Citation Nr: 19166314 Decision Date: 08/27/19 Archive Date: 08/27/19 DOCKET NO. 14-24 535 DATE: August 27, 2019 REMANDED 1. Entitlement to increases in the combined rating assigned for a right knee disability is remanded. 2. Entitlement to service connection for a right ankle disability is remanded. 3. Entitlement to service connection for a low back disability is remanded. 4. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is remanded REASONS FOR REMAND The appellant is a Veteran who served on active duty from January 2004 to May 2004 and from September 2006 to April 2009. These matters are before the Board of Veterans’ Appeals (Board) on appeal of a May 2013 Department of Veterans Affairs (VA) rating decision. A January 2019 rating decision assigned a separate (10 percent) rating for knee instability. In April 2019, a videoconference hearing was held before the undersigned; a transcript is the record. 1. Entitlement to increased ratings for a right knee disability. At the April 2019 hearing, the Veteran testified that the award of a separate 10 percent rating for instability did not satisfy her appeal for a higher rating for the right knee disability as the knee would not stay in alignment. Notably, her testimony appears to be alleging that the knee is symptomatic post semilunar cartilage removal. She has also indicated that the disability has increased in severity since she was last examined. [Records in her file show a musculoskeletal examination scheduling request (received on August 14, 2019) to assess the severity of her service-connected right knee disability.] 2. Entitlement to service connection for a right ankle disability. The Veteran contends that her right ankle disability became manifest in service, and alternatively that it is secondary to her service-connected right knee disability. An August 2011 MRI was interpreted as suggesting posterior tibial tenosynovitis. An April 2018 private treatment record notes that while standing in her bathtub the Veteran fell when her knee gave out, twisting her ankle. On examination, a chronic soft tissue injury was suspected. Private treating providers’ opinions in support of the claim are inadequate for rating purposes as they do not include adequate rationale. A December 2016 private opinion is stated in speculative terms, and a January 2011 private opinion did not include rationale for the opinion that the ankle disability is secondary to the right knee disability. The opinion on March 2013 VA examination is also inadequate as it does not address the secondary service connection theory of entitlement. An examination to obtain a fully adequate medical opinion is necessary. 3. Entitlement to service connection for a low back disability. The Veteran contends that her back disability became manifest in service, and alternatively that it is secondary to her service-connected right knee disability. An April 2018 MRI by a private provider found mild facet arthrosis at L3-L4 and L4-L5 levels. The Veteran has submitted multiple opinions by her private providers, but those opinions are inadequate for rating purposes as they do not include adequate rationale. In March 2016 a private provider stated the lower back and extremity issues have been a “known problem” since she fell in service but does not provide explanation for that conclusion. A November 2016 private opinion states her “back pain” is related to an altered gait but does not identify the source of the altered gait (i.e., whether due to the right knee). A March 2019 private opinion notes “most if not all of her complaints” can be correlated to her service-connected knee condition but does not provide adequate explanation. On May 2017 VA examination, the provider opined that the Veteran’s back disability was not secondary to her service-connected right knee disability, stating she had no bilateral knee pathology. Notably, the Veteran has compensable right knee disability and the opinion is based in an inaccurate factual premise. An examination to obtain an adequate medical opinion in the matter is necessary. 4. Entitlement to TDIU. When evidence of unemployability is submitted during the course of an appeal of a rating assigned for a disability or such is specifically alleged, a claim for entitlement to a TDIU rating is considered part and parcel of the increased rating claim. See Rice v. Shinseki, 22 Vet. App. 447 (2009). In an October 2011 report of general information, the Veteran stated she could not work because of her right knee, raising an issue of entitlement to a TDIU rating in the context of her increased rating claim. This issue has not been developed for appellate consideration. It is also inextricably intertwined with the claims being remanded. Therefore, consideration of the matter must be deferred pending resolution of the other claims remanded. The matters are REMANDED for the following: 1. Determine what whether the VA examination of the Veteran’s right knee ordered in August 2019 took place. If so, review if for adequacy to rate the knee disability based on instability, limitation of motion, and symptomatic removal of semilunar cartilage. If the examination did not take place, or if the findings were inadequate, arrange for such examination to take place. 2. Also, arrange for an orthopedic examination of the Veteran to determine the nature and likely etiology of her claimed right ankle and low back disabilities. The Veteran’s record must be reviewed by the examiner in conjunction with the examination. The examiner should respond responses to the following: (a.) Identify (by diagnosis) each right ankle and low back disability entity found. (b.) Identify the likely etiology for each right ankle and low back disability entity diagnosed. Specifically, is it at least as likely as not (a 50% or greater probability) that the Veteran’s low back and/or right ankle disabilities were caused or aggravated by (increased in severity due to) her service-connected right knee disability (to include as due to an altered gait due to the knee disability). [The opinion must address aggravation.] (c.) If it is found that the service-connected right knee disability did not cause, but aggravated a diagnosed low back or ankle disability, specify, to the extent possible, the degree of disability (symptoms/impairment) that has resulted from such aggravation. All opinions must include rationale, to include comment on (expression of agreement or disagreement with) the opinions already in the record (March 2019 private provider, 2017 VA examiner, November 2016 private provider, March 2016 private provider, and January 2011 private provider). 3. Upon readjudication of the claims seeking service connection and an increased rating, and following all further development indicated, adjudicate the claim for a TDIU rating, advising the Veteran that that issue will be fully before the Board if she perfects an appeal of a denial of such claim.. GEORGE R. SENYK Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board A. Naumovich, 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.