Citation Nr: 19166231 Decision Date: 08/28/19 Archive Date: 08/27/19 DOCKET NO. 16-63 077 DATE: August 28, 2019 ORDER A rating in excess of 20 percent for a right knee disability with instability and recurrent subluxation is denied. A rating in excess of 10 percent for a right knee disability with limited flexion is denied. A rating in excess of 20 percent prior to February 26, 2016, and a rating in excess of 40 percent thereafter for a low back disability is denied. A rating in excess of 20 percent for radiculopathy of the left lower extremity sciatic nerve is denied. A rating in excess of 20 percent for radiculopathy of the left lower extremity femoral nerve is denied. REMANDED Service connection for a left knee disability, to include as secondary to a right knee disability is remanded. FINDINGS OF FACT 1. The Veteran’s right knee instability was not manifested by severe instability. 2. The Veteran’s right knee flexion was not limited to less than 90 degrees. 3. Prior to February 26, 2016, the Veteran’s lumbar spine disability manifested as forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; without forward flexion of the thoracolumbar spine 30 degrees or less, ankylosis, or intervertebral disc syndrome (IVDS) resulting in incapacitating episodes. 4. As of February 26, 2016, the Veterans’ service-connected low back disability did not result in unfavorable ankylosis of the thoracolumbar or entire spine; or IVDS resulting in incapacitating episodes. 5. The Veteran’s radiculopathy of the left lower extremity of the sciatic nerve has been moderate, but not moderately severe. 6. The Veteran’s radiculopathy of the left lower extremity of the femoral nerve has been moderate, but not severe. CONCLUSIONS OF LAW 1. The criteria for an initial rating in excess of 20 percent for right knee instability have not been met. 38 U.S.C. § §§ 1155, 5107; 38 C.F.R. § §§ 4.1, 4.2, 4.7, 4.71a, Diagnostic Code 5257. 2. The criteria for establishing a rating in excess of 10 percent for limitation of flexion of the right knee have not been met. 38 U.S.C. § §§ 1155, 5103, 5103A, 5107; 38 C.F.R. § §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.40, 4.45, 4.71a, Diagnostic Code 5260. 3. The criteria for a rating in excess of 20 percent for a low back disability prior to February 26, 2016, have not been met. 38 U.S.C. § §§ 1155, 5103, 5103A, 5107; 38 C.F.R. § §§ 3.102, 3.159, 4.1-4.14, 4.59, 4.71a, Diagnostic Code 5237. 4. As of February 26, 2016, the criteria for a rating in excess of 40 percent for chronic lumbar strain have not been met. 38 U.S.C. § §§ 1155, 5103, 5103A, 5107; 38 C.F.R. § §§ 3.102, 3.159, 4.1-4.14, 4.59, 4.71a, Diagnostic Code 5237. 5. The criteria for an initial rating in excess of 20 percent throughout the appeal period for lower left extremity radiculopathy of the sciatic nerve are not met. 38 U.S.C. § § 1155; 38 C.F.R. § § 4.124a, Diagnostic Code 8520. 6. 5. The criteria for an initial rating in excess of 20 percent for lower left extremity radiculopathy of the femoral nerve are not met. 38 U.S.C. § § 1155; 38 C.F.R. § § 4.124a, Diagnostic Code 8526. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from July 2006 to July 2010. This matter is on appeal from a November 2015 rating decision. In March 2017, the RO granted service connection for radiculopathy of the left lower extremity sciatic nerve with an evaluation of 20 percent, as well as service connection for radiculopathy of the left lower extremity femoral nerve with an evaluation of 20 percent. The Veteran did not file any document with VA expressing disagreement with the March 2017 decision; however, the radiculopathy is a manifestation of the Veteran’s service-connected low back disability. When the Veteran disagreed with the amount of compensation awarded for the back disability, he did not limit his appeal to one manifestation, but rather was seeking the highest rating or ratings available for disability due to his service-connected back disability. See AB v. Brown, 6 Vet. App. 35 (1993). Moreover, regulation provides that VA is to evaluate any neurologic abnormalities associated with a spine disability under an appropriate diagnostic code. 38 C.F.R. § § 4.71a, Note (1). The Board is therefore required to consider whether ratings were warranted for neurologic abnormalities associated with the low back condition. For these reasons, the Board concludes that when the Veteran appealed the initial rating assigned for his low back disability, his appeal encompassed ratings for all manifestations of the condition. The award of the separate rating for radiculopathy in the March 2017 decision could not limit the Board’s jurisdiction to less than it had acquired via the notice of disagreement filed in response to the rating action on appeal. Thus, the issues before the Board include the initial ratings for radiculopathy. Increased Rating Ratings for service-connected disabilities are determined by comparing the Veteran’s symptoms with criteria listed in VA’s Schedule for Rating Disabilities, which is based, as far as practically can be determined, on average impairment in earning capacity. Separate diagnostic codes identify the various disabilities. 38 C.F.R. § Parts 4. When rating a service-connected disability, the entire history must be considered. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § § 4.7. The Board must consider entitlement to “staged” ratings to compensate for times since filing the claim when the disability may have been more severe than at other times during the course of the appeal. See Fenderson v. West, 12 Vet. App. 119, 125-26 (1999). Where entitlement to compensation already has been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern, including the appropriateness of staged ratings whenever the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994); Hart v. Mansfield, 21 Vet. App. 505 (2007). The relevant temporal focus for adjudicating an increased rating claim is on the evidence concerning the state of the disability from the time period one year before the claim was filed until VA makes a final decision on the claim. Id. When evaluating musculoskeletal disabilities based on limitation of motion, the Veteran is entitled to at least the minimum compensable evaluation if motion is accompanied by pain. See 38 C.F.R. § § 4.59; Burton v. Shinseki, 25 Vet. App. 1 (2011). Additionally, pain is also relevant to assignment of a rating in excess of the minimum compensable rating, but only if that pain results in demonstrated functional impairment. Mitchell v. Shinseki, 25 Vet. App. 32, 3738 (2011); see 38 C.F.R. § §§ 4.40, 4.45. Functional impairment as contemplated by 38 C.F.R. § §§ 4.40 and 4.45 includes less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell, 25 Vet. App. at 44. Joint pain alone, without evidence of decreased functional ability, does not warrant a higher rating. See generally Mitchell, 25 Vet. App. at 32. Moreover, the Board must consider functional loss caused by pain or other factors listed in 38 C.F.R. § §§ 4.40 and 4.45 that could occur during flare-ups or after repeated use and, therefore, may not be reflected on range-of-motion testing. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell, 25 Vet. App. at 44. Nonetheless, despite the relevance of the background factors delineated in § 4.40 or 4.45 when evaluating a disability, the rating to be assigned is based on the extent to which motion is limited, pursuant to 38 C.F.R. § § 4.71a (musculoskeletal system) or § 4.73 (muscle injury); therefore, a separate or higher rating predicated solely on §§ 4.40 or 4.45 is not appropriate. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016) (“[I]t is clear that the guidance of § 4.40 is intended to be used in understanding the nature of the veteran’s disability, after which a rating is determined based on the § 4.71a [or § 4.73] criteria.”). 1. A rating in excess of 20 percent for a right knee disability with instability and recurrent subluxation 2. A rating in excess of 10 percent for a right knee disability with limited flexion The Veteran seeks a rating in excess of 10 percent for his service-connected right knee disability due to limitation of flexion and a rating in excess of 10 percent for his service-connected right knee disability due to instability. The procedural history shows that the Veteran was granted a 20 percent rating for his right knee disability based on instability prior to the period on appeal, and a separate 10 percent rating for his right knee disability based on limitation of flexion in a December 2016 rating decision. The Veteran’s service-connected right knee disability based on limitation of flexion was evaluated under the provisions of 38 C.F.R. § § 4.71a, Diagnostic Code 5260, and his right knee instability was evaluated under 38 C.F.R. § § 4.71a, Diagnostic Code 5257. Limitation of motion of the knee is evaluated under Diagnostic Codes 5260 and 5261. Under Diagnostic Code 5260, a 10 percent rating is warranted for flexion limited to 45 degrees, a 20 percent rating is warranted for flexion limited to 30 degrees, and a 30 percent rating is warranted for flexion limited to 15 degrees. Under Diagnostic Code 5261, a 10 percent rating is warranted for extension limited to 10 degrees, a 20 percent rating is warranted for extension limited to 15 degrees, a 30 percent rating is warranted for extension limited to 20 degrees, a 40 percent rating is warranted for extension limited to 30 degrees, and a 50 percent rating is warranted for extension limited to 45 degrees. 38 C.F.R. § § 4.71a, Plate II, indicates that normal flexion of the knee is 140 degrees and normal extension of the knee is zero degrees. Recurrent subluxation or lateral instability can be rated as slight (10 percent), moderate (20 percent), or severe (30 percent). 38 C.F.R. § § 4.71a, Diagnostic Code 5257. Evaluations for knee impairment can also be assigned due to ankylosis, dislocation or removal of semilunar cartilage, nonunion or malunion of the tibia and fibula, or genu recurvatum, but as the Veteran has not at any time been found to have ankylosis of the left knee, dislocation or removal of semilunar cartilage, nonunion or malunion of the tibia and fibula, or genu recurvatum, these diagnostic codes are not applicable and will not be further discussed. See 38 C.F.R. § § 4.71a, Diagnostic Codes 5256, 5258, 5259, 5662, 5263. The preponderance of the evidence shows that the Veteran’s right knee disability has been manifested by varying degrees of pain, limitation of flexion to not less than 90 degrees, and instability. See VA examination reports dated September 2015, February 2016, February 2017, and August 2018. With respect to limitation of motion, the preponderance of the evidence shows that the Veteran has demonstrated extension to 0 degrees, with varying degrees of flexion from 90 to 140 degrees. See VA examination reports dated September 2015, February 2016, February 2017, and August 2018. Despite the consistent evidence of painful, limited motion, the evidence does not reflect that his pain (or any other symptoms, such as lack of endurance or fatigability) results in any additional functional loss in his range of motion other than as reflected by the currently assigned rating of 10 percent for his right knee based upon the loss of range of motion. The preponderance of the evidence shows that a rating in excess of 20 percent for the Veteran’s right knee instability under Diagnostic Code 5257 is not warranted because the Veteran’s knee did not manifest a severe level of instability. For example, the September 2015 VA examination found that the Veteran’s right knee joint was stable; however, the examiner found that the Veteran’s left knee manifested anterior, posterior, medial and lateral instability of 1+ (0-5 mm). The February 2016 VA examination found that the Veteran’s right knee joint was stable and all instability tests were normal. The February 2017 VA examination found that the Veteran’s right knee joint was stable, and all instability tests were normal; however, the examiner noted there was slight recurrent subluxation. The August 2018 VA examination found that the Veteran’s right knee joint was stable, and all instability tests were normal. Thus, the Board finds that a higher rating under Diagnostic Code 5257 is unwarranted because the Veteran did not have severe instability. 3. A rating in excess of 20 percent prior to February 26, 2016, and a rating in excess of 40 percent thereafter for a low back disability The Veteran seeks a higher rating for his service-connected low back disability, currently rated at 20 percent prior to February 26, 2016, and at 40 percent thereafter. The Veteran asserts that his lumbar spine disability is more severe than as reflected by the currently assigned ratings. Historically, the Veteran’s lumbar spine disability has been rated under Diagnostic Code 5237 for lumbosacral strain. Such disability is rated on the basis of limitation of motion, and the General Rating Formula for Diseases and Injuries of the Spine, effective beginning on September 26, 2003, contemplates limitation of motion. Under the General Rating Formula for Diseases and Injuries of the Spine, 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, ratings are provided as follows. A 10 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees, or 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 body 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 combined range of motion of the thoracolumbar spine greater than 120 degrees; or muscle spasm or guarding severe enough to result in an abnormal gait or abnormal contour such as scoliosis. A 40 percent rating is warranted when there is forward flexion of the thoracolumbar spine to 30 degrees or less, or with favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is awarded for unfavorable ankylosis of the entire thoracolumbar spine, and a 100 percent rating is warranted for unfavorable ankylosis of the entire spine. Note (1) to the rating formula specifies that any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, should be separately evaluated under an appropriate diagnostic code. Note (2): (See also Plate V.) For VA compensation purposes, normal forward flexion of the cervical spine is zero to 45 degrees, extension is zero to 45 degrees, left and right lateral flexion are zero to 45 degrees, and left and right lateral rotation are zero to 80 degrees. 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 cervical spine is 340 degrees and 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. Intervertebral disc syndrome (preoperatively or postoperatively) may be evaluated either under the General Rating Formula for Diseases and Injuries of the Spine or under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, whichever method results in the higher evaluation when all disabilities are combined. See 38 C.F.R. § § 4.25 (combined ratings table). The Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes provides that a 10 percent evaluation is warranted when there are incapacitating episodes having a total duration of at least one week but less than 2 weeks during the past 12 months and a 20 percent evaluation is warranted when there are incapacitating episodes having a total duration of at least 2 weeks but less than 4 weeks during the past 12 months. A 40 percent evaluation is warranted when there are incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months. A 60 percent evaluation is warranted when there are incapacitating episodes having a total duration of at least 6 weeks during the past 12 months. Note (1) provides that an incapacitating episode is a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician. Under Diagnostic Code 8520, a 10 percent rating is warranted for mild incomplete paralysis of the sciatic nerve, and a 20 percent rating requires moderate incomplete paralysis. A 40 percent rating requires moderately severe incomplete paralysis of the sciatic nerve. A 60 percent rating requires severe incomplete paralysis with marked muscular atrophy. An 80 percent rating requires complete paralysis, i.e. the foot dangles and drops, no active movement of the muscles below the knee is possible, and flexion of the knee is weakened or (very rarely) lost. 38 C.F.R. § § 4.124a, Diagnostic Code 8520. A note prior to the rating schedule for disease of the peripheral nerves states that when the involvement is wholly sensory, the rating should be for the mild, or, at most, the moderate degree. Incomplete paralysis of the femoral nerve warrants a 10 percent rating if it is mild, 20 percent rating if it is moderate, and a 30 percent rating if it is severe. Complete paralysis of the femoral nerve (paralysis of the quadriceps extensor muscles) warrants a 40 percent rating. 38 C.F.R. § § 4.124a, Diagnostic Code 8526. Applying these criteria to the facts of the Veteran’s claim, the Board finds the evidence failed to establish that the Veteran met the criteria for a rating in excess of 20 percent prior to February 26, 2016, or a rating in excess of 40 percent thereafter for his low back disability. Further, the Board finds the evidence fails to establish the Veteran met the criteria for a rating in excess of 20 percent for lower left extremity radiculopathy of the sciatic or femoral nerve. The Veteran was afforded a VA examination in September 2015. The Veteran reported flare-ups of low back pain when sitting. His back would lock up and he could not stand. Standing would result in pain down the back of his legs. Physical examination revealed muscle spasm and localized tenderness that were not severe enough to be responsible for abnormal gait or abnormal spinal contour. Range of motion testing showed forward flexion to 90 degrees, extension to 30 degrees, right and left lateral flexion to 30 degrees, and right and left lateral rotation to 30 degrees. Pain was noted with extension but did not result in functional loss. Repetitive use testing did not result in additional range of motion limitation. Pain, weakness, fatigability, or incoordination did not significantly limit functional ability with repeated use over time or with flare-ups. There was no ankylosis or radicular symptoms. The Veteran did have regular use of a brace. The lumbar spine disability did not impact his ability to work. The Veteran was afforded another VA examination in February 2016. The Veteran reported back pain kept him from doing day to day activities on certain days. He reported flare-ups resulted in severe back pain with stiffness when he sat for prolonged periods. The pain would shoot down the back of his legs at times. He reported functional loss with severe pain noted as the inability to bend or stoop. He could not be on his feet or walk for long. Physical examination revealed muscles spasm and localized tenderness that did not result in abnormal gait or abnormal spinal contour. Range of motion testing showed forward flexion to 35 degrees, extension to 25 degrees, right and left lateral flexion to 15 degrees, and right lateral rotation and left lateral rotation to 30 degrees. Pain was noted on examination and caused functional loss. Repetitive use testing did not result in additional range of motion limitation. Pain, fatigue, and weakness caused functional loss with repeated use over time and with flare-ups. This resulted in limited range of motion with forward flexion to 25 degrees, extension to 20 degrees, right and left lateral flexion to 10 degrees, and right lateral rotation and left lateral rotation to 25 degrees. Functional loss was contributed to by less movement than normal and weakened movement. There was no ankylosis or radicular symptoms. The Veteran continued to have regular use of a brace. The lumbar spine disability impacted employment by prohibiting lifting more than 10 pounds. He also could not go under vehicles at work or stand or walk for long periods of time. Getting up from a bent position was also a challenge. The Veteran was afforded another VA examination in February 2017. The Veteran reported he could not sit or stand for more than 20-30 minutes without pain. He reported flare-ups that resulted in pain and numbness down his legs. Functional loss was noted as the inability to sit or stand for over 20 minutes without back pain which made travelling especially difficult. Physical examination revealed localized tenderness that did not result in abnormal gait or abnormal spinal contour. Range of motion testing showed forward flexion to 50 degrees, extension to 15 degrees, right lateral flexion to 25 degrees, left lateral flexion to 20 degrees, right lateral rotation to 30 degrees, and left lateral rotation to 30 degrees. Range of motion itself contributed to functional loss as shown by the limited range of motion. Pain was noted on range of motion and caused functional loss. There was no evidence of pain with weight-bearing. Repetitive use testing did not result in additional range of motion limitation. Pain caused functional loss with repeated use over time that resulted in forward flexion to 50 degrees, extension to 15 degrees, right lateral flexion to 25 degrees, left lateral flexion to 20 degrees, right lateral rotation to 30 degrees, and left lateral rotation to 30 degrees. Pain also caused functional loss during a flare-up and resulted in forward flexion to 45 degrees, extension to 10 degrees, right lateral flexion to 20 degrees, left lateral flexion to 15 degrees, right lateral rotation to 25 degrees, and left lateral rotation to 25 degrees. There was no ankylosis. There was moderate left lower extremity radiculopathy of the sciatic nerve and moderate left lower extremity radiculopathy of the femoral nerve. The examiner noted there was intervertebral disc syndrome (IVDS) without any episodes that required bed rest prescribed by a physician in the past 12 months. The lumbar spine disability impacted employment because the Veteran would be sent home on bad days. He was also unable to sit or stand for over 20 minutes and travelling by road or plane was and issue due to prolonged sitting and pain. VA treatment records throughout the appeal period are consistent with the findings in the VA examination reports. Prior to February 26, 2016, the record fails to demonstrate that the Veteran met or approximated the criteria for a higher rating or suffered from additional functional loss that is not contemplated by the Ratings Schedule. The Veteran was in receipt of a 20 percent rating prior to February 26, 2016, due to forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees. A higher rating is not warranted for this period because the record does not show that the Veteran suffered from forward flexion of the thoracolumbar spine 30 degrees or less, or favorable ankylosis of the thoracolumbar spine. Moreover, intervertebral disc syndrome did not result in incapacitating episodes having a total duration of at least four weeks, but less than six weeks during the past 12 months. From February 26, 2016, to present, the Veteran met the criteria for a rating of 40 percent, but no higher, for his lumbosacral strain by having forward flexion of the thoracolumbar spine 30 degrees or less. A rating in excess of 40 percent is not warranted because at no point has the Veteran had ankylosis of the thoracolumbar or entire spine, nor has he had intervertebral disc syndrome resulting in incapacitating episodes. The Board has also considered Correia v. McDonald, 28 Vet. App. 158 (2016) which holds that the final sentence of 38 C.F.R. § § 4.59 requires that VA examinations include joint testing for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint. In the July 2019 Appeal Brief, the Veteran’s representative noted it was not clear whether the examination reports included range of motion testing for active and passive range of motion. However, the Board notes that the February 2017 VA examiner noted that passive range of motion testing was not performed as it was not medically appropriate because lumbar passive range of motion could not be performed safely due to the concern of possibly aggravating the neck or causing additional injury. There was objective evidence of pain on non-weight-bearing. Additionally, in Vilfranc v. McDonald, the Court recently held that 38 C.F.R. § § 4.59 is not applicable where, as here, the Veteran already has a compensable limitation of motion. Vilfranc v. McDonald, No. 15-0904 (U.S. Vet. App. Jan. 5, 2017). Moreover, given that the Veteran is receiving the maximum rating based on limitation of motion of the thoracolumbar spine and a higher rating requires unfavorable ankylosis of the thoracolumbar spine or unfavorable ankylosis of the entire spine, there is no prejudice in any VA examination not having conformed to 38 C.F.R. § § 4.59 as interpreted in Correia. The Board notes that the Veteran’s radiculopathy of the left lower extremity sciatic and femoral nerves are each currently rated as 20 percent disabling from February 14, 2017. An initial rating higher than the currently assigned 20 percent is not warranted at any time during the period under review. The Board notes the Veteran’s sciatic nerve involvement was wholly sensory, and therefore the rating should be at most the moderate degree, warranting a 20 percent rating under Diagnostic Code 8520. See Note at “Diseases of the Peripheral Nerves” in 38 C.F.R. § § 4.124(a). These sensory debilitations were first shown to exist at the February 2017 VA examination. At no time has any physician identified more severe symptoms to include muscle atrophy, and the Veteran does not indicate as much. As noted above, VA examiners in September 2015 and February 2016 have noted the Veteran had no radicular symptoms and normal sensory examinations. Because only sensory impairment is demonstrated during the period under review, an initial rating in excess of 20 percent is not warranted. With respect to femoral nerve impairment, the Board finds no evidence that is contrary to the February 2017 examiner’s conclusion that the symptoms of incomplete paralysis of the left lower extremity are moderate in degree. The Veteran’s normal sensation to light touch of the bilateral upper anterior thighs lends support to the finding that this condition is mild. Under Diagnostic Code 8526, moderate incomplete paralysis of the femoral nerve warrants a 20 percent rating. The rating criteria allow for a 30 percent rating for severe impairment. There is no indication of atrophy and the muscle strength testing was normal. The deep tendon reflexes were 2+. Thus, the Board finds the symptoms described most closely approximate moderate impairment, such that the 20 percent ratings presently in place, effective the date of the February 2017 examination, are appropriate. REASONS FOR REMAND 1. Service connection for a left knee disability, to include as secondary to a right knee disability is remanded. The Veteran contends that he is entitled to service connection for a left knee condition. An August 2015 VA treatment records shows the Veteran reported his knee pain was stable on medication. An assessment of osteoarthrosis involving the left knee more than the right was made by the treating physician. The Veteran underwent a VA examination in September 2015. There was no diagnosis for the left knee. The Veteran had full range of motion of his left knee and no pain was noted on examination. The examiner opined the left knee condition was less likely than not due to the right knee patellofemoral pain syndrome as there were no findings or a diagnosis for the left knee. The Veteran underwent another VA examination in February 2016. The examiner diagnosed the Veteran with left knee strain. Range of motion was from 0-130 degrees. Pain was noted on examination and caused functional loss. The examiner further noted that pain and fatigue due to flare-ups caused further functional loss from 0-125 degrees. The examiner noted that the knee conditions impacted the Veteran’s ability to work by limiting lifting to less than 10 pounds and created difficulty with standing and walking around his place of employment. In December 2016, an examiner opined that the left knee condition was not at least as likely as not aggravated beyond its natural progression by the service-connected right knee disability. The examiner explained that the diagnosis for the left knee was in question. There was no evidence of any baseline diagnosis or severity for   the left knee. There are no records of any treatment foe the left knee and the diagnosis of left knee strain was not supported by objective findings, only by the reported pain. The examiner further opined that without evidence of an actual anatomic diagnosis for the left knee there could not be an assessment of aggravation secondary to the right knee disability. The Board notes that at the time of the December 2016 VA examination, pain alone was not a disability for VA compensation purposes. See Sanchez-Benitez v. West, 13 Vet. App. 282 (1999) (holding that pain alone is not a disability for VA compensation purposes); see also Sanders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018) (amending the previous legal standard by holding that pain can be considered a disability for VA compensation purposes). The Veteran subsequently underwent a VA examination in August 2018, and the examiner held that the Veteran had a current diagnosis of a left knee strain. Range of motion was from 0-120 degrees. No pain was noted on examination. The examiner further noted that pain, fatigue, and weakness due to flare-ups caused further functional loss from 0-115 degrees. The examiner noted that the knee conditions impacted the Veteran’s ability to work by prohibiting lifting and prolonged standing or walking. No further opinion regarding service-connection for the left knee disability was given. Pain alone may be considered a disability if it impairs the Veteran’s ability to work, which in this case it does. See Sanders. The Veteran has been diagnosed with a left knee disability and pain with functional loss has been noted on examination. Once VA undertakes to provide the Veteran with a VA examination it must provide the Veteran with an adequate one, and an adequate examination is sufficiently detailed so as to ensure that VA’s evaluation is a fully formed one. Barr v. Nicholson, 21 Vet. App. 303 (2007). Therefore, this matter must be remanded for a new VA examination.   The matters are REMANDED for the following action: 1. Obtain any updated VA treatment records. 2. Then schedule the Veteran for a VA examination to determine the current nature of his left knee condition. The Veteran’s claims file, to include a copy of this remand, should be made available to the examiner in conjunction with the examination. Any medically indicated tests should be accomplished. After a review of the evidence, to include the Veteran’s service treatment records, VA treatment records and examination report, and with consideration of the Veteran’s lay statements regarding his symptoms of onset, the examiner should provide an opinion as to: (a.) whether it is at least as likely as not (50 percent probability or more) that his left knee condition began in service, was caused by service, or is otherwise related to service. (b.) whether it is at least as likely as not (50 percent probability or more) that his left knee condition was caused by the right knee disability or low back disability, or aggravated by a right knee disability or low back disability. The examiner should consider all evidence of record. A complete rationale should be provided for any opinion or conclusion expressed. If the examiner is unable to come   to an opinion without resorting to mere speculation, then the examiner must explain why and mention any additional information that would be needed to make a decision, if possible. MARJORIE A. AUER Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Kelly A. Gastoukian, Associate Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential, and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § § 20.1303.