Citation Nr: 20034537 Decision Date: 05/18/20 Archive Date: 05/18/20 DOCKET NO. 08-06 143 DATE: May 18, 2020 ORDER Entitlement to service connection for hypertension is denied. Entitlement to an evaluation in excess of 10 percent prior to January 11, 2017, and a 20 percent thereafter for degenerative joint disease of the right knee is denied. A 20 percent rating for a right knee meniscal tear is granted. REMANDED Entitlement to service connection for a left shoulder disorder is remanded. Entitlement to service connection for a left hip disorder, to include as secondary to a service-connected bilateral knee disability, is remanded. Entitlement to service connection for a right hip disorder, to include as secondary to a service-connected bilateral knee disability, is remanded. Entitlement to service connection for a right ankle disorder, to include as secondary to a service-connected bilateral knee disability, is remanded. Entitlement to service connection for a left foot disorder, to include as secondary to a service-connected bilateral knee disability, is remanded. Entitlement to service connection for a right foot disorder, to include as secondary to a service-connected bilateral knee disability, is remanded. Entitlement to service connection for a left hand rash, to include as a result of service-connected disability, is remanded. FINDINGS OF FACT 1. Hypertension did not manifest during active service or within one year of service and is not otherwise related to service. 2. For the entire period on appeal, the Veteran’s right knee disability was not productive of actual or functional flexion limited to 45 degrees; actual or functional extension limited to 10 degrees; recurrent subluxation or lateral instability; ankylosis; impairment of the tibia and fibula; or genu recurvatum. 3. The Veteran has a right knee meniscal tear that has been manifested by frequent episodes of locking and joint effusion. CONCLUSIONS OF LAW 1. Hypertension was not incurred in active service and may not be presumed to have been so incurred. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1131, 1137; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309. 2. Prior to January 11, 2017, the criteria for an evaluation in excess of 10 percent for the degenerative joint disease of the right knee have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.102, 4.1-4.14, 4.40-4.45, 4.59 4.71a, Diagnostic Codes 5003, 5010, 5257, 5260-5263. 3. Since January 11, 2017, the criteria for an evaluation in excess of 20 percent for the degenerative joint disease of the right knee have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.102, 4.1-4.14, 4.40-4.45, 4.59 4.71a, Diagnostic Codes 5003, 5010, 5257, 5260-5263. 4. The criteria for a separate 20 percent evaluation for a right knee meniscal tear have been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.102, 4.1-4.14, 4.40-4.45, 4.59 4.71a, Diagnostic Code 5258. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from January 1982 to November 1994. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from February 2007, June 2009, and July 2011 rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO). A June 2017 rating decision granted an increased 20 percent rating for the Veteran’s service-connected right knee degenerative joint disease with meniscal tear. In December 2016, the Veteran testified at a hearing before the undersigned Veterans Law Judge. A copy of the transcript of that hearing is of record. The Board remanded the case for further development in November 2011 and August 2018. The case has since been returned to the Board for appellate review. The Board notes that the issue of entitlement to service connection for coronary artery disease has been addressed in a separate decision. Service Connection Service connection may be established for disability resulting from personal injury suffered or disease contracted in line of duty in the active military, naval, or air service. 38 U.S.C. §§ 1110, 1131. That an injury or disease occurred in service is not enough; there must be chronic disability resulting from that injury or disease. If there is no showing of a resulting chronic condition during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity. 38 C.F.R. § 3.303(b). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). For the showing of chronic disease in service, there is a required combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. As hypertension is considered to be a chronic disease for VA compensation purposes, if chronicity in service is not established, a showing of continuity of symptoms after discharge may support the claim. 38 C.F.R. §§ 3.303 (b), 3.309; Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). In addition, for veterans who have served 90 days or more of active service during a war period or after December 31, 1946, certain chronic disabilities, including hypertension, are presumed to have been incurred in service if they manifested to a degree of 10 percent or more within one year from the date of separation from service. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. For VA purposes, “hypertension” means that the diastolic blood pressure is predominantly 90 millimeters (mm.) or greater, and “isolated systolic hypertension” means that the systolic blood pressure is predominantly 160 mm. or greater with a diastolic blood pressure of less than 90 mm. Hypertension or isolated systolic hypertension must be confirmed by readings taken two or more times on at least three different days. See 38 C.F.R. § 4.104, Diagnostic Code 7101, Note (1). The requirement of two or more blood pressure readings on at least three different days applies only to an initial diagnosis of hypertension diagnosis. See Gill v. Shinseki, 26 Vet. App. 386, 391 (2013). In considering the evidence of record under the laws and regulations as set forth above, the Board concludes that the Veteran is not entitled to service connection for hypertension. The Veteran has claimed that he has hypertension as a result of active service. In his December 2008 claim, he asserted that his hypertension developed due to his high cholesterol in service. During the December 2016 hearing, he testified that he began having elevated blood pressure readings in service, but that they were not recorded because his medical care providers kept him in the office and retested him until his blood pressure went down. He also reiterated his claim that his hypertension, which was first diagnosed in 2004, had developed as a result of a high cholesterol disorder that began in service. VA records show that the Veteran’s service connection claim for high cholesterol was denied in February 2007. It was noted that high cholesterol was a laboratory finding and was not a disability for VA compensation purposes. The Veteran’s service treatment records include diagnoses of high cholesterol, but they are negative for complaint, treatment, or diagnosis related to hypertension. In fact, a June 1994 separation examination revealed a normal clinical evaluation of the vascular system, and his blood pressure was recorded as 131/71. VA treatment records show that the Veteran has received treatment for hypertension, including in June 2010. However, those records do not contain an opinion regarding the etiology of the disorder. A May 2018 VA medical opinion noted that the Veteran’s hypertension was diagnosed 10 years after his discharge from active service. It was also noted that he was not treated for hypertension during service and that his separation examination in June 1994 revealed a normotensive blood pressure of 131/71. A January 2019 VA examiner observed that the Veteran was diagnosed with hypertension in 2008 The examiner also noted that the Veteran reported that he was not sure when he was first diagnosed with hypertension or when medication was started, but he found that the documentation of the diagnosis and treatment was consistent after 2008. The examiner opined that the disorder was less likely than not incurred in or caused by the claimed in-service injury, event, or illness, as there was no objective evidence to support that the onset was temporally or causally related to an in-service condition or injury. A July 2019 VA medical opinion noted that the Veteran was service-connected for hypertension and that hypertension and hyperlipidemia contributed to coronary artery disease. It was noted, in essence, that there was only evidence of high cholesterol in service. The Veteran has not been granted service connection for hypertension, and it is unclear as to whether the examiner believed that the disorder was related to service, as no explanation was provided for the statement he was service-connected. Based upon the evidence of record, the Board finds that hypertension did not manifest during active service or within a year of discharge and that the preponderance of the evidence does not establish that the disorder is otherwise causally or etiologically related to service. In fact, as noted above, the Veteran was not diagnosed with the disorder until many years after service. Nor is there competent evidence indicating that any elevated blood pressure readings or findings of elevated cholesterol in service led to his subsequent development of hypertension. Rather, the January 2019 VA examiner specifically found that there was no objective evidence to support that the onset of the Veteran’s hypertension was temporally or causally related to an in-service condition or injury. Moreover, the May 2018 and January 2019 VA opinions in this case are highly probative because they are based on a review of the claims file and an accurate factual premise, including the Veteran’s own statements, and are supported by rationale. Although a July 2019 VA medical opinion erroneously noted that service connection had been established for hypertension, the examiner did not indicate that hypertension actually manifested in service or was otherwise related thereto. Thus, the opinion does not have high probative value. See Madden v. Gober, 125 F.3d 1477 (Fed. Cir. 1997); Owens v. Brown, 7 Vet. App. 429 (1995). The Board acknowledges the Veteran’s statements that his hypertension is related to his military service. However, the Veteran is not competent to provide a nexus opinion regarding the nature and etiology of his hypertension. Although lay persons are competent to provide opinions on some medical issues, Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), as to the specific issue in this case, the diagnosis and etiology of his hypertension, falls outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007) (lay persons not competent to diagnose cancer). The question of etiology goes beyond a simple and immediately observable cause-and-effect relationship, particularly in light of the delayed onset of the disorder. Moreover, even assuming the Veteran’s lay assertions regarding etiology are competent, the Board nevertheless finds the VA medical opinions to be more probative, as they are based on a review of the record, an examination, and the examiners’ medical expertise, training, and knowledge. The examiners also supported their conclusions with rationale. Based on the foregoing the Board finds that a preponderance of the evidence is against the Veteran’s claim for service connection for hypertension. Because the preponderance of the evidence is against the Veteran’s claim, the benefit of the doubt provision does not apply. Accordingly, the Board concludes that service connection for hypertension is not warranted. 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 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. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. 38 C.F.R. § 4.7. In considering the severity of a disability, it is essential to trace the medical history of the veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41. Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). While the regulations require review of the recorded history of a disability by the adjudicator to ensure a more accurate evaluation, the regulations do not give past medical reports precedence over the current medical findings. Where entitlement to compensation has already been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Where VA’s adjudication of the claim for increase is lengthy and factual findings show distinct time periods where the service-connected disability exhibits symptoms which would warrant different ratings, different or “staged” ratings may be assigned for such different periods of time. Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007). Disability of the musculoskeletal system is primarily the inability, due to damage or infection in the parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. It is essential that the examination on which ratings are based adequately portray the anatomical damage and the functional loss with respect to all of these elements. In evaluating disabilities of the musculoskeletal system, it is necessary to consider, along with the schedular criteria, functional loss due to flare-ups of pain, fatigability, incoordination, pain on movement, and weakness. DeLuca v. Brown, 8 Vet. App. 202 (1995). The functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated innervation, or other pathology and evidenced by visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. § 4.40. Pain on movement, swelling, deformity or atrophy of disuse as well as instability of station, disturbance of locomotion, interference with sitting, standing and weight bearing are relevant considerations for determination of joint disabilities. 38 C.F.R. § 4.45. Painful, unstable, or malaligned joints, due to healed injury, are entitled to at least the minimal compensable rating for the joint. 38 C.F.R. § 4.59. Although pain may cause functional loss, pain itself does not constitute functional loss. Rather, pain must affect some aspect of “the normal working movements of the body,” such as “excursion, strength, speed, coordination, and endurance,” in order to constitute functional loss. See Mitchell v. Shinseki, 25 Vet. App. 32, 38-43 (2011). In this case, the Veteran’s degenerative joint disease of the right knee with a meniscal tear is currently assigned a 10 percent evaluation prior to January 11, 2017, and a 20 percent evaluation thereafter, pursuant to 38 C.F.R. § 4.71a, Diagnostic Codes 5003-5258. Diagnostic Code 5010 states that traumatic arthritis is to be rated as degenerative arthritis under Diagnostic Code 5003, which in turn, states that the severity of degenerative arthritis, established by X-ray findings, is to be rated on the basis of limitation of motion under the appropriate diagnostic code for the specific joint or joints affected. When there is arthritis with at least some limitation of motion, but to a degree which would be noncompensable under a limitation-of-motion code, a 10 percent rating will be assigned for each affected major joint or group of minor joints. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. In the absence of limitation of motion, a 10 percent evaluation is warranted if there is X-ray evidence of involvement of two or more major joints or two or more minor joint groups, and a 20 percent evaluation is authorized if there is X-ray evidence of involvement of two or more major joints or two or more minor joint groups and there are occasional incapacitating exacerbations. 38 C.F.R. § 4.71a, Diagnostic Code 5003. Under Diagnostic Code 5260, a noncompensable evaluation is contemplated for flexion limited to 60 degrees. A 10 percent disability evaluation is assigned when flexion is limited to 45 degrees, and a 20 percent disability evaluation is warranted when flexion is limited to 30 degrees. A 30 percent disability evaluation is assigned when flexion is limited to 15 degrees, which is the maximum evaluation available under Diagnostic Code 5260. Under Diagnostic Code 5261, a noncompensable evaluation is assigned for extension limited to 5 degrees, and a 10 percent disability evaluation is contemplated for extension limited to 10 degrees. When there is limitation of extension to 15 degrees, a 20 percent disability evaluation is warranted. A 30 percent rating will be assigned for extension limited to 20 degrees, and a 40 percent rating is contemplated for limitation of extension to 30 degrees. A 50 percent disability evaluation is warranted for extension limited to 45 degrees. The regulations provide that the normal range of motion of the knee is zero degrees on extension to 140 degrees on flexion. 38 C.F.R. § 4.71, Plate II. Under Diagnostic Code 5258, dislocated semilunar cartilage, with frequent episodes of locking, pain, and effusion into the joint, warrants a 20 percent disability rating. 38 C.F.R. § 4.71a, Diagnostic Code 5258. Semilunar cartilage is the meniscus lateralis articulation is genus (lateral meniscus) and the meniscus medialis articulation is genus (medial meniscus). See DORLAND’S ILLUSTRATED MEDICAL DICTIONARY 273, 1013 (28th ed. 1994). A 20 percent rating is the maximum schedular evaluation available under Diagnostic Code 5258. Under Diagnostic Code 5257, a 10 percent disability rating is assigned for slight recurrent subluxation or lateral instability. A 20 percent disability rating is warranted when there is moderate recurrent subluxation or lateral instability, and a 30 percent disability rating requires severe recurrent subluxation or lateral instability. 38 C.F.R. § 4.71a, Diagnostic Code 5257. The words “slight,” “mild,” “moderate,” and “severe” as used in the various diagnostic codes are not defined in the VA Rating Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence, to the end that its decisions are equitable and just. 38 C.F.R. § 4.6. Under Diagnostic Code 5259, a 10 percent disability evaluation is assigned for the symptomatic removal of semilunar cartilage. Under Diagnostic Code 5262, pertaining to impairment of the tibia and fibula, a 10 percent disability rating is assigned for malunion with slight knee or ankle disability, and a 20 percent disability rating is warranted for malunion with moderate knee or ankle disability. A 40 percent disability rating is appropriate where there is nonunion of the tibia and fibula with loose motion requiring a brace. 38 C.F.R. § 4.71a, Diagnostic Code 5262. The Veteran has claimed that he is entitled to a rating in excess of 10 percent prior to January 11, 2017, and a rating in excess of 20 percent thereafter. In statements and testimony in support of his claim, he has reported that he experienced loss of flexibility, instability, locking, swelling, and pain in the right knee. His claim for an increased rating was received by VA on September 14, 2010. VA treatment records show that the Veteran underwent a right knee arthroscopy with meniscal debridement in December 2007. An April 2008 rehabilitation medicine clinic note later documented pain with some associated intermittent swelling. A July 2009 VA examination included a diagnosis of bilateral knee degenerative arthrosis. It was noted that the Veteran complained of constant bilateral moderate knee pain with intermittent locking. The examiner noted there was evidence of right knee pain at rest, but no grinding, instability, patellar abnormality, meniscus abnormality, abnormal tendons or bursae, or other knee abnormalities. Right knee range of motion was record as being 0 to 75 degrees. An x-ray also revealed mild tricompartmental degenerative arthrosis of the knees with a prominent ossification in the region of the distal right posterior cruciate ligament. During an April 2011 VA examination, the Veteran complained of constant moderate to severe knee pain that was worsened by prolonged standing, walking, stooping, and bending. He reported having symptoms of giving way, instability, pain, stiffness, weakness, incoordination, decreased speed of joint motion, locking episodes daily or more often, swelling, and tenderness. The examiner noted that the Veteran ambulated with an antalgic gait, and there was edema, tenderness, pain at rest, and guarding of movement to the right knee. There was no grinding, instability, patellar abnormality, meniscus abnormality, abnormal tendons or bursae, or other knee abnormalities. His right knee range of motion was documented as being 5 to 45 degrees. There was objective evidence of pain following repetitive motion, but no additional limitation of motion after three repetitions of range of motion. It was further noted that an x-ray revealed no significant change from prior studies. A June 2013 VA examiner diagnosed the Veteran with bilateral knee degenerative joint disease. It was noted he complained of chronic daily pain that was worse with overuse. His range of right knee motion was from 0 to 45 degrees with objective evidence of pain at that point. There was no change in motion after repetitive-use testing, although there was functional loss after repetitive-use testing with less movement than normal and pain on movement. His right knee muscle strength was 5/5, and joint stability tests were normal for the right knee. There was no history of recurrent patellar subluxation or dislocation. It was noted that the Veteran had a history of a right meniscal tear with frequent episodes of joint pain and frequent episodes of joint effusion. Imaging studies revealed degenerative or traumatic arthritis bilaterally without x-ray evidence of patellar subluxation. The examiner stated the Veteran’s knee disabilities would impair physical labor, but would not impair sedentary employment. During a February 2017 VA examination, the Veteran was diagnosed with bilateral meniscal tears and bilateral degenerative arthritis. He reported having reported chronic, moderately severe, shooting, throbbing bilateral knee pain that was worse with any activity. He indicated that he used knee braces, a walker, and a cane. The examiner also noted that range of motion testing could not be performed due to sciatic nerve pain. The Veteran’s muscle strength was 5/5, and there was no history of recurrent subluxation, lateral instability, or recurrent effusion. The examiner noted that joint stability testing was indicated, but it also could not be performed due to sciatic nerve pain. The examiner indicated that a January 11, 2017, magnetic resonance imaging (MRI) study revealed a medial meniscal tear, medial chondromalacia, and patellofemoral degenerative changes. There was no evidence of pain on passive range of motion testing or pain when the joint was used in non-weight bearing. The examiner noted that the Veteran would not be able to do work that required prolonged standing, walking, kneeling, squatting, lifting, or carrying over 20 pounds, but sedentary work might be appropriate. A May 2017 VA examination report noted the findings of the February 2017 examination and additionally found that it was at least as likely as not that the Veteran’s bilateral meniscal tear was proximately due to or caused by his bilateral osteoarthritis of the knees. A June 13, 2017, VA examination provided a diagnosis of left knee degenerative arthritis, but the examiner report abnormal range of motion of the right knee from 0 to 100 degree, which itself contributed to functional loss. There was evidence of pain with weight bearing and objective evidence of localized tenderness or pain on palpation. Repetitive-use testing could not be performed due to pain. The examiner indicated that the examination was neither medically consistent nor inconsistent with the Veteran’s statements describing functional loss with repetitive use over time. The examiner stated that it was not noted that pain, weakness, fatigability, and incoordination limited functional ability during flare-ups or when the joint was used repeatedly beyond that which was described in the examination as documented. There was also additional range of motion loss due to pain on use during flare-ups beyond that which was documented in the examination. Muscle strength testing was reduced in the right knee with 3/5 strength on flexion and 4/5 strength on extension, but the reduction was not entirely due to the knee disability. It was noted that there was sciatica pain and increased pain in the knees with movement. There was no muscle atrophy or ankylosis. There was also no history of recurrent subluxation, lateral instability, or recurrent effusion. The examiner noted that joint stability testing was indicated, but could not be performed due to sciatic nerve pain. It was noted that the Veteran had a history of a right meniscal tear with frequent episodes of locking, frequent episodes of joint pain, and frequent episodes of joint effusion. There was evidence of pain on passive range of motion testing and pain when the joint was used in non-weight bearing. The examiner stated the Veteran’s knee disabilities limited his ability to walk, stand, climb stairs, and kneel due to increased pain and limited range of motion. It was also noted this would affect ability to perform a physical job, but would not affect ability to perform a sedentary job. A February 2019 VA examination report included diagnoses of right degenerative joint disease with a meniscal tear and right arthroscopic surgery in 2007 with residual pain and loss of motion. It was noted that the Veteran complained of chronic pain and swelling with increased pain and stiffness during flare-ups. His range of right knee motion was recorded as being 0 to 95 degrees that itself contributed to a functional loss and impaired ambulation. There was pain that caused functional loss with flexion and extension. There was also a report of severe pain on very light palpation of the knee directly related to degenerative joint disease. There was evidence of pain on weight-bearing and objective evidence of crepitus. There was no additional loss of function or range of motion after repetitive use testing. There was significantly limited functional ability with repeated use over a period of time and during flare-ups due to pain, fatigue, weakness, and lack of endurance with range of motion from 0 to 90 degrees. Muscle strength testing was reduced in the right knee with 4/5 strength on flexion and 4/5 strength on extension. There was no muscle atrophy or ankylosis. There was also no history of recurrent subluxation, lateral instability, or recurrent effusion. Joint stability testing revealed normal joints. It was noted that the Veteran had a history of a right meniscal tear with frequent episodes of joint pain. There was evidence of pain when the joint was used in non-weight bearing, but passive range of motion was the same as active range of motion. The examiner stated that the functional impact of the Veteran’s knee disability impaired his ability to ambulate or stand for long periods due to pain and decreased range of motion. The examiner also noted that the Veteran’s pain response was exaggerated. Based upon the evidence of record, the Board finds that the evidence does not show that the Veteran had flexion limited to 45 degrees or less throughout the appeal period. Thus, he is not entitled to an increased evaluation for either time period under Diagnostic Code 5260. The Veteran has also not been shown to have extension limited to 10 degrees or less. Therefore, he is not entitled to a separate or higher evaluation for either time period under Diagnostic Code 5261. In addition, the Board notes that the Veteran is currently assigned ratings under Diagnostic Codes 5010-5258, which contemplates painful motion. There is no x-ray evidence showing involvement of 2 or more major joints or 2 or more minor joint groups, with occasional incapacitating exacerbations. Thus, increased or separate evaluations are not warranted under Diagnostic Code 5010. Nevertheless, the Board finds that the Veteran is entitled to a separate 20 percent evaluation under Diagnostic Code 5258. The evidence shows that he has a right meniscal tear that is productive of frequent episodes of locking and joint effusion, and an evaluation of a knee disability under diagnostic codes 5260 does not preclude a separate evaluation under diagnostic code 5258. See Lyles, 29 Vet. App. 107. A 20 percent evaluation is the maximum schedular rating available under Diagnostic Code 5258. A higher evaluation cannot be granted under Diagnostic Code 5259, as 10 percent is the maximum schedular evaluation available under that diagnostic code, and the symptomatology attributable to the Veteran’s semilunar cartilage impairment is already contemplated in the 20 percent evaluation now assigned under Diagnostic Code 5258. In an effort to afford the Veteran the highest possible rating, the Board has also considered whether any other rating criteria are applicable. The assignment of a particular diagnostic code is “completely dependent on the facts of a particular case.” 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 current diagnosis, and demonstrated symptomatology. See Pernorio v. Derwinski, 2 Vet. App. 625, 629 (1992). Thus, the Board has considered the propriety of assigning a higher, or separate, rating under another diagnostic code. See Tedeschi v. Brown, 7 Vet. App. 411, 414 (1995). The Board finds that the Veteran is not entitled to a higher or separate evaluation for lateral instability or recurrent subluxation under Diagnostic Code 5257. The Board acknowledges the Veteran’s statements that his knee gives way. However, the June 2013 VA examiner indicated that joint stability tests were normal for the right knee, and there was no history of recurrent patellar subluxation or dislocation. The February 2017, June 2017, and February 2019 VA examiners also stated that there was no history of recurrent subluxation or lateral instability. Thus, the Board finds that the weight of evidence is against a finding of lateral instability or recurrent subluxation. The Board has also considered whether a higher or separate evaluation is warranted under any other diagnostic code for the right knee. However, as the evidence of record does not demonstrate that the Veteran has ankylosis, impairment of the tibia and fibula, or genu recurvatum, he is not entitled to higher evaluations under Diagnostic Codes 5256 (ankylosis), 5262 (impairment of the tibia and fibula), and 5263 (genu recurvatum). There is simply no evidence of such manifestations. Indeed, based on the aforementioned range of motion findings, the record shows that the Veteran’s right knee is not fixated or immobile. Ankylosis is defined as “immobility and consolidation of a joint due to disease, injury, surgical procedure.” Lewis v. Derwinski, 3 Vet. App. 259 (1992) (internal medical dictionary citation omitted). Moreover, the February 2019 VA examiner specifically indicated that the Veteran did not have ankylosis of the right knee. Therefore, separate or higher ratings are not warranted under Diagnostic Codes 5256, 5262, and 5263, for the right knee. The Board has also considered the provisions of 38 C.F.R. §§ 4.40, 4.45, 4.59, and the holdings in DeLuca. However, am increased evaluations for the Veteran’s right knee disability is not warranted on the basis of functional loss due to pain or weakness in this case, as the Veteran’s symptoms are supported by pathology consistent with the assigned evaluations, and no higher. In this regard, the Board observes that the Veteran has complained of pain throughout the appeal period. However, the effect of the pain in the Veteran’s right knee is already contemplated in the assigned evaluations. The Veteran’s complaints do not, when viewed in conjunction with the medical evidence, tend to establish weakened movement, excess fatigability, or incoordination to the degree that would warrant an increased evaluation beyond those already assigned. Accordingly, the Board concludes that an increased or separate evaluation is not warranted for the Veteran’s service-connected knee disabilities under DeLuca. The Veteran and his representative have not raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 368 (2017) (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 The Veteran has claimed that he has a left shoulder disorder, left and right hip disorders, a right ankle disorder, left and right foot disorders, and a left hand rash as a result of active service. The Board notes that these matters were remanded for additional development in August 2018 and that a remand confers, as a matter of law, the right to compliance with the remand orders. See Stegall v. West, 11 Vet. App. 268 (1998). Following the remand, the Veteran was afforded VA examinations in February 2019 in connection with his claims. However, the opinions are inadequate and do not comply with the remand directives. Therefore, the Board finds that additional VA medical opinions are needed. The matters are REMANDED for the following action: 1. The AOJ should request that the Veteran provide the names and addresses of any and all health care providers who have provided treatment for left shoulder, bilateral hip, rash, bilateral foot, and right ankle disorders. After acquiring this information and obtaining any necessary authorization, the AOJ should obtain and associate these records with the claims file. Any outstanding VA medical records should also be obtained and associated with the claims file. 2. After the above development has been completed, the Veteran should be afforded a VA examination to determine the nature and etiology of any left shoulder disorder that may be present. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran’s service treatment records, post-service medical records, and assertions. The examiner should note that the Veteran is competent to attest to matters of which he has first-hand knowledge, including observable symptomatology. If there is a medical basis to support or doubt the history provided by the appellant, the examiner should provide a fully reasoned explanation. The examiner should opine as to whether it is at least as likely as not that the Veteran has a current left shoulder disorder that is causally or etiologically related to his military service, to include any injury or symptomatology therein. He or she should specifically consider the June 1984 and June 1994 records pertaining to the Veteran’s left shoulder. The examiner should also opine as to whether it is at least as likely as not that the Veteran has a left shoulder disorder that is caused by or aggravated by medications that has been prescribed. If the left shoulder disorder is the result of a prescribed medication, the examiner should indicate what disorder(s) necessitated this prescription. The examiner should consider the Veteran’s in-service symptoms, the May 2005 VA examination, the December 2016 private medical opinion, and the prior diagnoses of muscle strain, adhesive capsulitis, and rotator cuff tendonitis in his or her opinion. (The term “at least as likely as not” does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of a certain conclusion as it is to find against it.) A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. Because it is important “that each disability be viewed in relation to its history [,]” 38 C.F.R. § 4.1, copies of all pertinent records in the appellant’s claims file, or in the alternative, the claims file, must be made available to the examiner for review. 3. After the above development has been completed, the Veteran should be afforded a VA examination to determine the nature and etiology of any left and right hip disorder that may be present. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran’s service treatment records, post-service medical records, and assertions. The examiner should note that the Veteran is competent to attest to matters of which he has first-hand knowledge, including observable symptomatology. If there is a medical basis to support or doubt the history provided by the appellant, the examiner should provide a fully reasoned explanation. The examiner should opine as to whether it is at least as likely as not that the Veteran has a current left and right hip disorder that is causally or etiologically related to his military service, to include any injury or symptomatology therein. The examiner should also opine as to whether it is at least as likely as not that the Veteran has a left and right hip disorder that is caused by or aggravated by his service-connected low back strain, service-connected bilateral knee disabilities, and/or any medications that he has been prescribed. If a hip disorder is the result of a prescribed medication, the examiner should indicate what disorder(s) necessitated this prescription. (The term “at least as likely as not” does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of a certain conclusion as it is to find against it.) A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. Because it is important “that each disability be viewed in relation to its history [,]” 38 C.F.R. § 4.1, copies of all pertinent records in the appellant’s claims file, or in the alternative, the claims file, must be made available to the examiner for review. 4. After the above development has been completed, the Veteran should be afforded a VA examination to determine the nature and etiology of any left hand rash disorder that may be present. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran’s service treatment records, post-service medical records, and assertions. The examiner should note that the Veteran is competent to attest to matters of which he has first-hand knowledge, including observable symptomatology. If there is a medical basis to support or doubt the history provided by the appellant, the examiner should provide a fully reasoned explanation. The examiner should opine as to whether it is at least as likely as not that the Veteran has a current left hand rash disorder, diagnosed at any time during the appeal period, that is causally or etiologically related to his military service, to include any injury or symptomatology therein. The examiner should also opine as to whether it is at least as likely as not that the Veteran has a left- and rash disorder that is caused by or aggravated by an acquired psychiatric disorder and/or any medications that he has been prescribed. If there is a rash that is the result of a prescribed medication, the examiner should indicate what disorder(s) necessitated this prescription. (The term “at least as likely as not” does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of a certain conclusion as it is to find against it.) A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. Because it is important “that each disability be viewed in relation to its history [,]” 38 C.F.R. § 4.1, copies of all pertinent records in the appellant’s claims file, or in the alternative, the claims file, must be made available to the examiner for review. 5. After the above development has been completed, the Veteran should be afforded a VA examination to determine the nature and etiology of any bilateral foot disorder that may be present. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran’s service treatment records, post-service medical records, and assertions. The examiner should note that the Veteran is competent to attest to matters of which he has first-hand knowledge, including observable symptomatology. If there is a medical basis to support or doubt the history provided by the appellant, the examiner should provide a fully reasoned explanation. The examiner should opine as to whether it is at least as likely as not that the Veteran has a current bilateral foot disorder that is causally or etiologically related to his military service, to include any injury or symptomatology therein. The examiner should also opine as to whether it is at least as likely as not that the Veteran has a bilateral foot disorder that is caused by or aggravated by his service-connected low back strain, service-connected bilateral knee disabilities, and/or any medications that he has been prescribed. If a foot disorder is the result of a prescribed medication, the examiner should indicate what disorder(s) necessitated this prescription. (The term “at least as likely as not” does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of a certain conclusion as it is to find against it.) A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. Because it is important “that each disability be viewed in relation to its history [,]” 38 C.F.R. § 4.1, copies of all pertinent records in the appellant’s claims file, or in the alternative, the claims file, must be made available to the examiner for review. 6. After the above development has been completed, the Veteran should be afforded a VA examination to determine the nature and etiology of any right ankle disorder that may be present. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran’s service treatment records, post-service medical records, and assertions. The examiner should note that the Veteran is competent to attest to matters of which he has first-hand knowledge, including observable symptomatology. If there is a medical basis to support or doubt the history provided by the appellant, the examiner should provide a fully reasoned explanation. The examiner should opine as to whether it is at least as likely as not that the Veteran has a current right ankle disorder that is causally or etiologically related to his military service, to include any injury or symptomatology therein. The examiner should also opine as to whether it is at least as likely as not that the Veteran has a right ankle disorder that is caused by or aggravated by his service-connected low back strain, service-connected bilateral knee disabilities, and/or any medications that he has been prescribed. If a right ankle disorder is the result of a prescribed medication, the examiner should indicate what disorder(s) necessitated this prescription. (The term “at least as likely as not” does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of a certain conclusion as it is to find against it.) A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. Because it is important “that each disability be viewed in relation to its history [,]” 38 C.F.R. § 4.1, copies of all pertinent records in the appellant’s claims file, or in the alternative, the claims file, must be made available to the examiner for review. 7. The AOJ should conduct any other development as may be indicated. J.W. ZISSIMOS Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board T. Douglas 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.