion to be of little probative value. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008) (the probative value of a medical opinion comes from when it is the factually accurate, fully articulated, and sound reasoning for the conclusion); Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998) (the failure of the physician to provide a basis for his/her opinion goes to the weight or credibility of the evidence). In contrast, the Board finds the September 2016 VA examiner’s opinion particularly probative as to the question of etiology, as the opinion was based upon a thorough review of the record and thoughtful analysis of the Veteran’s entire history. See Bloom, 12 Vet. App. at 187 (the probative value of a physician’s statement is dependent, in part, upon the extent to which it reflects “clinical data or other rationale to support his opinion”). Significantly, after reviewing the Veteran’s medical history, the September 2016 examiner concluded that the Veteran’s diagnosed erectile dysfunction is not etiologically related to his service-connected herpes progenital. To the extent the Veteran asserts that his currently diagnosed erectile dysfunction is causally related to his service-connected herpes progenital, the Board is cognizant that lay evidence may be competent on a variety of matters concerning the nature and cause of disability. Jandreau v. Shinseki, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). In this case, the Veteran’s assertions as to etiology concern an internal medical process, which extends beyond an immediately observable cause-and-effect relationship that is of the type that the courts have found to be beyond the competence of lay witnesses. Cf. Jandreau, 492 F.3d at 1376; Barr, 21 Vet. App. at 308-9; Falzone, 8 Vet. App. at 403 (lay person competent to testify to pain and visible flatness of his feet); with Clemons, 23 Vet. App. at 6 (“It is generally the province of medical professionals to diagnose or label a mental condition, not the claimant”); Woehlaert, 21 Vet. App. at 462 (unlike varicose veins or a dislocated shoulder, rheumatic fever is not a condition capable of lay diagnosis); Jandreau, 492 F.3d at 1377, n. 4 (“sometimes the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer”). See also Colantonio, 606 F.3d at 1382 (recognizing that in some cases lay testimony “falls short” in proving an issue that requires expert medical knowledge). Questions of competency notwithstanding, the Veteran’s lay theory regarding the etiology of his disability are contradicted by the conclusion of the September 2016 VA examiner who specifically considered the Veteran’s lay statements in rendering his negative opinion. The Board finds the specific, reasoned opinion of the trained health care provider who conducted the September 2016 VA medical opinion to be of greater probative weight than the more general lay assertions of the Veteran which lack a rationale. Considering the overall evidence, including the post-service medical evidence, the VA medical opinion, and the lay evidence presented by the Veteran, the Board finds that the negative evidence is more persuasive and of greater probative value. In conclusion, the preponderance of the evidence is against the Veteran’s claim that he suffers from erectile dysfunction which is causally related to his service-connected herpes progenital. Thus, the benefit-of-the-doubt rule is not applicable to the claim and the matter must be denied. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 54-56. Schedular Consideration 5. Entitlement to an initial rating for service-connected right knee DJD in excess of 50 percent prior to September 1, 2015 and 40 percent thereafter. 6. Entitlement to a separate rating for a meniscal tear of the right knee. Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities. 38 C.F.R. Part 4. The Board determines the extent to which a veteran’s service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, and the assigned rating is based, as far as practicable, upon the average impairment of earning capacity in civil occupations. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.10. Where there is a question as to which of two ratings should be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. In general, when an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). When the appeal arises from an initial assigned rating, consideration must be given to whether staged ratings should be assigned to reflect entitlement to a higher rating at any point during the pendency of the claim. Fenderson v. West, 12 Vet. App. 119 (1999). However, staged ratings are also appropriate in any increased rating claim in which distinct time periods with different ratable symptoms can be identified. Hart v. Mansfield, 21 Vet. App. 505 (2007). Here, analysis in this decision has therefore been undertaken with consideration of the possibility that different ratings may be warranted for different time periods as to the pending initial rating claim. In all cases, the Board must determine the value of all evidence submitted, including lay and medical evidence. Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). The evaluation of evidence generally involves a three-step inquiry. First, the Board must determine whether the evidence comes from a “competent” source. The Board must then determine if the evidence is credible, or worthy of belief. Barr, at 308 (observing that once evidence is determined to be competent, the Board must determine whether such evidence is also credible). The third step of this inquiry requires the Board to weigh the probative value of the proffered evidence in light of the entirety of the record. In this function, the Board may properly consider internal inconsistency, facial plausibility, and consistency with other evidence submitted on behalf of the claimant. Caluza v. Brown, 7 Vet. App. 498, 511-12 (1995), aff’d, 78 F.3d 604 (Fed. Cir. 1996) (per curiam) (table). The Board has considered all evidence of record as it bears on the issues before it. See 38 U.S.C. § 7104(a) (“Decisions of the Board shall be based on the entire record in the proceeding and upon consideration of all evidence and material of record”); 38 U.S.C. § 5107(b) (“Secretary shall consider all information and lay and medical evidence of record in a case”). Although the Board has an obligation to provide reasons and bases supporting these decisions, there is no need to discuss, in detail, the extensive evidence of record. The Federal Circuit has held that the Board must review the entire record, but does not have to discuss each piece of evidence. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board’s analysis below will focus specifically on what the evidence shows, or fails to show, as to the Veteran’s appeal. The Court has emphasized that when assigning a disability rating it is necessary to consider limitation of a joint’s functional ability due to flare-ups, fatigability, incoordination, and pain on movement, or when it is used repeatedly over a period of time functional loss due to flare-ups, fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202, 206-07 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). In Mitchell, the Court explained that pursuant to 38 C.F.R. §§ 4.40 and 4.45, the possible manifestations of functional loss include decreased or abnormal excursion, strength, speed, coordination, or endurance (38 C.F.R. § 4.40), as well as less or more movement than is normal, weakened movement, excess fatigability, and pain on movement (as well as swelling, deformity, and atrophy) that affects stability, standing, and weight-bearing (38 C.F.R. § 4.45). Joints should be tested for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint. 38 C.F.R. § 4.59; see also Correia v. McDonald, 28 Vet. App. 158, 169-170 (2016). In this case, the Veteran’s right knee disability is assigned a 50 percent rating pursuant to DC 5261 (limitation of extension), effective from February 8, 2012. See the rating decision dated October 2013. In a June 2015 rating decision, the RO reduced the assigned rating to 40 percent, from September 1, 2015. See the rating decision dated June 2015. To this end, in the context of a staged rating, the provisions of 38 C.F.R. § 3.105(e) are not applicable. See e.g. O’Connell v. Nicholson, 21 Vet. App. 89, 93 (2007). The RO’s reduction of the rating assigned for the Veteran’s right knee disability from 50 to 40 percent did not result in decreased compensation benefits. Tatum v. Shinseki, 24 Vet. App. 139 (2010). Diagnostic Code 5003 provides that degenerative arthritis that is established by x-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. When there is no limitation of motion of the specific joint or joints that involve degenerative arthritis, DC 5003 provides a 20 percent rating for degenerative arthritis with x-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups, with occasional incapacitating exacerbations, and a 10 percent rating for degenerative arthritis with x-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups. Note (1) provides that the 20 percent and 10 percent ratings based on x-ray findings will not be combined with ratings based on limitation of motion. Note (2) provides that the 20 percent and 10 percent ratings based on x-ray findings, above, will not be utilized in rating conditions listed under DCs 5013 to 5024, inclusive. When there is some limitation of motion of the specific joint or joints involved that is noncompensable (0 percent) under the appropriate diagnostic codes, DC 5003 provides a rating of 10 percent for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under DC 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. When there is limitation of motion of the specific joint or joints that is compensable (10 percent or higher) under the appropriate diagnostic codes, the compensable limitation of motion should be rated under the appropriate diagnostic codes for the specific joint or joints involved. 38 C.F.R. § 4.71a. The general rating schedules for limitation of motion of the knee are set forth in 38 C.F.R. § 4.71a, DCs 5260 and 5261. Normal range of motion of the knee is to 0 degrees extension and to 140 degrees flexion. See 38 C.F.R. § 4.71a, Plate II. Under DC 5260, a 10 percent disability rating is warranted for flexion limited to 45 degrees. A 20 percent disability rating is assigned for flexion limited to 30 degrees; and a 30 percent disability rating is assigned for flexion limited to 15 degrees. Under DC 5261, a 10 percent disability rating is warranted for extension limited to 10 degrees. A 20 percent disability rating is assigned for extension limited to 15 degrees. A 30 percent disability rating is assigned for extension limited to 20 degrees. A 40 percent disability rating is assigned for extension limited to 30 degrees; and a 50 percent disability rating is assigned for extension limited to 45 degrees. See 38 C.F.R. § 4.71a. In addition, separate ratings may be assigned for compensable limitation of both flexion and extension. See VAOPGCPREC 09-04 (separate ratings may be granted based on limitation of flexion (DC 5260) and limitation of extension (DC 5261) of the same knee joint). DC 5257 provides the rating criteria for impairment of the knee manifested by recurrent subluxation and lateral instability. Under this diagnostic code provision, a 10 percent disability rating is warranted where there is slight recurrent subluxation or lateral instability of the knee. A 20 percent disability rating is warranted where the recurrent subluxation or lateral instability of the knee is moderate. The maximum 30 percent disability rating is warranted where there is severe recurrent subluxation or lateral instability of the knee. 38 C.F.R. § 4.71a, DC 5257. DC 5258 provides that a 20 percent rating is warranted for dislocated semilunar cartilage with frequent episodes of “locking,” pain, and effusion into the joint. 38 C.F.R. § 4.71a, DC 5258. DC 5259 provides that a 10 percent rating is warranted for symptomatic removal of semilunar cartilage. 38 C.F.R. § 4.71a, DC 5259. In this matter, private treatment records dated in June 2008 indicate that the Veteran right knee “is swollen rather diffusely.” He had tenderness over the medial and lateral joint lines, but particularly over the mid-medial joint line area. The treatment provider stated that “[h]is ligaments are stable. Neurovascular status of the extremity is intact.” The Veteran was diagnosed with moderate degenerative osteoarthritis of the right knee and probable meniscal tears of the right knee. Subsequent magnetic resonance imaging (MRI) revealed a complex tear of the anterior horn and body of the lateral meniscus; a complex tear of the posterior horn of the medial meniscus; tri-compartmental severe chondromalacia; loose body within a Baker’s cyst; and a low-grade sprain of the MCL. A private examination, performed by Dr. P.N, dated in January 2012 documented the Veteran’s report of constant right knee pain in the subpatellar region. The Veteran indicated that his knee pops, grinds, and gives out at random. Physical examination revealed flexion to 90 degrees and mild subpatellar edema. Dr. P.N. indicated that there was palpable crepitus, popping, and grinding. He confirmed a diagnosis of DJD of the right knee. The Veteran was afforded a VA examination in August 2013 at which time the examiner confirmed a diagnosis of right knee sprain. The Veteran reported pain and swelling of the right knee. He stated that he is taking Ibuprofen, Volatren, and using a one-prong cane to ambulate. The Veteran endorsed flare-up; he stated, “[i]t swells and is painful, my mobility is not as good. I try not to do too much.” Range of motion testing revealed flexion to 75 degrees with pain and extension to 35 degrees with pain. Repetitive testing revealed flexion to 80 degrees and extension to zero degrees. There was pain on palpation. Muscle strength was 4/5. Joint stability was intact. The examiner reported that the Veteran had no history of recurrent patellar subluxation/dislocation. The examiner also reported that the Veteran does not have a meniscal condition. The examiner ntoed that the Veteran reported consistent pain, swelling, and instability with use of a cane for ambulation. The examiner noted that the Veteran’s right knee disability does impact his ability to work. Specifically, the examiner explained that the Veteran experienced difficulty with walking, prolonged standing and the use of an assistive device, and chronic pain and swelling. The examiner opined, “[n]o additional limitation of motion due to pain during flare-ups or when joint is used repeatedly over a period of time.” The Veteran was afforded another VA examination in January 2015 at which time the examiner confirmed a diagnosis of degenerative arthritis. He complained of constant, chronic mild to moderate pain with difficulty squatting. The Veteran denied flare-ups of right knee symptomatology. Range of motion testing revealed flexion to 120 degrees and extension to zero degrees. Pain upon flexion was noted upon examination, but did not result in/cause functional loss. There was no pain with weight-bearing. The examiner reported that there was no objective evidence of localized tenderness or pain on palpation. There was no additional limitation of motion on repetitive use testing. The examiner reported that pain, weakness, fatigability or incoordination significantly limit the Veteran’s functional ability of the right knee with repeated use. Muscle strength of the right knee was intact. There was no evidence of atrophy or ankylosis. The Veteran denied recurrent subluxation, lateral instability, and recurrent effusion. Joint stability testing was normal. The examiner reported that the Veteran does not have a meniscal condition. The examiner noted the Veteran’s regular use of a cane for ambulation. There was no crepitus. The examiner concluded that the Veteran’s right knee disability has no impact on his ability to work. In an April 2015 letter, the Veteran’s treatment provider, Dr. M.M. stated that the Veteran “has less than a 45 degree extension of both knees at [the] leg joint.” In a September 2015 statement, Dr. M.M. indicated that the Veteran “has less than 50 percent extension of both legs at the knee joints.” The Veteran submitted a November 2015 statement from Ms. B.S. who stated that she is aware the Veteran suffers from a lot of knee pain and requires assistance completing some projects. She reported, “sometimes his knee swells so large, he can barely walk.” VA treatment records dated in December 2015 indicated that the Veteran has progressive right knee pain, swelling, and catching. It was noted that the Veteran’s symptoms are now disabling and constant. The symptoms are aggravated by extreme motion and weight-bearing. The Veteran’s knee pain is treated with 600mg of Ibuprofen daily. Range of motion testing revealed flexion to 120 degrees and extension to zero degrees, with pain through motion. The treatment provider noted that the Veteran’s knee was stable without effusion. An x-ray confirmed osteoarthritis of the right knee. A steroid injection was performed. The Veteran was afforded a VA examination in July 2016 at which time the examiner confirmed diagnoses of right knee strain and osteoarthritis. The Veteran described pain with weight-bearing and walking. It was noted that the Veteran had a steroid injection into his right knee, which only helped for a month. He denied flare-ups. The examiner indicated that the Veteran’s right knee disability limits his activity. Range of motion revealed flexion to 90 degrees and extension to zero degrees. Pain causing functional loss was noted on examination. There was no objective evidence of localized tenderness or pain on palpation. The examiner noted crepitus of the right knee. There was no additional functional loss on repetitive testing. The examiner stated that pain and lack of endurance cause significant limitation of functional ability with repeated use over a period of time. There was swelling and disturbance of locomotion upon physical examination. Muscle strength was intact. There was no atrophy, ankylosis, recurrent subluxation, instability, and effusion. Joint stability testing was normal. The examiner indicated that the Veteran does not have a meniscal condition. The Veteran reported occasional use of a wheelchair, occasional use of a brace, and regular use of a cane. The examiner reported that the right knee disability does impact the Veteran’s occupational tasks; specifically, weight-bearing aggravated his knee. VA treatment records dated in September 2017 indicated that the Veteran suffers from severe right knee DJD; a total right knee athroplasty was recommended. As described above, the RO has rated the Veteran’s right knee strain with degenerative arthritis as 50 percent prior to September 1, 2015 and 40 percent thereafter under DC 5261 based upon limitation of extension. The Board recognizes that the RO reduced the rating to 40 percent based upon a finding that the Veteran had right knee extension ranging from 30 to 44 degrees, but no higher. See the rating decision dated June 2015. However, the RO failed to acknowledge the September 2015 and April 2015 letters from Dr. M.M. indicating that the Veteran had worse than a 45 degree extension in the right knee. The competent medical evidence of record demonstrates that the Veteran has repeatedly exhibited extension to at least 45 degrees. As such, the Board finds that the Veteran’s degenerative arthritis with limitation of extension warrants a 50 percent rating from the date of service connection. This is the maximum schedular rating available for limitation of extension under DC 5261. However, a separate rating for limitation of flexion is not warranted. The examination and treatment records referenced above demonstrate, at worst, 75 degrees of flexion of the right knee with pain. Such findings warrant noncompensable disability ratings under DC 5260. Critically, functional loss must be rated under the diagnostic code pertaining to limitation of motion of the affected joint, pursuant to 38 C.F.R. § 4.40; Schafrath v. Derwinski, 1 Vet. App. 589, 592 (1991) (noting that functional loss due to pain is to be rated at the same level as where motion is impeded); DeLuca v. Brown, 8 Vet. App. 202, 205-06 (noting that the disabling effect of painful motion must be considered when rating joint disabilities) (1995); Mitchell v. Shinseki, 25 Vet. App. 32, 37 (2011) (stating that functional loss caused by pain must be rated at the same level as if that functional loss were caused by some other factor that actually limited motion)); c.f., Petitti v. McDonald, No. 13-3469 (U.S. Vet. App. October 28, 2015). Hence, there is no basis upon which to find additional limitation due to functional factors. See 38 C.F.R. §§ 4.40, 4.45; DeLuca, 8 Vet. App. at 202; Mitchell, 25 Vet. App. at 32. As indicated above, the Veteran’s impaired range of motion upon repetitive motion and during flare-ups is contemplated in the assigned rating for degenerative arthritis with limitation of motion in the right knee. He nevertheless does not meet the criteria for the assignment of a separate disability rating for limitation of flexion under VAOPGCPREC 09-2004, VAOPGCPREC 23-97, or VAOPGCREC 9-98. Moreover, the Board finds that the most probative evidence shows that the Veteran does not have recurrent subluxation or lateral instability of the right knee to warrant a separate compensable rating under DC 5257. See 38 C.F.R. § 4.71a, DC 5257. As set forth above, repeated examination has consistently shown that the Veteran’s ligaments are stable and that no instability or subluxation is present. The Board has considered the fact that the Veteran reported some giving way of the right knee, but finds that the most probative evidence of record indicates that compensable recurrent subluxation or lateral instability is not present. As noted above, objective testing by examination and treatment providers has consistently shown that clinical subluxation or instability have never been present. The Board assigns the examination findings more probative weight as to the presence of subluxation and lateral instability than to the Veteran’s lay description of his symptoms, particularly as the Veteran’s reported symptoms were considered by the examiner and treatment provider, who nonetheless concluded that no instability or subluxation was present. Moreover, as described above, the Veteran’s reports of instability have not been consistent, as he has, at times, denied having instability or subluxation. Under these circumstances, the preponderance of the evidence is against the assignment of a separate compensable rating under DC 5257. A 30 percent disability rating may be assigned for ankylosis at a favorable angle in full extension, or in slight flexion between zero and 10 degrees. 38 C.F.R. § 4.71a, DC 5256. However, there is no indication that the Veteran has ankylosis of the right knee; therefore, a higher disability rating under DC 5256 is not warranted. The Board has also considered whether DC 5055 (knee replacement) is applicable in this matter. However, the evidence of record shows that a right total knee replacement has been recommended, there is no evidence that such a procedure has yet been performed. As such, DC 5055 is not for application. Moreover, there is no evidence to show, nor has the Veteran contended, that there is nonunion or malunion of the tibia and fibula. A rating under DC 5262 is therefore not warranted. In considering the applicability of other diagnostic codes, the Board notes that DC 5258 provides the rating criteria for dislocation of semilunar cartilage and DC 5259 provides the rating criteria for symptomatic removal of semilunar cartilage. Under DC 5258, a 20 percent disability rating is warranted when there is dislocation of the semilunar cartilage with frequent episodes of locking, pain, and effusion into the joint. To this end, the evidence shows that the Veteran has reported right knee symptoms including swelling, crepitus, catching, grinding, and pain. See, e.g., the private treatment records dated May 2008; see also the VA treatment records dated December 2015 and the VA examination report dated July 2016. Notably, as described in private treatment records a June 2008 MRI revealed a complex tear of the anterior horn and body of the lateral meniscus, as well as a complex tear of the posterior horn of the medial meniscus. As such, the Veteran has a history of meniscal tear of the right knee. Regarding DC 5258, the Board finds that a separate 20 percent rating for dislocated semilunar cartilage with frequent episodes of locking, pain, and effusion into the joint is warranted. Here, the evidence clearly documents a meniscal tear coupled with consistent documentation of locking, pain, crepitus, and effusion. Accordingly, a separate 20 percent rating is warranted for meniscal tear of the right knee under DC 5258. In sum, the Board has considered the entire record, including the Veteran’s reported symptomatology and the objective clinical evidence. For the reasons set forth above, the Board finds that a 50 percent rating, but no higher, is warranted for degenerative arthritis of the right knee with limitation of extension from the date of service connection. The Board also finds that the Veteran has met the criteria for a separate 20 percent for a meniscus tear of the right knee under DC 5258. The preponderance of the evidence is against the assignment of ratings in excess of those currently assigned. To that extent, the benefit of the doubt rule does not apply. 38 U.S.C. § 5107(b); see also Gilbert v. Derwinski, 1 Vet. App. 49 (1990). While there may have been day-to-day fluctuations in the manifestations of the Veteran’s service-connected right knee disabilities, the evidence shows no distinct periods of time during the appeal period, when his disabilities varied to such an extent that higher evaluations would be warranted. Hart, supra. Neither the Veteran nor his attorney 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 an acquired psychiatric disorder, to include PTSD and depressive disorder, NOS, is remanded. The Veteran contends that he developed an acquired psychiatric disorder to include PTSD and depression, NOS, as a result of his active military service. For the reasons set forth below, the Board finds that this matter must be remanded for further evidentiary development. The Veteran has asserted several in-service stressors including fear of hostile military or terrorist activity. See, e.g., the private psychological evaluation dated March 2012, the Veteran’s PTSD stressor statement dated May 2012, and the written argument of the Veteran’s attorney dated April 2018 Although the RO has not confirmed the entirety of the Veteran’s stressors, the Board observes that the Veteran’s service in the Republic of South Korea from December 1972 to January 1974 has been demonstrated by the record. In support of his claim, the Veteran submitted a private psychological evaluation dated March 2012 in which the examiner diagnosed the Veteran with depressive disorder, NOS. The Veteran was afforded a VA psychological examination in March 2013 at which time the examiner reported that the Veteran’s symptoms do not meet the diagnostic criteria for PTSD under DSM-IV criteria. He further stated that the Veteran does not have any mental disorder that conforms with DSM-IV criteria. Significantly, the March 2013 VA examiner failed to recognize that the Veteran’s prior diagnosis of depressive disorder, NOS in March 2012. Moreover, the Board notes that since the March 2013 examination was conducted, VA amended 38 C.F.R. § 4.125(a) to indicate that a diagnosis of a mental disorder, to include PTSD, must conform to the standards set in the DSM-5. The amendments are applicable to the Veteran’s claim. See 38 C.F.R. § 4.125; 79 Fed. Reg. 45,093, 45,094-096 (Aug. 4, 2014); 80 Fed. Reg. 14,308 (Mar. 19, 2015) (final) (providing that for claims that were initially certified for appeal to the Board, the Court, or the U.S. Court of Appeals for the Federal Circuit prior to August 4, 2014, DSM-IV will apply. For all applications for benefits received by VA or pending before the AOJ on or after August 4, 2014, DSM-5 will apply). As the Veteran’s claim was certified for appeal in January 2017, DSM-5 applies to the claim. As noted, the March 2013 VA examiner concluded that the Veteran did not meet the criteria for a diagnosis of PTSD under DSM-IV. Thus, the Board finds that remand of this issue is warranted in order to afford the Veteran with a VA psychiatric examination that uses DSM-V, in accordance with current VA regulations. The examiner must also address the etiology of any previously diagnosed psychiatric disability. See McClain v. Nicholson, 21 Vet. App. 319, 321 (2007) (the presence of a disability at the time of filing of a claim or during its pendency warrants a finding that the current disability requirement has been met, even if the disability resolves prior to the Board’s adjudication of the claim). Prior to arranging for the Veteran to undergo further VA examination, to ensure that all due process requirements are met, and that the record is complete, the AOJ should undertake appropriate action to obtain all pertinent, outstanding records. The matter is REMANDED for the following action: 1. Obtain all outstanding records of VA evaluation and/or treatment of the Veteran. Follow the procedures set forth in 38 C.F.R. § 3.159(c) with respect to requesting records from Federal facilities. All records/responses received should be associated with the claims file. 2. Schedule the Veteran for a VA examination to determine the etiology of his claimed acquired psychiatric disorder to include PTSD and depression, NOS. All indicated tests and studies should be conducted. The contents of the electronic claims file must be made available to the examiner for review in connection with the examination. Following examination of the Veteran and review of the entire claims file, the psychiatrist is requested to provide an opinion as to whether the Veteran meets the criteria for a diagnosis of PTSD under the DSM-5 criteria. If not, the examiner should specify which of the criteria are not met. If the Veteran does meet the PTSD criteria, the examiner shall specify the stressors supporting the diagnosis. If the diagnosis of PTSD is based upon a stressor involving fear of hostile military or terrorist activity, the examiner shall so state. For any additional psychiatric diagnosis (including any previously diagnosed psychiatric disorders such as depression, NOS, the psychiatrist is requested to provide an opinion as to whether it is at least as likely as not that said disability was incurred in the Veteran’s active duty service. In answering these questions, the examiner should address the Veteran’s assertions of continuity of symptomatology dating from his military service. The medical reasons for accepting or rejecting the Veteran’s statements regarding continuity since service should be set forth in detail. If the examiner determines that he/she cannot provide an opinion without resorting to speculation, the examiner should explain the inability to provide an opinion, identifying precisely what facts could not be determined. In particular, he/she should comment on whether an opinion could not be provided because the limits of medical knowledge have been exhausted or whether additional testing or information could be obtained that would lead to a conclusive opinion. K. Conner Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD K. K. Buckley, Counsel