Citation Nr: 18156082 Decision Date: 12/06/18 Archive Date: 12/06/18 DOCKET NO. 15-43 026 DATE: December 6, 2018 ORDER Entitlement to service connection for a bilateral ankle disability to include recurrent ankle sprain is granted. Entitlement to an initial rating in excess of 20 percent for intervertebral disc syndrome, spondylosis with degenerative disc disease and compression fracture, L1-2 (low back disability) is denied, prior to November 16, 2014. Entitlement to a 40 percent rating for a low back disability, but no higher, is granted, effective November 16, 2014, subject to the laws and regulations governing the payment of monetary benefits. Entitlement to a rating in excess of 40 percent for a low back disability, is denied, throughout the period on appeal. REMANDED Entitlement to service connection for a bilateral foot disability is remanded. Entitlement to a rating in excess of 20 percent for status post right knee arthroscopy with internal derangement (right knee disability) is remanded. FINDINGS OF FACT 1. It is at least as likely as not that the Veteran’s bilateral ankle disability to include recurrent ankle sprain is aggravated by service-connected disability. 2. Prior to November 16, 2014, the Veteran’s service-connected low back disability was manifested by, at worst, forward flexion to 40 degrees and a combined range of motion of 115 degrees with pain, without ankylosis. 3. From November 16, 2014, the Veteran’s service-connected low back disability was manifested by, at worst, forward flexion to 10 degrees and a combined range of motion of 40 degrees with severe pain, without ankylosis. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for a bilateral ankle disability to include recurrent ankle sprain are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303(a), 3.310. 2. Prior to November 16, 2014, the criteria for a disability rating in excess of 20 percent for a low back disability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.159, 4.3, 4.7, 4.71a, Diagnostic Code 5237. 3. Effective November 16, 2014, the criteria for a disability rating of 40 percent for a low back disability have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.159, 4.3, 4.7, 4.71a, Diagnostic Code 5237. 4. Throughout the period on appeal, the criteria for a disability rating in excess of 40 percent for a low back disability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.159, 4.3, 4.7, 4.71a, Diagnostic Codes 5237, 5239, 5240, 5242, and 5243. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served in the United States Navy from April 1972 to April 1992. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a January 2014 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Huntington, West Virginia. In October 2015, the RO increased the Veteran’s disability rating to 40 percent for intervertebral disc syndrome (IVDS), spondylosis with degenerative disc disease and compression fracture L1-2 formerly lumbosacral strain effective August 17, 2015. Because the increase in evaluation of the Veteran’s low back disability does not represent the maximum evaluation available for the condition, the Veteran’s claim remains in appellate status. See AB v. Brown, 6 Vet. App. 35, 38 (1993). 1. Entitlement to service connection for a bilateral ankle disability The Veteran seeks service connection for a bilateral ankle disability which he asserts is related to his service connected bilateral knee disabilities and back disability. In January 2015 and November 2015 statements, the Veteran stated that when his knees would swell and pop, his ankles would swell and cause a lot of pain; and his feet pointed at a 45-degree angle when he walked. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1166-1167 (Fed. Cir. 2004). For Veterans who have served 90 days or more of active service during a war period or after December 31, 1946, certain chronic disabilities, including arthritis, are presumed to have been incurred in or aggravated by service if manifest to a compensable degree (10 percent disabling) within one year of discharge from service. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. Where the evidence shows a “chronic disease” in service or “continuity of symptoms” after service, the disease shall be presumed to have been incurred in service. For the showing of “chronic” disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. With chronic disease as such in service, subsequent manifestations of the same chronic disease, at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. If a condition noted during service is not shown to be chronic, then generally a showing of “continuity of symptoms” after service is required for service connection. 38 C.F.R. § 3.303(b). Even if service connection is not warranted under one of the presumptive regulations, this does not preclude a claimant from establishing service connection with proof of direct causation. See Combee v. Brown, 34 F.3d 1039, 1043-1044 (Fed. Cir. 1994). Service connection may also be granted for a disability proximately due to or the result of a service-connected disability and where aggravation of a nonservice-connected disorder is proximately due to or the result of a service-connected disability. 38 C.F.R. § 3.310; Allen v. Brown, 7 Vet. App. 439, 446-449 (1995) (en banc). The Board has carefully reviewed the evidence of record and finds that the criteria for service connection for a bilateral ankle disability have been met. As noted, the Veteran served in the United States Navy from April 1972 to April 1992. Service treatment records in September 1978 reflect a diagnosis of right ankle sprain without a fracture. X-rays of the Veteran’s right bilateral ankles appeared negative. The treatment provider noted that the Veteran’s right ankle was swollen over the lateral and medial aspects, and discoloration was noted over the lateral aspect of the right ankle. Post-service VA treatment records reflect that the Veteran walked with an altered gait from at least April 2008; and reflect a diagnosis of ankle sprain from January 2012. April 2008 VA treatment records reflect a diagnosis of increased gait deviation. A treatment provider noted that the Veteran had no significant antalgia, and had mild external rotation of his right foot and leg during gait. A January 2012 VA treatment record reflects a diagnosis of ankle sprain. The treatment provider noted that the Veteran had fallen last week and twisted his ankle when his knee gave out. The treatment provider noted that the swelling had gone down quite a bit. A January 2012 x-ray revealed a minor abnormality of the Veteran’s right ankle. The Veteran was afforded a VA examination in December 2013 for a low back condition. The examiner noted that the Veteran had an antalgic gait due to pain. The examiner opined that the Veteran’s back condition was at least as likely as not (50 percent or greater probability) proximately due to or the result of the Veteran’s service-connected condition. The examiner noted that the Veteran had evidence of a bilateral knee injury and required surgery while in military service; due to the knee issues, this led to an altered gait, which led to back strain. The Veteran was afforded a VA examination in December 2013, which revealed a diagnosis of calcaneal spur. A December 2013 x-ray revealed bilateral ankle calcaneal spurs. The Veteran reported that his ankles began swelling in 2010. He stated that his knees had been getting worse, which caused both of his ankles to swell and pushed his feet outwards when he walked. He stated that when his knees would swell, his ankles would flare up, and he would be unable to put on his shoes. He also stated that he used a cane to assist in walking. The examiner opined that the Veteran’s bilateral ankle disability was less likely than not (less than 50 percent probability) proximately due to or the result of the Veteran’s service-connected condition. The examiner noted that there was no evidence to suggest that the ankles were involved other than calcaneal spur. The examiner did not discuss the September 1978 service treatment record which reflected a diagnosis of a right ankle sprain without fracture. The examiner also did not discuss the VA treatment records and VA examinations which reflect that the Veteran had an altered gait from at least April 2008. A November 2014 VA treatment record reflects that the Veteran reported that he fell from a tall ladder because his right knee buckled. He reported that he had increasing pain in his ankles. The treatment provider opined that the Veteran’s weight gain and chronic knee problems contributed to ankle pain. In January 2015, the November 2014 VA treatment provider opined that it was more likely than not that the Veteran’s ankle conditions were aggravated by his chronic knee problems. The treatment provider noted that the Veteran suffered from several chronic medical conditions including chronic knee pain, and these conditions could flare up off and on. When this occurred, the Veteran would often complain that his ankle pain was aggravated. Resolving all reasonable doubt in the Veteran’s favor, the Board finds that the criteria for service connection for a bilateral ankle disability on a secondary service connection basis have been met. As discussed, service treatment records in September 1978 reflect a diagnosis of right ankle sprain without a fracture. Post-service VA treatment records reflect that the Veteran walked with an altered gait from at least April 2008; and reflect a diagnosis of ankle sprain from January 2012. The November 2014 and January 2015 opinions from the Veteran’s VA treatment provider establishes that the Veteran’s bilateral ankle disability is related to the Veteran’s service-connected bilateral knee disabilities. The November 2014 and January 2015 opinions are competent, credible and probative, and coupled with the other medical evidence of record including the VA treatment records and lay evidence, support a conclusion that service connection for a bilateral ankle disability is warranted. In determining the weight assigned to this evidence, the Board also looks at factors such as the health care provider’s knowledge and skill in analyzing the medical data. See Guerrieri v. Brown, 4 Vet. App. 467, 470-471 (1993). In determining the probative value to be assigned to a medical opinion, the Board must consider three factors: whether a medical expert was fully informed of the pertinent factual premises (i.e., medical history) of the case; whether the medical expert provided a fully articulated opinion; and whether the opinion is supported by a reasoned analysis. The most probative value of a medical opinion comes from its reasoning. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Therefore, a medical opinion containing only data and conclusions is not entitled to any weight. In fact, a review of the claims file does not substitute for a lack of a reasoned analysis. See Nieves-Rodriguez, supra. The Board notes that the December 2013 VA examiner who opined that the Veteran’s bilateral ankle disability was less likely than not (less than 50 percent probability) proximately due to or the result of the Veteran’s service-connected condition, failed to discuss the September 1978 service treatment record, which reflected a diagnosis of right ankle sprain without a fracture. Further, although the examiner had previously noted in December 2013 that the Veteran’s bilateral knee issues led to an altered gait, which led to back strain; the examiner did not discuss whether the Veteran’s altered gait also led to the Veteran’s bilateral ankle disability. In contrast, the Veteran’s VA treatment provider was fully informed of the Veteran’s medical history and discussed the other contributing factors to the Veteran’s bilateral ankle disability. The Board therefore attaches significant probative value to the November 2014 and January 2015 opinions and the most probative value in this case, as the opinions were well reasoned, detailed, and consistent with other evidence of record. See Prejean v. West, 13 Vet. App. 444, 448-449 (2000). Thus, resolving all reasonable doubt in favor of the Veteran and based on the medical and lay evidence of record, the Board finds that evidence of record supports a finding that service connection for a bilateral ankle disability is warranted. See 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49, 54 (1990). 2. Entitlement to an initial rating in excess of 20 percent for a low back disability prior to August 17, 2015 and in excess of 40 percent thereafter The Veteran seeks an initial rating in excess of 20 percent for his service connected low back disability prior to August 17, 2015 and in excess of 40 percent thereafter. In January 2015 and November 2015 statements, the Veteran stated that on a scale of one to ten, with ten being the most severe pain, he rated his back pain at a nine. He stated that he had to walk with a cane to be ambulatory, and he had missed six weeks of work due to his back pain. Disability ratings are based on the average impairment of earning capacity resulting from disability. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities. 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. 38 C.F.R. § 4.7. Otherwise, the lower rating will be assigned. Id. In a claim for a higher original rating after an initial award of service connection, all of the evidence submitted in support of the Veteran’s claim is to be considered. See Fenderson v. West, 12 Vet. App. 119, 127 (1999). The United States Court of Appeals for Veterans Claims (Court) has held that in determining the present level of a disability for any increased evaluation claim, the Board must consider the application of staged ratings. See Hart v. Mansfield, 21 Vet. App. 505, 510 (2007). In other words, where the evidence contains factual findings that demonstrate distinct time periods in which the service-connected disability exhibited diverse symptoms meeting the criteria for different ratings during the course of the appeal, the assignment of staged ratings would be necessary. Service connection for lumbosacral sprain/strain (claimed as back condition) was granted with an evaluation of 20 percent effective from December 11, 2012, in a January 2014 rating decision. A rating decision issued in October 2015 increased the disability rating for IVDS, spondylosis with degenerative disc disease and compression fracture L1-2 formerly lumbosacral strain (DC 5237) to 40 percent effective August 17, 2015. The Veteran’s low back disability is rated under 38 C.F.R. § 4.71a, Diagnostic Code 5237 prior to August 17, 2015, and under Diagnostic Code 5243 from August 17, 2015. The Board will consider whether the Veteran is entitled to receive higher ratings for his low back disability under all applicable diagnostic codes. Under the General Rating Formula for Diseases and Injuries of the Spine (General Formula), the spine is evaluated with or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease. 38 C.F.R. § 4.71a. Concerning disabilities affecting the spine, any associated objective neurologic abnormalities are evaluated separately under an appropriate Diagnostic Code. 38 C.F.R. § 4.71a, General Formula, Note 1. In this case, the Veteran’s neurological symptoms have been separately rated and are not on appeal. For VA compensation purposes, normal forward flexion of the thoracolumbar spine is 0 to 90 degrees, extension is 0 to 30 degrees, left and right lateral flexion are 0 to 30 degrees, and left and right lateral rotation are 0 to 30 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion of the thoracolumbar spine is 240 degrees. The normal ranges of motion for each component of spinal motion provided in this note are the maximum that can be used for calculation of the combined range of motion. 38 C.F.R. § 4.71a, General Formula, Note 2; See also 38 C.F.R. § 4.71a, Plate V. Under the General Formula, a 20 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees, combined range of motion of the thoracolumbar spine not greater than 120 degrees, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. 38 C.F.R. § 4.71a, General Formula. A 40 percent rating is warranted for forward flexion of the thoracolumbar spine of 30 degrees or less or favorable ankylosis of the entire thoracolumbar spine. Id. A 50 percent rating is warranted for unfavorable ankylosis of the entire thoracolumbar spine, and a 100 percent rating is warranted for unfavorable ankylosis of the entire spine. Id. Unfavorable ankylosis is a condition in which the entire thoracolumbar spine is fixed in flexion or extension, and the ankylosis results in one of more of the following: difficulty walking because of a limited line of vision, restricted opening of the mouth and chewing, breathing limited to diaphragmatic respiration, gastrointestinal symptoms due to pressure of the costal margin on the abdomen, dyspnea or dysphagia, atlantoaxial or cervical subluxation or dislocation, or neurologic symptoms due to nerve root stretching. Id. at Note 5. Fixation of a spinal segment in neutral position always represents favorable ankylosis. Id. Back disabilities may also be evaluated under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes (Incapacitating Episodes Formula), which applies to IVDS. See 38 C.F.R. § 4.71a, Incapacitating Episodes Formula. An “incapacitating episode” for purposes of totaling the cumulative time is defined as “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, Incapacitating Episodes Formula, Note 1. Under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, a 20 percent disability rating is warranted for incapacitating episodes having a total duration of at least 2 weeks, but less than 4 weeks during the past 12 months; a 40 percent disability evaluation is warranted for incapacitating episodes having a total duration of at least four weeks but less than six weeks during the past 12 months; and a 60 percent disability evaluation is warranted for incapacitating episodes having a total duration of at least six weeks during the past 12 months. 38 C.F.R. § 4.71a, Diagnostic Code 5243. When evaluating joint disabilities rated based on limitation of motion, VA must consider granting a higher rating in cases in which functional loss due to pain, weakness, excess fatigability, or incoordination is demonstrated, and those factors are not contemplated in the relevant rating criteria. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202, 207 (1995). In Sharp v. Shulkin, 29 Vet. App. 26 (2017), the Court held that VA examiners must provide opinions regarding flare-ups based upon estimates derived from information procured from relevant sources, including lay statements, when a flare-up is not observable at the time of examination. The Court has also issued the opinion of Correia v. McDonald, 28 Vet. App. 158, 169-170 (2016), which clarifies additional requirements that VA examiners should address when assessing musculoskeletal disabilities, holding specifically, that 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. A review of the record reveals that, while the August 2015 VA examination satisfies the requirements of Sharp, the December 2013 examiner’s statement that it was not possible to estimate the range of motion due to pain or functional loss during flare-ups or when the joint is used repeatedly over time does not satisfy the requirements of Sharp. Nevertheless, the Board finds that a remand to satisfy the requirements of Sharp is not warranted here, since remanding for another VA examination would not remedy the inadequacies of the evidence prior to August 17, 2015 including the December 2013 VA examination, and for the period from August 17, 2015, a higher rating would require ankylosis of the spine and thus Sharp would not be applicable. For these reasons, the Board finds that VA examinations are in substantial compliance with applicable law and regulations, and that there is no prejudice to the Veteran in proceeding to a decision without a remand under the circumstances. After a review of the evidence, for reasons set forth below, the Board finds that a rating in excess of 20 percent is not warranted for the Veteran’s low back disability prior to November 16, 2014; a 40 percent rating is warranted for the Veteran’s low back disability effective from November 16, 2014; and a rating in excess of 40 percent is not warranted for the Veteran’s low back disability for the entire period on appeal. The Veteran was afforded a VA examination in December 2013, which reflected a diagnosis of lumbosacral sprain/strain and spondylolysis/isthmic spondylolisthesis and a VA examination in August 2015, which reflected a diagnosis of IVDS, spondylosis with degenerative disc disease of the lumbar spine, and compression fracture, L1 and L2 of the lumbar spine. Physical examination of the Veteran in December 2013 revealed forward flexion to 40 degrees without pain and a combined range of motion of 115 degrees with pain. The examiner noted that the Veteran was unable to perform right and left lateral rotation due to pain. The examiner noted that the Veteran did not have guarding or muscle spasms of the thoracolumbar spine; however, the Veteran did have an antalgic gait due to pain. November 2014 and December 2014 VA treatment records reflects that the Veteran fell from a tall ladder in November 2014 which worsened his preexisting lower back pain. Based on this evidence, the Veteran’s low back disability does not warrant a rating in excess of 20 percent prior to November 16, 2014 under Diagnostic Code 5237. Although, the December 2013 examiner noted that pain, weakness, fatigability or incoordination significantly limited functional ability with repeated use over time, range of motion remained unchanged. Muscle strength for hip flexion, knee flexion and extension was 4/5 bilaterally; and muscle strength of ankle plantar flexion and dorsiflexion, foot abduction and adduction, great toe extension was 5/5 bilaterally. The Veteran did not have muscle atrophy. Deep tendon reflexes were normal; sensory examination was normal; and straight leg raising was negative. Therefore, although the Board acknowledges the functional impairment due to the Veteran’s low back pain, there is no competent, credible and probative evidence that the Veteran is entitled to a rating in excess of 20 percent, prior to November 16, 2014, because his low back condition did not manifest as forward flexion to 30 degrees or less or favorable ankylosis even with consideration of functional impairment due to pain, on repetitive motion, and with flares, as outlined in DeLuca, supra. Physical examination of the Veteran in August 2015 revealed forward flexion to 10 degrees and a combined range of motion of 40 degrees with severe pain with attempt at range of motion. The examination indicated that the Veteran did not have additional limitation of forward flexion with repetitive use testing or during flare-ups. Resolving all reasonable doubt in favor of the Veteran, the Board finds that the symptoms of low back disability have more nearly approximated the criteria for a 40 percent rating, but not higher, under Diagnostic Code 5237, effective November 16, 2014, the date of the VA treatment record which reflects that the Veteran fell from a ladder, which worsened his back condition. The Board notes that the Veteran’s low back disability does not reflect findings of favorable or unfavorable ankylosis at any time during the pendency of the appeal. 38 C.F.R. § 4.71a, General Rating. The medical evidence of record clearly shows that the Veteran’s spine is not ankylosed at any level. Although the Veteran’s low back disability does manifest in significant limitation of motion from pain and stiffness, it is not in a fixed position without motion at any degree or angle, nor does the Veteran contend otherwise. The August 2015 VA examination reflects that the Veteran has been diagnosed with IVDS. However, in the past 12 months, the Veteran had not had incapacitating episodes requiring at least four weeks of bed rest prescribed by a physician. The Board acknowledges the November 2014 VA treatment record, which reflects that the treatment provider instructed the Veteran to remain out of work for one week to rest his back, and noted that the Veteran may need more time off. However, the treatment provider did not specifically prescribe bed rest for the Veteran. Even if it were found that the treatment provider had prescribed bed rest for the Veteran, the evidence does not reflect that the Veteran was prescribed bed rest for at least four weeks during the past 12 months, the requirement for a rating in excess of 20 percent for any relevant period of this appeal. 38 C.F.R. § 4.71a, Diagnostic Code 5243. Therefore, based on the evidence as outlined above, the Veteran’s low back disability does not warrant a rating in excess of 40 percent at any point during the period on appeal, under all applicable diagnostic codes, including Diagnostic Codes 5237, 5239, 5240, 5242 and 5243. Finally, there is no evidence of a separate associated neurological symptomatology that would warrant additional ratings, other than radiculopathy of the right lower extremity for which service connection has already been established (and which is not before the Board at this time). REASONS FOR REMAND 1. Entitlement to service connection for bilateral foot disability is remanded. The Veteran seeks service connection for a bilateral foot disability, which he asserts is related to service or to his bilateral knee disabilities and back disability. In January 2015 and November 2015 statements, the Veteran stated that when his knees swell and pop, his feet would swell and cause a lot of pain; and his feet pointed at a 45-degree angle when he walked. The Veteran was afforded a VA examination in December 2013, which reflected a diagnosis of bilateral calcaneal spur and bilateral osteoarthritis of the first metatarsophalangeal joint. The examiner opined that the Veteran’s claimed condition was less likely than not (less than 50 percent probability) proximately due to or the result of the Veteran’s service-connected condition. The examiner noted that there was no evidence of a foot condition that was due to the Veteran’s service-connected knee degenerative joint disease. Although the examiner had previously noted in a December 2013 VA opinion that the Veteran’s bilateral knee issues led to an altered gait, which led to back strain; the examiner did not discuss whether the Veteran’s altered gait also led to the Veteran’s bilateral foot disability, which renders the opinion inadequate. The Board finds that a supplemental VA opinion is warranted to determine the etiology of the Veteran’s bilateral foot disability. 2. Entitlement to a rating in excess of 20 percent for a right knee disability is remanded. The Veteran seeks a rating in excess of 20 percent for his service connected right knee disability. In January 2015 and November 2015 statements, the Veteran stated that his right knee was unstable, and would give out on him, requiring him to use a prosthetic device to maintain his balance. Although the record contains contemporaneous VA examinations regarding the Veteran’s right knee disability, the most recent VA examination in April 2016, does not comply with the requirements in Sharp. In Sharp, the Court held that in addressing the nature of any flare-ups, examiners must address the frequency, duration, characteristics, severity, and functional loss due to the flare-up. Although the Veteran reported that he had flare-ups of his right knee which he described as knee pain, swelling, and decreased range of motion, the VA examiner noted that pain, weakness, fatigability, or incoordination did not significantly limit functional ability with flare-ups. The VA examiner also did not discuss whether the Veteran had additional loss of range of motion during flare-ups, which renders the examination inadequate. The Board finds that a VA examination is warranted to determine the severity of the Veteran’s right knee disability. The matters are REMANDED for the following action: 1. Obtain a VA addendum opinion to ascertain the etiology of the Veteran’s bilateral foot disability. The claims file should be made available to and be reviewed by the examiner in conjunction with this inquiry. (a.) The examiner should address whether a foot disorder, to include pes planus, clearly and unmistakably (obvious, manifest, undebatable) existed prior to the Veteran’s period of active service from April 1972 to April 1992. (b.) If the examiner determines that there is clear and unmistakable evidence that a foot disorder preexisted active duty service, is there clear and unmistakable evidence that the preexisting foot disorder was NOT aggravated in service beyond the natural progression of such disorder during such service. (c.) If there is no clear and unmistakable evidence that the Veteran had a foot disorder that preexisted active duty service, then opine as to whether it is at least as likely as not (50 percent or greater likelihood) that any current foot disability had its onset in service or is otherwise causally or etiologically related to a period of active duty service. (d.) If there is no clear and unmistakable evidence that the Veteran had a foot disorder that preexisted active duty, then opine as to whether it is at least as likely as not (50 percent or greater likelihood) that any current foot disability is proximately due to a service-connected disability to include bilateral knee disabilities and back disability. (e.) If there is no clear and unmistakable evidence that the Veteran had a foot disorder that preexisted active duty service, then opine as to whether it is at least as likely as not (50 percent or greater likelihood) that any current foot disability is aggravated (non-temporary increase in severity beyond the natural progression of the disorder) by a service-connected disability to include bilateral knee disabilities or back disability. The examiner should consider and discuss the following: (a.) a May 1973 service treatment record, which reflects that the Veteran complained of pain in the outer aspect of his right foot; (b.) a September 1986 service treatment record, which reflects that the Veteran’s feet were swollen due to a cast; (c.) April 1975 Report of Medical History, which indicates that the Veteran reported he had foot trouble; (d.) post service treatment records and VA examinations, which reflect a diagnosis of pes planus from January 1993; (e.) post service treatment records and VA examinations, which reflect the Veteran walked with an altered gait from April 2008; (f.) a December 2013 VA opinion that the Veteran’s bilateral knee issues led to an altered gait, which led to back strain. The examiner should provide a complete rationale for all opinions expressed and conclusions reached. 2. Schedule the Veteran for a VA examination to ascertain the current severity of the Veteran’s service-connected right knee disability. All necessary tests should be conducted. The claims file should be made available to and be reviewed by the examiner in conjunction with the examination. The examiner must test the Veteran’s active motion, passive motion, and pain with weight-bearing and without weight-bearing. The examiner must also attempt to elicit information regarding the severity, frequency, and duration of any flare-ups, and the degree of functional loss during flare-ups. To the extent possible, the examiner should identify any symptoms and functional impairments due to the right knee disability alone and discuss the effect of the Veteran’s right knee disability on any occupational functioning and activities of daily living. If it is not possible to provide a specific measurement, or an opinion regarding flare-ups, symptoms, or functional impairment without speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). The examiner should provide a complete rationale for all opinions expressed and conclusions reached. S. L. Kennedy Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD G. Johnson, Associate Counsel