Citation Nr: 18155316 Decision Date: 12/04/18 Archive Date: 12/03/18 DOCKET NO. 16-16 902 DATE: December 4, 2018 ORDER Service connection for radiculopathy of the right lower extremity is granted. Service connection for radiculopathy of the left lower extremity is granted. An increased rating in excess of 20 percent for left shoulder osteoarthritis, impingement syndrome, and bursitis is denied. An increased rating in excess of 40 percent for low back trauma is denied. An increased rating in excess of 10 percent for right knee ACL tear is denied. REMANDED Service connection for a left knee condition is remanded. Service connection for a bilateral foot condition is remanded. TDIU is remanded. FINDINGS OF FACT 1. The evidence shows that radiculopathy of the right lower extremity is due to the Veteran’s service-connected low back disability. 2. The evidence shows that radiculopathy of the left lower extremity is due to the Veteran’s service-connected low back disability. 3. During the appeal period, the Veteran's left shoulder disability was manifested by pain and weakness, abduction of the left arm to 90 degrees and external rotation to 60 degrees. 4. During the appeal period, the Veteran has not had unfavorable ankylosis of the thoracolumbar spine or incapacitating episodes having a total duration of at least six weeks during any 12-month period. 5. During the appeal period, the Veteran's right knee disability was manifested by arthritis, with flexion limited to 110 degrees and full extension, and without locking into the right knee joint or recurrent subluxation or instability. CONCLUSIONS OF LAW 1. The criteria for service connection for radiculopathy of the right lower extremity have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.310. 2. The criteria for service connection for radiculopathy of the left lower extremity have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.310. 3. The criteria for a disability rating in excess of 20 percent for left shoulder osteoarthritis, impingement syndrome, and bursitis have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.3, and 4.71a, Diagnostic Code 5201. 4. The criteria for a disability rating in excess of 40 percent for degenerative osteoarthritis of the lumbar spine have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.21; 4.71a, Diagnostic Codes 5237, 5243. 5. The criteria for a rating in excess of 10 percent for right knee ACL tear have not been met. 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.10, 4.40, 4.14, 4.45, 4.59, 4.71a, DC's 5003, 5261. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had service in the Army Reserves from October 1980 to February 1981 and from August 2004 to August 2007. He served in the Army from December 1990 to June 1991, from August 2007 to September 2011, and from October 2011 to September 2012. 1. Service connection for radiculopathy of the lower extremities The Veteran seeks service connection for radiculopathy of the lower extremities secondary to his service-connected low back disability. Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. Establishing service connection generally requires competent evidence of three things: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship, i.e., a nexus, between the claimed in-service disease or injury and the current disability. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303 (a). Service connection may be established on a secondary basis for a disability that is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310 (a). Establishing service-connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) caused by or (b) aggravated by a service-connected disability. See 38 C.F.R. § 3.310 (a); see also Allen v. Brown, 7 Vet. App. 439 (1995) (en banc). When aggravation of a Veteran's non-service-connected condition is proximately due to or the result of a service-connected condition, the Veteran shall be compensated for the degree of disability over and above the degree of disability existing prior to the aggravation. Allen, supra. To prevail on the issue of secondary service causation, generally, the record must show (1) medical evidence of a current disability, (2) a service-connected disability, and (3) medical nexus evidence establishing a connection between the current disability and the service-connected disability. Wallin v. West, 11 Vet. App. 509, 512 (1998); Reiber v. Brown, 7 Vet. App. 513, 516-17 (1995). An April 1998 rating decision granted service connection for residuals of low back trauma. Upon VA examination in March 1997, normal reflexes were noted. The VA examiner opined that the Veteran did not have a discernible neurological problem. A December 2012 VA examination reflects that the Veteran reported bilateral sciatic and femoral radicular pain, which was constant in varying degrees. The examiner diagnosed right and left sciatic radicular pain secondary to discopathy and stenosis. The examiner opined that it is more likely than not directly related to the Veteran’s service-connected low back injury. The competent medical evidence of record links the Veteran’s radicular symptoms to his service connected low back disability. The Board finds that service connection is warranted for sciatic radicular pain of the left and right lower extremities. Accordingly, service connection is warranted for radiculopathy and carpal tunnel syndrome of the bilateral upper extremities secondary to the degenerative disk disease of the cervical spine. Increased Rating 1. Entitlement to an increased rating in excess of 20 percent for left shoulder osteoarthritis, impingement syndrome, and bursitis Disability evaluations (ratings) are determined by the application of a schedule of ratings which is based, as far as can practically be determined, on the average impairment of earning capacity. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. The degrees of disability specified are considered adequate to compensate for a loss of working time proportionate to the severity of the disability. 38 C.F.R. § 4.1 . Each service-connected disability is rated on the basis of specific criteria identified by Diagnostic Codes. 38 C.F.R. § 4.27. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability more closely approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. It is the policy of the VA to administer the law under a broad interpretation, consistent with the facts in each case, with all reasonable doubt to be resolved in favor of the claimant. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. After careful consideration of the evidence, any reasonable doubt remaining is resolved in the claimant's favor. 38 C.F.R. § 4.3. When evaluating disabilities of the musculoskeletal system, 38 C.F.R. § 4.40 allows for consideration of functional loss due to pain and weakness causing additional disability beyond that reflected on range of motion measurements. DeLuca v. Brown, 8 Vet. App. 202 (1995). Further, 38 C.F.R. § 4.45 provides that consideration also be given to decreased movement, weakened movement, excess fatigability, incoordination, and pain on movement, swelling, and deformity or atrophy of disuse. With any form of arthritis, painful motion is an important factor of disability, the facial expression, wincing, etc., on pressure or manipulation, should be carefully noted and definitely related to affected joints. Muscle spasm will greatly assist the identification. Sciatic neuritis is not uncommonly caused by arthritis of the spine. The intent of the schedule is to recognize painful motion with joint or particular pathology as productive of disability. It is the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. Crepitation either in the soft tissues such as the tendons or ligaments, or crepitation within the joint structures should be noted carefully as points of contact which are diseased. Flexion elicits such manifestations. The joints involved should be tested for pain on both active and passive motion, in weight-bearing and non-weight-bearing and, if possible, with the range of the opposite undamaged joint. 38 C.F.R. § 4.59. Under 38 C.F.R. § 4.59, painful motion is a factor to be considered with any form of arthritis; however, 38 C.F.R. § 4.59 is not limited to disabilities involving arthritis. See Burton v. Shinseki, 25 Vet. App. 1 (2011). The United States Court of Appeals for Veterans' Claims also has held, that "pain itself does not rise to the level of functional loss as contemplated by VA regulations applicable to the musculoskeletal system." Mitchell v. Shinseki, 25 Vet. App. 32, 38 (2011). Rather, pain, may result in functional loss, but only if it limits the ability "to perform the normal working movements of the body with normal excursion, strength, speed, coordination [,or] endurance." Id., quoting 38 C.F.R. § 4.40. In both claims for an increased rating on an original claim and an increased rating for an established disability, only the specific criteria of the Diagnostic Code are to be considered. Massey v. Brown, 7 Vet. App. 204, 208 (1994). In order to evaluate the level of disability and any changes in severity, it is necessary to consider the complete medical history of the disability. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). An April 2014 rating decision granted service connection for left shoulder osteoarthritis, impingement syndrome, and bursitis. A non-compensable (0 percent) rating was assigned from October 2012. A March 2016 rating decision assigned a 20 percent rating from October 1, 2012, the day after the Veteran’s discharge. The Veteran's left shoulder disability is rated under Diagnostic Code 5201. The Veteran is right-handed; therefore, the rating criteria for the minor extremity are applicable. Diagnostic Code 5201 provides that limitation of motion of the arm from midway between the side and shoulder level warrants a 20 percent rating for the minor extremity. Limitation of motion to 25 degrees from the side warrants a 30 percent rating for the minor extremity. See 38 C.F.R. § 4.71a, Diagnostic Code 5201. In assessing the severity of limitation of shoulder motion, it is necessary to consider both forward flexion and abduction. See Mariano v. Principi, 17 Vet. App. 305, 317-18 (2003). Normal shoulder motion is from 0 to 180 degrees of forward elevation (flexion), from 0 to 180 degrees of abduction, and from 0 to 90 degrees of internal and external rotation. See 38 C.F.R. § 4.71, Plate I. A July 2012 entry in the service treatment records reflects diagnoses of osteoarthritis and shoulder impingement of the left shoulder. The record noted limitation of motion of the shoulder, but no specific range of motion measurements were recorded. The Veteran had a VA examination in March 2016. The examiner diagnosed bicipital tendon tear, rotator cuff arthritis, and acromioclavicular joint osteoarthritis. The Veteran reported left shoulder pain since 2009. He reported that he used Aleve for severe pain and sometimes used a TENS unit. The Veteran reported flare-ups with more intense pain about once a week on average. The Veteran reported that his functional loss included difficulty with any activity involving lifting the left upper extremity above the head and difficulty carrying heavy items with the left upper extremity. The examination showed flexion to 90 degrees, abduction to 90 degrees, external rotation to 60 degrees, and internal rotation to 90 degrees. The examiner indicated that the Veteran did not actively flex or abduct his shoulder more than 90 degrees because of pain. The Veteran also resisted attempts to passively flex and abduct the shoulder. The examiner noted pain with use and diffuse tenderness of the shoulder, which was most severe anteriorly. Repetitive use testing with three repetitions did not show additional functional loss or range of motion. The examiner was unable to state whether pain, weakness, fatigability, or incoordination significantly limited the Veteran’s functional ability with repeated use over a period of time. The examiner indicated that it would be speculative to opine with regard to a hypothetical situation. Ankylosis was not present. The examiner was unable to test for impingement. There was no instability or dislocation of the shoulder. There was no condition of the clavicle, scapula, acromioclavicular joint, or sternoclavicular joint suspected. The Veteran did not have loss of head (flail shoulder), nonunion (false flail shoulder), or fibrous union of the humerus. He did not have malunion of the humerus with moderate or marked deformity. The evidence reflects that the Veteran’s left shoulder disability is manifested by pain and functional loss of the shoulder, including difficulty lifting or carry heavy objects. The Veteran has normal flexion, abduction, and internal rotation of the left shoulder. His external rotation is 60 degrees. The criteria for a rating in excess of 20 percent are not met, as the evidence does not more nearly approximate limitation of motion to 25 degrees from the side. The Board has considered whether a higher disability rating is warranted based on functional loss due to pain or weakness, fatigability, incoordination, or pain on movement of a joint. See 38 C.F.R. §§ 4.40, 4.45, 4.59; see also DeLuca, 8 Vet. App. at 202. The range of motion findings do not more nearly approximate the criteria for a 30 percent rating. See 38 C.F.R. § 4.71a, Diagnostic Code 5201. Even considering additional functional loss due to pain, the limitation in range of motion due to pain, fatigue, or weakness, does not meet the criteria for a higher disability evaluation for left shoulder disability during the period on appeal. Accordingly, the Board finds that a higher rating is not warranted under the DeLuca criteria and section 4.59. The Board has considered whether any other diagnostic codes pertaining to the shoulder are applicable. DC 5200 pertains to ankylosis of the scapulohumeral articulation, DC 5202 pertains to impairment of the humerus, and DC 5203 pertains to impairment of the clavicle or scapula. See 38 C.F.R. § 4.71a. As there is no evidence showing that any of these conditions have been present during the appeal period, a higher rating is not assignable based on those criteria. The Board concludes that there is a preponderance of the evidence against the claim for a rating in excess of 20 percent for left shoulder osteoarthritis, impingement syndrome, and bursitis. The Board has considered the benefit-of-the-doubt rule in making this decision. 38 U.S.C. § 5107 (b). 2. Entitlement to an increased rating in excess of 40 percent for low back trauma The Veteran's lumbar spine disability is rated according to the General Rating Formula for Diseases and Injuries of the Spine. 38 C.F.R. § 4.71a. Under the General Rating Formula, with or without symptoms such as pain, stiffness or aching in the area of the spine affected by residuals of injury or disease, the following ratings will apply: a 20 percent rating is assigned when forward flexion of the thoracolumbar spine is greater than 30 degrees but not greater than 60 degrees; or, forward flexion of the cervical spine is greater than 15 degrees but not greater than 30 degrees; or, the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, the combined range of motion of the cervical spine not greater than 170 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis or abnormal kyphosis; a 30 percent rating is awarded for forward flexion of the cervical spine 15 degrees or less; or, favorable ankylosis of the entire cervical spine; a 40 percent rating is assigned for unfavorable ankylosis of the entire cervical spine; or, forward flexion of the thoracolumbar spine 30 degrees or less; or favorable ankylosis of the entire thoracolumbar spine; a 50 percent rating is awarded for unfavorable ankylosis of the entire thoracolumbar spine; and a 100 percent rating is warranted for unfavorable ankylosis of the entire spine. There are several notes following the General Rating Formula criteria, which provide the following: First, associated objective neurological abnormalities are to be rated separately under an appropriate diagnostic code. Second, for purposes of VA compensation, normal forward flexion of the thoracolumbar spine is 0 to 90 degrees, extension is 0 to 30 degrees, left and right lateroflexion is 0 to 30 degrees, and left and right lateral rotation is 0 to 30 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateroflexion, and left and right rotation. The normal combined range of motion of the thoracolumbar spine is to 240 degrees. Third, in exceptional cases, an examiner may state that, because of age, body habitus, neurological disease, or other factors not the result of disease or injury of the spine, the range of motion of the spine in a particular individual should be considered normal for that individual, even though it does not conform to the normal range of motion stated in the regulation. 38 C.F.R. § 4.71a. The Formula for Rating Intervertebral Disc Syndrome based upon Incapacitating Episodes provides that a 20 percent rating is warranted with incapacitating episodes having a total duration of at least 2 weeks but less than 4 weeks during the past 12 months. A 40 percent rating is assignable with incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months. A 60 percent rating is assignable with incapacitating episodes having a total duration of at least 6 weeks during the past 12 months. For purposes of evaluations under diagnostic code 5243, an incapacitating episode is a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician. 38 C.F.R. § 4.71a, Diagnostic Code 5243, Note (1). The current claim for an increased rating for low back trauma was received in October 2012. An April 2014 rating decision granted service connection for low back trauma and assigned a 40 percent rating, effective from October 2012. The Veteran had a VA examination in March 2016. The Veteran reported persistent back pain since 1991. His current symptoms included severe low back pain every day. He reported that he treated his back pain with Aleve and a TENS unit. The Veteran reported flare-ups every month with more severe pain than his typical daily pain, which was quite severe. He reported difficulty with bending and lifting objects. He reported that he was unable to participate in any sports. The Veteran was unable to complete range of motion testing. He could not attempt more than a few degrees of flexion, extension, or any other range of motion, stating that he had too much pain. There was no evidence of pain with weight bearing. There was objective evidence of localized tenderness or pain on palpation of the joints. The Veteran reported that he had diffuse tenderness in the low back with very light pressure applied. The examiner was unable to opine regarding repetitive use testing, as the Veteran could not perform range of motion testing. The examiner was unable to assess functional loss over a period of time due to pain, weakness, fatigability, or incoordination, as such an opinion required speculation. The examiner was also unable to assess functional loss due to flare-ups. The examiner indicated that such an opinion would require resort to speculation. Ankylosis of the spine was not present. The Veteran did not have intervertebral disc syndrome. The examiner indicated that radiculopathy was not present. There were no other neurological abnormalities related to the lumbar spine. The Board finds that the Veteran is not entitled to an initial disability rating in excess of 40 percent for the service-connected lumbar spine disability at any time during the rating period. The next higher 50 percent rating requires favorable ankylosis of the entire thoracolumbar spine, unfavorable ankylosis of the entire thoracolumbar spine, or unfavorable ankylosis of the entire spine. See 38 C.F.R. § 4.71a , DCs 5235-5243 (2017). A higher 50 percent rating is not appropriate in this case as the evidence does not reflect findings of unfavorable ankylosis. A rating in excess of 40 percent is also not warranted based upon incapacitating episodes of intervertebral disc syndrome, as the Veteran does not have a diagnosis of intervertebral disc syndrome. See 38 C.F.R. § 4.71 (a), DC 5243. The Board notes that the Veteran has been separately service-connected for radiculopathy of the lower extremities. The ratings assigned for those disabilities are not before the Board at this time. There are no other findings of neurological manifestations associated with the Veteran's lumbar spine disability. For these reasons, the Board finds that the criteria for an initial disability rating in excess of 40 percent for degenerative osteoarthritis of the lumbar spine have not been met at any time during the initial rating period. The Board has considered the benefit-of-the-doubt rule in making this decision. 38 U.S.C. § 5107 (b). 3. Entitlement to an increased rating in excess of 10 percent for right knee ACL tear Diagnostic Code (DC) 5260 pertains to limitation of flexion. A 10 percent evaluation is assignable when flexion is limited to 45 degrees. A 20 percent evaluation is assignable where flexion is limited to 30 degrees. An evaluation of 30 percent is assignable when flexion is limited to 15 degrees. 38 C.F.R. § 4.71a. DC 5261 applies to limitation of extension of the leg. A 10 percent evaluation is assignable for extension limited to 10 degrees. A 20 percent evaluation is assignable for extension limited to 15 degrees. A 30 percent evaluation is assignable for extension limited to 20 degrees. A 40 percent evaluation is assignable for extension limited to 30 degrees. A 50 percent evaluation is assignable when extension is limited to 50 degrees. 38 C.F.R. § 4.71a. Full range of motion of the knee is from 0 to 140 degrees. 38 C.F.R. § 4.71, Plate II. In VAOPGCPREC 23-97, the VA General Counsel interpreted that a veteran who has arthritis and instability of the knee may be rated separately under DC's 5003 and 5257, provided that a separate rating is based upon additional disability. Subsequently, in VAOPGCPREC 9-98, the VA General Counsel further explained that, if a veteran has a disability rating under DC 5257 for instability of the knee, and there is also x-ray evidence of arthritis, a separate rating for arthritis could also be based on painful motion under 38 C.F.R. § 4.59. The General Counsel has also directed that separate ratings are available if a particular knee disability causes both compensable (10 percent) limitation of extension (Diagnostic Code 5261) and compensable limitation of flexion (Diagnostic Code 5260) of the same joint. Specifically, where a veteran has both a compensable limitation of flexion and a compensable limitation of extension of the same leg, the limitations must be rated separately to adequately compensate for functional loss associated with injury to the leg. VAOPGCPREC 9-04. Diagnostic Code (DC) 5003 provides that 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. Service connection for a right knee ACL tear was granted in a March 2016 rating decision. A 10 percent rating was assigned for painful motion of the knee, pursuant to Diagnostic Code 5261. The Veteran had a VA examination in March 2016. The examination noted diagnoses of right knee strain, meniscal tear, anterior cruciate ligament tear, and osteoarthritis. The Veteran reported monthly flare-ups of pain, which was sometimes severe. Examination revealed flexion limited to 110 degrees and full extension to 0 degrees. The examiner noted pain on examination, which caused functional loss. There was mild tenderness medial to the patella. The Veteran did not have additional functional loss or range of motion after three repetitions of range of motion. There was no evidence of pain with weight-bearing. The examiner was unable to opine as to whether the knee was additionally limited by pain, weakness, fatigability, or incoordination with repeated use over a period of time. The examiner indicated that such an opinion would be speculative. The examiner was unable to say whether the knee was additionally limited by pain, weakness, fatigability, or incoordination with flare-ups. The examiner opined that such an opinion would be speculative. The examination reflects that there was no ankylosis. Tests of joint stability were normal. The examiner noted a history of recurrent effusion. The Veteran reported a history of significant swelling approximately 15 years earlier. The Veteran denied any recent swelling of the right knee. The examiner noted that the Veteran had a history of a meniscus condition with a meniscus tear and frequent episodes of joint pain. The Veteran had a history of meniscectomy in 1997. The Veteran reported that he occasionally used a brace. The Board finds that a rating in excess of 10 percent is not warranted for limitation of flexion. Even considering the Veteran's subjective complaints and the objective findings of functional loss due to pain, his limitation of flexion does not approximate flexion limited to 30 degrees, as is required for the next higher 20 percent rating under Diagnostic Code 5260. A separate rating is not warranted for limitation of extension, as the Veteran has not exhibited compensable limitation of extension during the rating period. The evidence does not reflect recurrent subluxation or instability of the right knee. Accordingly, a separate rating for those disabilities is not warranted. Regarding a separate rating for dislocated semilunar cartilage under DC 5258, the evidence shows a history of meniscectomy in 1997. The evidence shows knee pain during the appeal period, but there are no findings of locking. The Veteran last reported that he experienced effusion of the knee approximately 15 years ago. The criteria under Diagnostic Code 5258 are conjunctive, not disjunctive; thus, all criteria must be met. See Melson v. Derwinski, 1 Vet. App. 334 (June 1991) (use of the conjunctive "and" in a statutory provision meant that all of the conditions listed in the provision must be met). Accordingly, a separate rating under DC 5258 is not warranted for the entire appeal period. A separate rating under DC 5259 is not warranted, as the Veteran does not have semilunar cartilage removal of the right knee. There have been no findings of ankylosis of the right knee to warrant the assignment of a higher rating under Diagnostic Code 5256. The Board finds that the criteria for a rating in excess of 10 percent for right knee ACL tear are not met. The Board has considered the benefit-of-the-doubt rule in making this decision. 38 U.S.C. § 5107 (b). REMANDED ISSUES 4. Service connection for a left knee condition is remanded. A March 2016 VA examination noted that the clinical presentation of the left knee was consistent with patellofemoral pain syndrome. The examination did not include a medical opinion about the etiology of patellofemoral pain syndrome. The case is being remanded for a VA examination and medical opinion to ascertain whether his current left knee disability is related to service or to his right knee disability. 5. Service connection for a bilateral foot condition is remanded Service treatment records show that the Veteran underwent bunion surgery on his right foot and was diagnosed with hallux valgus of the right foot, hallux valgus of the left foot and hallux rigidus. A March 2016 VA examination noted a history of hallux valgus with bunion. The examiner also diagnosed degenerative arthritis of both feet. The examiner noted residual numbness of both incision sites of both feet. The examiner noted surgery for hallux valgus but did not indicate when the surgery occurred. There was no etiology opinion given. The case is being remanded for a VA examination and opinion. 6. Entitlement to a TDIU is remanded. The Board finds that the Veteran meets the schedular criteria for consideration for TDIU under 38 C.F.R. § 4.16 (a) from October 1, 2012. His VA examinations in March 2016 indicated that the Veteran was employed as a fruit and vegetable inspector. It is not clear whether the Veteran is presently employed. On remand, the RO should clarify the Veteran’s current employment status. The matters are REMANDED for the following action: 1. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any left knee disability. The examiner must opine whether a current left knee disability is at least as likely as not related to an in-service injury, event, or disease. The examiner must opine whether a current left knee disability is at least as likely as not (a) proximately due to or (b) aggravated (worsened) by the Veteran’s service-connected left knee disability. 2. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any bilateral foot disability. The examiner must diagnose all current disabilities of the bilateral feet. The examiner must opine whether any current foot disability is at least as likely as not related to an in-service injury, event, or disease. The examiner must consider the following: a. The Veteran underwent left and right great toe arthrodesis with bunionectomy during service in 2011 and 2012; b. Service treatment records reflect diagnoses of hallux valgus of both feet and hallux rigidus. 3. Contact the Veteran and request clarification as to whether he is currently employed. Request clarification as to his position and whether he worked full or part-time, and the dates of employment. JOHN Z. JONES Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Catherine Cykowski