Citation Nr: 21002742 Decision Date: 01/14/21 Archive Date: 01/14/21 DOCKET NO. 15-04 214A DATE: January 14, 2021 ORDER Entitlement to a rating in excess of 10 percent prior to February 28, 2011, and in excess of 20 percent thereafter, for a right shoulder chronic tendonitis is denied. Entitlement to a rating in excess of 10 percent for degenerative joint disease of the left knee is denied. Entitlement to a rating in excess of 10 percent for degenerative joint disease of the right knee is denied. Entitlement to a rating in excess of 10 percent prior to June 8, 2011, and a compensable rating thereafter, for left knee instability is denied. Entitlement to service connection for an unspecified depressive disorder as secondary to service connected disabilities is granted. REMANDED Entitlement to service connection for a stomach condition is remanded. FINDINGS OF FACT 1. For the appeal period prior to February 28, 2011, the Veteran’s right shoulder chronic tendonitis manifested by painful motion without approximate limitation to shoulder level or less, ankylosis, malunion of the humerus, recurrent dislocation at the scapulohumeral joint, fibrous union of the humerus, nonunion of the humerus or loss of head of the humerus. 2. For the appeal period beginning February 28, 2011, the Veteran’s right shoulder chronic tendonitis manifested by painful and limited range of motion without approximate limitation to midway between side and shoulder level, or less, ankylosis, malunion of the humerus, recurrent dislocation at the scapulohumeral joint, fibrous union of the humerus, nonunion of the humerus or loss of head of the humerus. 3. For the entire period on appeal, the Veteran’s degenerative joint disease of the left knee has been manifested by painful motion, flexion that was limited to, at worst, 80 degree and extension to 10 degrees, at worst, even in contemplation of functional loss due to symptoms such as pain, fatigue, weakness, lack of endurance, or incoordination, or as a result of repetitive motion and/or flare-ups without effusion, ankylosis, impairment of the tibia and fibula, or genu recurvatum. 4. For the entire period on appeal, the Veteran’s degenerative joint disease of the right knee has been manifested by painful motion, flexion limited to, at worst, 80 degrees and extension to 10 degrees, at worst, even in contemplation of functional loss due to symptoms such as pain, fatigue, weakness, lack of endurance, or incoordination, or as a result of repetitive motion and/or flare-ups without recurrent subluxation or lateral instability, effusion, ankylosis, impairment of the tibia and fibula, or genu recurvatum. 5. For the entire period on appeal, the Veteran’s left knee instability was manifested by, at worst, slight lateral instability. 6. Resolving all reasonable doubt in the Veteran's favor, his unspecified depressive disorder was aggravated by his service connected disabilities. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 10 percent prior to February 28, 2011, and in excess of 20 percent thereafter for a right shoulder disorder have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1—4.14, 4.27, 4.40, 4.45, 4.71a, Diagnostic Codes 5200-5203. 2. For the entire period on appeal, the criteria for an initial rating in excess of 10 percent for degenerative joint disease of the left knee have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.2, 4.3, 4.6, 4.7, 4.40, 4.45, 4.71a, Diagnostic Codes 5256-5263. 3. For the entire period on appeal, the criteria for an initial rating in excess of 10 percent for degenerative joint disease of the right knee have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.2, 4.3, 4.6, 4.7, 4.40, 4.45, 4.71a, Diagnostic Codes 5256-5263. 4. For the entire period on appeal, the criteria for an initial rating in excess of 10 percent for left knee instability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.2, 4.3, 4.6, 4.7, 4.40, 4.45, 4.71a, Diagnostic Codes 5256-5263. 5. The criteria for service connection for unspecified depressive disorder as secondary to service connected disabilities have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from August 1974 to October 1977, and from January 1979 to October 1982. The period of service from November 1982 to May 1986 is dishonorable for VA purposes. This matter comes to the Board of Veterans’ Appeals (Board) on appeal from January 2009, April 2010, and September 2011 rating decisions issued by the Department of Veterans Affairs (VA) Regional Office (RO). Jurisdiction of this appeal is currently with the RO in Chicago, Illinois. This case was most recently before the Board in May 2018, at which time the appeal was remanded to the Agency of Original Jurisdiction (AOJ) for further development. Specially, it was remanded to obtain the Veteran’s updated VA treatment records and to schedule a VA examination to determine the current nature and severity of his right shoulder chronic tendonitis, right knee degenerative joint disease and left knee degenerative joint disease. Updated VA treatment records have been associated with the record and a December 2018 VA examination was conducted to determine the current nature and severity of his right shoulder chronic tendonitis, right knee degenerative joint disease and left knee degenerative joint disease. Therefore, the Board finds that there has been substantial compliance with its previous remand. Stegall v. West, 11 Vet. App. 268 (1998). The case has now been returned to the Board for appellate action. In September 2020, the Veteran’s attorney requested a 90 extension of time to submit evidence and argument. The Board granted this Motion for Extension of Time in October 2020. Additional evidence and argument in support of this appeal was received in December 2020 and the requested period of extension has expired. Increased Rating Disability evaluations are determined by evaluating the extent to which a Veteran’s service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing his symptomatology with the criteria set forth in the Schedule for Rating Disabilities (Rating Schedule). 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10. Where there is a question as to which of two evaluations shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that evaluation. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Reasonable doubt as to the degree of disability will be resolved in the Veteran’s favor. 38 C.F.R. § 4.3. It is permissible to switch diagnostic codes to reflect more accurately a claimant’s current symptoms. See Read v. Shinseki, 651 F.3d 1296, 1302 (Fed. Cir. 2011). Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Although a rating specialist is directed to review the recorded history of a disability in order to make a more accurate evaluation, see 38 C.F.R. § 4.2, the regulations do not give past medical reports precedence over current findings. Francisco v. Brown, 7 Vet. App. 55 (1994). Pertinent regulations do not require that all cases show all findings specified by the Rating Schedule, but that findings sufficiently characteristic to identify the disease and the resulting disability and above all, coordination of rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21. Therefore, the Board has considered the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the Veteran, as well as the entire history of the Veteran’s disability in reaching its decision. Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). In general, all disabilities, including those arising from a single disease entity, are rated separately, and all disability ratings are then combined in accordance with 38 C.F.R. § 4.25. Pyramiding, the evaluation of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when rating a Veteran’s service-connected disability. 38 C.F.R. § 4.14. It is possible for a Veteran to have separate and distinct manifestations from the same injury which would permit rating under several diagnostic codes, however, the critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the conditions is duplicative or overlapping with the symptomatology of the other condition. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). Separate ratings can be assigned for separate periods based on the facts found - a practice known as “staged” ratings. Francisco v. Brown, 7 Vet. App. 55, 58 (1994); Hart v. Mansfield, 21 Vet. App. 505 (2007). Staged ratings are appropriate whenever the factual findings show distinct periods where the service-connected disability exhibits symptoms that would warrant different ratings. Id. The basis of disability evaluation is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. When an evaluation of a disability is based upon limitation of motion, the Board must also consider, in conjunction with the otherwise applicable diagnostic code, any additional functional loss the Veteran may have sustained by virtue of other factors as described in 38 C.F.R. §§ 4.40 and 4.45. DeLuca v. Brown, 8 Vet. App. 202, 206 (1995). Such factors include more or less movement than normal, weakened movement, excess fatigability, incoordination, pain on movement, swelling, and deformity or atrophy from disuse. A finding of functional loss due to pain must be supported by adequate pathology and evidenced by the visible behavior of the Veteran. 38 C.F.R. § 4.40; Johnston v. Brown, 10 Vet. App. 80, 85 (1997). 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. Functional loss may be due to the absence or deformity of structures or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior in 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. In Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011), the Court of Appeals for Veterans Claims (Court) held that, although pain may cause a functional loss, “pain itself does not rise to the level of functional loss as contemplated by VA regulations applicable to the musculoskeletal system.” Rather, pain may result in functional loss, but only if it limits the ability “to perform the normal working movements of the body with normal excursion, strength, speed, coordination, or endurance.” Id., quoting 38 C.F.R. § 4.40. With respect to joints, in particular, the factors of disability reside in reductions of normal excursion of movements in different planes. Inquiry will be directed to more or less than normal movement, weakened movement, excess fatigability, incoordination, pain on movement, swelling, deformity or atrophy of disuse. 38 C.F.R. § 4.45; DeLuca v. Brown, 8 Vet. App. 202 (1995). The intent of the Rating Schedule is to recognize actually painful, unstable or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint, even in the absence of arthritis. 38 C.F.R. § 4.59; Burton v. Shinseki, 25 Vet. App. 1, 5 (2011). In this regard, 38 C.F.R. § 4.59 requires that “[t]he joints involved should be tested for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with the range of the opposite undamaged joint.” Correia v. McDonald, 28 Vet. App. 158 (2016). Further, 38 C.F.R. § 4.59 is applicable to the evaluation of musculoskeletal disabilities involving actually painful, unstable or malaligned joints or periarticular regions, regardless of whether the Diagnostic Code under which the disability is evaluated is predicated on range of motion measurements. Southall-Norman v. McDonald, 28 Vet. App. 346 (2016). Although the Board has an obligation to provide reasons and bases supporting its decision, there is no obligation to discuss, in detail, the extensive evidence of record. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (holding that the Board must review the entire record but does not have to discuss each piece of evidence). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board’s analysis will focus specifically on what the evidence shows, or fails to show, as it relates to the Veteran’s claims. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). 1. Right Shoulder Chronic Tendonitis The Veteran asserts that he should be in receipt of higher ratings for his right shoulder chronic tendonitis as his symptoms are more severe than that which is reflected by the current ratings assigned. Specifically, the Veteran asserts that his right shoulder chronic tendonitis severely limits the use of his right arm and hurts almost all of the time. See August 2011 VA Form 21-4138 Statement in Support of Claim. Further, he asserts that he is losing grip in his right and left hands, mostly in large part due to his head injuries. See August 2011 VA Form 21-4138 Statement in Support of Claim. The Veteran’s service-connected right shoulder chronic tendonitis is rated as 10 percent disabling prior to February 28, 2011 and 20 percent thereafter under Diagnostic Code 5201. 38 C.F.R. § 4.71a. Disabilities and injuries of the shoulder are evaluated under Diagnostic Codes 5200, 5201, 5202 and 5203. See 38 C.F.R. § 4.71(a). The evidence establishes the Veteran is right-handed, so his right shoulder is rated for the impairment of the major upper extremity. 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). Therefore, the Board will evaluate the Veteran’s right shoulder disorder under the diagnostic code that will provide the most favorable rating, mindful not to pyramid and overly compensate him for the same symptom. See, e.g., Esteban v. Brown, 6 Vet. App. 259, 261 (1994). Under Diagnostic Code 5201, for the major side, a 20 percent rating is warranted for limitation of arm motion to shoulder level; a 30 percent rating is warranted for limitation of arm motion to midway between the side and shoulder level; and a maximum 40 percent rating is warranted for limitation of arm motion to 25 degrees from the side. 38 C.F.R. § 4.71a, Diagnostic Code 5201. Under Diagnostic Code 5202, for the major side, a 20 percent rating is warranted for malunion of with moderate deformity; a 30 percent rating is warranted for malunion of with marked deformity. Under Diagnostic Code 5202, humerus, other impairment of, a 20 percent rating is warranted for recurrent dislocation of at scapulohumeral joint with infrequent episodes, and guarding of movement only at shoulder level; a 30 percent rating is warranted for recurrent dislocation of at scapulohumeral joint with frequent episodes and guarding of all arm movements; a 50 percent rating is warranted for fibrous union of; a 60 percent rating is warranted for nonunion of (false flail joint); and an 80 percent rating is warranted for loss of head of (flail shoulder). 38 C.F.R. § 4.71a, Diagnostic Code 5202. Under Diagnostic Code 5203, clavicle or scapula, impairment of, for the major side, a 10 percent rating is warranted for malunion of; a 10 percent rating is warranted for nonunion of without loose movement; a 20 percent rating is warranted for nonunion of with loose movement; and a 20 percent rating is warranted for dislocation of. 38 C.F.R. § 4.71a, Diagnostic Code 5203. Normal forward flexion of the shoulder is zero to 180 degrees; abduction is zero to 180 degrees; and internal and external rotation are from zero to 90 degrees. 38 C.F.R. § 4.71a, Plate I. Forward flexion and abduction to 90 degrees amounts to shoulder level. The Veteran was afforded a VA examination in November 2008. At that time, he reported he strained his right shoulder during active service when lifting heavy guns and ammunition. Upon physical examination, the Veteran did not have evidence of abnormal weight-bearing of the right shoulder. Range of motion measurements were as follows: flexion (forward elevation) active motion against gravity was from 0 to 180 degrees, pain was not shown on examination, and there was no additional loss of motion on repetitive use; abduction active motion against gravity was from 0 to 180 degrees, with pain beginning at 90 degrees and ending at 150 degrees; passive range of motion was from 0 to 180 degrees, with pain beginning at 90 degrees and ending at 150 degrees, and there was no additional loss of motion on repetitive use; external rotation active motion against gravity was from 0 to 90 degrees, pain was not shown on examination, and there was no additional loss of motion on repetitive use; internal rotation active movement against gravity was from 0 to 90 degrees, pain was not shown on examination, and there was no additional loss of motion on repetitive use. There was no loss of a bone or part of a bone, recurrent shoulder dislocations, inflammatory arthritis, nor joint ankylosis. The Veteran had right shoulder bursitis with painful movement. The Veteran was afforded another VA examination in June 2011. At that time, he reported that his right shoulder was worse since his last examination, and had more pain. He did not report any additional or new treatments at that time. The Veteran’s shoulder did not have deformity, giving way, instability, weakness, incoordination, episodes of dislocation or subluxation, locking episodes, effusion, nor flare-ups. The Veteran had pain, stiffness, decreased speed of joint motion, tenderness, and affected motion of the joint. Upon physical examination, the right shoulder had tenderness. Range of motion measurements were as follows: flexion was from 0 to 180 degrees; abduction was from 0 to 180 degrees; internal rotation was from 0 to 90 degrees; and external rotation was from 0 to 90 degrees. There was objective evidence of pain following repetitive motion, and there were no additional limitations after three repetitions of range of motion. Pain was present on the right shoulder on extremes of range, and no change on repetition. There was no joint ankylosis. Diagnostic imaging results showed mild osteoarthritis involving the acromioclavicular joint, unremarkable glenohumeral joint, subacromial space was maintained and there was no abnormal calcification. The examiner diagnosed mild acromioclavicular osteoarthritis. The examiner noted there was no significant effect on the Veteran’s usual occupation or on usual daily activities. The Board notes that VA treatment records from January 2009, May 2009, and July 2009 noted the Veteran did not have limitation or instability of the joints and the January 2009 VA treatment record indicated the knee joints had satisfactory range of motion without deformity or instability. The Veteran was afforded another VA examination in December 2018. At that time, he reported he had continued daily pain in the back of his right shoulder. He did not have a history of hospitalization, surgery, or specialized procedures for his right shoulder disorder. He stated his right shoulder pain was aggravated by any type of pressure to the shoulder and when he was in a stooped posture. He stated he had a dull ache that was constant, and when aggravated was described as a sharp pain inside the right shoulder. He stated that with flare-up pain, he was unable to move his shoulder; and treated with rest and icy hot topical cream to alleviate the pain. He did not have problems with his left shoulder. He was right hand dominant. He endorsed flare-ups of the shoulder and described the flare-up as that his shoulder had a sharp stabbing pain. He reported functional loss or functional impairment that he could no longer drive the big rig trucks and was transferred to a sedentary job. Upon physical examination, range of motion measurements of the right shoulder was as follows: flexion was to 100 degrees; abduction was to 90 degrees; external rotation was to 40 degrees; and internal rotation was to 70 degrees. Range of motion itself was noted to contribute to a functional loss due to less motion. Pain was noted on flexion, abduction, external rotation, and internal rotation; and caused functional loss. There was no evidence of pain with weight-bearing. There was objective evidence of localized tenderness or pain on palpation of the scapular tenderness to palpation related to inflammation. There was no objective evidence of crepitus. In the December 2018 VA examination, the Veteran was able to perform repetitive use testing with at least three repetitions; and there was no additional functional loss or range of motion after three repetitions. The Veteran was not examined immediately after repetitive use over time and the examination was neither medically consistent nor inconsistent with the Veteran’s statements describing functional loss with repetitive use over time. The examiner was unable to state whether pain, weakness, fatigability or incoordination significantly limited functional ability with repeated use over a period of time, and noted that the examiner was unable to state what loss of function the Veteran experienced because there was not a current scientific way that the clinician based on experience and clinical acumen was able to objectively measure or evaluate the degrees of additional range of motion loss due to “pain on use or during the Veteran’s experienced ‘flare-ups’ as any attempt to provide this data would be mere speculation.” The examination was not conducted during a flare-up and the examination was medically consistent with the Veteran’s statements describing functional loss during flare-ups. The examiner was unable to state whether pain, weakness, fatigability or incoordination significantly limited functional ability during flare-ups, and noted that the examiner was unable to state what loss of function the Veteran experienced because there was not a current scientific way that the clinician based on experience and clinical acumen was able to objectively measure or evaluate the degrees of additional range of motion loss due to “pain on use or during the Veteran’s experienced ‘flare-ups’ as any attempt to provide this data would be mere speculation.” There were no additional contributing factors of disability found. Muscle strength testing showed active movement against some resistance, and there was a reduction in muscle strength. The reduction was entirely due to the Veteran’s service-connected right shoulder disorder. The Veteran did not have muscle atrophy. There was no ankylosis. A rotator cuff condition was suspected. The Veteran had a positive Hawkins’ Impingement Test, positive Empty-can Test, positive external rotation/infraspinatus strength test, and positive lift-off subscapularis test. There was no shoulder instability, dislocation or labral pathology suspected. There was no clavicle, scapula, acromioclavicular joint or sternoclavicular joint condition suspected. The Veteran did not have loss of head (flail shoulder), nonunion (false flail shoulder), or fibrous union of the humerus. There were no other pertinent physical findings, complications, conditions, signs and/or symptoms found. The Veteran denied the use of any assistive devices. Functioning was not so diminished that amputation with prosthesis would equally serve the Veteran. The examiner noted the Veteran’s right shoulder pain with repetitive overhead use and heavy lifting impacted his ability to work. Passive and weight-bearing range of motion was not examined due to potential for injury to the Veteran. Here, the Board has considered the effects of repeated use over time and flare-ups along with the adequacy of the VA examinations in light of the Court’s holdings in Correia and Sharp. See Correia v. McDonald, supra, and Sharp v. Shulkin, supra. In this case, the November 2008 and June 2011 VA examinations were conducted prior to Correia and Sharp and provides only partial information as described above. The November 2008 and June 2011 VA examiners indicated there was no interference with weight-bearing and that pain was noted on examination. The effect of pain on range of motion is described above. Regarding repeated use over time, the Board notes that even though the examiners could not provide an opinion regarding additional functional impairment during a flare-up, the examinations are still adequate even with consideration of the decision in Sharp v. Shulkin, supra. In this regard, the Veteran denied experiencing flare-ups of his right shoulder at his November 2008 and June 2011 VA examinations; and described functional impairment during a flare-up at his December 2018 VA examination as increased pain. Given the information provided by the Veteran, the Board finds that the functional impairment during a flare-up is adequately described despite the examiner’s inability to provide an opinion regarding such. Therefore, the November 2008, June 2011, and December 2018 VA examinations are adequate for adjudication purposes. As noted above, the Board acknowledges that the examiners were not able to provide opinions regarding additional functional impairment during flare-ups or following repetition. However, the Board finds that all information required for rating purposes was provided. In this regard, the Board notes that the examiners clearly noted that the Veteran specifically reported increased pain, and reported inability to lift his arm. There is no other indication from the record, to include the Veteran’s own statements, that he experiences additional decreased range of motion, weakness, or incoordination during flare-ups or following repeated use other than shown above. As the Veteran has not endorsed those symptoms, the Board finds the examinations of record to be adequate for rating purposes. See Correia v. McDonald, supra; see also Sharp v. Shulkin, supra. Although the Veteran had pain throughout all ranges of motion, the Court has clearly indicated that painful motion does not equate to limited motion. Mitchell v. Shinseki, supra. Rather, pain must affect some aspect of the normal working movements of the body such as excursion, strength, speed, coordination, and endurance to constitute a functional loss. Id. To the extent that the Veteran pain in his right shoulder, the effect of such pain in the Veteran’s right shoulder is already contemplated in the assigned rating. Based on the foregoing, the Board finds that the totality of the evidence does not support a rating higher than 10 percent for his right shoulder prior to February 28, 2011. As noted, range of motion testing was performed during the November 2008 VA examination. Range of motion was, at worst, 180 degrees of flexion and zero degrees of extension, and zero to 90 degrees of internal and external rotation each. The reports do not suggest that the specific findings on examination, in terms of range of motion, would change to the degree required for a higher rating during a flare-up, after repetitive use, due to pain, or with weight bearing, nor does any other evidence of record to include the Veteran’s lay statements. In this regard, the VA examiners noted that the Veteran did not experience additional functional loss following repetitive use, and that shoulder joint function was additionally limited by pain on motion. Specifically, the Veteran denied flare-ups of the right shoulder. Thus, the Board finds that the Veteran’s right shoulder disorder pictures does not more closely approximate limitation to shoulder level. There is no indication from the functional impairment described in the various medical reports of record that the Veteran had impairment of the right shoulder that more closely approximated an inability to lift the right shoulder to shoulder level or less. Further, consideration has been given to the functional impairment the Veteran experiences after repeated use over time and during flare-ups. However, there is no indication from the record that the additional impairment more closely approximates an inability to lift his right arm to shoulder level. Those symptoms do not support a higher rating. As such, a higher rating, prior to February 28, 2011, for the Veteran’s right shoulder chronic tendonitis is not warranted. 38 C.F.R. § 4.71a, Diagnostic Code 5201. Based on the foregoing, the Board finds that the totality of the evidence does not support a rating higher than 20 percent for his right chronic tendonitis beginning February 28, 2011. As noted, range of motion testing was performed during the June 2011 and December 2018 VA examinations. Range of motion was, at worst, flexion was to 100 degrees; abduction was to 90 degrees; external rotation was to 40 degrees; and internal rotation was to 70 degrees. The reports do not suggest that the specific findings on examination, in terms of range of motion, would change to the degree required for a higher rating during a flare-up, after repetitive use, due to pain, or with weight bearing, nor does any other evidence of record to include the Veteran’s lay statements. In this regard, the VA examiners noted that the Veteran did not experience additional functional loss following repetitive use, and that shoulder joint function was additionally limited by pain on motion. The December 2018 VA examiner noted the Veteran had increased pain with repeated use. Thus, the Board finds that the Veteran’s right shoulder disorder pictures does not more closely approximate limitation to midway between side and shoulder level. There is no indication from the functional impairment described in the various medical reports of record that the Veteran had impairment of the right shoulder that more closely approximated an inability to lift the right shoulder to shoulder level or less. Further, consideration has been given to the functional impairment the Veteran experiences after repeated use over time and during flare-ups. However, there is no indication from the record that the additional impairment more closely approximates an inability to lift his right arm to midway between side and shoulder level, or less. Those symptoms do not support a higher rating. As such, a higher rating, beginning February 28, 2011 for the Veteran’s right shoulder chronic tendonitis is not warranted. 38 C.F.R. § 4.71a, Diagnostic Code 5201. The Board has also considered whether higher ratings are warranted under any other diagnostic code at any time. However, given the objective evidence of movement of the right shoulder during the examinations outlined above, the joint is clearly not ankylosed. In fact, ankylosis was specifically noted by the examiners to not be present. 38 C.F.R. § 4.71a, Diagnostic Code 5200. In addition, there is no competent evidence that there is fibrous union or other impairment of the humerus to warrant a higher rating at any time during the period on appeal. 38 C.F.R. § 4.71a, Diagnostic Code 5202. The Board acknowledges the Veteran’s statements that his right shoulder chronic tendonitis is more severe than evaluated. The Veteran is competent to report his symptoms and has presented credible statements in this regard, to include inability to lift his arm on occasion. Layno v. Brown, supra. The Board finds, however, that neither the Veteran’s statement nor medical evidence demonstrates that the criteria for higher ratings have been met. The Board also acknowledges that the Veteran’s VA treatment records note complaints of and treatment for his right shoulder. However, these records do not address the specific rating criteria necessary to determine severity. In determining the actual degree of disability, the examination findings are more probative of the degree of impairment. The Board has considered whether further staged rating under Hart, supra, are warranted, however, the Board finds that his symptomatology has been stable throughout each period on appeal. Therefore, assigning additional staged ratings is not warranted. Further, neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, supra. Finally, the Board notes the ruling of the Court in Rice v. Shinseki, 22 Vet. App. 447 (2009). In Rice, the Court held that a claim for a total rating based on unemployability due to service-connected disability (TDIU), either expressly raised by the Veteran or reasonably raised by the record, involves an attempt to obtain an appropriate rating for a disability and is part of the claim for an increased rating. In this case, the Veteran reported working as a manager for a trucking company in a December 2018 VA examination. As such, Rice is inapplicable in this case. Accordingly, the Board finds that the preponderance of the evidence is against the assignment of a rating higher than 10 percent prior to February 28, 2011 and in excess of 20 percent thereafter for a right shoulder chronic tendonitis is not warranted. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, supra. 2. Left and Right Knees Degenerative Joint Disease The Veteran asserts that he should be in receipt of higher ratings for his degenerative joint disease of the left knee, degenerative joint disease of the right knee, and left knee instability as his symptoms are more severe than that which is reflected by the current ratings assigned. Specifically, the Veteran asserts that his knees prevent him from working, cannot stand or walk for prolonged periods, and has difficulty standing on some days. See May 2011 VA Form 21-4138 Statement in Support of Claim; see also August 2011 VA Form 21-4138 Statement in Support of Claim. The Veteran’s service-connected degenerative joint disease of the left and right knee are each currently rated as 10 percent disabling by analogy under Diagnostic Codes 5010 and 5260; and his service-connected left knee instability is currently rated as 10 percent disabling under Diagnostic Code 5257. 38 C.F.R. § 4.71a. Separate ratings can be assigned for knee disabilities when none of the symptomatology overlaps and the separate rating is based on additional disabling symptomatology; this includes separate ratings based on limitation of flexion (Diagnostic Code 5260), limitation of extension (Diagnostic Code 5261), lateral instability or recurrent subluxation (Diagnostic Code 5257), and meniscal conditions (Diagnostic Codes 5258, 5259). See VAOPGCPREC 23-97, 62 Fed. Reg. 63,603 (1997); VAOPGCPREC 9-98, 63 Fed. Reg. 56,703 (1998); VAOPGCPREC 9-2004; 69 Fed. Reg. 59,988 (2004); Lyles v. Shulkin, 29 Vet. App. 107 (2017). The normal range of motion of the knee is from zero degrees extension to 140 degrees flexion. 38 C.F.R. § 4.71, Plate II. Limitation of flexion warrants 10, 20, and 30 percent ratings when limitation is to 45 degrees, 30 degrees, and 15 degrees, respectively. 38 C.F.R. § 4.71a, Diagnostic Code 5260. Limitation of extension warrants 10, 20, 30, 40, and 50 percent ratings when limitation is to 10 degrees, 15 degrees, 20 degrees, 30 degrees, and 45 degrees, respectively. 38 C.F.R. § 4.71a, Diagnostic Code 5261. A 10 percent rating can also be assigned for the knee joint if there is painful motion without compensable limitation of motion. 38 C.F.R. §§ 4.59, 4.71a, Diagnostic Code 5003; see also Burton v. Shinseki, 25 Vet. App. 1 (2011) (holding that the applicability of 38 C.F.R. § 4.59 is not limited to arthritis claims). Recurrent subluxation and lateral instability of the knee warrants a 10, 20, or 30 percent rating if slight, moderate, or severe, respectively. 38 C.F.R. § 4.71a, Diagnostic Code 5257. Ratings can also be assigned when the knee disability affects the meniscus, with a 20 percent rating for dislocated semilunar cartilage with frequent episodes of “locking,” pain, and effusion into the joint and a 10 percent rating for removal of semilunar cartilage (e.g., meniscectomy) and current residual symptoms. 38 C.F.R. § 4.71a, Diagnostic Codes 5258, 5259. Ratings can also be assigned for impairment of the tibia or fibula, genu recurvatum, or ankylosis of the knee. 38 C.F.R. § 4.71a, Diagnostic Codes 5256, 5262, 5263. Ankylosis is stiffening or fixation of a joint as the result of a disease process, with fibrous or bony union across the joint. Dinsay v. Brown, 9 Vet. App. 79, 81 (1996). Ankylosis is also defined as “immobility and consolidation of a joint due to disease, injury, or surgical procedure.” Dorland’s Illustrated Medical Dictionary 93 (30th ed. 2003). In this case the evidence does not reflect, and the Veteran does not allege, that he has tibia or fibula impairment, genu recurvatum, or ankylosis of either knee. As such, those diagnostic codes are not for application. The Veteran was afforded a VA examination in November 2008. At that time, the Veteran reported he injured his knees while running during active service with combat boots on. He reported there was no specific injury, just repeated “stress and strain.” He did not require assistive aids needed for walking. There were no constitutional symptoms of arthritis, incapacitating episodes or arthritis, functional limitations on standing, nor functional limitations on walking. There was no deformity, giving way, nor instability. The Veteran had pain in both knees, and stiffness bilaterally. There was no weakness, episodes of dislocation or subluxation, locking episodes, nor effusion. He denied flare-ups of the knees. There was no inflammation. The condition affected motion in the knees bilaterally. Upon physical examination, the Veteran had an antalgic gait. There was no evidence of abnormal weight-bearing. Range of motion measurements of the left knee was as follows: flexion active motion against gravity was from 0 to 120 degrees, with pain beginning at 100 degrees and pain ending at 120 degrees; passive range of motion was from 0 to 120 degrees, with pain beginning a 100 degrees and pain ending at 120 degrees; and there was no additional loss of motion on repetitive use. Range of motion measurements of the right knee was as follows: flexion active motion against gravity was from 0 to 120 degrees, with pain beginning at 90 degrees and pain ending at 120 degrees; passive range of motion was from 0 to 120 degrees, with pain beginning at 90 degrees and pain ending at 120 degrees; and there was no additional loss of motion on repetitive use. There was no loss of a bone or part of a bone, recurrent dislocations, inflammatory arthritis, nor joint ankylosis. The Veteran did not have Osgood-Schlatter’s disease, crepitation, mass behind knee, click or snaps, grinding, instability, patellar abnormality, meniscus abnormality, nor other tendon or bursa. Diagnostic imaging conducted in conjunction with the November 2008 VA examination documented medial compartment narrowing with arthritis. The examiner diagnosed degenerative arthritis of the knees bilaterally. General occupational effect was significant, and impact was due to pain. Effects of the knees on daily activities were as follows: mild effect on chores; moderate effect on shopping; severe effect on exercise; preventative effect on sports; and a severe effect on recreation. The Board notes that VA treatment records from January 2009, May 2009, and July 2009 noted the Veteran did not have limitation or instability of the joints; and the January 2009 VA treatment record indicated the knee joints had satisfactory range of motion without deformity or instability. The Veteran was afforded another VA examination in March 2010. At that time, the Veteran reported increased bilateral knee pain that was constant, and the knee severity was reported as an average of 7 out of 10 pain intensity on the left side, and 5 out of pain intensity on the right side. He reported he took pain medication and used a brace to treat his knees. There was no history of hospitalization or surgery, trauma, nor neoplasm. The Veteran had deformity, giving way, instability, pain, stiffness, and decreased speed of joint motion. There was no weakness, instability, locking, effusion, nor inflammation. The Veteran reported flare-ups that were severe, and occurred once a year, and lasted more than one month in duration. Flare-ups were described as poor weight bearing tolerance for few weeks, requiring the use of a walker for approximately two months until weight-bearing was tolerated. He was able to stand for 15 to 30 minutes, and unable to walk more than a few years. He used a cane about half of the time and brace constantly as assistive devices. Upon physical examination, the Veteran had an antalgic gait. There was evidence of abnormal weight-bearing. The Veteran had increased wear on the outside edge of both shoes on his heels. There was no loss of a bone or part of a bone, nor inflammatory arthritis. The Veteran was shown to have crepitus, tenderness, pain at rest, abnormal motion, and guarding of motion bilaterally. He did not have Osgood-Schlatter’s disease nor grinding bilaterally. The Veteran had abnormal tracking of the patellar bilaterally. The did not have instability, meniscus abnormality, abnormal tendons or bursae, or other knee abnormalities on the right side. For the left side, the Veteran had mild medial or lateral instability; normal anterior/posterior cruciate ligament stability in 30 and 90 degrees of flexion; and mild laxity of the collateral ligament instability in neutral position. The Veteran had a meniscus abnormality, with evidence of a tear, and positive McMurray’s test on the left side. The March 2010 VA examination found range of motion measurements of the knees bilaterally as follows: flexion was from 0 to 130 degrees; the maximum for the Veteran considering morbidly obsess status and girth of the thigs; with facial grimace observed at 70 degrees; without change of range of motion on repetition; and extension was to 0 degrees without pain, and without change of range of motion repetition. There was no ankylosis bilaterally. Diagnostic imaging results showed very mild degenerative joint disease without acute abnormalities; and chondromalacia, medial meniscus tear of the left knee. The examiner noted that the Veteran was employed full time, for more than 20 years, and had lost no time from work in the last 12 months. He was a truck driver until 2006, when his knees would not allow him to continue driving, and the company he worked for transferred him to a position that required minimal mobility. The examiner diagnosed patellofemoral syndrome and degenerative joint disease of the knees bilaterally, and medial meniscus tear of the left knee. The examiner noted there was significant effects of the bilateral degenerative joint disease of the knees on his usual occupation due to decreased mobility and pain. Effects of the knees on daily activities were as follows: moderate effect on chores, severe effect on shopping, severe effect on exercise, preventative effect on sports, moderate effect on recreation, mild effect on traveling and mild effect on driving. The Veteran was afforded another VA examination in June 2011. At that time, he reported that he had more pain in his left knee than last year, and that his right knee had not changed. He reported he used pain medication to treat his knees. There was no history of hospitalization or surgery, or trauma, nor neoplasm. Symptoms for the left knee were as follows: no deformity, giving way, instability, pain, stiffness, weakness, no incoordination, decreased speed of joint motion, episodes of dislocation or subluxation several times a week, no locking episodes, no effusion, and flare-ups that were severe, occurring weekly, and lasting hours, with spontaneous onset, and alleviated with rest and pain medication. Symptoms for the right knee were as follows: no deformity, no giving way, no instability, pain, stiffness, no weakness, no incoordination, decreased speed of motion, no episodes of dislocation or subluxation, no locking episodes, no effusion, tenderness, and flare-ups that were severe, occurring weekly, and lasting hours, with spontaneous onset, and alleviated with rest and pain medication. Impairment during flare-ups of the bilateral knees required the Veteran to stay in bed. There were no constitutional symptoms of arthritis nor incapacitating episodes of arthritis. The Veteran was unable to stand for more than a few minutes and unable to walk for more than few yards. The Veteran endorsed the constant use of a cane and brace. Upon physical examination under the June 2011 VA examination, the Veteran had an antalgic gait. There was no evidence of abnormal weight-bearing. There was no loss of bone or part of a bone. There was no inflammatory arthritis. Tenderness was shown bilaterally. He did not have Osgood-Schlatter’s disease, mass behind the knee, grinding, instability, patellar abnormality, nor meniscus abnormality bilaterally. The Veteran was shown to have clicking or snaps on the left side. Range of motion measurements of the left knee was as follows: flexion was from 0 to 120 degrees; extension was normal; and there was objective evidence of pain with active movement on the left side. Range of motion measurements of the right knee was as follows: flexion was from 0 to 130 degrees; extension was normal; and there was objective evidence of pain with active motion on the right side. There was no ankylosis bilaterally. Other significant physical findings included that pain started at 120 degrees of flexion bilaterally, and no change with repetition. The examiner noted that the Veteran was employed full time, for 10 to 20 years, and had lost 16 weeks from work in the last 12 months due to pain in the knees. The examiner diagnosed mild degenerative joint disease of the knees and patellofemoral syndrome bilaterally. The examiner noted there were significant effects on the usual occupation due to decreased mobility, pain, and resulting increased absenteeism. There were no effects of the bilateral knees on the usual daily activities. The Veteran was afforded another VA examination in January 2018. At that time, the Veteran reported increasing pain and giving out, and used braces as prescribed. He stated he had several falls due to his knees giving out, but was able to get up and not get injured. He reported daily bilateral knee pain and with flare-ups, and used a walked due to his recent falls. He stated prolonged standing, walking and using stairs aggravated his knee pain. He stated he could not climb ladders and squat due to his knee condition; and that he rested, laid down, stretched for many hours, and icy hot topical creams to alleviate the pain. He stated takes indomethacin daily for arthritis knee pain. He endorsed flare-ups of the knee pain that was described as sharp pain inside his knees, and having to stop and rest and use icy hot cream on his knees. Functional loss or functional impairment was reported as limited walking and standing to n more than 5 to 10 minutes, unable to squat, and unable to climb ladders. Range of motion measurements of the bilateral knees were as follows: flexion was from 5 to 100 degrees each; and extension was to 5 degrees each. Range of motion itself contributed to a functional loss due to less motion bilaterally. Pain was noted on flexion and extension and caused a functional loss bilaterally. There was evidence of pain on weight-bearing bilaterally. There was objective evidence of crepitus bilaterally. There was objective evidence of localized tenderness or pain on palpation of the joint related to inflammation bilaterally. The Veteran was able to perform repetitive use testing with at least three repetitions bilaterally and there was additional functional loss or range of motion after repetition due to pain and lack of endurance. Range of motion after three repetitions of the bilateral knees were as follows: flexion was from 10 to 80 degrees each; and extension was to 10 degrees each. The January 2018 VA examiner noted that the Veteran was examined immediately after repetitive use over time bilaterally and the examiner was unable to say without mere speculation whether pain, weakness, fatigability, or incoordination significantly limited functional ability with repeated use over a period of time. In that regard, the examiner noted that the examiner was unable to state what loss of function the Veteran experienced because there was not a current scientific way that the clinician, based on experience and clinical acumen, was able to objectively measure or evaluate the degrees of additional range of motion loss due to “pain on use or during the Veteran’s experienced ‘flare-ups’ as any attempt ot provide this data would be mere speculation.” The Veteran was not being conducted during a flare-up; and the examination was medically consistent with the Veteran’s statements describing functional loss during flare-ups. The examiner was unable to say without mere speculation whether pain, weakness, fatigability, or incoordination significantly limited functional ability during a flare-up. In that regard, the examiner noted that the examiner was unable to state what loss of function the Veteran experienced because there was not a current scientific way that the clinician based on experience and clinical acumen was able to objectively measure or evaluate the degrees of additional range of motion loss due to “pain on use or during the Veteran’s experienced ‘flare-ups’ as any attempt to provide this data would be mere speculation.” Additional factors contributing to disability included less movement than normal due to ankylosis, adhesions, disturbance of locomotion, and interference with standing bilaterally. The January 2018 VA examiner determined that muscle strength testing was normal, and there was no reduction in muscle strength bilaterally. There was no muscle atrophy bilaterally. There was no ankylosis bilaterally. The Veteran did not have a history of recurrent subluxation, lateral instability, nor recurrent effusion bilaterally. Joint stability testing was normal for the knees bilaterally, and there was no instability found. The Veteran did not have or had ever had recurrent patellar dislocation, “shin splints,” stress fractures, chronic exertional compartment syndrome or any other tibial and/or fibular impairment. The Veteran did not have or has ever had a meniscus (semilunar cartilage) condition. There were no other pertinent physical findings, complications, conditions, signs and/or symptoms found. The Veteran endorsed the occasional use of a brace as a normal mode of locomotion. Functioning was not so diminished that amputation with prosthesis would equally serve the Veteran. Diagnostic imaging studies documented bilateral degenerative or traumatic arthritis. The examiner noted that the Veteran’s bilateral knees impacted his ability to work due to bilateral knee pain with prolonged standing, walking, and using the stairs. Passive and weight-bearing range of motion was not examined due to potential for injury to the Veteran. Further review of the record shows that the Veteran receives VA treatment and from private treatment providers for various disabilities. However, there is no indication from the treatment notes of record that the Veteran has reported knee symptoms that are worse than those noted above. In Sharp v. Shulkin, supra, the Court held that before a VA examiner opines that he or she cannot offer an opinion as to additional functional loss during flare-ups without resorting to speculation based on the fact that the examination was not performed during a flare, the examiner must “elicit relevant information as to the veteran’s flares or ask her to describe the additional functional loss, if any, she suffered during flares and then estimate the veteran’s functional loss due to flares based on all the evidence of record, including the veteran’s lay information, or explain why she could not do so.” Here, the Board has considered the effects of repeated use over time and flare-ups along with the adequacy of the VA examinations in light of the Court’s holdings in Correia and Sharp. See Correia v. McDonald, supra, and Sharp v. Shulkin, supra. In this case, the November 2008, March 2010, and June 2011 VA examinations were conducted prior to Correia and Sharp and provides only partial information as described above. The November 2008, March 2010, and June 2011 VA examiners indicated interference with weight-bearing and that pain was noted on examination. The effect of pain on range of motion is described above. Regarding repeated use over time, the Board notes that even though the examiners could not provide an opinion regarding additional functional impairment during a flare-up, the examinations are still adequate even with consideration of the decision in Sharp v. Shulkin, supra. In this regard, the Veteran denied experiencing flare-ups of his knees at his November 2008 VA examination; and described functional impairment during a flare-up at his March 2010 VA examination as severe and impaired weight-bearing tolerance for a few weeks, and at his June 2011 VA examination as increased pain requiring bed rest. Given the information provided by the Veteran, the Board finds that the functional impairment during a flare-up is adequately described despite the examiner’s inability to provide an opinion regarding such. Therefore, the November 2008, March 2010, and June 2011 VA examinations are adequate for adjudication purposes. As noted above, the Board acknowledges that the examiners were not able to provide opinions regarding additional functional impairment during flare-ups or following repetition. However, the Board finds that all information required for rating purposes was provided. In this regard, the Board notes that the examiners clearly noted that the Veteran specifically reported pain, intolerance for weight-bearing, and requiring bed rest. There is no other indication from the record, to include the Veteran’s own statements, that he experiences additional decreased range of motion, weakness, or incoordination during flare-ups or following repeated use other than shown above. As the Veteran has not endorsed those symptoms, the Board finds the examinations of record to be adequate for rating purposes. See Correia v. McDonald, supra; see also Sharp v. Shulkin, supra. Although the Veteran had pain throughout all ranges of motion, the Court has clearly indicated that painful motion does not equate to limited motion. Mitchell v. Shinseki, supra. Rather, pain must affect some aspect of the normal working movements of the body such as excursion, strength, speed, coordination, and endurance to constitute a functional loss. Id. To the extent that the Veteran pain in his knees, the effect of such pain in the Veteran’s knees is already contemplated in the assigned rating. Based on the foregoing, the Board finds that the totality of the evidence does not support a rating higher than 10 percent for his degenerative joint disease of the left and right knees. As noted, range of motion testing was performed during the various VA examinations of record. Range of motion was, at worst, 80 degrees of flexion and 10 degrees of extension in each knee. The reports do not suggest that the specific findings on examination, in terms of range of motion, would change to the degree required for a higher rating during a flare-up, after repetitive use, due to pain, or with weight bearing, nor does any other evidence of record to include the Veteran’s lay statements. In this regard, the VA examiners noted that the Veteran did not experience additional functional loss following repetitive use, and that knee joint function was additionally limited by pain on motion. The VA examiners noted the Veteran had increased pain with repeated use. Based on the foregoing, the Board finds the evidence, to include the Veteran’s reported symptoms as considered in the VA examination reports and treatment records, does not demonstrate symptoms that rise to the level as required for a higher rating under the diagnostic criteria. While the Veteran has essentially stated that he has reduced motion in his knees, he has not described a range of motion less than that found on examinations. In this regard, he reported that he experienced symptoms that included pain. The Veteran’s statements do not show the requisite limitation of motion necessary for higher or separate ratings. Treatment records do not show greater limitations of motion than the above examination findings. Specifically, the Veteran was not shown to have range of motion that was limited to 30 degrees of flexion or 15 degrees of extension in the either knee. Given the above, even when considering the impact of knee pain on physical activities, higher or separate ratings are not warranted based on limitation of motion. 38 C.F.R. § 4.71a, Diagnostic Code 5260, 5261. With respect to the Veteran’s left knee instability rated under Diagnostic Code 5257, the Board finds that a higher rating is not warranted in his left knee. 38 C.F.R. § 4.71a. The Veteran has generally alleged that he experienced instability and some giving way resulting in falls. However, there are specific objective tests that are designed to reveal instability and laxity of the joints. These tests were administered by a medical professional during those examinations, and the testing revealed no instability or laxity at the VA examinations of record. Given the objective testing performed are generally recognized in the medical community as diagnostic for instability and subluxation, the results are afforded high probative value. Specifically, for the Veteran’s left knee, the Board notes that the Veteran was shown to have mild instability at his March 2010 VA examination, and subluxation or lateral instability was not shown at any other time. And with regard to the Veteran’s right knee, the Board notes that the Veteran was not shown to have subluxation or lateral instability at any time. If subluxation or lateral instability were present to a slight degree, as required for a separate compensable rating, the Board would expect that this would have been identified at least once during the multiple tests that were performed or by the Veteran himself during examination. See 38 C.F.R. §§ 4.31, 4.71a, Diagnostic Code 5257. Instead, the examiners stated that there was no history of recurrent subluxation and lateral instability and consistently found that joint testing revealed no instability. Hence, the most probative evidence is against a higher or separate rating for either his right or left knees under Diagnostic Code 5257. 38 C.F.R. § 4.71a. The Board has considered the applicability of other potential diagnostic codes. As the evidence of record fails to demonstrate a meniscus injury, ankylosis, impairment of the tibia or fibula, or genu recurvatum, the Veteran is not entitled to a higher or separate rating under 5258, 5259, 5256, 5262, or 5263, respectively, for his right and left knee strains. The Board acknowledges the Veteran’s statements that his right and left knee strains are more severe than evaluated. The Veteran is competent to report his symptoms and has presented credible statements in this regard, to include pain, difficulty standing, and requiring bed rest. Layno v. Brown, supra. The Board finds, however, that neither the Veteran’s statement nor medical evidence demonstrates that the criteria for ratings in excess of 10 percent have been met. The Board also acknowledges that the Veteran’s VA treatment records note complaints of and treatment for his right and left knees. However, these records do not address the specific rating criteria necessary to determine severity. In determining the actual degree of disability, the examination findings are more probative of the degree of impairment. The Board has considered whether a staged rating under Hart, supra, are warranted, however, the Board finds that his symptomatology has been stable throughout the period on appeal. Therefore, assigning staged ratings is not warranted. Further, neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, supra. Finally, the Board notes the ruling of the Court in Rice v. Shinseki, supra. In Rice, the Court held that a claim for a TDIU, either expressly raised by the Veteran or reasonably raised by the record, involves an attempt to obtain an appropriate rating for a disability and is part of the claim for an increased rating. In this case, the Veteran reported working as a manager for a trucking company in a December 2018 VA examination. As such, Rice is inapplicable in this case. Accordingly, the Board finds that the preponderance of the evidence is against the assignment of a rating higher than 10 percent for degenerative joint disease of the left knee, against the assignment of a rating higher than 10 percent for degenerative joint disease of the right knee, and the assignment of a rating higher than 10 percent for left knee instability. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, supra. Service Connection Unspecified Depressive Disorder The Veteran asserts that he experiences major depressive disorder which is related to his active service. In the alternative, he alleges that his major depressive disorder was caused or aggravated by his service connected disabilities. To prevail on a direct service connection claim, there must be competent evidence of (1) a current disability, (2) in-service incurrence or aggravation of a disease or injury, and (3) a nexus between the in-service disease or injury and the current disability. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009); 38 U.S.C. §§ 1110, 1131; 38 C.F.R. §§ 3.303(a). Service connection may also be established on a secondary basis for a disability that is shown to be proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) caused by or (b) aggravated by a service-connected disability. Id.; Allen v. Brown, 7 Vet. App. 439 (1995)(en banc). Service treatment records indicate that in July 1979, following a head injury, he was evaluated for a dis-associative reaction, psychosomatic characteristic, possible manic depressive problems, and depression. An August 1983 examination found the Veteran to be psychiatrically normal. Turning to the question of whether there is an etiological relationship between the Veteran's major depressive disorder and service, the Board notes that the record contains two separate etiology opinions which must be considered and weighed. See Hayes v. Brown, 5 Vet. App. 60, 69-70 (1993) (citing Wood v. Derwinski, 1 Vet. App. 190, 192-93 (1992)). See also Guerrieri v. Brown, 4 Vet. App. 467, 470-471(1993) (stating that the probative value of medical evidence is based on the physician's knowledge and skill in analyzing the data, and the medical conclusion the physician reaches; as is true of any evidence, the credibility and weight to be attached to medical opinions are within the province of the Board). When faced with conflicting medical opinions, the Board may favor one medical opinion over the other. See Evans v. West, 12 Vet. App. 22, 30 (1998), citing Owens v. Brown, 7 Vet. App. 429, 433 (1995). The Board will consider each of these opinions below. A November 2010 VA examiner noted that the Veteran was diagnosed with a manic depressive reaction during active duty in July 1979 with notes that the Veteran had a chaotic childhood and three marriages. The examiner opined that it was less likely than not that the Veteran's current depression was related to his manic depressive episode in service, because it was more likely related to witnessing his sister's death when he was a child, childhood abuse, three failed marriages, estrangement from his son, and financial stress. The examiner does not explain how the Veteran's current diagnosis of depression, based in part on his chaotic childhood and three divorces, is not related to his in-service diagnosis of a manic depressive reaction, which was based on the same underlying stressors. The Board found that this opinion was inadequate in its May 2018 remand. In February 2017, the Veteran submitted a private psychiatric evaluation which opined his depression began while on active duty service and continued to the present day. This private nexus opinion also opined that the Veteran's depression was aggravated by his service-connected physical disabilities, but provided no rationale to support that opinion. However, the Board previously noted that this opinion had no supporting rationale other than relying on lay statements from the Veteran's siblings asserting that he was depressed after separating from active duty. The Board found that this opinion was inadequate in its May 2018 remand. A December 2018 VA examination opined the Veteran’s depressive disorder was less likely than not as a result of his active service. The examiner noted that the Veteran had mental health issues in service but the symptoms were not consistent with his current psychiatric symptoms, and that there was no evidence that the symptoms were continuous since service. Therefore, the examiner found there was no nexus between military service and the current diagnosis. Further, in a January 2020 VA addendum opinion, the examiner opined the Veteran’s depressive disorder not otherwise specified was less likely than not proximately due to or the result of his service-connected disabilities as there was no clinical documentation or medical evidence associating his mental health symptoms to his service-connected tendonitis, right shoulder and/or patellofemoral syndrome with degenerative joint disease, or bilateral knees. The examiner opined the Veteran’s unspecified anxiety disorder was less likely than not aggravated beyond its natural progression by his service-connected disabilities as there was no evidence indicating that the Veteran’s symptoms or functioning changed as a result of such disabilities. However, no rationale was provided for this opinion. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A]medical opinion... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions"). This opinion is therefore afforded little, if any, probative weight. A December 2020 private Mental Disorders Disability Benefits Questionnaire (DBQ) report submitted by Dr. H.H.G., Ph.d.. The provider opined that the Veteran's unspecified depressive disorder was more likely than not began in service, continued uninterrupted to the present and is aggravated by his right shoulder injury residuals, left and right knee patellofemoral syndrome with degenerative joint disease, forehead scar with posttraumatic neuralgia, left knee instability and bilateral hearing loss. The provider noted that there is a body of literature detailing the emergence of mental health symptoms within active duty servicemen, that there is also a body of literature detailing the connection between medical issues, such as the issues that the Veteran struggles with and psychiatric disorder, similar to his depressive disorder complaints. The provider noted that individuals with medical issues and depressive disorder debilitation become disabled due to the holistic effect of medical and psychiatric disturbances just like the right shoulder injury residuals, left and right knee patellofemoral syndrome with degenerative joint disease, forehead scar with posttraumatic neuralgia, left knee instability, bilateral hearing loss and secondary depressive endured by the Veteran renders him incapacitated. No rationale was provided for the direct service connection opinion; to that extent, this opinion is afforded little, if any probative weight. Id. In sum, based on the evidence of record, the Board finds that the evidence presently before it is sufficient to grant the appeal, as the Veteran has been diagnosed with an unspecified depressive disorder and has been service connected for a variety of disabilities, to include right shoulder chronic tendonitis, left and right knee patellofemoral syndrome with degenerative joint disease, forehead scar with posttraumatic neuralgia, left knee instability and bilateral hearing loss. Although the December 2020 private opinion contain only a brief rationale as to secondary service connection, and only one opinion has tied the Veteran's current unspecified depressive disorder to his service connected disabilities, the Board notes that it is prohibited from developing additional evidence for the purpose of obtaining evidence against a claimant's case. See Mariano v. Principi, 17 Vet. App. 305 (2003). Accordingly, resolving all doubt in the Veteran's favor, the Board finds that service connection for an unspecified depressive disorder as secondary to service connected disabilities is warranted. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, supra. REASONS FOR REMAND With regard to the Veteran’s claim for service connection for a stomach condition, as noted in the May 2018 Board remand, the Veteran had been afforded a VA examination in March 2011. At that time, the examiner sought treatment during active service, and had current diagnoses for gastritis due to H. pylori was not etiologically related to the symptoms complained of in service. However, the May 2018 Board remand found the March 2011 VA opinion inadequate to decide the claim. Specifically, the Board noted that the opinion did not adequately provide supporting rationale for the conclusions reached. Thus, the May 2018 Board remanded the claims for service connection for a stomach condition after determining that the analyses were inadequate. Pursuant to the May 2018 Board remand directives, the Veteran was afforded a new stomach VA examination in December 2018. The December 2018 VA examiner opined the Veteran’s stomach condition was less likely than not as a result of his active service. Specifically, the examiner noted the Veteran had complaints of acute gastrointestinal conditions in his service treatment records, that there were no follow up medical records noted available, that his separation exam was silent for stomach and duodenal conditions, that there was a diagnosis of irritable bowel syndrome in 2003, and H. pylori bacterial gastritis in 2010 and that an August 2018 VA treatment record was silent for stomach complaints, but the Veteran was prescribed stomach medication. Thus, the December 2018 examiner opined that the records “failed to document chronicity of the stomach condition during or since separation from the service.” The Board finds December 2018 medical opinion is incomplete to decide the claim as the VA examiners did not address the Veteran’s lay statements and contentions regarding the onset and continuity of his symptoms, and did not have adequate supporting rationale for the conclusions reached. Accordingly, the Board finds that a remand is required to obtain an adequate VA medical opinion for the Veteran’s claims for entitlement to service connection for a stomach condition and for compliance with Board remand instructions. Stegall v. West, 11 Vet. App. 268 (1998) (A remand by the Board confers upon the claimant, as a matter of law, the right to compliance with the remand order.) The matters are REMANDED for the following action: 1. The Veteran should be given the opportunity to identify any outstanding private or VA treatment records relevant to the claim on appeal. After obtaining any necessary authorization from the Veteran, all outstanding records should be obtained, to include updated VA treatment records. For private treatment records, make at least two (2) attempts to obtain records from any identified sources. If any such records are unavailable, inform the Veteran and his representative and afford him an opportunity to submit any copies in her possession. For federal records, all reasonable attempts should be made to obtain such records. If any records cannot be obtained after reasonable efforts have been made, issue a formal determination that such records do not exist or that further efforts to obtain such records would be futile, which should be documented in the claims file. The Veteran must be notified of the attempts made and why further attempts would be futile, and allowed the opportunity to provide such records, as provided in 38 U.S.C. § 5103A(b)(2) and 38 C.F.R. § 3.159(e). 2. Following the receipt of outstanding records, the Veteran should be afforded an appropriate VA examination to determine the etiology of his claimed stomach condition. The record, to include a copy of this Remand, must be made available to and be reviewed by the examiner. Any indicated evaluations, studies, and tests should be conducted. The need for further physical examination is left to the discretion of the examiner. Thereafter, the examiner is asked to furnish an opinion with respect to the following questions: Was is it at least as likely as not (a probability of 50 percent or greater) that a stomach condition had its onset in service or is etiologically related to service? The examiner should address the Veteran’s complaint of, and treatment for a nervous stomach in February 1975; nausea and vomiting in January 1980; acute stomach pain and spitting up blood in September 1981; nausea, vomiting, and stomach cramps in August 1975; and two days of vomiting in February 1977. The examiner must indicate that the record was reviewed. A complete rationale should be provided for all opinions given and must reflect a thorough review of the record. KRISTY L. ZADORA Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Mariah N. Sim, 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.