Citation Nr: 20009664 Decision Date: 02/06/20 Archive Date: 02/05/20 DOCKET NO. 09-37 734A DATE: February 6, 2020 ORDER Entitlement to a rating in excess of 10 percent for degenerative arthritis of the left knee, for accrued benefits purposes, is denied. Entitlement to a separate 10 percent, but no higher, rating from June 14, 2011 through the appeal period for painful limitation of extension of the left knee, for accrued benefits purposes, is granted, subject to the regulations governing the payment of monetary awards. Entitlement to a separate 10 percent, but no higher, rating beginning June 14, 2011 for lateral instability of the left knee, for accrued benefits purposes, is granted, subject to the regulations governing the payment of monetary awards. REMANDED Entitlement to service connection for a herniated nucleus pulposus of the lumbosacral spine, to include as secondary to a service-connected knee condition, for accrued benefits purposes, is remanded. FINDINGS OF FACT 1. Throughout the appeal period, the Veteran’s degenerative arthritis of the left knee has been manifested by flexion at most limited to 60 degrees with pain. 2. Prior to June 14, 2011, the Veteran’s degenerative arthritis of the left knee was manifested by full extension with no pain on extension. 3. Prior to June 14, 2011, the Veteran’s degenerative arthritis of the left knee was manifested by no lateral instability. 4. From June 14, 2011, the Veteran’s degenerative arthritis of the left knee was manifested by extension at most limited to 5 degrees, according to range of motion testing, with pain. 5. From June 14, 2011, the Veteran’s degenerative arthritis of the left knee was manifested by mild lateral instability. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 10 percent for degenerative arthritis of the left knee are not met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.3, 4.7, 4.71a, Diagnostic Code 5260 (2018). 2. From June 14, 2011 through the appeal period, the criteria for a separate 10 percent, but no higher, rating for painful limitation of extension of the left knee are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.7, 4.71a, Diagnostic Code 5261. 3. From June 14, 2011, the criteria for a 10 percent, but no higher, rating for left knee instability are met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.3, 4.7, 4.71a, Diagnostic Code 5257 (2018). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty with the United States Air Force from July 1971 to October 1976. The Veteran died in July 2016. The appellant is the Veteran’s mother. In a March 2019 notification letter, the appellant was found to be an appropriate substitute in the Veteran’s case. These matters are before the Board of Veterans’ Appeals (Board) on appeal from a February 2009 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified before the Board at a hearing in July 2014. A transcript of the hearing is of record. Subsequently, the Board remanded the case in October 2014, May 2015, and December 2015 for further development. Following the additional development, in December 2016 the Board dismissed the claims for lack of jurisdiction due to the death of the Veteran and there being no substitute party. See 38 U.S.C. § 7104(a) (2012); 38 C.F.R. § 20.1302 (2018). The appellant filed a timely request to be substituted as the appellant in January 2017. Thereafter, in March 2019, the RO notified the appellant that she meets the basic eligibility requirements to be the substitute party. Thus, the Board will proceed with addressing the appeal. In September 2019, the appellant was notified that she was scheduled for a Travel Board hearing at Waco RO on October 21, 2019. The Veterans Appeals Control and Locator System (VACOLS), the electronic claims processing system used by Veterans Law Judges, reflects that the appellant did not appear for the scheduled hearing. Therefore, the appellant’s hearing request is considered to be withdrawn. 38 C.F.R. § 20.704(d) (2018). Lastly, the Board notes that the Appellant’s appeal has been advanced on the docket (AOD) based on age. 38 C.F.R. § 20.900(c) (2018). INCREASED RATINGS The appellant and her representative generally contend the Veteran was entitled to an increased rating for his degenerative joint disease of the left knee. Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule). 38 C.F.R. Part 4. The Rating Schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. See 38 U.S.C. § 1155; 38 C.F.R. § 4.1. A Veteran’s entire history is to be considered when making disability evaluations. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). 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. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). The Board acknowledges that with respect to a claim for an increased rating for an already service-connected disability, a Veteran may experience multiple distinct degrees of disability that might result in different levels of compensation. See Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007). The following analysis is therefore undertaken with consideration of the possibility that different ratings may be warranted for different time periods. The RO has assigned the Veteran’s degenerative joint disease of the left knee a 10 percent rating throughout the appeal period under hyphenated Diagnostic Code 5010-5260. From April 6, 2015, the RO has assigned the Veteran’s limitation of extension due to arthritis a noncompensable rating under hyphenated Diagnostic Code 5010-5261. Hyphenated diagnostic codes are used when a rating under one code requires use of an additional diagnostic code to identify the basis for the rating. 38 C.F.R. § 4.27. Here, the hyphenated diagnostic codes indicate that the Veteran’s knee disabilities are rated, by analogy, under the criteria for degenerative arthritis (Diagnostic Code 5003) limitation of flexion (Diagnostic Code 5260), and limitation of extension (Diagnostic Code 5261). Under Diagnostic Code 5257, a 10 percent rating is warranted for slight recurrent subluxation or lateral instability, a 20 percent rating is warranted for moderate recurrent subluxation or lateral instability, and a 30 percent rating is warranted for severe recurrent subluxation or lateral instability. 38 C.F.R. § 4.71a. Under Diagnostic Code 5258, a 20 percent rating is warranted for cartilage, semilunar, dislocated, with frequent episodes of locking, pain, and effusion into the joint. 38 C.F.R. § 4.71a. Under Diagnostic Code 5259, a 10 percent rating is warranted for removal of cartilage, semilunar, that is symptomatic. 38 C.F.R. § 4.71a. Under Diagnostic Code 5260, a 10 percent rating is warranted where flexion is limited to 45 degrees, a 20 percent rating is available where flexion is limited to 30 degrees, and a 30 percent rating is warranted where flexion is limited to 15 degrees. 38 C.F.R. § 4.71a. Under Diagnostic Code 5261, a 10 percent rating is warranted where extension of the knee is limited to 10 degrees, a 20 percent rating is warranted where extension is limited to 15 degrees, a 30 percent rating is warranted where extension is limited to 20 degrees, a 40 percent rating is warranted where extension is limited to 30 degrees, and a 50 percent rating is warranted where extension is limited to 45 degrees. 38 C.F.R. § 4.71a. Normal ranges of motion of the knee are to 0 degrees in extension, and 140 degrees in flexion. 38 C.F.R. § 4.71, Plate II. Separate ratings under Diagnostic Code 5260 and Diagnostic Code 5261 may be assigned for disability of the same joint. VAOPGCPREC 9-2004 (Sept. 17, 2004). The Veteran may also be assigned separate ratings for limitation of motion under Diagnostic Code 5260 or Diagnostic Code 5261 and for instability under Diagnostic Code 5257. See VAOPGCPREC 23-97 (July 1, 1997). When evaluating musculoskeletal disabilities, VA may, in addition to applying schedular criteria, 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 or during flare-ups, and those factors are not contemplated in the relevant rating criteria. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202, 204-07 (1995). The provisions of 38 C.F.R. § 4.40 and 38 C.F.R. § 4.45 are to be considered in conjunction with the diagnostic codes predicated on limitation of motion. See Johnson v. Brown, 9 Vet. App. 7 (1996). Degenerative and/or traumatic arthritis as shown by X-ray studies are rated based on limitation of motion of the affected joint. 38 C.F.R. § 4.71a, Diagnostic Codes 5003, 5010. When, however, the limitation of motion is noncompensable under the appropriate diagnostic code, a rating of 10 percent may be applied to each such major joint or group of minor joints affected by limitation of motion. 38 C.F.R. § 4.71a, Diagnostic Code 5003. The limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. Id. The intent of the rating schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. Thus, with or without degenerative arthritis, it is the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59; see Burton v. Shinseki, 25 Vet. App. 1, 5 (2011). In Petitti v. McDonald, 27 Vet. App. 415 (2015), the United States Court of Appeals for Veterans Claims (Court) rejected VA’s argument that § 4.59 requires painful motion, such that the mere presence of joint pain is not sufficient. Id. at 428-29. The Court held that under § 4.59, “the trigger for a minimum disability rating is an actually painful, unstable, or malaligned joint,” explaining that § 4.59 speaks to both painful motion of joints and actually painful joints. Id. at 425. Moreover, the Court held that § 4.59 does not require “objective” evidence but can be satisfied with lay and other non-medical evidence. Id. at 429. Consideration of other diagnostic codes for rating a knee disability (5256, 5262, 5263) is inappropriate in this case as the Veteran’s left knee disabilities did not include the pathology required in the criteria for those diagnostic codes (ankylosis, malunion or nonunion of tibia or fibula, or genu recurvatum). 38 C.F.R. § 4.71a. Here, the Board will address the evidence as it relates to the Veteran’s knee disabilities prior to addressing the appellant’s claim for an increased rating for the Veteran’s degenerative joint disease of the left knee. The Veteran attended a VA examination in October 2008 for an evaluation of his left knee. The Veteran had left knee flexion to 125 degrees without pain and full extension without pain. The Veteran had no additional loss of range of motion after performing repetitive squats. The examiner noted the Veteran had no tenderness, normal strength, no joint instability, no effusion, and no ankylosis. The examiner noted the Veteran’s left knee had no effect on usual daily activities. The Veteran reported at the examination that his left knee constantly ached. The Veteran attended an additional VA examination in June 2011 for an evaluation of his left knee. The Veteran had left knee flexion to 120 degrees and full extension. The Veteran had muscle guarding at the extremes of range of motion. The Veteran had no additional loss of range of motion or pain upon repetitive use testing. The examiner noted the Veteran had no tenderness and no swelling. The examiner noted the Veteran utilized a cane due to his left knee and back. The Veteran reported at the examination that he had increased left knee pain for 15 years. Furthermore, he reported daily knee pain and that his knee would give out all of the time if it was not for the pain medication. In addition, he reported flare-ups that occur about two times per week and last three to four hours. He reported the flare-ups consisted of swelling, and that he minimized weightbearing during flare-ups. The Veteran also reported that he could walk for about one quarter mile, but he stopped due to back and left knee pain. He reported he could stand for 10 to 15 minutes at a time, but he needed to rest due to back and left knee pain. The examiner noted it was very difficult to separate the limitations due to his left knee condition verse the limitations due to his back condition. An October 2014 physical examination reveals the Veteran had flexion to 70 degrees and full extension. At the appointment, the Veteran reported bilateral knee pain for three months. Furthermore, the Veteran reported that he exercised at home, which included yard work. At a VA examination in December 2014 for an evaluation of his left knee, the Veteran had left knee flexion to 85 degrees with pain and full extension with pain. The Veteran had no additional loss of range of motion or functional loss upon repetitive use testing. The examiner noted pain and lack of endurance significantly limited the Veteran’s functional ability with repeated use over time, which could be described in the form of an additional reduction of 20 degrees of flexion. In addition, the examiner noted the Veteran reported that during flare-ups his knee would not go straight, so extension was about to 10 to 20 degrees and flexion was to 80 degrees. The examiner noted that additional contributing factors of disability were less movement than normal due to ankylosis and adhesions, instability of station, and interference with standing. The examiner noted the Veteran utilized an unloader hinged knee brace all of the time, used a cane constantly, and a walker regularly. The examiner noted the Veteran had pain with weightbearing, he had localized tenderness or pain on palpation in the medial and lateral joint space and behind the knee, he had reduced strength at 4/5 with forward flexion and normal strength with abduction, he had muscle atrophy, and no ankylosis. Furthermore, the examiner noted the Veteran had no joint instability. The examiner noted the Veteran’s left knee condition caused functional impact in the form of restrictions in lifting and carrying, bending and twisting, kneeling, walking, squatting, standing, sitting, climbing, and reaching overhead. The Veteran reported at the examination that his left knee was getting progressively worse and that he had regular swelling. The Veteran reported pain in the medial and lateral joint line and deep to the patella and behind the left knee. He reported the pain was constant at a 2 to 3 out of 10, but with flare-ups the pain was a 7 to 8 out of 10. He reported the flare-ups occurred every day and could be a few minutes with shooting pain, but that they could last one to two days every two to three months. The Veteran reported he took meloxicam and hydrocodone for the pain. The Veteran attended two additional VA examinations in June 2015 for an evaluation of his left knee. At the first June 2015 examination on June 16, 2015, the Veteran had left knee flexion to 90 degrees with pain and extension to 5 degrees with pain. The Veteran had no additional loss of extension upon repetitive use testing, but he had flexion to 60 degrees upon repetitive use testing. The examiner noted the Veteran’s reduced range of motion contributed to functional loss in the form of the Veteran being unable to perform normal functions of the knee like kneeling, bending, ascending and descending stairs, and limited weightbearing. The examiner noted that additional contributing factors of disability bilaterally were the Veteran had less movement than normal, swelling, instability of station, interference with sitting, and interference with standing. The examiner noted the examination was conducted during a flare-up and that pain contributed to functional loss. The examiner was unable to describe in terms of range of motion without resorting to speculation, but that presumably further loss of range of motion would be experienced during a flare-up as the Veteran suffered considerable loss of range of motion with minimal use during the examination. The examiner noted the Veteran utilized a cane constantly and walker on a regular basis. The examiner noted the Veteran had pain on palpation in the joint spaces and pain on weightbearing. The examiner noted the Veteran had reduced strength at 4/5 with flexion and extension. Furthermore, the examiner noted the Veteran had no joint instability, no subluxation, and no ankylosis bilaterally. However, the examiner noted the Veteran had a history of recurrent effusion described as frequent episodes of noticeable swelling and a history of joint aspirations. In terms of the functional impact of the Veteran’s knee condition, the examiner noted that the Veteran’s ability to walk and stand was so limited that most jobs would be eliminated from consideration. The Veteran reported at the examination that he had progressive and continuous pain, limited weightbearing, and loss of range of motion. Furthermore, the Veteran reported flare-ups that consisted of increased pain and swelling, which occurred one to two times per week. In addition, he reported he was unable to ascend stairs, and that he had to recline for most of the day. At the second June 2015 examination on June 23, 2015, the Veteran had left knee flexion to 110 degrees with pain and full extension with pain. The Veteran had no additional loss of range of motion upon repetitive use testing. The examiner noted the Veteran’s reduced range of motion contributes to functional loss in the form of pain. The examiner noted the examination was not conducted during a flare-up, but the examiner noted that pain, fatigue, weakness, lack of endurance, and incoordination contributed to functional loss. The examiner was unable to describe in terms of range of motion without resorting to speculation. The examiner noted the Veteran utilized a brace on a regular basis and a walker on an occasional basis. The examiner noted the Veteran had mild tenderness on palpation in the knee. The examiner noted the Veteran had normal strength, no atrophy, no ankylosis, and no instability. In terms of the functional impact of the Veteran’s knee condition, the examiner noted that the Veteran was employed, but that during his prior employment, the Veteran had difficulty with climbing ladders and crawling into spaces needed in his job as an electrician. The Veteran reported at the examination that he had constant pain, and that he took hydrocodone for pain. Furthermore, the Veteran reported flare-ups that consisted of difficulty in walking, walking up hilly terrain, standing, mowing the lawn, and standing to wash dishes. Furthermore, the Veteran reported he could not run. Following a review of the evidence addressed above, the Board concludes that the evidence most nearly approximates the currently assigned 10 percent rating for the Veteran’s left knee disability throughout the appeal period for degenerative joint disease under hyphenated Diagnostic Code 5210-5260. Throughout the entire period, the Veteran had no point where flexion in his left was less than 45 degrees, even when considering additional factors of pain, fatigue, weakness, lack of endurance, and swelling. Although the June 16, 2015 VA examiner indicated the Veteran experienced additional loss of flexion on repetitive use, such additional loss was noted to be to 60 degrees. As such, even when considering these additional contributing factors, the evidence does not more nearly approximate flexion limited to less than 45 degrees in the left knee. Therefore, a preponderance of the evidence is against a rating in excess of 10 percent based on limitation of flexion at any point during the appeal period for the Veteran’s left knee. 38 C.F.R. § 4.71a, Diagnostic Code 5260. Regarding the Veteran’s rating for limitation of extension due to arthritis, the RO has assigned a noncompensable rating since April 6, 2015 under hyphenated Diagnostic Code 5010-5261. The Board acknowledges that the RO awarded service connection for limitation of extension due to arthritis in a June 2015 rating decision. However, as the RO received the Veteran’s increased rating claim for a left knee disability in July 2008, the Board has considered whether the Veteran is entitled to a separate compensable rating for limitation of extension of the left knee as of July 2008. Irrespective of the June 2015 rating decision, the Board finds that the evidence more nearly approximates an actually painful left knee joint on extension beginning June 14, 2011 through the appeal period, as reflected by the June 14, 2011 VA examination report that illustrates the Veteran had guarding at the extreme of range of motion during the left knee range of motion testing. Furthermore, the December 2014 VA examination report and both June 2015 VA examination reports continue to reflect objective evidence of painful extension upon range of motion testing. Prior to June 14, 2011, there is no evidence of painful extension in the left knee. The Board acknowledges that the Court has held that 38 C.F.R. § 4.59 does not require “objective” evidence of painful motion and can be satisfied with lay and other non-medical evidence. Petitti, 27 Vet. App. at 429. However, the October 2008 VA examination reflects no objective or subjective evidence of painful extension. Although the Veteran reported prior to June 14, 2011 that he experienced a constant ache in his knee pain at the October 2008 VA examination and increased knee pain for 15 years at the June 2011 VA examination, the evidence does not clearly indicate whether such pain was experienced upon both flexing and extending the knee; as such, the general symptoms of pain reported and shown at that time have been considered in the assigned 10 percent rating prior to June 14, 2011. Thus, the Board concludes that a separate 10 percent rating for an actually painful left knee joint with limitation of extension pursuant to 38 C.F.R. § 4.59 is warranted beginning June 14, 2011, and through the appeal period, based on competent and credible evidence of painful extension. A rating in excess of 10 percent under Diagnostic Code 5261 is not warranted as there is no evidence in the record that illustrates the Veteran has extension limited beyond 10 degrees in the left knee. Prior to June 14, 2011, a separate rating for an actually painful left knee joint with limitation of extension pursuant to 38 C.F.R. § 4.59 is not warranted as there is no objective or subjective evidence of painful extension in the left knee. Furthermore, in evaluating the Veteran’s increased rating claim for his left knee, the Board must address the provisions of 38 C.F.R. §§ 4.40 and 4.45. The Board recognizes the Veteran’s statements that his knee condition caused constant pain and swelling. Furthermore, he reported his left knee disabilities caused difficulties with weightbearing, walking, standing, kneeling, bending, and navigating stairs. Additionally, the VA examination reports indicate that pain, fatigue, weakness, and lack of endurance have a functional impact. However, even when considering the reported functional loss, the Veteran’s disability picture did not more nearly approximate flexion limited to 30 degrees or extension limited to 15 degrees in the left knee for the relevant periods under consideration. The Board has also considered whether the Veteran is entitled to a separate rating under Diagnostic Code 5257 for left knee instability as the Veteran reported at the June 2011 VA examination that his left knee gave out. Furthermore, the Veteran reported at his July 2014 Board hearing that his left knee had given out for the preceding year and a half to two years. The Board acknowledges that all of the VA examination reports reflect no objective evidence of instability. However, the Court has held that Diagnostic Code 5257 does not require objective evidence of instability. English v. Wilkie, 30 Vet. App. 347 (2018). Therefore, as the Veteran’s report of his left knee giving out at the July 2014 Board hearing is consistent with his subjective report at the June 2011 VA examination, in giving the appellant the benefit of the doubt, the Board finds the evidence most nearly approximates a 10 percent, but no higher, rating for recurrent mild subluxation or lateral instability beginning June 14, 2011. 38 C.F.R. § 4.71a, Diagnostic Code 5257. Prior to June 14, 2011, a separate rating for recurrent subluxation or lateral instability is not warranted as there is no objective or subjective evidence of instability in the left knee. The Board has also considered whether the Veteran is entitled to a separate rating under Diagnostic Code 5258 or Diagnostic Code 5259 for a semilunar cartilage condition as the Veteran underwent an arthrotomy and lateral meniscectomy in October 1971. Regarding Diagnostic Code 5258, a review of the evidence illustrates that the Veteran was noted to have effusion since the June 2011 VA examination. In addition, the Board acknowledges that all of the VA examination reports addressed above reflect that the Veteran did not have a meniscal condition, which conflicts with the Veteran’s October 1971 lateral meniscectomy. However, a review of the record illustrates that there is no evidence of locking throughout the appeal period. Additionally, the symptom of joint pain is contemplated by the ratings assigned for flexion and extension. Therefore, the Board concludes that a preponderance of the evidence is against a finding that a separate rating under Diagnostic Code 5258 is warranted. Regarding Diagnostic Code 5259, the record illustrates evidence of symptomatic removal of cartilage as the record demonstrates left knee pain throughout the appeal period. However, the Veteran’s symptoms of joint pain and reduced range of motion are contemplated by the ratings assigned for flexion and extension. Therefore, assigning a separate rating under Diagnostic Code 5259 for these symptoms would constitute impermissible pyramiding. See 38 C.F.R. § 4.14 (“[t]he evaluation of the same disability under various diagnoses, “a practice called ‘pyramiding,’” is to be avoided); Brady v. Brown, 4 Vet. App. 203, 206 (1993) (the rationale for the prohibition on pyramiding is that “the rating schedule may not be employed as a vehicle for compensating a claimant twice (or more) for the same symptomatology; such a result would overcompensate the claimant for the actual impairment” suffered). Therefore, the Board concludes that a preponderance of the evidence is against a finding that a separate rating under Diagnostic Code 5259 is warranted. In reaching the above conclusions, the Board acknowledges that the December 2014 VA examination report indicates the Veteran was scheduled to undergo a left knee total replacement surgery in March 2015, but his health circumstances changed prior to undergoing the replacement surgery. Irrespective of the scheduled surgery, the objective and subjective evidence in the record do not support that the Veteran was entitled to ratings in excess of the above findings during the relevant periods under consideration. The Board also acknowledges that the December 2014 VA examination report contains an internal conflict in the examination report. The examination report reflects that an additional factor contributing to disability was that the Veteran had less movement than normal due to ankylosis. However, in the specific section for ankylosis on the examination report, the VA examiner noted that the Veteran did not have ankylosis. Furthermore, a review of the rest of the medical evidence of record illustrates that there is no other notation of the Veteran having ankylosis of the left knee. As such, a separate rating under Diagnostic Code 5256 is not warranted. 38 C.F.R. § 4.71a. In sum, the Board finds the criteria for a rating in excess of 10 percent for the Veteran’s left knee disability based on limitation of flexion have not been met during the pendency of the appeal. The Board finds that the Veteran is entitled to a separate 10 percent, but no higher, rating for painful limitation of extension of the left knee beginning June 14, 2011. Furthermore, the Board finds that the Veteran is entitled to a separate 10 percent, but no higher, rating for mild lateral instability of the left knee beginning June 14, 2011. The Veteran is not entitled to any further separate ratings for the left knee. REASONS FOR REMAND Entitlement to service connection for a herniated nucleus pulposus of the lumbosacral spine, to include as secondary to a service-connected knee condition, for accrued benefits purposes, is remanded. Following a December 2014 VA examination, the VA examiner opined that the Veteran’s lumbar spine condition was less likely than not incurred in or caused by the Veteran’s service. Regarding whether the Veteran’s service-connected left knee disability caused or aggravated the Veteran’s lumbar spine condition, the VA examiner opined it is “not likely” that the Veteran’s lumbar spine condition was secondary to or aggravated by his left knee disability. Initially, the Board notes that the VA examiner used the incorrect standard regarding whether the Veteran’s service-connected left knee disability caused or aggravated his lumbar spine condition. Therefore, an additional opinion is necessary as to whether it is at least as likely as not (50 percent or greater probability) that the Veteran’s lumbar spine condition was caused by or aggravated by his service-connected left knee disability. Furthermore, the December 2014 VA examiner’s rationale in support of the secondary service connection opinion focuses entirely on the causation question. The VA examiner provided no rationale in support of the opinion as to aggravation. Therefore, an additional opinion is necessary with supporting rationale for both the causation and aggravation questions. The matter is REMANDED for the following action: After taking any necessary development, obtain a medical opinion from an appropriate medical professional regarding the Veteran’s lumbar spine condition. After reviewing the claims file, the medical professional should address the following: (a.) Is it at least as likely as not (50 percent or greater probability) that the Veteran’s lumbar spine condition was caused by his service-connected left knee disability? (b.) Is it at least as likely as not (50 percent or greater probability) that the Veteran’s lumbar spine condition was aggravated (i.e., any increase in the severity beyond its natural progression) by his service-connected left knee disability? If the Veteran’s lumbar spine condition was aggravated by his service-connected left knee disability, the medical professional should also indicate the extent of such aggravation by identifying the baseline level of disability. This may be ascertained by the medical evidence of record and also by the Veteran’s statements in the record as to the nature, severity, and frequency of his observable symptoms over time. The medical professional must provide rationale for both the causation and aggravation questions, with citation to supporting clinical data/lay statements, as deemed appropriate. If the examiner cannot provide the requested opinion without resorting to speculation, he or she should expressly indicate this and provide a supporting rationale as to why an opinion cannot be made without resorting to speculation. DAVID L. WIGHT Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board N. Breitbach, 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.