Citation Nr: 19172161 Decision Date: 09/17/19 Archive Date: 09/17/19 DOCKET NO. 18-42 559A DATE: September 17, 2019 ORDER An initial rating higher than 30 percent for bilateral pes planus is denied. For the entire rating period on appeal, an initial 10 percent disability rating, but no higher, for service-connected costochondritis is granted. REMANDED Entitlement to service connection for bilateral hearing loss is remanded. Entitlement to an initial rating higher than 10 percent for the service-connected right knee patellofemoral syndrome is remanded. Entitlement to an initial rating higher than 10 percent for the service-connected left knee patellofemoral syndrome is remanded. Prior to October 27, 2015, entitlement to an initial rating higher than 20 percent for service-connected left knee ACL tear, and beginning January 1, 2016, entitlement to a compensable rating for the left knee ACL tear, status post reconstruction, (excluding the period of temporary total disability) is remanded. Entitlement to an initial compensable rating for left knee surgical scar is remanded. Entitlement to an initial compensable rating for traumatic brain injury (TBI) residuals is remanded. Entitlement to an initial rating higher than 50 percent for the service-connected posttraumatic stress disorder (PTSD) is remanded. Entitlement to an initial rating higher than 20 percent for the left shoulder disability is remanded. Entitlement to an initial rating higher than 10 percent for the service-connected thoracolumbar spine disability is remanded. Entitlement to an initial rating higher than 10 percent for the service-connected right elbow disability is remanded. Entitlement to an initial rating higher than 10 percent for the service-connected left elbow disability is remanded. Entitlement to an initial total disability rating due to individual unemployability (TDIU) is remanded. FINDINGS OF FACT 1. The bilateral pes planus disability did not manifest in symptoms of marked pronation, extreme tenderness of plantar surfaces of the feet, or marked inward displacement and severe spasm of the tendo achillis on manipulation, not improved by orthopedic shoes or appliances. 2. The Veteran’s chronic costochondritis causes no more than moderate muscle impairment productive primarily of pain/fatigue. CONCLUSIONS OF LAW 1. The criteria for a disability rating higher than 30 percent for the service connected bilateral pes planus have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5276. 2. The criteria for an initial 10 percent disability rating, but no higher, for the service-connected chronic costochondritis are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.7, 4.40, 4.56, 4.73, Diagnostic Codes (DC) 5297, 5321. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from April 2011 to April 2015. This matter comes on appeal before the Board of Veterans’ Appeals (Board) from July 2015 and April 2016 rating decisions of a Department of Veterans Affairs (VA) Regional Office (RO). As will be discussed in further detail below, the record raises the issue of unemployability due to the Veteran’s service-connected disabilities. See 38 C.F.R. §§ 3.340, 4.16; Rice v. Shinseki, 22 Vet. App. 447, 453 (2009) (holding, in pertinent part, that the issue of entitlement to TDIU is part and parcel of an increased rating claim when unemployability due to the disability at issue is raised by the Veteran or the record). The Veteran waived a hearing before the Board in his September 2018 and December 2018 substantive appeals, via a VA Form 9. Preliminary Matters The Board has limited the discussion below to the relevant evidence required to support its finding of fact and conclusion of law, as well as to the specific contentions regarding the case as raised directly by the Veteran and those reasonably raised by the record. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015); Robinson v. Peake, 21 Vet. App. 545, 552 (2008); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016). Increased rating Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule) found in 38 C.F.R. Part 4. 38 U.S.C. § 1155. It is not expected that all cases will show all the findings specified; however, findings sufficiently characteristic to identify the disease and the disability therefrom and coordination of rating with impairment of function will be expected in all instances. 38 C.F.R. § 4.21. Where there is a question as to which of two disability 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 low rating will be assigned. 38 C.F.R. § 4.7. It is the defined and consistently applied policy of VA to administer the law under a broad interpretation, consistent, however, with the facts shown in every case. When after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability such doubt will be resolved in favor of the claimant. 38 C.F.R. § 4.3. In general, all disabilities, including those arising from a single disease entity, are rated separately, and all disability ratings are then combined in accordance with 38 C.F.R. § 4.25. Pyramiding, the rating of the same disability, or the same manifestation of a disability, under different diagnostic codes (DC or DCs), is to be avoided when rating a veteran’s service-connected disabilities. 38 C.F.R. § 4.14. It is possible for a veteran to have separate and distinct manifestations from the same injury which would permit rating under several Diagnostic Codes; however, the critical element in doing so is that none of the symptomatology is duplicative or overlapping with the symptomatology of the other condition. Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). When an unlisted condition is encountered it will be permissible to rate under a closely related disease or injury in which not only the functions affected, but the anatomical localization and symptomatology are closely analogous. Conjectural analogies will be avoided, as will the use of analogous ratings for conditions of doubtful diagnosis, or for those not fully supported by clinical and laboratory findings. Nor will ratings assigned to organic diseases and injuries be assigned by analogy to conditions of functional origin. 38 C.F.R. § 4.20. The assignment of a particular Diagnostic Code is “completely dependent on the facts of a particular case.” See Butts v. Brown, 5 Vet. App. 532, 538 (1993). One Diagnostic Code may be more appropriate than another based on such factors as an individual’s relevant medical history, the Diagnostic Code, and the demonstrated symptomatology. Any change in a Diagnostic Code by VA must be specifically explained. See Pernorio v. Derwinski, 2 Vet. App. 625 (1992). Where an increase in the level of a service-connected disability is at issue, the primary concern is the present level of disability. See Francisco v. Brown, 7 Vet. App. 55 (1994). Staged ratings are appropriate for any initial rating claim when the factual findings show distinct time periods during the appeal period where the service-connected disability exhibits symptoms that would warrant different ratings. Fenderson v. West, 12 Vet. App. 119, 126 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). When evaluating musculoskeletal disabilities under schedular criteria, the Board may consider granting a higher rating in cases in which the claimant experiences additional functional loss due to pain, weakness, excess fatigability, or incoordination, to include with repeated use during flare-ups, and those factors are not contemplated in the relevant rating criteria. See 38 C.F.R. § 4.40; DeLuca v. Brown, 8 Vet. App. 202, 204-7 (1995). A veteran is competent to report symptoms because this requires only personal knowledge, not medical expertise, as it comes to him through their senses. See Layno v. Brown, 6 Vet. App. 465 (1994). Lay testimony is competent to establish the presence of observable symptomatology, where the determination is not medical in nature and is capable of lay observation. Barr v. Nicholson, 21 Vet. App. 303 (2007). In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive and provide the reasons for its rejection of any material favorable to the claimant. Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994). When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with a veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. 1. An initial rating higher than 30 percent for the service-connected bilateral pes planus is denied. The bilateral pes planus disability is currently rated as 30 percent disabling under Diagnostic Code 5276. The Veteran contends it warrants a higher rating. Under 38 C.F.R. § 4.71a, Diagnostic Code 5276, a 30 percent disability rating for bilateral pes planus is assigned where there is a severe disability with objective evidence of marked deformity (pronation, abduction, etc.), pain on manipulation and use accentuated, indications of swelling on use, and characteristic callosities. A 50 percent disability rating for bilateral pes planus requires a pronounced condition manifested by marked pronation, extreme tenderness of the plantar surfaces of the feet, marked inward displacement, severe spasm of the tendon Achilles on manipulation, not improved by orthopedic shoes or appliances. 38 C.F.R. § 4.71a, Diagnostic Code 5276. The words “slight,” “moderate,” and “severe” as used in the various Diagnostic Codes are not defined in the VA Schedule for Rating Disabilities. Rather than applying a mechanical formula, the Board must evaluate all the evidence, to the end that its decisions are “equitable and just.” 38 C.F.R. § 4.6. Turning to the relevant evidence of record, the Veteran’s service treatment records are silent for symptoms or treatment for bilateral pes planus. The Veteran was afforded a pre-discharge VA examination in December 2014. The Veteran describes pain in and on the sides of both feet. The Veteran had flare-ups that resulted in increased aching in his feet at the end of the day or after a long hike. The examiner, a physician, reported the Veteran had pain in both feet with use and on manipulation. The Veteran had decreased longitudinal arch height on weightbearing bilaterally. No swelling or callouses were found. The Veteran did not use arch supports, built-up shoes, or orthotics. No extreme tenderness of the plantar surfaces, marked pronation, “inward” bowing of the Achilles’ tendons, or marked inward displacement and severe spasm of the Achilles’ tendons were found. The Veteran’s weight-bearing line did not fall over or medial to the great toe in either foot. No other lower extremity deformity caused alteration to the weight bearing line. The Veteran did not have Morton’s Neuroma, hammer toes, hallux valgus, hallux rigidus, acquired pes cavus, foot injuries, or other foot conditions. The examiner noted the Veteran had pain on non-weight bearing that contributed to the Veteran’s functional loss. However, the examiner found that there was no pain, weakness, fatigability, or incoordination that significantly limited the Veteran’s functional ability during a flare up or after repeated use over time. No other functional loss or other physical findings, complications, conditions, signs, symptoms were found during flare ups or with repeated use over time. The Veteran did not use assistive devices. Imaging studies had been performed and no degenerative or traumatic arthritis was found. The examiner found that the bilateral pes planus did not affect the Veteran’s ability to work. The Veteran submitted a private medical opinion from Dr. P.J.Y., a physician and diagnostic medical consultant. Dr. P.J.Y. noted that he concurred with the currently assigned rating. After a review of all the evidence, lay and medical, the Board finds that the criteria for a rating higher than 30 percent for the pes planus have not been met or more nearly approximated. Throughout the rating period on appeal, the bilateral pes planus has not manifested in symptoms of marked pronation, extreme tenderness of plantar surfaces of the feet, or marked inward displacement and severe spasm of the tendo achillis’ on manipulation that was not improved by orthopedic shoes or appliances. As a preponderance of the evidence is against an initial rating higher than 30 percent, the benefit of the doubt doctrine is not for application. See 38 U.S.C. § 5107 (b); Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). Finally, the Board notes that the Veteran has not raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 69-70 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record).   2. For the entire rating period on appeal, an initial 10 percent rating is assigned for the service-connected costochondritis. The service-connected costochondritis is currently rated as noncompensable under Diagnostic Code 5399-5321. Hyphenated diagnostic codes are used when a rating under one code requires use of an additional diagnostic code to identify the basis for the evaluation assigned. 38 C.F.R. § 4.27. When an unlisted condition is encountered, it is permissible to rate under a closely related disease or injury in which not only the functions affected, but the anatomical localization and symptomatology are closely analogous. 38 C.F.R. § 4.20. According to the policy in the Rating Schedule, when a disability is not specifically listed, the diagnostic code will be “built up,” meaning that the first 2 digits will be selected from that part of the schedule most closely identifying the part of the body involved, and the last 2 digits will be “99.” 38 C.F.R. § 4.27. For example, DC 5399 is used to identify unlisted muscle injuries. Costochondritis is not listed in the rating schedule. Where a particular disability is not listed, it may be rated by analogy to a closely related disease in which not only the functions affected, but also the anatomical area and symptomatology, are closely analogous. 38 C.F.R. §§ 4.20, 4.27; Lendenmann v. Principi, 3 Vet. App. 345, 349-50 (1992). Here, because there is no specific diagnostic code for costochondritis, the Veteran’s condition was initially rated by analogy under Diagnostic Code 5399-5321, which governs the muscles of respiration. Costochondritis is an inflammation of the cartilage that connects the ribs to the breastbone (i.e., the costochondral joints). See MedlinePlus, U.S. National Library of Medicine. Accordingly, costochondritis may be rated as a musculoskeletal disability under 38 C.F.R. § 4.71a, or alternatively, as a muscle disability under 38 C.F.R. § 4.73. Under Diagnostic Code 5297, which applies to the removal of ribs, a 10 percent disability rating is warranted if there is a removal of one rib or resection of two or more ribs without regeneration. A 20 percent rating requires removal of two ribs. Removal of three or four ribs warrants a 30 percent rating. A 40 percent rating is assigned for removal of five or six ribs. Removal of more than six ribs warrants a 50 percent rating. 38 C.F.R. § 4.71a, Diagnostic Code 5297. Under Diagnostic Code 5321, which applies to the thoracic muscle group XXI, a noncompensable (zero percent) disability rating is assigned for slight muscle disability, a 10 percent rating is assigned for moderate disability, a 20 percent rating is assigned for a moderately severe or severe disability. 38 C.F.R. § 4.73, Diagnostic Code 5321. The factors for determining whether muscle disability is slight, moderate, or severe are particular to the evaluation of healed wounds, such as those from gunshots or other missiles. 38 C.F.R. §§ 4.55, 4.56. For VA rating purposes, the cardinal signs and symptoms of muscle disability are loss of power, weakness, lowered threshold of fatigue, fatigue-pain, impairment of coordination, and uncertainty of movement. 38 C.F.R. § 4.56(c). A slight disability of muscles is defined as a simple wound of muscle without debridement or infection. Service treatment records (STRs) will show a superficial wound with brief treatment and return to duty healing with good functional results and no cardinal signs or symptoms of muscle disability. There will be minimal scarring and no evidence of facial defect, atrophy, or impaired tonus. Also, no impairment of function or retained metallic fragments retained will be present. 38 C.F.R. § 4.56(d)(1). A moderate disability of muscles is defined as a through and through or deep penetrating wound of short track from a single bullet, small shell or shrapnel fragment, without explosive effect of high velocity missile, residuals of debridement, or prolonged infection. Objective findings will include entrance and (if present) exit scars, some loss of deep fascia or muscle substance or impairment of muscle tone and loss of power or lowered threshold of fatigue when compared to the sound side. 38 C.F.R. § 4.56(d)(2). A moderately severe disability of muscles is defined as a through and through or deep penetrating wound by small high velocity missile or large low-velocity missile, with debridement, prolonged infection, or sloughing of soft parts, and intramuscular scarring. Service department records should show hospitalization for a prolonged period for treatment of wound. Objective findings will include entrance and (if present) exit scars indicating track of missile through one or more muscle groups along with indications on palpation of exit scars, some loss of deep fascia or muscle substance or impairment of muscle tone and loss of power or lowered threshold of fatigue when compared to the sound side. Tests of strength and endurance compared with sound side demonstrate positive evidence of impairment. 38 C.F.R. § 4.56 (d)(3). Severe disability of the muscles is defined as a through and through or deep penetrating wound due to high-velocity missile, or large, or multiple low velocity missiles, or with shattering bone fracture or open comminuted fracture with extensive debridement, prolonged infection, sloughing of soft parts, and intramuscular binding and scarring. Objective findings will include ragged, depressed and adherent scars; loss of deep fascia or muscle substance or soft flabby muscles in the wound area; and severe impairment on tests of strength, endurance, or coordinated movements compared with the corresponding muscles of the uninjured side. 38 C.F.R. § 4.56(d)(4). If present, the following are also signs of severe muscle disability: (a) x-ray evidence of minute multiple scattered foreign bodies; (b) adhesion of the scar; (c) diminished muscle excitability on electrodiagnostic tests; (d) visible or measurable atrophy; (e) adaptive contraction of an opposing group of muscles; (f) atrophy of muscle groups not in the track of the missile; or (g) induration or atrophy of an entire muscle following simple piercing by a projectile. 38 C.F.R. § 4.56 (d)(4). Finally, an open comminuted fracture with muscle or tendon damage will be rated as a severe injury of the muscle group involved unless, for locations such as in the wrist or over the tibia, evidence establishes that the muscle damage is minimal. 38 C.F.R. § 4.56(a). Turning to the evidence, a December 2014 VA examination reflects that the Veteran reported that his chest was slightly elevated on one side, which resulted in irritation when he wore a flak vest. He indicated his chest was sore when he woke up. The Veteran reported no overall functional impairment from the disability. The examiner, a physician, diagnosed the Veteran with costochondritis. On examination, the examiner indicated the Veteran had an injury of muscle group XXI affecting muscles of respiration on the left. No scars, fascia defects, or injuries affecting muscle substance or function were noted. The Veteran exhibited constant fatigue/pain on the left side of his chest. No loss of power, weakness, lowered thresholds of fatigue, impairment of coordination, uncertainty of movement, or muscle atrophy were found on examination. Muscle strength testing was normal in all muscle groups. The Veteran did not use assistive devices due to the costochondritis. Chest x-ray and left rib x-ray studies were within normal limits. No other significant diagnostic findings were noted. The examiner indicated the costochondritis did not impact the Veteran’s ability to work. VA treatment records are silent as to symptoms or treatment for chest pain, chest muscle soreness, or costochondritis. The Veteran submitted a January 2016 private medical evaluation, but it did not address the severity or symptoms of the service-connected costochondritis. The Veteran’s costochondritis is currently rated under Diagnostic Code 5321, applicable to muscles of respiration, which, in this case, the Board finds is the most appropriate code. In evaluating this claim, the Board initially notes that, because the Veteran’s disability is assigned by analogy to a muscle injury, the exact characteristics of a muscle injury, as described in the rating criteria (i.e., penetrating wounds) are not adequate descriptors of the Veteran’s overall disability picture. Nevertheless, the Board is mindful of 38 C.F.R. § 4.40, which states that, with respect to disabilities of the musculoskeletal system, “functional loss... may be due to pain.” DeLuca, 8 Vet. App. at 204. The Board notes that, while no associated bone or joint abnormalities have been identified as related to the Veteran’s chronic costochondritis, the evidence reflects that during the period on appeal there has been a finding that the Veteran experienced constant pain-fatigue, as noted in the December 2014 VA examination, which is a cardinal sign and symptom of a muscle disability. However, the Veteran has not complained of pain on movement, functional loss, or flare-ups during the appellate period. Although the Veteran’s costochondritis appears to be mild, a noncompensable rating requires that there be “no cardinal signs or symptoms” of a muscle disability. Here the December 2014 VA examiner did, in fact, determine the Veteran had pain-fatigue, which is a cardinal sign or symptom of a muscle disability. Therefore, the Veteran’s costochondritis more nearly approximates a 10 percent rating assigned for a moderate injury to a muscle of the respiratory system under Diagnostic Code 5321. The Board has considered whether a rating higher than 10 percent was warranted under Diagnostic Code 5321; however, the evidence does not show symptoms that are consistent with a moderately severe or severe impairment. The Veteran has not undergone prolonged treatment or hospitalization during service, and there is no evidence of impaired respiratory function or decreased strength and endurance in the upper extremities. In this regard, the Board notes the Veteran has consistently reported pain with his condition but has not asserted that he experiences loss of muscle power. Notably, during the December 2014 VA examination, the Veteran’s muscle strength tested normal. The lay and medical evidence of record shows that his costochondritis is manifested by constant pain-fatigue, but it does not impair his ability to perform certain movements, as opposed to loss of muscle power or strength or other functional loss in the costochondral junctions or upper extremities. Further, there is no evidence of record that the service-connected costochondritis prevents the Veteran from keeping up with work requirements. Therefore, the Board finds that the Veteran’s costochondritis is moderate, at worst, and does not warrant a rating higher than 10 percent rating under Diagnostic Code 5321. The Board also considered whether a rating in excess of 10 percent is warranted under other potentially applicable diagnostic codes. As noted above, costochondritis involves the rib and its cartilage. See MedlinePlus, supra. As a result, Diagnostic Code 5297, applicable for removal of the ribs, was considered; however, the evidence of record does not show that the Veteran has ever had a rib removed or resected, meaning he would not meet the criteria for a 20 percent rating under DC 5297, which requires the removal of at least two ribs. The Board finds that these criteria are not analogous to the Veteran’s primary symptom of chronic non-cardiac chest pain. The Board also considered the application of Diagnostic Codes 5003 and 5019 for arthritis or bursitis, respectively; however, there is no evidence of arthritis or bursitis in the VA examination or any other medical records. In any event, those disabilities are evaluated based upon limitation of motion of the affected parts. The evidence does not show that the Veteran experiences limitation of motion in any affected area, including his chest and upper extremities, related to his costochondritis. Thus, the Board finds that DCs 5003 and 5019 do not assist the Veteran in obtaining a rating higher than 10 percent with respect to his costochondritis. Finally, the Board finds there is no basis for staged rating of the Veteran’s costochondritis pursuant to Hart, as the lay and medical evidence shows the Veteran’s costochondritis has manifested by symptoms that more nearly approximate a 10 percent rating throughout the appeal period. Accordingly, resolving any doubt in the Veteran’s favor, the Board finds that a disability rating of 10 percent, but no higher, for chronic costochondritis is warranted for the entire period on appeal. Finally, the Veteran has not raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette, 28 Vet. App. at 369-70 (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). REASONS FOR REMAND 1. Entitlement to service connection for bilateral hearing loss disability is remanded. A remand is necessary before this claim can be adjudicated. The Veteran was afforded a VA examination in December 2014, three months before he was discharged from service. No hearing loss for VA purposes was found. In January 2016, the Veteran submitted a medical report from Dr. P.J.Y, a private physician and diagnostic consultant, that indicated the Veteran had 40 percent functional hearing loss bilaterally in normal conditions of conversation. He indicated the Veteran would submit an additional private audiogram and that an addendum opinion was to follow. However, no additional private audiogram or addendum opinion was submitted by the Veteran. Although there is no evidence associated with the claims file showing hearing loss for VA purposes currently, the report from Dr. P.J.Y. indicates the Veteran’s bilateral hearing loss may have worsened since his most recent pre-discharge examination in December 2014. Thus, the Veteran should be afforded an additional VA examination to determine if he meets the criteria for a bilateral hearing loss diagnosis for VA purposes under 38 C.F.R. § 3.385, and if so, determine if it had onset or was otherwise related to service. 2. Entitlement to an initial rating higher than 10 percent for the right knee disability is remanded. A remand is necessary before the claim can be adjudicated on the merits. The December 2014 VA examination is not adequate in its current form to decide this claim as it is not in compliance with Correia v. McDonald, 28 Vet. App. 158 (2016) and Sharp v. Shulkin, 29 Vet. App. 26, 33 (2017). The December 2014 VA examiner neither described the Veteran’s additional functional loss in terms of range of motion during flare-ups or after repetitive use over time. Range of motion measurements were also not reported in active and passive motion or on weightbearing and non-weightbearing positions. Finally, the examiner indicated that the Veteran’s functional loss included pain but did not include weakness, fatigability, or incoordination in the DBQ, but further indicated in the remarks section that “there are contributing factors of pain, weakness, fatigability and/or incoordination...” Clarification is needed to determine if the Veteran only has additional functional loss only due to pain or if he also experiences weakness, fatigability, and/or incoordination during flare ups or with repeated use over time. In addition, the January 2016 private evaluation suggests that the Veteran’s service connected right knee disability has worsened since the Veteran’s most recent December 2014 VA examination. See January 2016 private examination report. The fact that a VA examination is more than 4.5 years old is not a valid basis, unto itself, to provide the Veteran with another VA examination. See Palczewski v. Nicholson, 21 Vet. App. 174, 181-83 (2007); Snuffer v. Gober, 10 Vet. App. 400, 403 (1997); VAOPGCPREC 11-95 (1995). However, in this case, the January 2016 private medical opinion from Dr. P.J.Y. suggests that the Veteran’s right knee disability has worsened after the most recent VA examination; therefore, a new VA examination is needed to assist in determining the current severity of the Veteran’s service-connected right knee disability. Snuffer, 10 Vet. App. at 400. Based on the reasons set forth above, a remand is warranted to afford the Veteran an additional VA examination for the right knee disability. 3. Entitlement to an initial rating higher than 10 percent for the service connected left knee patellofemoral pain syndrome; & 4. Prior to October 27, 2015, entitlement to a rating higher than 20 percent for the left knee anterior cruciate ligament tear, status post reconstruction, and entitlement to a compensable rating beginning January 1, 2016 (excluding the period of temporary total disability); & 5. Entitlement to an initial compensable rating for a left knee surgical scar are remanded. As a procedural history, the July 2015 rating decision granted service connection for the left knee patellofemoral syndrome and assigned a 10 percent rating effective April 4, 2015, the day after service discharge. The Veteran filed a timely February 2016 notice of disagreement, and this appeal ensued. In January 2019, during the pendency of the appeal, the RO issued an additional rating decision which assigned a separate 20 percent rating effective April 4, 2015, a temporary total 100 percent disability rating effective October 27, 2015, and a noncompensable rating effective January 1, 2016, for the left knee ACL tear, status post reconstruction. Additionally, the RO granted service-connected for the left knee surgical scar and assigned a noncompensable rating effective April 4, 2015. Subsequently, the Veteran submitted a January 2019 notice of disagreement, contending that the left knee ACL tear, status post reconstruction, should be assigned a 20 percent rating effective January 1, 2016 and that his left knee surgical scar was painful and warranted a compensable rating. Because the claim for an increased rating for the left knee was already on appeal when the January 2019 rating decision was issued, the additional staged ratings for the left knee ACL tear, status post reconstruction, and the separate rating assigned to the left knee surgical scar are also before the Board as part of the Veteran’s appeal for increased ratings for the left knee disabilities. The Board also notes the Veteran has been assigned a 100 percent temporary total disability rating effective October 27, 2015 to December 31, 2015. As this is the full benefit sought on appeal, this period will not be addressed by the Board. Turning to the issue at hand, the evidence suggests that the Veteran’s service connected left knee disability has worsened since the Veteran’s most recent pre-discharge December 2014 VA examination. The Veteran has undergone a left knee ACL reconstruction with an anterior cruciate ligament, medial collateral ligament, and medial meniscus repair. See January 2016 private evaluation report. Therefore, a new VA examination is needed to assist in determining the current severity of the Veteran’s service-connected left knee disability. Id. Additionally, during the pendency of the appeal, the Veteran was awarded a noncompensable rating for a left knee scar from the ACL reconstruction surgery; however, the Veteran has not yet been afforded a VA scar examination. The Veteran indicates that the scar is painful on a January 2019 notice of disagreement. On remand, the severity of the left knee scar should be evaluated. Finally, as discussed above with regard to the increased rating claim for the right knee, the December 2014 VA examination is inadequate in its current form to adjudicate the claim as it is not in compliance with Correia, 28 Vet. App. at 158 and Sharp, 29 Vet. App. at 33. 6. Entitlement to an initial compensable rating for service connected TBI residuals; and 7. Entitlement to an initial rating higher than 50 percent for the service-connected PTSD is remanded. A remand is necessary to afford the Veteran additional VA examinations for the TBI residuals and the PTSD. The Veteran was afforded a December 2014 VA TBI examination. The examiner, a physician, essentially found no TBI residuals. Subsequently, only six months later in a June 2015 VA second tier TBI evaluation, the Veteran attributed symptoms of moderate headaches, difficulty hearing, difficulty making decisions, slowed thinking, difficulty with organization, difficulty completing tasks, fatigue, depression, poor frustration tolerance, feeling overwhelmed, severe irritability, difficulty falling and staying asleep, anxiety, forgetfulness, and poor concentration to the TBI. See also August 2015 VA TBI plan of care. Furthermore, the Veteran submitted a January 2016 private TBI evaluation that indicated the Veteran had residuals of chronic daily frontal headaches, vertigo, visual disturbances, incompetent right to left consensual reflex, and perseveration in his thought processes and speech. Also, during the pendency of the increased rating claim for the TBI residuals, the Veteran was granted service-connection for PTSD. The Veteran was afforded a VA psychiatric examination in April 2016 which diagnosed the Veteran with PTSD and depressive disorder. The VA examiner indicated that the symptoms of the PTSD and depression could not be differentiated, and that based on the December 2014 TBI examination, all psychiatric symptoms must be attributed to the PTSD. However, not all of the Veteran’s reported psychiatric symptoms were accounted for in the April 2016 VA PTSD examination. See June and August 2016 VA treatment records and April 2016 private PTSD DBQ. Subsequently, the Veteran also submitted an April 2016 private PTSD disability benefits questionnaire (DBQ). Dr. W.J.A., a psychologist, diagnosed the Veteran with PTSD with dissociative symptoms and derealization, depressive disorder, and mild alcohol abuse disorder. Dr. W.J.A. indicated that the depressive disorder and PTSD symptoms could not be differentiated and included anhedonia, difficulty concentrating, and survivor’s guilt. She also concluded that the symptoms of his TBI and PTSD could not be differentiated, but only cited an overlapping symptom of difficulty with concentration. The other symptoms noted in the June 2015 VA treatment records or the January 2016 private medical evaluation were not addressed. It is unclear as to which psychiatric symptoms are attributable to the TBI and which symptoms are attributable to the PTSD. Further, neither the TBI nor the PTSD examination addressed all of the Veteran’s reported psychiatric and cognitive symptoms, and the December 2014 VA TBI examination failed to address whether the Veteran’s reported physical symptoms are residuals of the TBI, and if so, the severity of each. Further examination would be helpful determine which symptoms are attributable to the PTSD, and to try to identify separate cognitive or psychosocial difficulties attributable to the TBI. Further, it is unclear if the Veteran has been afforded neuropsychological testing at any point during examination. On remand, the Veteran should be provided with comprehensive VA examinations for both the TBI and PTSD to determine whether any of psychiatric or physical symptoms can be attributed to his now service-connected TBI, as well as to address the severity of the PTSD. 8. Entitlement to an initial rating higher than 20 percent for the left shoulder disability is remanded. As a procedural history, the July 2015 rating decision assigned a 10 percent rating to the left shoulder disability effective April 4, 2015, the day after service. The Veteran filed a timely notice of disagreement, and this appeal ensued. In January 2019, the RO issued a new rating decision revising the assigned rating to 20 percent for the left shoulder disability effective April 4, 2015. Since this increase in rating was not a full grant of the benefit sought on appeal, this matter is still before the Board. Turning to the matter at hand, the Veteran was afforded a December 2014 VA examination. The examiner, a physician, noted the Veteran reported flare-ups of his left shoulder. The Veteran described the flare-ups as the left shoulder injuries returned when he went to the gym. Further, in a January 2016 private evaluation submitted by the Veteran, Dr. P.J.Y. indicated that the Veteran’s flare ups also consist of intensified pain and dysfunction with motion, even when lifting something as light as a bag of groceries. He also noted the Veteran was at significant risk for spontaneous dislocation of the left shoulder. The December 2014 VA examination is not adequate in its current form to decide this claim as it is not in compliance with Correia, 28 Vet. App. at 158 and Sharp, 29 Vet. App. at 33. The deficiencies in the December 2014 VA examination reports have been set forth and discussed above with regard to the bilateral knee claims, and the same deficiencies exist with regard to the December 2014 VA left shoulder examination. In addition, Dr. P.J.Y.’s private examination report indicates worsening of the left shoulder disability since the most recent December 2014 VA examination. The fact that a VA examination is more than 4.5 years old is not a valid basis, unto itself, to provide the Veteran with another VA examination. See Palczewski v. Nicholson, 21 Vet. App. 174, 181-83 (2007); Snuffer, 10 Vet. App. at 403; VAOPGCPREC 11 95 (1995). However, in this case, the evidence indicates that the left should disability may have worsened after the most recent December 2014 VA examination; therefore, a new VA examination is needed to assist in determining the current severity of the Veteran’s service-connected left shoulder disability. Snuffer, 10 Vet. App. at 400. 9. Entitlement to an initial rating higher than 10 percent for the service connected thoracolumbar spine disability is remanded. A remand is necessary before the claim can be adjudicated on the merits. The December 2014 VA examination is not adequate in its current form to decide this claim as it is not in compliance with Correia, 28 Vet. App. 158 (2016) and Sharp, 29 Vet. App. at 33. The examination report deficiencies have been discussed with regard to the bilateral knee claims, also remanded above, and the same deficiencies exist with regard to the December 2014 VA back examination. In addition, the examiner indicated the Veteran reported flare-ups of his back but reported the flare ups were described as pain in his feet and on the sides of his feet. This description is verbatim what was reported for the symptoms during a flare-up in the December 2014 VA examination for bilateral pes planus. It is unclear if this report was in error and unrelated to the back disability or whether the symptoms were the same for the bilateral pes planus and for the back disability. Thus, a remand is warranted to address these issues. 10. & 11. Entitlement to an initial rating higher than 10 percent for the service-connected right and left elbow disabilities is remanded. A remand is necessary before these claims can be adjudicated on the merits. The December 2014 VA examination is not adequate in its current form to decide this claim as it is not in compliance with Correia, 28 Vet. App. at 158 and Sharp, Vet. App. at 33. The deficiencies in the December 2014 examination are discussed above, and the same deficiencies are in the December 2014 VA bilateral elbow examination report. Thus, a remand is warranted to address these issues. In addition, the January 2016 private evaluation suggests that the Veteran’s service connected left elbow disability has worsened since the Veteran’s most recent December 2014 VA examination. See January 2016 private examination report. The fact that a VA examination is more than 4.5 years old is not a valid basis, unto itself, to provide the Veteran with another VA examination. See Palczewski, 21 Vet. App. at 181-83; Snuffer, 10 Vet. App. at 403; VAOPGCPREC 11-95 (1995). However, in this case, the January 2016 private medical opinion from Dr. P.J.Y. suggests that the Veteran’s left elbow disability has worsened after the most recent VA examination; therefore, a new VA examination is needed to assist in determining the current severity of the Veteran’s service-connected left elbow disability. Snuffer, 10 Vet. App. at 400. Based on the reasons set forth above, a remand is warranted to afford the Veteran an additional VA examination for the left elbow disability. 12. Entitlement to a TDIU is remanded. As indicated above, the record raises the issue of entitelment to a TDIU. Specifically, the January 2016 private examination report reflects that the Veteran’s disabilities impact his ability to work, specifically when reviewing his TBI and PTSD residuals. The Veteran reported that his TBI residual symptoms cause difficulty at school, at work, and in his daily life. Although the Veteran is working part time, it appears he works as a mechanic part time for a family owned business. Therefore, although the Veteran appears to be employed, more information is necessary to evaluate whether the Veteran’s employment is substantially gainful or whether he may be employed in a protected environment. Accordingly, the issue of entitlement to TDIU is also on appeal. On remand, the Veteran should be requested to fill out an application for TDIU (VA Form 21 8940), including his work history and educational background. He should also be sent a VCAA notice letter informing him of the requirements for establishing entitlement to TDIU. The aforementioned matters are REMANDED for the following action: 1. Obtain any outstanding pertinent VA and/or private treatment records and associate them with the claims file. Of note, the Veteran sees outside physicians through the VA Choice program and any outstanding treatment records from the VA Choice physicians should also be obtained and associated with the claims file. 2. Send the Veteran a letter notifying him of the requirements for substantiating entitlement to TDIU. 3. Provide the Veteran with a VA Form 21-8940, Application for Increased Compensation Based on Unemployability, for him to complete, with instructions to return the form to the RO. Also afford the Veteran the opportunity to identify or submit any additional pertinent evidence in support of the TDIU claim. 4. Schedule the Veteran for an additional VA examination to determine the nature and etiology of the Veteran’s bilateral hearing loss disability. All necessary testing, evaluations, and studies should be afforded to the Veteran. If the Veteran has hearing loss in either ear that meet the criteria for a hearing loss disability for VA purposes, provide a medical opinion as to whether the hearing loss had onset or is otherwise related to service. 5. Schedule the Veteran for additional VA musculoskeletal examinations to evaluate the nature and severity of the bilateral knee, bilateral elbow, thoracolumbar spine, and left shoulder disabilities. After a thorough review of the claims file, the examiner is asked to respond to the following: a) Elicit from the Veteran all signs and symptoms of the service-connected bilateral knee, bilateral elbow, thoracolumbar spine, and left shoulder disabilities. In doing so, obtain information from the Veteran (or the treatment records) as to the frequency, duration, characteristics, severity, and/or functional loss with any repetitive use over time and during flare-ups. b) Full range of motion testing must be performed where possible. The joints involved should be tested in (1) active motion, (2) passive motion, (3) in weight bearing, and (4) in non-weight-bearing. If the examiner is unable to conduct the required testing or concludes that the required testing is not necessary in this case, the examiner should clearly explain why that is so. If pain is found during the examination, the examiner should note when the pain begins. c) In assessing functional loss, flare-ups, and increased functional loss on repetitive use over time must be considered. In addition to current findings, to the extent possible, assess any additional functional loss during the Veteran’s flare-ups and any increased functional loss on repetitive use over time. The examiner must consider all procurable and ascertainable data and describe the extent of any pain, incoordination, weakened movement, and excess fatigability on use, and, to the extent possible, report functional impairment due to such factors in terms of additional degrees of limitation of motion. *If the examiner is unable to provide such an opinion without resorting to speculation, the examiner must provide a rationale for this conclusion, with specific consideration of the instructions in the VA Clinician’s Guide to estimate, “per [the] veteran,” what extent, if any, flare-ups affect functional impairment. *The examiner must include a discussion of any specific facts that cannot be determined if unable to opine without speculation. Sharp v. Shulkin, 29 Vet. App. 26, 36 (2017). 6. Schedule the Veteran for a VA scar examination to determine the nature and severity of the left knee surgical scar. The Veteran’s claims file should be reviewed and all appropriate rating criteria addressed. 7. Schedule the Veteran for a VA TBI examination with an appropriate clinician to determine the nature and severity of any TBI residuals. All necessary testing, evaluations, and studies should be afforded to the Veteran, including neuropsychological testing, if necessary. If not necessary, explain why not. After a thorough review of the claims file, the examiner should address the following: a) Clarify which psychiatric and/or cognitive symptoms are associated with the TBI and which symptoms are associated with the PTSD. A complete rationale should be provided. *The Veteran has indicated that he has psychiatric symptoms and/or cognitive difficulties, including difficulty making decisions, slowed thinking, difficult with organization, difficulty completing tasks, fatigue, depression, poor frustration tolerance, feeling overwhelmed, severe irritability, difficulty falling and staying asleep, anxiety, forgetfulness, poor concentration, and preservation in his thought processes and speech. b) Identify any physical TBI residuals. *The Veteran has reported physical residuals of the TBI to include headaches, vertigo, visual disturbances such as blurred or double vision, incompetent right to left consensual reflex, and hearing loss. c) Evaluate the severity of each physical TBI residual using the appropriate diagnostic codes. To the extent that any of these reported physical symptoms are not attributed to the TBI, provide an opinion as to whether each symptom is a symptom of an additional disability, whether service-connected or not, or a disability in and of itself (i.e. hearing loss). 8. After the VA TBI examination report has been completed and associated with the claims file, then schedule the Veteran for a VA psychiatric examination with an appropriate clinician to determine the nature and severity of the service-connected PTSD. Any pertinent testing, evaluation, or studies should be afforded to the Veteran. After reviewing the entire claims file, the examiner should: a) Review the VA TBI examination, and clarify, if necessary, which psychiatric symptoms are associated with the TBI and which symptoms are associated with the service-connected PTSD. A complete rationale should be provided. b) Evaluate the current nature and severity of the service connected PTSD. *The Veteran has indicated that he has psychiatric symptoms and/or cognitive difficulties, including difficulty making decisions, slowed thinking, difficult with organization, difficulty completing tasks, fatigue, depression, poor frustration tolerance, feeling overwhelmed, severe irritability, difficulty falling and staying asleep, anxiety, forgetfulness, poor concentration, and preservation in his thought processes and speech. 9. Readjudicate the claims on appeal. E. Blowers Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board T. Harper, 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.