Citation Nr: 21000877 Decision Date: 01/06/21 Archive Date: 01/06/21 DOCKET NO. 15-02 946 DATE: January 6, 2021 ORDER Entitlement to an effective date of August 6, 2008, but no earlier, the award of service connection for right knee instability is granted. Entitlement to a rating higher than 30 percent for right knee degenerative joint disease based on limitation of motion since December 31, 2019, is denied. Entitlement to a separate 20 percent rating, but no higher, for a right knee medial and lateral meniscus disorder since December 31, 2019, is granted. Entitlement to an initial rating higher than 10 percent for right knee instability is denied. REMANDED Entitlement to an initial rating higher than 10 percent for right knee degenerative joint disease from August 6, 2008, to May 28, 2013, from July 1, 2013, to February 21, 2017, and from April 1, 2017, to December 30, 2019 is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. FINDINGS OF FACT 1. The Veteran submitted a claim for service connection for a right knee disability on August 6, 2008. There is no correspondence from the Veteran prior to this date which could constitute a formal or informal claim for benefits. 2. New and material evidence was received within one year of the January 2013 rating decision, and affording the Veteran the benefit of the doubt, the medical evidence indicates that the Veteran has had slight right knee instability throughout the entire appeal period. 3. Since December 31, 2019, the Veteran’s right knee degenerative arthritis has not manifested with flexion limited to 45 degrees or extension limited to 30 degrees. 4. Since December 31, 2019, the Veteran has had a medial and lateral meniscus disorder manifesting as a cartilage disorder causing frequent episodes of locking, pain, and effusion. 5. For the entire period since August 6, 2008, the Veteran’s right knee disability has manifested with slight instability, but has not shown instability that is at least moderate.  CONCLUSIONS OF LAW 1. The criteria for an effective date of August 6, 2008, but no earlier, for the award of a separate 10 percent evaluation for right knee instability have been met. 38 U.S.C. §§ 5107(a), 5110; 38 C.F.R. § 3.400. 2. The criteria for a rating higher than 30 percent for right knee degenerative joint disease based on limitation of motion since December 31, 2019, have not been met.  38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.3, 4.10, 4.14, 4.40, 4.45, 4.71a, Diagnostic Codes 5260, 5261.  3. The criteria for a separate 20 percent rating for a right knee medial and lateral meniscus disorder since December 31, 2019, have been met.  38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.3, 4.10, 4.14, 4.40, 4.45, 4.71a, Diagnostic Code 5258. 4. The criteria for an initial rating higher than 10 percent for right knee instability have not been met.  38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.3, 4.10, 4.14, 4.40, 4.45, 4.71a, Diagnostic Code 5257.  REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from July 1978 to February 1993. This case comes to the Board of Veterans’ Appeals (Board) on appeal from February 2009 and January 2014 rating decisions of the Department of Veterans Affairs (VA) Regional Office. In May 2016, the Board remanded these issues in order to afford the Veteran a hearing before a Decision Review Officer. In July 2016, the Veteran, through his attorney, wrote that they wished to withdraw the request for a person hearing. This hearing request is therefore considered withdrawn. The issues were again remanded by the Board in September 2018 for further development. Effective Date for Right Knee Disabilities The Veteran has requested an effective date earlier than April 12, 2013, for the award of a separate compensable rating for right knee instability. The Veteran first submitted a claim for service connection for a right knee disability in August 2008. The claim was initially denied, but after the Veteran appealed the denial to the Board, a January 2013 Board decision was issued, granting entitlement to service connection for a right knee disability. In a January 2013 rating decision effectuating the Board’s decision, the Veteran was granted service connection for right knee degenerative arthritis with derangement of the anterior cruciate and medial and lateral meniscus and status post arthroscopy, rated as 10 percent disabling, effective August 6, 2008. The laws in effect at the time of the January 2013 rating decision required that a Notice of Disagreement be a written communication from a claimant or his representative expressing dissatisfaction or disagreement with a determination and a desire to contest the result, submitted within one year of the rating decision. 38 C.F.R. §§ 20.201, 20.302 (2013). While the Veteran did not submit a formal Notice of Disagreement with the rating assigned in this decision, he did submit a request for an increased rating for his right knee disability in April 2013, which the Board will accept was intended to be a Notice of Disagreement with the January 2013 rating decision. Furthermore, within one year of the January 2013 rating decision, the Veteran attended a VA examination in August 2013. At this examination, he was found to have symptoms which had worsened since his prior VA examination in April 2010, including painful right knee flexion at 110 degrees, frequent episodes of locking, and slight anterior instability. If new and material evidence is received within the one-year appeal period, that evidence will be considered as having been filed in connection with the pending claim. 38 U.S.C. § 7105(c); 38 C.F.R. §§ 3.156(b), 20.1103. This new evidence gathered at the August 2013 VA examination was the basis for the subsequent grant of a separate rating for right knee instability, rated as 10 percent disabling, in the January 2014 rating decision. The Board therefore finds that this examination clearly constitutes new and material evidence that can be considered as part of the initial claim which was submitted in August 2008 and was still pending. The Board has also reviewed all of the evidence and finds that an effective date of August 6, 2008 is warranted for the award of a separate 10 percent rating for right knee instability. The effective date of an evaluation and award of compensation based on an original claim or a claim for increase will be the date of receipt of the claim or the date entitlement arose, whichever is the later. 38 C.F.R. § 3.400. In this case, the Board acknowledges that the Veteran’s right knee instability is part of his right knee disability, and therefore it was encompassed by the claim submitted on August 6, 2008. The Board also finds that there is medical evidence that this symptom was present well before it was noted at the August 2013 VA examination. At the April 2010 VA examination, the Veteran reported “giving way” of the knee, and he had a positive Lachman test, which is a test for instability in the anterior cruciate ligament. In June 2010, he reported to his primary care physician that he had pain, crepitus, and instability in his right knee. At the July 2012 Board hearing, the Veteran reported that his knee would frequently “buckle.” The Board therefore affords the Veteran the benefit of the doubt and finds that his slight instability was as likely as not present throughout the entire period on appeal, August 6, 2008 to the present. An effective date earlier than August 6, 2008 is not warranted, nor has the Veteran or his attorney requested a date any earlier than this. The Veteran clearly submitted his initial claim on August 6, 2008, and there is no correspondence from the Veteran submitted any earlier than this which could be considered a formal or informal claim for benefits. Entitlement to an effective date of August 6, 2008, but no earlier, is granted. Right Knee Degenerative Arthritis The Veteran has requested higher initial ratings for his service-connected right knee degenerative joint disease. In a January 2013 rating decision, the Veteran was granted service connection for right knee degenerative arthritis and assigned a 10 percent rating, effective August 6, 2008. In a July 2020 rating decision, the Veteran’s evaluation for right knee degenerative arthritis was increased to 30 percent, effective December 31, 2019. The Board currently adjudicates only the period from December 31, 2019, to the present. Disability ratings are determined by applying the criteria set forth in VA’s Schedule for Rating Disabilities, which is based on the average impairment of earning capacity.  Individual disabilities are assigned separate diagnostic codes.  38 U.S.C. § 1155; 38 C.F.R. § 4.1.  Disability of the musculoskeletal system is primarily the inability, due to damage or infection in 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 portrays the anatomical damage, and the functional loss, with respect to these elements.  The intent of the schedule is to recognize painful motion with joint or periarticular pathology as productive of disability.  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.  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. 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; 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). The Veteran’s right knee degenerative arthritis was assigned a 30 percent rating since December 31, 2019 under Diagnostic Code 5261. Range of motion of the knee is measured in flexion and extension. For VA purposes, a normal range of knee motion is from 0 degrees of extension to 140 degrees of flexion. 38 C.F.R. § 4.71, Plate II. A limitation of leg extension is evaluated as 30 percent disabling when extension is limited to 20 degrees, and an evaluation of 40 percent is assigned when extension is limited to 30 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5261. A limitation of flexion of the leg allows for a 10 percent evaluation when it is limited to 45 degrees, a 20 percent evaluation when it is limited to 30 degrees, and a 30 percent evaluation when it is limited to 15 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5260. Separate ratings for knee disabilities may be assigned for disability of the same joint if none of the symptomatology on which each rating is based is duplicative or overlapping. See VAOPGCPREC 9-04 (2004); 69 Fed. Reg. 59,990 (2004); 38 C.F.R. § 4.14. Symptomatic removal of the semilunar cartilage is assigned a rating of 10 percent. Dislocated semilunar cartilage with frequent episodes of locking, pain, and effusion into the joint is assigned a rating of 20 percent. 38 C.F.R. § 4.71a, Diagnostic Codes 5258, 5259. Additionally, the Veteran’s separate rating for lateral instability has been separately rated, and is discussed below. Evaluations for knee impairment can also be assigned due to ankylosis, malunion/nonunion of the tibia and fibula, or genu recurvatum. The Veteran has not at any time during the appellate term been found to have these disorders; these diagnostic codes are therefore not applicable and will not be further discussed. See 38 C.F.R. § 4.71a, Diagnostic Codes 5256, 5262, 5263. Arthritis (degenerative joint disease) can also be assigned a primary evaluation under Diagnostic Code 5003. When the limitation of motion is noncompensable under the appropriate diagnostic codes, a rating of 10 percent may be applied to each major joint or group of minor joints. 38 C.F.R. § 4.71a, Diagnostic Code 5003. In this case, the Veteran has already been assigned at least 10 percent or higher; this diagnostic code would not allow for any higher rating, and will not be further discussed. Based on the evidence of record, the Board finds that a rating higher than 30 percent for the Veteran’s right knee disability based on limitation of motion since December 31, 2019, is not warranted. The Veteran attended a VA examination in December 2019, and he reported having pain throughout his knee which was intermittent and sharp. He stated that it was worse with activity and that he treated it with topical creams and a TENS device. He also reported flare ups, caused by daily activities, prevented him from moving, and required physical therapy. The Veteran was unable to run or to walk for long periods. Range of motion testing found flexion and extension from 10 to 90 degrees. There was tenderness to palpation, pain with weight bearing, and crepitus. The Veteran did not perform repetitive use testing due to fear of pain. The examiner found that the examination was medically consistent with the Veteran’s statements describing functional loss with repetitive use over time and during flare ups. He estimated that with repetitive use and during flare ups, there would be flexion and extension of 20 to 90 degrees. There was reduction in muscle strength, but no ankylosis or recurrent subluxation. The Veteran did not have recurrent patellar dislocation. The Veteran also had a meniscus condition, caused by a meniscus tear, which had resulted in arthroscopy, possible removal of loose body, and anterior cruciate repair. It caused frequent episodes of joint locking, joint pain, and joint effusion. The Veteran reported painful locking and swelling of the knee. The Veteran’s private and VA treatment records show past reports of pain in his right knee, but there is no indication in any of the most recent records of symptoms worse than those shown at the December 2019 VA examination. In October 2020, the Veteran’s physician noted that his knees had normal range of motion and no swelling. The Board finds that based on limitation of flexion and extension, a rating higher than 30 percent is not warranted since December 31, 2019. The December 2019 VA examination found that the Veteran had right knee flexion to 90 degrees, including with consideration of repeated use and flare ups. He had extension to 10 percent on testing, but the examiner estimated that during flare ups, it would be limited to 20 degrees. It is this finding that was the basis for the Veteran’s increased rating of 30 percent. There is no evidence showing that the Veteran has ever had limitation of motion greater than this, such as flexion limited to 45 degrees or extension limited to 30 degrees. In the absence of any such findings, there is no basis for a higher rating based on limitation of flexion or extension. See 38 C.F.R. § 4.71a, Diagnostic Codes 5260, 5261. The Board has considered the provisions of 38 C.F.R. §§ 4.40, 4.45, 4.59, and in fact the increased rating of 30 percent for right knee degenerative arthritis was based on a finding that the Veteran would have decreased range of motion due to flare ups or repeated use, even though a limitation of extension of 20 degrees was not clinically observed on examination. See Sharp v. Shulkin, 29 Vet. App. 26 (2017). There is no evidence indicating that any higher evaluation can be assigned, even taking painful motion and functional loss due to pain, weakness, or excess fatigability into account. The Board does find, however, that a separate 20 percent rating can be assigned for a medial and lateral meniscus disorder based on dislocated semilunar cartilage with frequent episodes of locking, pain, and effusion. 38 C.F.R. § 4.71a, Diagnostic Code 5258. While the Board has carefully considered whether such a grant would constitute pyramiding with symptoms already encompassed by the Veteran’s current ratings, under Lyles v. Shulkin, 29 Vet. App. 107 (2017), the Court of Appeals for Veterans Claims (Court) found that the evaluation of a knee disability under Diagnostic Code 5261 would not, as a matter of law, preclude separate evaluation of a meniscal disability of the same knee under Diagnostic Codes 5258 or 5259. It stated that consideration must be given to symptoms which were specifically associated with a meniscus disorder, such as popping, locking, grinding, and swelling. The Veteran’s grant of service connection for his knee disorder was specifically characterized as right knee degenerative arthritis with derangement of the anterior cruciate and medial and lateral meniscus, status post arthroscopy. It was therefore clearly intended to encompass any residuals of the surgery he had undergone on his torn meniscus. The December 2019 VA examiner found that the Veteran had a meniscus condition, caused by a meniscus tear, which caused frequent episodes of joint locking, joint pain, and joint effusion. This is exactly the criteria required for a separate evaluation of 20 percent under 38 C.F.R. § 4.71a, Diagnostic Code 5258. 20 percent is the highest evaluation available for this condition. The Board considered the Veteran’s lay statements regarding the functional impact of his service-connected knee disability.  He is competent to report his own observations with regard to the severity of his disability, including reports of pain and decreased mobility.  See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007).  The Veteran’s statements of having increased pain with activity and being unable to walk for long periods are credible and consistent with the ratings assigned.  The occurrence of pain while performing activities and limitations on movement and activity are the practical effect of the symptoms of pain, instability, and limited range of motion which have been clinically observed and measured in the Veteran’s examination.  To the extent that the Veteran argues his symptomatology is more severe than shown on evaluation, his statements must be weighed against the other evidence of record.  Here, the specific examination findings of trained health care professionals are of greater probative weight than the Veteran’s more general lay assertions.  In sum, the preponderance of the evidence is against finding that a rating higher than 30 percent since December 31, 2019 for a right knee disability based on limitation of motion is warranted, but a separate evaluation of 20 percent, but no higher, for a right knee medial and lateral meniscus disorder can be assigned, effective December 31, 2019. In reaching this decision, the Board has considered the applicability of the benefit of the doubt doctrine; however, as the preponderance of the evidence is against any higher ratings than those now assigned for this period, that doctrine is not applicable. 38 U.S.C. § 5107(b). For the earlier stage on appeal, which spans from August 6, 2008, to December 30, 2019, the issue is being remanded, in order to request a retrospective opinion which was requested in the Board’s prior September 2018 remand, but not yet obtained. Right Knee Instability In a January 2014 rating decision, the Veteran was granted a separate rating for right knee instability, rated as 10 percent disabling, effective April 12, 2013. As was discussed at length above, the Board has found that an earlier effective date of August 6, 2008 is warranted. Recurrent subluxation or lateral instability can be rated as slight (10 percent), moderate (20 percent), or severe (30 percent). 38 C.F.R. § 4.71a, Diagnostic Code 5257. Terms such as “slight,” “moderate,” and “severe” are not defined in the rating schedule. Rather than applying a mechanical formula, VA must evaluate all the evidence so that its decisions are equitable and just. 38 C.F.R. § 4.6. The Board has reviewed all of the evidence of record, but finds that at no time has the Veteran’s right knee disability been found to be at least “moderate,” and an initial rating higher than 10 percent is not warranted. While past VA examinations have found some instability and positive Lachman test results, at no time has any examiner ever found that the Veteran’s instability was “moderate” or worse. At the April 2010 VA examination, the Veteran reported “giving way” of the knee, and he had a positive Lachman test, although there was no finding of any significant instability. The August 2013 VA examination found 1+ (0-5 millimeters) anterior instability, which was the lowest measurable amount. Posterial and medial-lateral stability was normal. At a June 2014 VA examination, joint stability testing was normal, although the Veteran reported having instability. The December 2019 VA examiner did not find any current instability based on clinical evaluation, and joint stability testing was normal, including the Lachman test. The examiner did, however, write that the Veteran needed braces, crutches, and a cane due to degenerative changes and instability. A March 2017 Disability Benefits Questionnaire was submitted, completed by private physician W.J. He wrote that the Veteran had instability, which he measured as 2+ (3-10 millimeters) of anterior instability. Posterior and medial-lateral instability were normal. The Veteran’s VA and private treatment records show no indication of an instability disorder which has caused significant effects or that could be considered at least “moderate.” While the Veteran reported to his VA provider in June 2010 that he had right knee instability, his treatment providers noted on several occasions in 2011-2012 that he did not have instability in his right knee. Private treatment from January 2010 found 1+ stability, but subsequent physical therapy records did not indicate any instability. A June 2010 statement from physician J.A. stated that the Veteran had lateral instability, but did not specify the severity of it. The Board therefore finds that the preponderance of the evidence shows that while the Veteran has reported having instability in his knee, there is no clinical evidence that it was ever worse than “slight,” and a rating higher than 10 percent is not warranted. The Board acknowledges that the March 2017 Disability Benefits Questionnaire found anterior instability of 2+, which is greater than the instability found at VA examinations previously. The subsequent December 2019 VA examination, however, found no measurable instability, and the Board therefore finds that the March 2017 finding is an outlier, and is not, on its own, sufficient to establishing that the Veteran had “moderate” instability in his right knee. The Board has again considered the Veteran’s lay statements, including his frequent assertions of having instability, buckling, and “giving way” in his knee. The Board accepts that these assertions are credible, and the Veteran is competent to report on his symptoms as he experiences them. See Jandreau, 492 F.3d 1372, 1376-77. The Board also acknowledges the Court’s holding in English v. Wilkie, 30 Vet. App. 347, 353 (2018), which held that the Board cannot categorically favor objective stability test results over lay reports of instability. In this case, however, the Board has not rejected the Veteran’s reports, but find that they are consistent with the clinical findings of occasional mild instability. The Veteran has never indicated that his stability was “moderate” or “severe,” or even that it has ever caused further functional impairment, such as falling or inability to walk. The Board finds that the medical evidence and the Veteran’s reports, when taken into their entirety, indicate a disability picture which does not more closely approximate a disorder that is “moderate.” The Board therefore finds that an initial rating higher than 10 percent for right knee instability is not warranted. The Board has again the benefit of the doubt doctrine, but the preponderance of the evidence is against finding that a higher rating for right knee instability is warranted. 38 U.S.C. § 5107(b). REASONS FOR REMAND Right Knee Degenerative Arthritis The Veteran requests initial ratings higher than 10 percent from August 2008, to May 28, 2013, from July 1, 2013, to February 21, 2017, and from April 1, 2017 to December 30, 2019. For the periods from May 29, 2013, to June 30, 2013 and February 22, 2017, to March 31, 2017, the Veteran was assigned temporary total evaluations (100 percent). As he was assigned the maximum available rating during these periods, they are not part of the current appeal. In September 2018, the Board remanded this issue in order to afford the Veteran with a new VA examination and to obtain a retrospective medical opinion regarding whether the Veteran’s range of motion test results for active motion, passive motion, weight-bearing, and nonweight-bearing and during flare ups could be estimated for each of the Veteran’s past examinations. A new VA examination was held in December 2019, but unfortunately the examiner did not provide the retrospective opinion as requested. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (A Board remand confers a right on a claimant to compliance with the remand order.); Dyment v. West, 13 Vet. App. 141, 147 (1999) (clarifying that substantial compliance with Board remand is required). The Board currently finds that a retrospective opinion on active motion, passive motion, weight-bearing, and nonweight-bearing is not required or even feasible for an examiner to provide. However, the Board does remand this issue again so that a retrospective opinion on estimated range of motion during flare ups can be obtained, in compliance with Sharp v. Shulkin, 29 Vet. App. 26 (2017). The examiner is asked to specifically consider whether the findings at the December 2019 examination, which indicated extension limited to 20 degrees during flare ups and with repeated use, would have likely existed in the years prior to this examination. TDIU In June 2014, the Veteran requested entitlement to a TDIU, indicating that he was prevented from working due to depression and cirrhosis of the liver. He wrote that he had last worked as a carpenter in 2007. In May 2019, he wrote that “all” of his service-connected disabilities prevented him from working, and described how he had pain on the job from his joint disorders and had difficulty with irritability and relationships. Physician R.B. submitted a letter in August 2020 stating that the Veteran had been under his care since 2008. He wrote that the Veteran had been unable to work for several years due to major depressive disorder, right knee pain, and low back pain. He wrote that the Veteran had last worked in 2007 and was a high school graduate. According to the physician, the Veteran’s records showed that his disabilities caused marked interference with employment, including preventing him from carrying out routine duties and responsibilities as a carpenter. Dr. R.B. wrote that the Veteran’s back and right knee disabilities caused difficulty sitting and standing for long periods of time, and his mental disability caused occupation and social impairment. He concluded that the overall picture of the Veteran’s disabilities would at least as likely as not render him unable to obtain or maintain gainful occupation, both physical and sedentary. The Board finds that while the August 2020 letter from R.B. does provide evidence in favor of the claim, it is unclear from this letter when the Veteran stopped being able to work, as the physician only wrote that he had been unable to work “for several years.” The physician’s rationale also is not consistent with the Veteran’s own reports that it was not back and knee pain that caused him to stop working as a carpenter, but was depression and cirrhosis of the liver. This issue is currently intertwined with the issue being remanded, as this issue will affect the Veteran’s total rating throughout the appeal period. The Board notes that the Veteran only currently meets the criteria for a schedular TDIU from February 4, 2013, although the current appeal dates back to August 6, 2008. While unemployability is a legal determination, as was explained in Moore v. Shinseki, 555 F.3d 1369, 1373 (Fed. Cir. 2009), the Board finds that there is a paucity of medical evidence directly addressing the impact of the Veteran’s service-connected disabilities on his occupational functioning, and the Board is unable to make this determination without addition medical information. The Board requests that a VA examiner also discuss the impact that all of the Veteran’s service-connected disabilities have had on his occupational functioning and to identify, if possible, if and when his disabilities may have become so severe that they would have prevented maintaining gainful employment. If it is found that a new VA examination is required to make this assessment, schedule such an examination. After all appropriate development is completed, the Agency of Original Jurisdiction should consider whether referral to the Under Secretary for Benefits/Director of the Compensation Service for an extraschedular TDIU should for the period from August 6, 2008 to February 3, 2013, if appropriate. The matters are REMANDED for the following action: 1. Obtain an addendum VA medical opinion from the VA examiner who conducted the December 2019 knees examination. If that examiner is no longer available, obtain an opinion from a similarly qualified examiner. The examiner should review the prior VA examination reports and all VA and private treatment records. He/she should then provide a retrospective opinion discussing whether it was possible to estimate the Veteran’s range of motion (flexion and extension) in the right knee at the time of the April 2010, August 2013, and June 2014 VA examinations. Range of motion estimates for the Veteran’s right knee during flare ups and with repeated motion should be provided for the entire period on appeal, August 2008 to the present, if possible. The examiner is asked to comment on the findings of the December 2019 VA examination, which found that during flare ups and with repeated motion, the Veteran would have extension limited to 20 degrees. Is it as likely as not that the Veteran had extension limited to 20 degrees with flare ups and with repeated motion in the years prior to this examination? A complete and fully explanatory rationale must be provided for any opinion offered. The Board advises that it is inadequate for the examiner to state that he or she is unable to offer such an opinion because the examinations were not performed during flare ups. Rather, the examiner must attempt to estimate the functional loss based on statements provided by the Veteran and available medical records. If the examiner is not able to provide such estimates without resorting to speculation, the examiner must fully explain why. 2. Obtain a medical opinion regarding the impact of the Veteran’s service-connected disabilities on his occupational functioning. If it is found that a VA examination must be held prior to providing such an opinion, schedule the Veteran for an examination. It may be conducted via telehealth or similar service during social distancing restrictions.  The record and a copy of this remand must be made available to, and reviewed by, the examiner.  The examiner is asked to discuss what impact the Veteran’s service-connected disabilities have on his occupational functioning. The examiner is advised that the Veteran is currently service connected for major depressive disorder, right knee disorders, chronic lumbar strain, left wrist fracture, tinnitus, and left ear hearing loss. The examiner is also asked whether it is possible to determine, based on a review of the record, if and when the Veteran’s disabilities became so severe that he was unable to continue working. A complete and fully explanatory rationale must be provided for any opinion offered. 3. If warranted by the evidence, the issue of entitlement to a TDIU on an extraschedular basis prior to February 4, 2013 should be referred to the Under Secretary for Benefits/Director of the Compensation Service for consideration under 38 C.F.R. § 4.16(b). DELYVONNE M. WHITEHEAD Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Mary E. Rude, 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.