Citation Nr: 20026041 Decision Date: 04/15/20 Archive Date: 04/15/20 DOCKET NO. 09-08 810 DATE: April 15, 2020 ORDER Prior to November 26, 2014, a rating in excess of 10 percent for a right knee disability (tibial or fibular impairment) is denied. From November 26, 2014 onward, a rating in excess of 10 percent for a right knee disability (limited extension) is denied. For the period on appeal, a separate rating of 10 percent, but no higher, for a right knee disability (instability) is granted. Prior to May 15, 2017, a rating in excess of 10 percent for a left knee disability (limited extension) is denied. From May 15, 2017 onward, a rating in excess of 10 percent for a left knee disability (limited flexion) is denied. For the period on appeal, a separate rating of 10 percent, but no higher, for a left knee disability (instability) is granted. From December 13, 2016 onward, a separate rating of 20 percent for a left knee disability based on a meniscus tear is granted. REMANDED Entitlement to an initial rating for posttraumatic stress disorder (PTSD) in excess of 30 percent prior to February 28, 2008; in excess of 50 percent as of February28, 2008, and prior to January 21, 2011; and in excess of 30 percent as of January 21, 2011 is remanded. Entitlement to a total rating based on individual unemployability (TDIU) is remanded. FINDINGS OF FACT 1. The Veteran does not have patellar dislocation, shin splints, stress fractures, chronic exertional compartment syndrome, or any other tibial or fibular impairment. 2. The Veteran has had normal range of motion (zero degrees) for his right knee extension. 3. For the entire period on appeal, the Veteran has had mild instability in his right knee. 4. Prior to May 15, 2017, the Veteran’s left knee disability (limited extension) was normal (zero degrees). 5. From May 15, 2017 onward, the Veteran’s left knee disability (limited flexion) was greater than 75 degrees. 6. For the period on appeal, the Veteran has had mild instability in his left knee. 7. From December 13, 2016 onward, the Veteran’s left knee disorder is manifested by symptoms such as frequent episodes of locking, pain, and swelling. CONCLUSIONS OF LAW 1. Prior to November 26, 2014, the criteria for a rating in excess of 10 percent disabling for residuals of a right knee disability have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.3, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes (DC) 5262. 2. From November 26, 2014 onward, the criteria for a rating in excess of 10 percent disabling for residuals of a right knee disability (limited flexion) have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.3, 4.10, 4.40, 4.45, 4.59, 4.71a, DC 5261. 3. For the entire period on appeal, the criteria for a separate rating of 10 percent disabling for residuals of right knee instability have been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.3, 4.10, 4.40, 4.45, 4.59, 4.71a, DC 5257. 4. Prior to May 15, 2017, the criteria for a rating in excess of 10 percent for residuals of a left knee disability (limited extension) have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.3, 4.10, 4.40, 4.45, 4.59, 4.71a, DC 5261. 5. From May 15, 2017 onward, the criteria for a rating in excess of 10 percent for residuals of a left knee disability (limited flexion) have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.3, 4.10, 4.40, 4.45, 4.59, 4.71a, DC 5260. 6. For the entire period on appeal, the criteria for a separate rating of 10 percent disabling for residuals of a left knee instability have been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.3, 4.10, 4.40, 4.45, 4.59, 4.71a, DC 5257. 7. From December 13, 2016 onward, the criteria for a separate rating of 20 percent for a left knee disability (meniscus tear) have been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.3, 4.10, 4.40, 4.45, 4.59, 4.71a, DC 5258. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service in the United States Army from December 1985 to December 1993. These matters are before the Board of Veterans’ Appeals (Board) on appeal from September 2007 (PTSD) and February 2016 (knee) rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified before the undersigned Veterans Law Judge (VLJ) at a Travel Board hearing in January 2017 (PTSD) and a videoconference hearing in 2020 (knee). Transcripts are of record. Initially, the Board notes that a remand by the Board confers on the Veteran, as a matter of law, the right to compliance with the remand orders. Stegall v. West, 11 Vet. App. 268, 271 (1998). Unfortunately, this matter must once again be remanded for compliance with the directives of the December 2017 Board remand. The PTSD and TDIU matters were previously before the Board in December 2017. The Board directed that a new examination be given and provided directives to be addressed. While a new examination was performed, the directives were not addressed. This was contrary to the prior remand instructions. See Stegall v. West, 11 Vet. App. at 268. Additionally, the Board notes that the Veteran inadvertently initially appealed only his right knee increased rating. In light of the Veteran asserting that his left knee is worse than his right knee, the Board will adjudicate both knees from the time of the February 2017 notice of disagreement. Increased Rating Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. The percentages are based on the average impairment of earning capacity as a result of service-connected disability, and separate diagnostic codes identify the various disabilities and the criteria for specific ratings. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. If two disability evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. All reasonable doubt as to the degree of disability will be resolved in favor of the claimant. 38 C.F.R. § 4.3. Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, the Board must also consider staged ratings, which are appropriate in this case. Hart v. Mansfield, 21 Vet. App. 505, 509–10 (2007). Hyphenated diagnostic codes are used when a rating under one diagnostic code requires the use of an additional diagnostic code to identify the basis for the evaluation assigned; the additional code is shown after the hyphen. The evaluation of the same disability under several diagnostic codes, known as pyramiding, must be avoided; however, separate ratings may be assigned for distinct disabilities resulting from the same injury so long as the symptomatology for one condition is not duplicative of or overlapping with the symptomatology of the other. Esteban v. Brown, 6 Vet. App. 259, 262 (1994); 38 C.F.R. § 4.14. Degenerative arthritis is rated based on limitation of motion under the appropriate diagnostic code for the specific joint or joints involved. Where there is noncompensable limitation of motion, a 10 percent evaluation is assigned for each major joint or group of minor joints, where the limitation is objectively confirmed by swelling, muscle spasm, or satisfactory evidence of painful motion. Where there is no limitation of motion, a 10 percent evaluation is assigned for x-ray evidence of involvement of two or more major joints or minor joint groups, and a 20 percent evaluation is assigned for x-ray evidence of involvement of two or more major joints or minor joint groups, with occasional incapacitating exacerbations. 38 C.F.R. § 4.71a, DC 5003, Note (1). When evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use and, therefore, not be reflected on range-of-motion testing. 38 C.F.R. § 4.45 requires consideration also be given to 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 v. Shinseki, 25 Vet. App. 32, 44 (2011). Nonetheless, even when the background factors listed in § 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a (musculoskeletal system) or § 4.73 (muscle injury); a separate or higher rating under § 4.40 or 4.45 itself 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.”). However, a veteran may be entitled to a higher disability evaluation than that supported by mechanical application of the rating schedule where there is evidence that his or her disability causes “additional functional loss—i.e., ‘the inability... to perform the normal working movements of the body with normal excursion, strength, speed, coordination[,] and endurance’—including as due to pain and/or other factors” or “reduction of a joint’s normal excursion of movement in different planes, including changes in the joint’s range of movement, strength, fatigability, or coordination.” Lyles v. Shulkin, 29 Vet. App. 107, 117-18 (2017) (quoting 38 C.F.R. § 4.40 and citing 38 C.F.R. § 4.45); Mitchell v. Shinseki, 25 Vet. App. 32, 36-37 (2011); DeLuca v. Brown, 8 Vet. App. 202, 205-07 (1995). The intent of the rating schedule is to recognize painful motion with joint and periarticular pathology as productive of disability. It is the intention to recognize actually painful, unstable, or maligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. The Veteran is competent to report symptoms and experiences observable by his senses. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); 38 C.F.R. § 3.159(a). Entitlement to an initial rating in excess of 10 percent for a right and a rating in excess of 10 percent for a left knee disability. The Veteran’s right knee is currently rated at 10 percent disabling under DC 5010-5261. A February 2015 rating decision changed the diagnostic code as prior to November 26, 2014, he was rated as 10 percent under DC 5010-5262. The Veteran’s left knee is also currently rated at 10 percent disabling under DC 5010-5260. An August 2017 rating decision changed the diagnostic code as prior to May 15, 2017, it was rated at 10 percent disabling under DC 5010-5261. The Board notes that the February 2017 notice of disagreement only disagreed with the rating decision for the right knee. His attorney explained in April 2017 that the increased rating for the left knee NOD was inadvertently not included with the February 2017 NOD. In response, the RO issued a statement of the case in September 2018 that addressed the rating for the left knee, which was perfected with a timely VA Form 9. Normal flexion of the knee is to 140 degrees, and normal extension of the knee is to 0 degrees. 38 C.F.R. § 4.71, Plate II. Under 38 C.F.R. § 4.71a, DC 5257 covers “other impairment of the knee,” and an assignment of a 10 percent rating is warranted when there is slight recurrent subluxation or lateral instability. A 20 percent rating is warranted when there is moderate recurrent subluxation or lateral instability. A 30 percent evaluation is for severe knee impairment with recurrent subluxation or lateral instability. Additionally, DC 5258 covers dislocated semilunar cartilage with frequent episodes of locking, pain and effusion into the joint; this warrants a 20 percent rating. Finally, DC 5259 covers removal of symptomatic semilunar cartilage, which warrants a 10 percent rating. Under DC 5260, leg flexion limited to 60 degrees warrants a noncompensable rating. Leg flexion limited to 45 degrees warrants a 10 percent rating. Leg flexion limited to 30 degrees warrants a 20 percent rating. Leg flexion limited to 15 degrees warrants a 30 percent rating. 38 C.F.R. § 4.71a, DC 5260. Under DC 5261, leg extension limited to 5 degrees warrants a noncompensable rating. Leg extension limited to 10 degrees warrants a 10 percent rating. Leg extension limited to 15 degrees warrants a 20 percent rating. Leg extension limited to 20 degrees warrants a 30 percent rating. Leg extension limited to 30 degrees warrants a 40 percent rating. Leg extension limited to 45 degrees warrants a 50 percent rating. 38 C.F.R. § 4.71a, DC 5261. A knee disability can be rated for both limitation of leg flexion under DC 5260 and limitation of leg extension under DC 5261. See VAOPGCPREC 9-2004 (Sept. 17, 2004). Additionally, General Counsel Opinion 9-98 directs that with respect to Diagnostic Code 5259, limitation of motion can be a relevant consideration so the provisions of 38 C.F.R. § 4.40 and 4.45 must be considered. Because there is no indication that the structural integrity of the Veteran’s service-connected joints is compromised, such that passive range of motion in this case would be more limited than active, and because testing in weight-bearing conditions is more demonstrative of the degree of pathology, the Board finds that the failure to test for limitation of motion on passive range of motion and in non-weight-bearing is not prejudicial. The Board will therefore evaluate the Veteran’s range of motion using the available findings of active range of motion and looking at all the relevant medical and lay evidence. It is acknowledged that some of examiners did not provide an estimated loss of motion during flare-ups. Sharp v. Shulkin, 29 Vet. App. 26 (2017). However, the Board finds that additional development solely for this purpose would serve only to delay the claim. Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991); see also Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to an appellant’s failure to raise a duty to assist argument before the Board). As noted below, the examination report contains evidence regarding the frequency, severity, and duration of the Veteran’s pain level during flare-ups per his report. The Board finds such information pertinent and useful when evaluating the disability picture concerning the Veteran’s service-connected disabilities. He underwent a VA examination in January 2015. At the time, he did not have flare-ups, but reported functional loss in that he would have pain and stiffness after sitting too long or walking too far. He had normal range of motion testing bilaterally without pain. He had bilateral pain with weight-bearing, and mild localized tenderness over the medical and lateral joint lines. He was able to perform repetitive testing with no further range of motion limitation. He was not examined immediately following repetitive use, and the examiner found that the examination was neither medically consistent nor inconsistent with the Veteran’s statements. Pan and fatigue significantly limited functional ability with repeated use over a period of time. The examiner was unable to describe in terms of range of motion, but increased pain and general weakness was reported. He had normal muscle strength, no atrophy, and no ankylosis. The examiner reported that he did not have a history of recurrent subluxation, lateral instability, or a history of recurrent effusion. He had normal joint instability testing for Lachman, posterior, medial, and lateral instability. Mild crepitation was reported. He did not have recurrent patellar dislocation, shin splints, stress fractures, chronic exertional compartment syndrome, or any other tibial or fibular impairment. He occasionally used braces. Arthritis was reported. The Board notes that although this examination did not report swelling or instability, the Veteran’s medical records document swelling and instability. He underwent an additional examination in July 2017. He had flare-ups two to three times per month which last two to three days, and had functional loss after prolonged sitting (more than ten minutes), standing (more than 20 minutes), or walking (more than a block). He had right knee flexion of 120 degrees with pain and normal extension. Left knee flexion was 115 degrees with pain with normal extension. The reduced range of motion contributed to functional loss. There was pain with weight-bearing bilaterally, and he had localized tenderness for his left knee. He was able to perform repetitive use testing with reduced range of motion of 110 degrees of flexion for his right knee and 100 degrees for his left knee. Pain, weakness, fatigability, and incoordination did not significantly limit functional ability with repeated use over time. The examiner reported that the examination was medically consistent with the Veteran’s statements, and pain significantly limited functional ability with flare-ups. Range of motion was estimated to be 90 degrees of flexion for the right knee and 75 degrees for the left knee. He had normal muscle strength, no atrophy, and no ankylosis. The examiner reported that he did not have a history of recurrent subluxation or lateral instability. Recurrent effusion was reported. He had normal joint instability testing for Lachman, posterior, medial, and lateral instability. He did not have recurrent patellar dislocation, shin splints, stress fractures, chronic exertional compartment syndrome, or any other tibial or fibular impairment. He had had a meniscal tear for his left knee. The Veteran regularly used a brace and occasionally used a cane. He did not have pain on passive range of motion or non-weight bearing. His medical records document a history of injections for his knees and pain. He has a history of knee swelling and instability. Increased laxity was reported for his left knee in December 2016. He tore his left medical collateral ligament during this time (December 13, 2016). Knee popping and grinding were reported in July 2017. He reported his knee gives way. Private medical records show considerable swelling and tenderness. He testified at the Board hearing that he has swelling in his left knee and that his right knee is worsening. Elevating his legs helped to relieve pain and swelling. Right Knee The Veteran’s right knee is currently rated at 10 percent disabling under DC 5010-5261. Prior to November 26, 2014, he was rated as 10 percent under DC 5010-5262. Prior to November 26, 2014 After review of the competent and probative evidence, the Board finds that a rating in excess of 10 percent is not warranted under DC 5262 prior to November 26, 2014. In this regard, there is no evidence that the Veteran had a moderate knee or ankle disability. The Board acknowledges that during this time, the Veteran’s knee required injections to help with his pain. However, there is no evidence that he had patellar dislocation, shin splints, stress fractures, chronic exertional compartment syndrome, or any other tibial or fibular impairment. As such, a rating in excess of 10 percent prior to November 26, 2014, under DC 5262 is denied. Additionally, compensable ratings under DC 5260 and DC 5261 are not warranted as the Veteran had normal range of motion upon testing as documented at the January 2015 examination. There is no indication that during this time that his extension was limited to 10 degrees or his flexion limited to 45 degrees. As such, compensable ratings under DCs 5260 and 5261 are not warranted. Additionally, a separate rating is not warranted for the knee under DC 5259 as the competent evidence does not show removal of symptomatic semilunar cartilage in the right knee. Finally, a rating under DC 5256 is also not warranted as the Veteran does not have ankylosis. November 26, 2014 onward After review of the competent and probative evidence, the Board finds that a compensable rating after November 26, 2014 is not warranted under DC 5262. In this regard, there is no evidence that the Veteran had a separate slight knee or ankle disability. At the January 2015 and July 2017 examinations, the examiners reported that he did not have patellar dislocation, shin splints, stress fractures, chronic exertional compartment syndrome, or any other tibial or fibular impairment. The Board assigns high probative value to these examinations. As such, a compensable rating from November 26, 2014 onward is denied. A compensable rating for limited flexion under DC 5260 is not warranted as the Veteran had 120 degrees of flexion as noted in the July 2017 examination. Even following repetitive use testing with diminished range of motion testing, the Veteran had 110 degrees of flexion, and had 90 degrees estimated range of motion during flare-ups. As such, a compensable rating under DC 5260 is not warranted. Additionally, under DC 5261, a rating in excess of 10 percent after November 26, 2014 is not warranted as the Veteran had normal extension as shown in the July 2017 examination. As such, a rating in excess of 10 percent is not warranted as the Veteran has had normal extension during this period on appeal. As noted above, a 20 percent rating for moderate instability under DC 5257 is not warranted as his examination reports do not show moderate instability. Furthermore, a separate rating under DC 5258 is not warranted for the Veteran’s right knee as the Veteran does not have a meniscal condition for either period on appeal. The examination reports and medical records do not show that the Veteran has had a meniscus condition for his right knee. Moreover, a separate rating is not warranted for the knee under DC 5259 as the competent evidence does not show removal of symptomatic semilunar cartilage. Ratings under DCs 5256 and 5262 are also not warranted as the Veteran does not have ankylosis or impairment of the tibia and fibula. A separate rating for instability is discussed below. Additionally, for both periods on appeal, the weight of the evidence does not support a finding that the Veteran’s disability picture due to functional loss/limitations or flare-ups with limitation of motion is more nearly approximated by a higher rating. Considering the Deluca and Mitchell factors, and the evidence of record, the Board finds that the current ratings already compensate the Veteran for any functional loss due to pain affecting the right knee, to include pain and limited motion. Deluca, 8 Vet. App. at 204-07. For example, as noted above, the medical reports reflect that he had pain. In light of the foregoing, the Board finds that an increased rating due to functional impairment would not be appropriate under the criteria for 38 C.F.R. §§ 4.40 and 4.45. In this regard, VA regulations state that the knee is considered a single major joint. 38 C.F.R. § 4.45. Instability The Board finds that a separate rating under DC 5257 is warranted as the evidence shows that the Veteran has knee instability based on his competent and credible testimony from testifying that his knees give way, and his medical records showing instability. See English v. Wilkie, 30 Vet. App. 347. 352–53 (2018) (finding that DC 5257 does not require objective medical evidence of lateral instability for a rating to be assigned and when weighing evidence to determine whether there is lateral instability, the Board cannot find objective medical evidence is automatically more probative than lay evidence). The Veteran has testified that his knee gives out. The Board acknowledges he did not have instability at his January 2015 examination or July 2017, but finds his competent statements to be credible regarding his knee buckling and his medical treatment records show instability. For these reasons, the Board finds that a separate rating of 10 percent for instability of the right knee is warranted. However, the Board finds that a higher rating of moderate instability is not warranted as there is not competent medical evidence of instability (positive instability testing) or 3/5 weakness during this period on appeal as noted in the medical records and January 2015 and July 2017 examination reports. Indeed, several joint stability tests showed were normal. Given the tests performed are generally recognized in the medical community as diagnostic for instability and subluxation, the results are afforded high probative value. Left Knee The Veteran’s left knee is currently rated at 10 percent disabling under DC 5010-5260. Prior to May 15, 2017, it was rated at 10 percent disabling under DC 5010-5261. Prior to May 15, 2017 After review of the competent and probative evidence, the Board finds that a rating in excess of 10 percent under DC 5261 for the left knee is not warranted prior to May 15, 2017. In this regard, the Veteran’s 2015 and 2017 examinations showed that he had normal range of motion testing for extension. As such, a rating in excess of 10 percent under DC 5261 is not warranted. A compensable rating under DC 5260 is not warranted for this period on appeal. At the January 2015 examination, he had normal range of motion for his left knee flexion. The Board also finds that a separate rating under DC 5258 is warranted for the Veteran’s left knee from December 13, 2016 onward. He has had a documented left knee meniscus tear. Additionally, the evidence shows locking, pain, and swelling. Moreover, the Board finds the pain associated with the Veteran’s meniscus tear is separate than the pain associated with his painful range of motion. As such, a rating of 20 percent, but no higher as this is the only rating available under this diagnostic code, is warranted from December 13, 2016 onward.   May 15, 2017 onward A rating in excess of 10 percent for limited flexion is not warranted from May 15, 2017 onward. In this regard, at the July 2017 examination, the Veteran had left knee flexion of 115 degrees with pain. With repetitive use testing he had 100 degrees of flexion. Range of motion was estimated to be 75 degrees of flexion during flare-ups. As his flexion was not limited to 30 degrees or less, a rating in excess of 10 percent is not warranted under DC 5260. As noted above, the Veteran has had full range of motion for his extension for his left knee. As such, a compensable rating under DC 5261 from May 15, 2017 onward is not warranted. A separate rating is not warranted under DC 5259 as the competent evidence does not show removal of symptomatic semilunar cartilage and this would likely result in pyramiding. 38 C.F.R. § 4.14. Additionally, ratings under 5256 and 5262 are also not warranted as the Veteran does not have ankylosis or impairment of the tibia and fibula. Additionally, for both periods on appeal, the weight of the evidence does not support a finding that the Veteran’s disability picture due to functional loss/limitations or flare-ups with limitation of motion is more nearly approximated by a higher rating. Considering the Deluca and Mitchell factors, and the evidence of record, the Board finds that the current ratings already compensate the Veteran for any functional loss due to pain affecting the left knee, to include pain and limited motion. Deluca, 8 Vet. App. at 204-07. For example, as noted above, the medical reports reflect that he had pain. In light of the foregoing, the Board finds that an increased rating due to functional impairment would not be appropriate under the criteria for 38 C.F.R. §§ 4.40 and 4.45. Instability During this period on appeal, the Board finds that a separate rating under DC 5257 is warranted as the evidence shows that the Veteran has left knee instability based on his medical records and his lay testimony. See English v. Wilkie, 30 Vet. App. 347. 352–53 (2018) (finding that DC 5257 does not require objective medical evidence of lateral instability for a rating to be assigned and when weighing evidence to determine whether there is lateral instability, the Board cannot find objective medical evidence is automatically more probative than lay evidence). The Veteran has stated that his knee gives out, and his medical records document a history of instability. However, the Board acknowledges he did not have objective instability at January 2015 examination, but finds his statements to be competent and credible regarding his knee buckling. For these reasons, the Board finds that a separate rating of 10 percent for instability of the left knee is warranted. Additionally, the Board finds that a higher rating of moderate instability is not warranted as there is not competent medical evidence of instability (positive instability testing) or 3/5 weakness during this period on appeal as noted in the medical records and the January 2015 and July 2017 examination reports (reflecting normal joint stability testing by a competent medical professional). Given the tests performed are generally recognized in the medical community as diagnostic for instability and subluxation, the results are afforded high probative value and given greater weight. Additionally, the Veteran does not have moderate instability as documented at the July 2017 examination report showing normal joint stability/muscle strength. As such, a rating of 10 percent, but no higher, is warranted for the period on appeal. REASONS FOR REMAND 1. Entitlement to an initial disability rating for posttraumatic stress disorder (PTSD) in excess of 30 percent prior to February 28, 2008; in excess of 50 percent as of February 28, 2008, and prior to January 21, 2011; and in excess of 30 percent as of January 21, 2011 is remanded. A VA examination was provided in March 2018. However, the examiner did not address the Board’s directives from December 2017. In this regard, the Board directed the examiner to address all acquired psychiatric disorders from January 2006 to present; whether any such disorder was related to service or secondary to his PTSD; and to determine which symptoms were attributable to each disorder. It appears the examiner only reviewed records up until 2005, and only accounted for acquired psychiatric disorders at the time of the March 2018 examination. As such, a new examination is needed. 2. Entitlement to a total rating based on individual unemployability (TDIU) is remanded. The Board cannot issue a decision on the issue of TDIU because it is inextricably intertwined with the above remanded increased rating for PTSD. See Harris v. Derwinksi, 1 Vet. App. 180, 183 (1991) (noting that two issues are “inextricably intertwined” when they are so closely tied together that a final Board decision on one issue cannot be rendered until the other issue has been considered). As such, this issue is deferred pending the receipt of additional evidence, as directed below. The matters are REMANDED for the following actions: 1. Obtain any outstanding VA treatment records. [The January 2020 SSOC indicates records were obtain thru January 23, 2020.] All requests and responses for the records must be documented. If any identified records cannot be obtained, notify the Veteran of the missing records, the efforts taken, and any further efforts that will be made by VA to obtain such evidence, and allow him an opportunity to provide the missing records. 2. After completing directive #1, schedule the Veteran for an examination with a psychologist or psychiatrist to clarify the etiology of all psychiatric symptoms, as well as the etiology o fall diagnosed acquired psychiatric disorders (other than PTSD). The examiner should be provided and review the file, including a copy of this Remand. The examiner should address the following: -- Identify all acquired psychiatric disorders (other than PTSD) that are currently present (or present during the period of January 31, 2006, to present). For each diagnosis, the examiner should clearly explain how the diagnostic criteria have been met. If the examiner disagrees with a diagnosis already established in the medical records, he/she should so state and explain why. The Board notes that the record contains a diagnosis of paranoid schizophrenia. See 6/28/2013, VA Examination. For all diagnosed acquired psychiatric disorders other than PTSD: (a.) Is it at least as likely as not (50 percent or greater probability) that the disorder manifested during or is otherwise related to the Veteran’s period of active service? (b.) Whether it is at least as likely as not (50 percent or greater probability) that any diagnosed psychiatric disorder (other than PTSD) was caused by the Veteran’s PTSD. (c.) Whether it is at least as likely as not (50 percent or greater probability) that any diagnosed psychiatric disorder (other than PTSD) has been aggravated (i.e., worsened beyond the normal progression of that disease) by the Veteran’s PTSD. **The examiner is to consider and address the Veteran’s lay testimony as to hearing voices in service and in-service incidents of fighting and destroying property, as well as any lay evidence demonstrating changes in personality from before and after service.** Additionally, identify all psychiatric symptoms. The examiner should comment on the effect that the service-connected PTSD has on his ability to function in an occupational environment and describe any functional impairment/limitations caused by this service-connected disability. Then, to the extent possible, determine which symptoms (and resulting functional limitations) are attributable to the Veteran’s service-connected PTSD, and which are due solely to a psychiatric disorder other than PTSD. If the examiner determines that it is not possible to separate the symptoms and resulting effects of the Veteran’s psychiatric disorders, then he or she should explain why that is so. The term “aggravated” refers to a worsening of the underlying condition beyond the natural progression of the disease, as opposed to temporary or intermittent flare-ups or symptoms that resolve with return to the baseline level of disability. If aggravation is found, please state, to the extent possible, the baseline level of disability prior to aggravation. A comprehensive rationale for all opinions is to be provided. All pertinent evidence, including both lay and medical, should be considered. If an opinion cannot be given without resorting to speculation, the examiner should explain why and state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), the record (additional facts are required), or the examiner (does not have the knowledge or training).   3. Then, readjudicate the TDIU issue. Paul Sorisio Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Garrett Morales, 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.