Citation Nr: 18159456 Decision Date: 12/19/18 Archive Date: 12/19/18 DOCKET NO. 17-08 838 DATE: December 19, 2018 ORDER The application to reopen the claim of entitlement to service connection for dry eye syndrome due to photo refractive keratotomy (PRK) surgery is denied. Service connection for a right shoulder condition is denied. Service connection for bruxism is denied. Service connection for chronic fatigue syndrome is denied. A rating of 50 percent, effective September 11, 2014 to February 10, 2016, for adjustment disorder with mixed emotional features and residuals of TBI is granted. A rating in excess of 50 percent, effective February 10, 2016, for adjustment disorder with mixed emotional features and residuals of TBI is denied. A rating of 40 percent, effective September 11, 2014, for degenerative disc disease with spondylolisthesis and spondylolysis is granted. A rating of 20 percent, effective September 11, 2014, for right lower extremity radiculopathy is granted. A rating of 20 percent, effective September 11, 2014, for left lower extremity radiculopathy is granted. A rating in excess of 10 percent, effective September 11, 2014, for a right ankle sprain is denied. A compensable rating, effective September 11, 2014, for tension headaches is denied. A rating of 10 percent, effective September 11, 2014, for right knee range of motion is granted. A rating of 10 percent, effective September 11, 2014, for left knee range of motion is granted. A rating in excess of 30 percent, effective April 15, 2015, for chronic bronchitis with obstructive pulmonary disease is denied. REMANDED The issue of entitlement to compensable ratings for the Veteran’s right knee instability, subluxation, and locking is remanded. The issue of entitlement to compensable ratings for the Veteran’s left knee instability, subluxation, and locking is remanded. FINDINGS OF FACT 1. In February 2007 VA denied service connection for dry eye syndrome due to PRK surgery. The Veteran was informed in writing of the adverse determination and his appellate rights in February 2007. He did not submit a notice of disagreement (NOD) with the decision. 2. The February 2007 rating decision is final. 3. Evidence associated with the claims file since the February 2007 rating decision is not new and material and does not raise a reasonable possibility of substantiating the Veteran’s claim. 4. A right shoulder condition did not originate as a result of the Veteran’s active service. 5. The Veteran’s bruxism is not a disability for which service connection can be granted. 6. The Veteran’s chronic fatigue is not an undiagnosed illness and did not originate as a result of the Veteran’s active service. 7. During the periods on appeal, the Veteran’s PTSD has been characterized by no more than impaired short-term memory, depression, anxiety, difficulty sleeping, some reduced reliability and productivity, no suicidal or homicidal ideation, and no hallucinations. The Veteran successfully balances multiple obligations including as a student and a food truck owner while interning and participating in volunteer activities. The Veteran also maintains relationships and has reported enjoyment of hobbies including playing sports, going to ball games, reading, and camping. 8. During the period on appeal, the Veteran’s degenerative disc disease of the spine has been shown to be manifested by no more than range of motion measurements including flexion to 10 degrees, extension to 15 degrees, no neurologic abnormalities such as bowel or bladder problems and no ankylosis or IVDS. 9. During the period on appeal, the Veteran’s right and left lower extremity radiculopathy has been characterized by mild constant pain, severe intermittent pain, moderate paresthesias, and moderate numbness. 10. During the period on appeal, the Veteran’s right ankle sprain has been shown to be manifested by no more than painful motion. 11. During the period on appeal the, the Veteran’s tension headaches have not resulted in prostrating attacks. 12. During the period on appeal, the Veteran’s right and left knee limited range of motion disabilities have been characterized by no more than chronic pain and normal range of motion. 13. During the period on appeal, the Veteran’s chronic bronchitis with obstructive pulmonary disease has been characterized by no more than pre-bronchodilator forced vital capacity (FEV-1) of 68 percent. CONCLUSIONS OF LAW 1. The February 2007 rating decision that denied service connection for dry eye syndrome due to PRK surgery is final. 38 U.S.C.A. § 7105 (West 2014); 38 C.F.R. § 20.1103 (2017). 2. New and material evidence sufficient to reopen the Veteran’s claim for dry eye syndrome due to PRK surgery has not been presented. 38 U.S.C.A. §§ 5103, 5103A, 5107, 5108 (West 2014); 38 C.F.R. §§ 3.102, 3.156, 3.159, 3.326(a) (2017). 3. The criteria to establish service connection for a right shoulder condition have not been met. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2017). 4. The criteria to establish service connection for bruxism have not been met. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2017). 5. The criteria to establish service connection for chronic fatigue syndrome, to include as due to an undiagnosed illness have not been met. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.317 (2017). 6. The criteria to establish a rating of 50 percent, effective September 11, 2014 to February 10, 2016, for adjustment disorder with mixed emotional features and residuals of TBI have been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.2, 4.7, 4.14, 4.21, 4.130, Diagnostic Code 9434 (2017). 7. The criteria to establish a rating in excess of 50 percent, effective February 10, 2016, for adjustment disorder with mixed emotional features and residuals of TBI have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.2, 4.7, 4.14, 4.21, 4.130, Diagnostic Code 9434 (2017). 8. The criteria to establish a rating of 40 percent, effective September 11, 2014, for degenerative disc disease with spondylolisthesis and spondylolysis have been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.321, 3.326(a), 4.7, 4.10, 4.14, 4.21, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5242 (2017). 9. The criteria to establish a rating of 20 percent, effective September 11, 2014, for right lower extremity radiculopathy have been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.321, 3.326(a), 4.7, 4.10, 4.14, 4.40, 4.45, 4.59, 4.124a, Diagnostic Code 8520 (2017). 10. The criteria to establish a rating of 20 percent, effective September 11, 2014, for left lower extremity radiculopathy have been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.321, 3.326(a), 4.7, 4.10, 4.14, 4.40, 4.45, 4.59, 4.124a, Diagnostic Code 8520 (2017). 11. The criteria to establish a rating in excess of 10 percent, effective September 11, 2014, for right ankle sprain have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.321, 3.326(a), 4.7, 4.10, 4.14, 4.21, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5271 (2017). 12. The criteria to establish entitlement to a compensable rating, effective September 11, 2014, for tension headaches have not been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.3, 4.7, 4.124a, Diagnostic Code 8100 (2017). 13. The criteria to establish a rating of 10 percent, effective September 11, 2014, for right knee painful motion have been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.321, 3.326(a), 4.7, 4.10, 4.14, 4.21, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5260, 5261 (2017). 14. The criteria to establish a rating of 10 percent, effective September 11, 2014, for left knee painful motion have been met. 38 U.S.C.A. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.321, 3.326(a), 4.7, 4.10, 4.14, 4.21, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5260, 5261 (2017). 15. The criteria to establish a rating in excess of 30 percent, effective April 15, 2015, for chronic bronchitis with obstructive pulmonary disease have not been met. 38 U.S.C. § 1155 ;38 C.F.R. §3.102, 3.321, 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.14, 4.96, 4.97, Diagnostic codes 6600 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active duty service from March 25, 1997, to January 9, 2007. Effective January 2016, the Veteran is in receipt of a 100 percent combined schedular evaluation of service-connected disorders. New and Material Evidence As to the issue of whether new and material evidence has been received to reopen the Veteran’s claim of entitlement to service connection for dry eye syndrome due to PRK surgery, the Board is required to consider the question without regard to the RO’s determination in order to establish the Board’s jurisdiction to address the underlying claims and to adjudicate the claims on a de novo basis. Jackson v. Principi, 265 F.3d 1366, 1369 (Fed. Cir. 2001); Barnett v. Brown, 83 F.3d 1380 (Fed. Cir. 1996). Generally, absent the filing of an NOD within one year of the date of mailing of the notification of the initial review and determination of a veteran’s claim and the subsequent filing of a timely substantive appeal, a rating determination is final and is not subject to revision upon the same factual basis except upon a finding of clear and unmistakable error (CUE). 38 U.S.C.A. §§ 5108, 7105; 38 C.F.R. §§ 20.200, 20.300, 20.1103. A claimant may reopen a finally adjudicated claim by submitting new and material evidence. New evidence means existing evidence not previously submitted to agency decision makers. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). The provisions of 38 C.F.R. § 3.156(a) create a low threshold, with the phrase “raises a reasonable possibility of substantiating the claim” enabling rather than precluding reopening and not constituting a third requirement that must be met before the claim is reopened. Shade v. Shinseki, 24 Vet. App. 110 (2010); Evans v. Brown, 9 Vet. App 273, 283 (1996). See Hodge v. West, 155 F.3d 1356 (Fed. Cir. 1998). New and material evidence received prior to the expiration of the appeal period will be considered as having been filed in connection with the claim which was pending at the beginning of the appeal period. 38 C.F.R. § 3.156(b). Where documents are within VA’s control and could reasonably be expected to be a part of the record, such documents are, in contemplation of law, before VA and should be included in the record. Bell v. Derwinski, 2 Vet. App. 611, 613 (1992). In February 2007, the RO denied service connection for dry eye syndrome due to PRK surgery because the evidence indicated that the Veteran’s PRK surgery was an elective procedure and dry eye syndrome was a known residual. The RO noted that the Veteran signed a document acknowledging possible residuals prior to the procedure. The Veteran was informed in writing of the adverse decision and his appellate rights in February 2007. He did not submit an NOD. The evidence received prior to the February 2007 rating decision reflects that the Veteran underwent PRK surgery in April 2004 while in-service. In subsequent treatment records the Veteran complained of chronic dry eyes. New and material evidence pertaining to the issue of service connection for dry eye syndrome was not received by VA or constructively in its possession within one year of written notice of the February 2007 rating decision. Therefore, that decision became final. 38 C.F.R. § 3.156(b). The additional documentation received since February 2007 only consists of continued complaints of chronically dry eyes due to the Veteran’s PRK surgery. When determining whether a claim should be reopened, the credibility of the newly submitted evidence is presumed. Justus v. Principi, 3 Vet. App. 510 (1992). Here, the additional evidence is not new. The additional treatment notes with complaints of dry eyes reiterate the same symptoms which are already of record and do not present evidence, even if the credibility is presumed, which raise a reasonable possibility of substantiating the Veteran’s claim. As new evidence has not been received, the Veteran’s claim of entitlement to dry eye syndrome due to PRK surgery is not reopened. Service Connection Service connection may be granted for current disability arising from disease or injury incurred or aggravated by active service. 38 U.S.C.A. § 1110. Service connection may 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). Service connection generally requires (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the current disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection shall be granted on a secondary basis under the provisions of 38 C.F.R. § 3.310 (a) where it is demonstrated that a service-connected disorder has caused a nonservice-connected disability. Allen v. Brown, 7 Vet. App. 439 (1995). 1. Entitlement to service connection for right shoulder condition In the Veteran’s August 2006 medical examination for service separation, he denied having a painful shoulder, elbow, or wrist. The Veteran did not note treatment or a diagnosis for a right shoulder condition or symptoms. The Veteran’s denial of such symptoms, and the service medical records are highly probative. They were generated with a view towards ascertaining the Veteran’s then-state of physical fitness and are akin to statements of diagnosis or treatment. Rucker v. Brown, 10 Vet. App. 67, 73 (1997) (observing that although formal rules of evidence do not apply before the Board, recourse to the Federal Rules of Evidence may be appropriate if it assists in the articulation of the reasons for the Board’s decision); see also LILLY’S: AN INTRODUCTION TO THE LAW OF EVIDENCE, 2nd Ed. (1987), pp. 245-46 (many state jurisdictions, including the federal judiciary and Federal Rule 803(4), expand the hearsay exception for physical conditions to include statements of past physical condition on the rationale that statements made to physicians for purposes of diagnosis and treatment are exceptionally trustworthy since the declarant has a strong motive to tell the truth in order to receive proper care). The Veteran was seen with complaints of right shoulder pain on multiple occasions including August 2013, September 2013, and February 2014. A September 2013 MRI study revealed no acute abnormality of the right shoulder. In June 2014, the Veteran was seen with complaints of right shoulder pain. The Veteran reported an injury to his right shoulder in 2013. The examiner noted full range of motion and an MRI study revealed multicomponent rotator cuff tendinopathy with small tears in the supraspinatus, infraspinatus, and subscapularis. The Board has considered the Veteran’s assertions that his right shoulder disability is caused by his military service. The Veteran is not competent, however, to offer an opinion as to the etiology of this type of medical condition due to the medical complexity of the matter involved. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007); Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007); Layno v. Brown, 6 Vet. App. 465, 469 (1994). A preponderance of the evidence is against a finding that the Veteran’s right shoulder originated during service. The Veteran’s STRs and medical examination for service separation do not contain complaints, treatment, or a diagnosis for a right shoulder condition. The Veteran was first seen with complaints of right shoulder pain many years after service separation, and there is no competent medical evidence that the Veteran’s right shoulder disability began in or as a result of service. Therefore, service connection is not warranted and the claim is denied. 2. Entitlement to service connection for bruxism to include as due to adjustment disorder with mixed emotional features The Veteran was denied service connection for a dental condition to include mercury fillings in a May 2013 rating decision. In an April 2015 rating decision, the Veteran was denied service connection for bruxism (teeth grinding), secondary to adjustment disorder with mixed emotional features. The Regional Office (RO) indicated reopened the claim from May 2013. However, the Veteran’s assertions of service connection are instead properly construed as seeking service connection for a generalized dental disorder and a separate bruxism disorder. The Board therefore evaluates the claim for service connection for teeth grinding as a separate claim that does not require reopening. Service connection for treatable carious teeth, replaceable missing teeth, dental or alveolar abscesses, or periodontal disease will be considered solely for the purpose of establishing eligibility for outpatient dental treatment. 38 C.F.R. § 3.381 (a). Service connection for compensation purposes is not available for a dental condition other than for injuries sustained as a result of dental trauma. The rating activity will consider each defective or missing tooth and each disease of the teeth and periodontal tissues separately to determine whether the condition was incurred or aggravated in the line of duty during active service. When applicable, the rating activity will determine whether the condition is due to combat or other in-service trauma, or whether the veteran was interned as a prisoner of war. 38 C.F.R. § 3.381 (a), (b). Dental disabilities which may be awarded compensable disability ratings are set forth under 38 C.F.R. § 4.150. These disabilities include chronic osteomyelitis or osteoradionecrosis of the maxilla or mandible, loss of the mandible, nonunion or malunion of the mandible, limited temporomandibular motion, loss of the ramus, loss of the condyloid or coronoid processes, loss of the hard palate, loss of teeth due to the loss of substance of the body of the maxilla or mandible and where the lost masticatory surface cannot be restored by suitable prosthesis, when the bone loss is a result of trauma or disease but not the result of periodontal disease. 38 C.F.R. § 4.150, Diagnostic Codes 9900-9916. To establish entitlement to service connection for loss of a tooth, the Veteran must have sustained a combat wound or other in-service trauma. 38 U.S.C.A. § 1712; 38 C.F.R. § 3.381 (b). The significance of finding that a dental condition is due to in-service trauma is that a veteran will be eligible for VA outpatient dental treatment, without being subject to the usual restrictions of a timely application and one-time treatment. 38 C.F.R. § 17.161 (c) The Veteran has reported grinding his teeth at night but has not been diagnosed with a corresponding disability for VA purposes. In a June 2006 in-service dental questionnaire, the Veteran reported no dental symptoms other than painful joints (including his jaw). The Veteran’s service treatment records (STRs) also contain no complaints regarding dental trauma. In the Veteran’s August 2006 medical examination for service separation, he denied severe tooth or gum trouble and noted no relevant treatment or diagnosis. The Veteran’s denial of such symptoms, and the service medical records are highly probative. Rucker, 10 Vet. App. 67 at 73. In August 2013 and November 2013 treatment notes, the Veteran reported grinding his teeth and requested a mouth guard. In a December 2014 letter, the Veteran’s dentist indicated that the Veteran was clenching and grinding his teeth at night and had temporomandibular joint dysfunction requiring treatment with a bite splint to alleviate symptoms. The dentist did not opine as to the etiology of the Veteran’s condition. In January 2015, the Veteran was afforded a VA examination. The Veteran reported grinding his teeth and being provided with a mouth guard while in-service. However, the examiner noted no diagnosable disability. In an August 2016 treatment note, the Veteran was seen with reports of grinding is teeth at night and requested a night guard. The Board concludes that the probative and competent evidence of record is against the Veteran’s claim of entitlement to service connection for bruxism. As noted above, the threshold requirement for service connection to be granted is competent evidence of the current existence of the claimed disorder. See Degmetich v. Brown, 104 F. 3d 1328 (1997); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). There is no medical evidence demonstrating that the Veteran was diagnosed with a separate bruxism disorder during the pendency of the appeal. See McClain v. Nicholson, 21 Vet. App. 319, 321 (2007) (service connection may be granted if a disability existed at the time a claim for VA disability compensation was filed or at any time during the pendency of the claim, even if the disability resolves prior to the adjudication of the claim); see Sanchez-Benitez v. Principi, 239 F.3d 1356 (Fed. Cir. 2001) and Sanchez-Benitez v. West, 13 Vet.App. 282 (1999) (service connection may not be granted for symptoms unaccompanied by a diagnosed disability). 3. Entitlement to service connection for chronic fatigue syndrome Service connection may be also warranted for a Persian Gulf Veteran who exhibits objective indications of a qualifying chronic disability that became manifest during active military, naval or air service in the Southwest Asia theater of operations during the Persian Gulf War, or that became manifest to a degree of 10 percent or more not later than December 31, 2016. 38 C.F.R. § 3.317 (a)(1) (2017). The Veteran, in this case, served in the Gulf from August 2005 to February 2006. Therefore, the Veteran is considered a Persian Gulf War Veteran. For purposes of 38 C.F.R. § 3.317, there are three types of qualifying chronic disabilities: (1) an undiagnosed illness; (2) a medically unexplained chronic multi-symptom illness; and (3) a diagnosed illness that the Secretary determines in regulations prescribed under 38 U.S.C.A § 1117(d) warrants a presumption of service connection. Disabilities that have existed for six months or more and disabilities that exhibit intermittent episodes of improvement and worsening over a six-month period will be considered chronic. 38 C.F.R. § 3.317(a)(4). In a November 2002 service treatment record, the Veteran denied symptoms of fatigue. In the Veteran’s August 2006 medical examination for service separation, he noted frequent trouble sleeping but did not report additional symptoms or treatment for chronic fatigue. The Veteran’s denial of such symptoms, and the service medical records are highly probative. Rucker, 10 Vet. App. 67 at 73. In an October 2006 service treatment record, the Veteran indicated that he frequently awoke around 2:00 a.m. with symptoms of anxiety and fatigue. In a November 2014 treatment note the Veteran had complaints of fatigue and questioned whether he had a diagnosis for chronic fatigue syndrome. In December 2014, the Veteran was afforded a Gulf War general medical examination. The examiner noted the Veteran’s symptoms of fatigue were due to iron-deficiency anemia. The examiner also noted that the Veteran did not have a diagnosis for chronic fatigue syndrome and there was no record of related symptoms in his STRs. In an October 2015 treatment note, the Veteran was reported to have a history of iron-deficiency anemia dating back to 2012. In a June 2016 treatment note the Veteran was treated with intravenous iron to maintain target levels of hemoglobin. The record reflects that the Veteran does not have and has never had: (1) an undiagnosed illness; (2) a diagnosable but medically unexplained chronic multi-symptom illness of unknown etiology; or (3) a diagnosable chronic multi-symptom illness with a partially explained etiology. As previously discussed, the Veteran’s chronic fatigue has a medical diagnosis of iron-deficiency anemia which causes fatigue. The Veteran has received treatment for this condition since approximately 2012. The Board has also considered whether the Veteran’s chronic fatigue is directly related to his service. However, a preponderance of the evidence is against a finding that the Veteran’s chronic fatigue originated during service. The Veteran was first seen for his condition many years after service separation, and there is no competent medical evidence that the Veteran’s chronic fatigue began in or because of service. Therefore, service connection is not warranted and the claim is denied. Increased Rating Disability evaluations are determined by comparing the Veteran’s current symptomatology with the criteria set forth in the Schedule For Rating Disabilities. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. Part 4 (2017). Disability of the musculoskeletal system is primarily the inability, due to damage or infection in the parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. It is essential that the examination on which ratings are based adequately portray the anatomical damage, and the functional loss, with respect to all these elements. The functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part which becomes painful on use must be regarded as seriously disabled. 38 C.F.R. §§ 4.10, 4.40, 4.45, 4.59. Pursuant to 38 C.F.R. § 4.59, painful motion should be considered limitation of motion, even though a range of motion may be possible beyond the point when pain sets in. See Powell v. West, 13 Vet. App. 31, 34 (1999); Hicks v. Brown, 8 Vet. App. 417, 421 (1995). When 38 C.F.R. § 4.59 is raised by the claimant or reasonably raised by the record, even in non-arthritis contexts, the Board should address its applicability. See Burton v. Shinseki, 25 Vet. App. 1 (2011) (holding that the Board had failed to address painful motion and the applicability of 38 C.F.R. § 4.59 to an initial disability rating for residuals of a left shoulder injury with surgical repair). If the Veteran’s musculoskeletal disabilities do not warrant a compensable rating under the appropriate diagnostic codes based on limitation of motion, the minimum compensable rating (10 percent) may be assigned where there is satisfactory evidence of painful motion. 38 C.F.R. § 4.59; Burton, 25 Vet. App. at 1. Where there is a question as to which of two disability evaluations should be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation. Otherwise, the lower evaluation will be assigned. 38 C.F.R. § 4.7. The evaluation of the same disability under several diagnostic codes, known as pyramiding, must be avoided. Separate ratings may be assigned for distinct disabilities resulting from the same injury so long as the symptomatology for one condition is not duplicative of, or overlapping with, the symptomatology of the other condition. 38 C.F.R. § 4.14; Esteban v. Brown, 6 Vet. App. 259, 262 (1994). 1. Entitlement to a rating in excess of 30 percent from September 11, 2014 to February 10, 2016 and in excess of 50 percent thereafter, for adjustment disorder with mixed emotional features and residuals of TBI The Veteran’s PTSD is presently evaluated as 30 percent for the period from September 11, 2014 to February 10, 2016 and 50 percent thereafter. A 30 percent evaluation contemplates occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). 38 C.F.R. § 4.130, Diagnostic Code 9434 (2017). A 50 percent evaluation contemplates symptoms of occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent evaluation requires occupational and social impairment with deficiencies in most areas such as work, school, family relations, judgment, thinking, or mood due to symptoms such as suicidal ideation, obsessional rituals which interfere with routine activities, intermittently illogical, obscure, or irrelevant speech, near continuous panic or depression affecting the ability to function independently, appropriately and effectively, impaired impulse control (such as unprovoked irritability with periods of violence), spatial disorientation, neglect of personal appearance and hygiene, difficulty in adapting to stressful circumstances (including work or a work like setting), and an inability to establish and maintain effective relationships. Id. A 100 percent evaluation requires total occupational and social impairment due to symptoms such as gross impairment in thought processes or communication, persistent delusions or hallucinations, grossly inappropriate behavior, a persistent danger of hurting himself or others, an intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene), disorientation to time or place, and memory loss for names of close relatives, own occupation, or own name. Id. The use of the phrase “such symptoms as,” followed by a list of examples, provides guidance as to the severity of symptomatology contemplated for each rating. In particular, use of such terminology permits consideration of items listed as well as other symptoms and contemplates the effect of those symptoms on the claimant’s social and work situation. See Mauerhan v. Principi, 16 Vet. App. 436 (2002). The Board notes a July 2018 rating decision finding clear and unmistakable error in an earlier RO decision regarding the Veteran’s claim for TBI. The RO elected to combine the ratings for the Veteran’s adjustment disorder with his rating for TBI and noted that the symptoms overlapped. Therefore, the RO elected to rate the Veteran under the Diagnostic Code used for his adjustment disorder since it is the predominate disability. In a November 2014 treatment note, the Veteran was seen with complaints of depression, memory loss, and trouble concentrating. In a separate November 2014 treatment note, the Veteran reported difficulty with motivation and effort. The examiner noted normal speech, neat appearance, and no evidence of homicidal or suicidal ideation. In a February 2015 treatment note, the Veteran reported ongoing symptoms of depression and anxiety, memory loss, and difficulty concentrating. The Veteran also reported symptoms such as anger with others over minor disagreements and noted a possible negative effect on work performance due to difficulties with focus, concentration, and communication. In March 2015, the Veteran was afforded a VA examination. The examiner noted a diagnosis of adjustment disorder. The Veteran’s symptoms included occupational and social impairment due to mild or transient symptoms which decreased work efficiency. The examiner reported that the Veteran continues to have a good relationship with his parents and enjoyed hanging out with friends and playing sports until physical injury limited his participation. The Veteran also reported involvement in multiple hobbies including going to ball games, reading, and camping. The Veteran also reported intermittent short term romantic relationships since his marriage ended in 2007 but did not provide additional details. The Veteran denied legal issues, disciplinary infringements, or alcohol or drug use. The Veteran also denied suicidal and homicidal ideation. In February 2016, the Veteran was afforded a VA examination. The examiner noted symptoms including depressed mood, anxiety, suspiciousness, mild memory loss, and difficulty establishing effective work and social relationships. The clinician noted no obsessional rituals and no suicidal ideation. In a July 2016 treatment note, the Veteran was noted to be somewhat agitated and expressed a low frustration tolerance. The clinician noted no suicidal or homicidal ideation. In a separate July 2016 treatment note, the Veteran indicated memory deficits requiring him to write information down frequently. However, the examiner reported that the Veteran appeared able to balance his schedules as a full-time student and volunteer. In an August 2016 treatment note, the Veteran reported difficulty sleeping and trouble with relationships. The examiner noted anxiety but the Veteran had normal speech, no suicidal or homicidal ideation, normal affect, intact impulse control, and no evidence of hallucinations, paranoia or delusions. In an August 2017 treatment note, the Veteran reported past memory issues and sometimes being confused and forgetting where he lived. The Veteran also noted having a fiancé and being in a “power struggle” with her but did not further elaborate on the relationship. The Veteran denied suicidal ideation but stated that sometimes he wants “to punch people in the face.” The Veteran explained that he had never been physically aggressive against people. In February 2018, the Veteran was afforded a VA examination. The Veteran reported difficulty with interpersonal relationships and stated this was due to his unique cultural background and religious beliefs. The examiner noted occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. The Veteran reported working as an intern in a homeless shelter and aspirations to attend graduate school. The Veteran also noted that he has owned a food truck for the previous three years and is the sole operator. The Veteran reported involvement in school, an internship, and volunteer work. The examiner noted the Veteran’s involvement in multiple activities and indicated that these characteristics do not support a severe level of mental health impairment. The Veteran denied suicidal or homicidal ideation, hallucinations, or self-injurious behavior. The examiner noted symptoms such as anxiety, chronic sleep impairment, mild memory loss, and depressed mood. The examiner reported that the Veteran’s speech, motor activity, posture, and gait were unremarkable. The examiner also reported that the Veteran exhibited no evidence of mania or overt anxiety. During both periods on appeal, the Veteran’s PTSD has been characterized by no more than impaired short-term memory, depression, anxiety, difficulty sleeping, some reduced reliability and productivity, no suicidal or homicidal ideation, and no hallucinations. The Veteran’s ability to maintain success as a student and a food truck owner while interning and participating in volunteer activities is noteworthy as it bears upon his mental functioning. The Board also notes the Veteran’s discussion of relationships including a fiancé in August 2017. The Veteran has also reported enjoyment of sports, going to ball games, reading, and camping. For the appellate period, the evidence demonstrates that the Veteran’s PTSD had been productive of symptomatology of a moderate nature, i.e., he exhibits occupational and social impairment with reduced reliability and productivity and difficulty in establishing and maintaining effective work and social relationships, and is adequately contemplated by the assigned 50 percent rating for both periods on appeal. As the U.S. Court of Appeals for the Federal Circuit explained, evaluation under § 4.130 is “symptom-driven,” meaning that “symptomatology should be the fact-finder’s primary focus when deciding entitlement to a given disability rating” under that regulation. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 116-17 (Fed.Cir.2013). The symptoms listed in DC 9434 are not exhaustive, but rather “serve as examples of the type and degree of symptoms, or their effects, that would justify a particular rating.” Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). In the context of determining whether a higher 70 percent disability evaluation is warranted, the DC requires not only the presence of certain symptoms but also that those symptoms have caused occupational and social impairment with deficiencies in most areas and inability to establish and maintain effective relationships -i.e., “the regulation... requires an ultimate factual conclusion as to the veteran’s level of impairment...” Vazquez-Claudio, 713 F.3d at 117-18 ; see 38 C.F.R. § 4.130, DC 9434. The preponderance of the evidence is against finding that the Veteran’s PTSD caused occupational and social impairment with deficiencies in most areas and inability to establish and maintain effective relationships, particularly given the fact that the Veteran has not demonstrated severe impairment even though he did exhibit a few (such as the desire to “punch people in the face” and temporarily forgetting where he lives) of the symptoms listed in the exemplar criteria for a 70 percent rating. There was no intermittently illogical, obscure or irrelevant speech. There was no near-continuous panic or depression affecting his ability to function independently, appropriately or effectively. There had been no evidence of impaired impulse control or spatial disorientation and no evidence of suicidal ideation. He had not shown an inability to adapt to stressful circumstances or to maintain effective relationships. There had been no periods of disorientation to time or place, or severe memory loss for names of close relatives or an occupation or home. In short, he does not have the collection of symptoms indicative of the more severe disability. Thus, the Board finds that a 70 percent rating is not warranted. 2. Entitlement to a rating of 40 percent, effective September 11, 2014, for degenerative disc disease with spondylolisthesis and spondylolysis Diagnostic Code 5242 provides ratings for lumbosacral strain. A 10 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, for the combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or, for muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or vertebral body fracture with loss of 50 percent or more of the height. A 20 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, for the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, for 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 40 percent rating is warranted for forward flexion of the thoracolumbar spine 30 degrees or less or for favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is warranted for unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent rating is warranted for unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a, Diagnostic Code 5242. There are also several relevant note provisions associated with Diagnostic Code 5242. Note (1): Evaluate any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, separately, under an appropriate diagnostic code. Note (2): (See also Plate V.) For VA compensation purposes, normal forward flexion of the thoracolumbar spine is zero to 90 degrees, extension is zero to 30 degrees, left and right lateral flexion are zero to 30 degrees, and left and right lateral rotation are zero 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. Note (3): In exceptional cases, an examiner may state that because of age, body habitus, neurologic 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 Note (2). Provided that the examiner supplies an explanation, the examiner’s assessment that the range of motion is normal for that individual will be accepted. Note (4): Round each range of motion measurement to the nearest five degrees. Note (5): For VA compensation purposes, unfavorable ankylosis is a condition in which the entire cervical spine, the entire thoracolumbar spine, or the entire spine is fixed in flexion or extension, and the ankylosis results in one or 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. Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. Note (6): Separately evaluate disability of the thoracolumbar and cervical spine segments, except when there is unfavorable ankylosis of both segments, which will be rated as a single disability. 38 C.F.R. § 4.71a, Diagnostic Code 5242. Lower extremity radiculopathy is rated according to Diagnostic Code 8520. Diagnostic Code 8520 provides ratings for paralysis of the sciatic nerve. A 10 percent rating is warranted for mild incomplete paralysis, a 20 percent rating is warranted for moderate incomplete paralysis, and a 40 percent rating is warranted for moderately severe incomplete paralysis. A 60 percent rating is warranted for severe incomplete paralysis with marked muscular atrophy. 38 C.F.R. § 4.124a, Diagnostic Code 8520. In a May 2014 treatment note, the Veteran reported his ability to bend his back was limited due to pain. The treatment note does not provide range of motion measurements. In December 2014, the Veteran was afforded a VA examination. The Veteran reported a history of back pain. The examiner noted range of motion measurements including flexion to 90 degrees, extension to 30 degrees, right lateral flexion to 30 degrees, left lateral flexion to 30 degrees, right lateral rotation to 30 degrees, and left lateral rotation to 30 degrees. The examiner noted no neurologic abnormalities such as bowel or bladder problems, no ankylosis, and no intervertebral disc syndrome (IVDS). In a January 2015 treatment note, the Veteran noted a history of low back pain accompanied by pain and tingling down to his lower extremities. In February 2016, the Veteran was afforded a VA examination. The examiner noted range of motion measurements including flexion to 10 degrees, extension to 15 degrees, right lateral flexion to 10 degrees, left lateral flexion to 10 degrees, right lateral rotation to 15 degrees, and left lateral rotation to 15 degrees. The examiner noted no neurologic abnormalities such as bowel or bladder problems, no ankylosis, and no intervertebral disc syndrome (IVDS). The examiner also noted moderate bilateral radiculopathy with symptoms including mild constant pain, severe intermittent pain, moderate paresthesias, and moderate numbness. During the period on appeal, the Veteran’s degenerative disc disease of the spine has been shown to be manifested by no more than range of motion measurements including flexion to 10 degrees, extension to 15 degrees, no neurologic abnormalities such as bowel or bladder problems, no ankylosis, or IVDS. The Veteran’s lower extremity radiculopathy has been characterized by mild constant pain, severe intermittent pain, moderate paresthesias, and moderate numbness. The Board will grant a 40 percent rating under Diagnostic Code 5242 for degenerative disc disease of the spine. A 50 percent rating is not warranted under Diagnostic Code 5242 because the Veteran does not have unfavorable ankylosis of the entire thoracolumbar spine. 38 C.F.R. § 4.71a, Diagnostic Code(s) 5242. The Board also finds that the Veteran’s current 40 percent rating for degenerative disc disease of the spine under Diagnostic Code 5242 adequately reflects his limitation of motion. 38 C.F.R. § 4.7. See Hart v. Mansfield, 21 Vet. App. 505 (2007). In making these determinations, the Board has considered, along with the schedular criteria, the Veteran’s functional loss due to pain. 38 C.F.R. §§ 4.40, 4.45 (2015); DeLuca v. Brown, 8 Vet. App. 202, 206-207 (1995). The Board also finds that the Veteran is entitled to a rating of 20 percent his right and left lower radiculopathy due to moderate radicular symptoms. A 40 percent rating is not warranted because the Veteran is not experiencing moderately severe incomplete paralysis. 3. Entitlement to a rating in excess of 10 percent, effective September 11, 2014, for a right ankle sprain Diagnostic Code 5271 provides ratings for limited range of motion for the ankle. A 10 percent disability rating is warranted for moderately limited motion and a 20 percent disability rating for marked limited motion. 38 C.F.R. § 4.71a, Diagnostic Code 5271. The Veteran had complaints of ankle pain in September 2013 and a MRI study indicated no abnormality in the right ankle. In December 2014, the Veteran was afforded a VA examination. The Veteran noted a history of ankle sprains. The examiner noted normal range of motion in the right ankle. In September 2017, the Veteran was afforded a VA examination. The examiner noted normal range of motion in the Veteran’s right ankle with some pain that did not result in functional loss. During the period on appeal, the Veteran’s right ankle sprain has been shown to be manifested by no more than painful motion. Given these facts, the Board finds that a 10 percent rating is warranted for the Veteran’s painful motion under 38 C.F.R. §4.59. A 20 percent rating is not warranted under Diagnostic Code 5271 because the Veteran does not have marked limited motion. In making these determinations, the Board has considered, along with the schedular criteria, the Veteran’s functional loss due to pain. 38 C.F.R. §§ 4.40, 4.45 (2015); DeLuca v. Brown, 8 Vet. App. 202, 206-207 (1995). 4. Entitlement to a compensable rating, effective September 11, 2014, for tension headaches According to DC 8100, headaches with very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability are rated 50 percent disabling; headaches with characteristic prostrating attacks occurring on an average once a month over the last several months are rated 30 percent disabling; headaches with characteristic prostrating attacks averaging one in 2 months over the last several months are rated as 10 percent disabling; and headaches with less frequent attacks are assigned a 0 percent rating. 38 C.F.R. § 4.124a, Diagnostic Code 8100 (2017). In a February 2015 treatment note, the Veteran reported debilitating headaches but the frequency was not recorded. In February 2015, the Veteran was afforded a VA examination. The Veteran reported daily headaches from stress and noted constant head pain. The examiner noted that the Veteran does not have prostrating headaches. In August 2015, the Veteran was afforded a VA examination. The examiner noted no prostrating attacks of headache pain. During the period on appeal the, the Veteran’s tension headaches have not resulted in prostrating attacks. Given these facts, the Board finds that a noncompensable rating is warranted for the Veteran’s headaches. A 10 percent rating is not warranted because the Veteran does not have prostrating attacks averaging one in 2 months over the last several months. 38 C.F.R. § 4.124a, Diagnostic Code 8100. 5. Entitlement to ratings of 10 percent, effective September 11, 2014 for the Veteran’s bilateral knee painful motion (previously claimed as right knee patellofemoral syndrome and left knee strain) Diagnostic Code 5260 provides ratings based on limitation of flexion of the leg. Limitation of flexion to 60 degrees warrants a noncompensable rating. Limitation of flexion to 45 degrees warrants a 10 percent rating. Flexion limited to 30 degrees warrants a 20 percent rating. 38 C.F.R. § 4.71a, Diagnostic Code 5260 (2017). Diagnostic Code 5261 provides ratings based on limitation of extension of the leg. Limitation of extension to 5 degrees warrants a noncompensable rating. Limitation of extension to 10 degrees warrants a 10 percent rating. Extension limited to 15 degrees warrants a rating of 20 percent. Extension limited to 20 degrees warrants a 30 percent rating. Extension limited to 30 degrees warrants a 40 percent rating. Limitation of extension to 45 degrees warrants a 50 percent rating. 38 C.F.R. § 4.71a, Diagnostic Code 5261 (2017). The Veteran had complaints of knee pain and limited range of motion in January 2013, July 2013, December 2013, February 2014, May 2014, September 2014. Range of motion measurements were not provided. In July 2013 the Veteran also noted that his knee sometimes buckles. In a June 2014 treatment note, the Veteran was seen with complaints of right knee pain and swelling. The Veteran reported locking and instability. The examiner noted range of motion from 0 to 135 degrees. An MRI study revealed minimal chondromalacia patella and an oblique tear. In December 2014, the Veteran was afforded a VA examination. The Veteran noted increased pain in both knees. The examiner noted range of motion measurements including flexion from 0 to 140 and extension from 140 to 0 in the right knee and flexion from 0 to 140 and extension from 140 to 0 in the left knee. The examiner noted no subluxation or instability in either knee. In a January 2015 treatment note, the Veteran was seen with a history of right knee pain including catching, locking, popping, and swelling. Upon examination the Veteran exhibited range of motion from 0 to 130 degrees. The examiner noted the Veteran was stable to varus and valgus stress. In a September 2015 treatment note, the Veteran reported that his right knee “came out of joint.” The Veteran also noted instability exacerbated by climbing stairs. The clinician noted that the Veteran’s knee was likely locking and reported that the Veteran had medial joint line tenderness but otherwise had no definite instability. In a December 2015 treatment note, the Veteran was seen with complaints of knee pain and locking. In an April 2016 treatment note, the Veteran was seen with complaints of right knee pain and locking. The Veteran noted instability in both knees. During the period on appeal, the Veteran’s right and left knee limited range of motion disabilities have been characterized by no more than chronic pain and normal range of motion. Given these facts, the Board finds that a 10 percent rating is warranted for painful motion under 38 C.F.R. §4.59. The Veteran’s right and left knees could also be rated under Diagnostic Codes 5260 or 5261 for loss of motion. However, the Veteran’s loss of motion is not severe enough to entitle a compensable rating under Diagnostic Codes 5260 or 5261. 6. Entitlement to a rating in excess of 30 percent, effective April 15, 2015, for chronic bronchitis with obstructive pulmonary disease Chronic bronchitis is rated under Diagnostic Code 6600. Evaluations under Diagnostic Code 6600 fall within service-connected disabilities related to the Trachea and Bronchi and utilize different Pulmonary Function Tests in evaluating disabilities. 38 C.F.R. § 4.97. These tests include Forced Expiratory Volume in one second (FEV-1), Forced Vital Capacity (FEV-1/FVC) and Diffusion Capacity of the Lung for Carbon Monoxide by the Single Breath Method (DLCO (SB)). Under Diagnostic Code 6600: A 30 percent rating is assigned for an FEV-1 of 56 to 70 percent predicted, or; FEV-1/FVC of 56 to 70 percent, or; DLCO (SB) 56 to 65 percent predicted; A 60 percent rating is assigned for an FEV-1 of 40 to 55 percent predicted, or; FEV-1/FVC of 40 to 55 percent, or; DLCO (SB) of 40 to 55 percent predicted, or; maximum oxygen consumption of 15 to 20 ml/kg/min (with cardiorespiratory limit); and A 100 percent rating is assigned for an FEV-1 less than 40 percent of predicted value; or the ratio of Forced Expiratory Volume in one second to Forced Vital Capacity (FEV-1/FVC) less than 40 percent, or; Diffusion Capacity of the Lung for Carbon Monoxide by the Single Breath Method (DLCO (SB)) less than 40 percent predicted, or; maximum exercise capacity less than 15 ml/kg/min oxygen consumption (with cardiac or respiratory limitation), or; cor pulmonale (right heart failure), or; right ventricular hypertrophy, or; pulmonary hypertension (shown by Echo or cardiac catheterization), or; episode(s) of acute respiratory failure, or the requirement for outpatient oxygen therapy. 38 C.F.R. § 4.97, Diagnostic Code 6600 In May 2015, the Veteran was afforded a VA examination. The examiner noted a diagnosis for chronic bronchitis since January 2007. The examiner noted pre-bronchodilator forced vital capacity (FEV-1) of 68 percent. During the period on appeal, the Veteran’s chronic bronchitis with obstructive pulmonary disease has been characterized by no more than pre-bronchodilator forced vital capacity (FEV-1) of 68 percent. Given these facts, the Board finds that a 30 percent rating is warranted for the Veteran’s chronic bronchitis under Diagnostic Code 6600. The Veteran is not entitled to a 60 percent rating because the Veteran’s force vital capacity is greater than 55 percent. REASONS FOR REMAND 1. Entitlement to compensable ratings for the Veteran’s right knee instability, subluxation, and locking is remanded. 2. Entitlement to compensable ratings for the Veteran’s left knee instability, subluxation, and locking is remanded. Remand is necessary to determine the symptomatology of the Veteran’s right and left knee disabilities. The matter is REMANDED for the following action: 1. Request that the Veteran provide the names and addresses of all health care providers who provided treatment for his right and left knee disabilities. After acquiring this information and obtaining any necessary authorization, obtain and associate any pertinent records with the claims file or e-folder. 2. After all available records have been associated with the claims file and/or e-folder, schedule the Veteran for a VA examination to determine the nature and severity of his right and left knee disabilities, specifically regarding symptoms of instability and locking. The Veteran’s claims file, to include a copy of this Remand, should be made available to and reviewed by the examiner. The examination report should reflect that such review was accomplished. a. The examiner must take a detailed history from the Veteran. If there is any clinical or medical basis for corroborating or discounting the credibility of the history provided by the Veteran, the examiner must so state, with a complete rationale in support of such a finding. b. The examiner must provide an opinion as to the nature and severity of the Veteran’s right and left knee disability symptoms. c. Specifically, the examiner should determine whether the Veteran’s knees lock or are unstable. d. As noted above, the examiner should review the record in conjunction with rendering the requested opinion; however, his/her attention is drawn to the following: * In July 2013 the Veteran noted that his knee sometimes buckles. * In a June 2014 treatment note, the Veteran was seen with complaints of right knee pain and swelling. The Veteran reported locking and instability. * In December 2014, the Veteran was afforded a VA examination. The Veteran noted increased pain in both knees. The examiner noted no subluxation or instability in either knee. * In a January 2015 treatment note, the Veteran was seen with a history of right knee pain including catching, locking, popping, and swelling. The examiner noted the Veteran was stable to varus and valgus stress. * In a September 2015 treatment note, the Veteran reported that his right knee “came out of joint.” The Veteran also noted instability exacerbated by climbing stairs. The clinician noted a probable locking episode and reported that the Veteran had medial joint line tenderness but otherwise had no definite instability. * In a December 2015 treatment note, the Veteran was seen with complaints of knee pain and locking. * In an April 2016 treatment note, the Veteran was seen with complaints of right knee pain and locking. The Veteran reported instability in both knees. 3. Thereafter, and after undertaking any additional development deemed necessary, readjudicate the issues on appeal. If the benefit sought on appeal remains denied, the Veteran and his representative must be provided with a Supplemental Statement of the Case (SSOC) and be afforded reasonable opportunity to respond. The case should then be returned to the Board for further appellate review, if otherwise in order. Vito A. Clementi Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Joshua Wozniak