Citation Nr: 21002887 Decision Date: 01/19/21 Archive Date: 01/19/21 DOCKET NO. 11-23 819 DATE: January 19, 2021 ORDER Prior to May 12, 2012, entitlement to an initial disability rating in excess of 50 percent for posttraumatic stress disorder (PTSD) is denied. From May 12, 2012, entitlement to an initial disability rating in excess of 70 percent for PTSD is denied. Prior to June 26, 2017, entitlement to an initial disability rating in excess of 10 percent for left knee instability is denied. From June 26, 2017, entitlement to an initial disability rating of 20 percent for left knee instability is granted, subject to the laws and regulations governing monetary benefits. REMANDED Entitlement to an initial rating in excess of 10 percent for left knee degenerative joint disease (DJD) is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. FINDINGS OF FACT 1. Prior to May 12, 2012, the Veteran’s PTSD symptoms have more closely approximated occupational and social impairment with reduced reliability and productivity. Her symptoms did not approximate occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. 2. From May 12, 2012, the Veteran’s PTSD symptoms have been characterized by occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. Her symptoms have not been characterized by total occupational and social impairment. 3. Prior to June 26, 2017, the Veteran’s left knee instability has more nearly approximated slight lateral instability; but not moderate recurrent subluxation or lateral instability. 4. From June 26, 2017, the Veteran’s left knee instability more closely approximated moderate lateral instability; but not severe recurrent subluxation or lateral instability. CONCLUSIONS OF LAW 1. Prior to May 12, 2012, the criteria for an initial disability rating in excess of 50 percent for PTSD have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.159, 3.321, 4.7, 4.130, Diagnostic Code (DC) 9411, General Rating Formula for Mental Disorders. 2. From May 12, 2012, the criteria for an initial disability rating in excess of 70 percent for PTSD have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.159, 3.321, 4.7, 4.130, DC 9411, General Rating Formula for Mental Disorders. 3. Prior to June 26, 2017, the criteria for an initial rating in excess of 10 percent for left knee instability have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.159, 3.321, 4.7, 4.71a, DC 5257. 4. From June 26, 2017, the criteria for an initial disability rating of 20 percent for left knee instability have been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.159, 3.321, 4.7, 4.71a, DC 5257. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from August 1983 to June 1991. These matters are before the Board of Veterans’ Appeals (Board) on appeal from an August 2011 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). In September 2016, the Veteran attended a Board hearing held by a Veterans Law Judge (VLJ). The transcript of that hearing is of record. However, the VLJ who conducted that hearing is no longer available to participate in this decision. The Veteran was put on notice of this fact in a January 2018 letter, and was provided an opportunity to request another Board hearing. That letter also informed the Veteran that if she did not respond within 30 days, the Board would proceed with his appeal. The Veteran did not respond to the letter within this time frame. The record also shows that in October 2020, the Veteran received a letter indicating that she could request a virtual tele-hearing instead of waiting for a travel board hearing. Upon further review, the Veteran does not have a pending hearing request. As previously noted, the Veteran provided testimony in a hearing with a Veterans Law Judge in September 2016. The Board has considered the transcript of that hearing as evidence in making its decision. This case was previously before the Board in June 2017, March 2018, and August 2019 when it was remanded for additional development. Concerning the issues of increased ratings for PTSD and left knee instability, the Board finds that there has been substantial compliance with its prior remand directives. However, for the issue of an increased rating for left knee DJD, unfortunately, for the reasons discussed below, another remand is required. See Stegall v. West, 11. Vet. App. 268 (1998). In a January 2014 rating decision, the RO increased to the Veteran’s service-connected PTSD from 30 percent to 50 percent, effective October 15, 2009, the original date of claim. In an October 2017 rating decision, the RO increased his PTSD again from 50 percent to 70 percent, effective May 15, 2012. As this does not constitute a full grant, these issues remain on appeal. AB v. Brown, 6 Vet. App. 35, 39 (1993). Increased Ratings Legal Criteria Disability ratings are determined by applying the criteria set forth in VA’s Schedule for Rating Disabilities. Ratings are based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. See 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating; otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. Staged ratings are, however, appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. 1. Prior to May 12, 2012, entitlement to an initial disability rating in excess of 50 percent for PTSD is denied. 2. From May 12, 2012, entitlement to an initial disability rating in excess of 70 percent for PTSD is denied. As there is considerable overlap in the applicable evidence for the Veteran’s claims, the Board will discuss them together. Legal Criteria Under the General Rating Formula for Mental Disorders, a 50 percent rating is warranted for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short-term and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. 38 C.F.R. § 4.130, DC 9440. A 70 percent rating is warranted for occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affection the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); inability to establish and maintain effective relationships. Id. The maximum 100 percent rating is warranted for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal person hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. Id. Factual Background Prior to May 15, 2012, the Veteran’s service-connected PTSD is rated 50 percent, effective October 15, 2009. From May 15, 2012, the Veteran’s PTSD is rated 70 percent. The Veteran’s PTSD is rated under DC 9411. 38 C.F.R. § 4.130, DC 9411. Prior to May 15, 2012 In a December 2010 VA examination report, the Veteran was diagnosed with chronic PTSD and depression not otherwise specified (NOS). The Veteran noted that since her sexual assault in the military, she has had a lot of trouble with intimacy. She reported that she was very anxious when she was alone with men. The Veteran stated that certain smells reminded her of the event and caused her to become physically sick. She noted that she was very overprotective of her children and did not want them out of her sight. The Veteran reported that she had difficulty trusting men and that she had nightmares about her assault. These nightmares initially occurred every night for the first year after the event. She stated that she had difficulty being in her house alone at night and that she frequently dreamt about her assault, but it was someone other than the actual perpetrator assaulting her. The Veteran described being hypervigilant when she was out and alone, especially at night. She had a history of an increased startle response. The Veteran reported that she had panic-like symptoms where her heart starts racing and she became short of breath. Ever since the assault, the Veteran noted that she had become irritable. She noted that she had trouble with her daughters because they felt she was over-controlling. The Veteran reported that for years after the assault, she thought about it “almost daily.” She stated that she has had a depressed mood ever since the incident. The Veteran had no history of psychiatric hospitalizations or suicide attempts. She worked for a chemical company for 7 years after the military and worked in human resources for the Department of Corrections for 6 years. The Veteran was married but had been divorced for 12 years. She has 3 children. During the examination, the Veteran was well groomed and made “fair” eye contact. Her speech was fair with a normal tone. The Veteran became tearful several times during the interview, especially when talking about her sexual assault. She was cooperative during the examination. Her mood was reported as “a little sad.” Her affect was congruent, and her thought processes were local and goal oriented. The Veteran’s concentration was intact to the interview and her memory was intact to past and recent events. Her fund of knowledge appeared average. The Veteran denied suicidal or homicidal ideation. She denied auditory or visual hallucinations. The Veteran was not reacting to internal stimuli, her insight was appropriate, and her judgment was intact. Based on the above, the probative medical evidence indicates that prior to May 15, 2012, a disability rating in excess of 50 percent for PTSD is not warranted. 38 C.F.R. § 4.130, DC 9411. There is no competent and credible evidence at any point prior to May 15, 2012 that characterized the Veteran’s symptoms as occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking or mood. Id. Rather, overall, the Veteran’s PTSD symptoms caused occupational and social impairment with reduced reliability and productivity. Id. Because of this, prior to May 15, 2012, a disability rating in excess of 50 percent for PTSD is not warranted. From May 15, 2012 In a May 2012 VA examination report, the Veteran was diagnosed with PTSD due to military sexual trauma (MST). The VA examiner noted that the Veteran had occupational and social impairment with occasional decreases in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care, and conversation. The VA examiner noted that the Veteran’s claims file was available but incomplete. It did not contain her original December 2010 Compensation and Pension examination report. The Veteran reported that her boyfriend broke up with her in September 2011 “because of my PTSD issues.” She stated that her 21-year old son joined the Navy and she had “anxiety about it.” The Veteran noted that her daughter and granddaughter moved out of her house in January 2012, which just left her and her 16-year old daughter at home. The VA examiner noted that the Veteran had PTSD symptoms of depressed mood, anxiety, suspiciousness, chronic sleep impairment, mild memory loss, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships. The Veteran reported that she did not like to be hugged or touched. The examiner noted that the Veteran was able to work full-time and that she was experiencing mild to moderate PTSD symptoms. In a June 2017 VA examination report, the Veteran was diagnosed with PTSD and major depressive disorder (MDD). The examiner noted that it was possible to differentiate the symptoms attributable to the Veteran’s different psychological disorders, but that her depression was related to her PTSD. The Veteran’s PTSD was characterized as causing occupational and social impairment with reduced reliability and productivity. The Veteran reported that she married for the second time. She noted that her relationship with her husband was “fairly good” and she tried to manage her irritability. The Veteran noted that her husband was supportive. She had 3 children and 4 grandchildren and her relationship with them was also good. The Veteran stated that she had no close friends but had 2 to 3 casual friends that she saw at work or at church. She was close to her sister and saw her once a month and they talked 2 to 3 times a week on the phone. The Veteran noted that she ate out around 3 times a week and attended church once a month. At the time of the VA examination report, the Veteran had been employed for the past 19 years. She noted that she became irritable at work but was usually able to manage it. The Veteran reported problems with concentration that slowed her down and caused her to make mistakes. Because of this, her boss had changed some of her duties to help her out. However, she noted that she was still verbally reprimanded. The VA examiner noted that the Veteran’s PTSD symptoms consisted of depressed mood, anxiety, suspiciousness, chronic sleep impairment, mild memory loss, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, difficulty in adapting to stressful circumstances, and intermittent inability to perform activities of daily living, including maintenance of minimal personal hygiene. The examiner reported that the Veteran’s mood was dysphoric, and her affect was mood congruent. Her thought process was logical and coherent, her speech was elaborative, and there was mild evidence of psychomotor retardation. The Veteran was neatly dressed and groomed, and she was pleasant and cooperative. There was no evidence of audio or visual hallucinations and the Veteran denied suicidal or homicidal ideation. In a February 2020 VA examination report, the Veteran was diagnosed with PTSD and MDD. The examiner noted that it was possible to differentiate the Veteran’s symptoms but that her depressed was the result of her PTSD. The VA examiner characterized the Veteran’s PTSD as occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood. The Veteran reported that she had been living with her second husband for the past two years. She noted that her PTSD and MDD symptoms contributed to difficulty in the marriage as a result of a decline in her libido, difficulty with physical contact, social withdrawal, and irritable mood. The Veteran reported increased frequency of nightmares around the month of April, the anniversary of her sexual assault. She also noted that her family of origin and her husband were supportive of her. The Veteran reported continued symptoms of increased vigilance, difficulty in darkened and tight spaces, and increased anxiety in social situations. At the time of this examination report, the Veteran noted that she was no longer employed and had difficulty working in predominantly male dominated environments. The VA examiner noted that the Veteran’s PTSD symptoms consisted of depressed mood, anxiety, suspiciousness, panic attacks weekly or less often, chronic sleep impairment, mild memory loss, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, difficulty in adapting to stressful circumstances, neglect of personal hygiene, and intermittent inability to perform activities of daily living, including maintenance of minimal person hygiene. The examiner reported that the Veteran was tearful during her assessment but remained cooperative. Her mood was depressed and anxious. The Veteran reported no suicidal or homicidal ideation. The Board notes that throughout the appeal period, the Veteran received medical treatment for her PTSD. These treatment reports did not evaluate the nature, extent, and severity of her PTSD. While not discussed specifically, the Board has reviewed them and taken them into consideration. Analysis Based on the foregoing evidence, from May 15, 2012, the assigned 70 percent rating for the Veteran’s PTSD fully contemplates her mental health symptoms. The Veteran’s symptoms more nearly approximate occupational and social impairment with deficiencies in most areas. 38 C.F.R. § 4.130, DC 9411. At no point during the appeal period has her PTSD been characterized by total occupational and social impairment. Id. The Board notes that while the Veteran’s symptom of intermittent inability to perform activities of daily living, including maintenance of minimal personal hygiene is listed under the criteria for a 100 percent rating, overall, the current severity and frequency of her PTSD symptoms more nearly approximate a 70 percent disability rating. Id. There is no indication that the Veteran’s symptoms have significantly interfered with the Veteran’s social and occupational functioning so as to support the maximum 100 percent rating. Id. The presence or absence of specific symptoms, which correspond to a particular rating, is not dispositive. 38 C.F.R. § 4.130; Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). Overall, at no time has the Veteran had total occupational and social impairment. The Board finds that the December 2010, May 2012, June 2017, and February 2020 VA examination reports, describing the Veteran’s PTSD symptoms, to be the most probative evidence of record because the examiners reviewed the claims file and provided detailed rationales. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). While the Veteran and the other lay statements of record from her family and friends are competent (qualified) to observe her PTSD symptoms, they do not have the training or credentials to determine the current nature, extent, and severity of those symptoms, as reflected by the applicable diagnostic criteria. Additionally, the Veteran and the other laypersons do not have the training or credentials to determine the proper disability evaluations concerning her PTSD. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Because of this, the preponderance of the evidence is against a finding that the Veteran’s PTSD warrants a rating in excess of 50 prior to May 15, 2012, and a rating in excess of 70 percent from May 15, 2012, and the claims must be denied. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 3. Prior to June 26, 2017, entitlement to an initial disability rating in excess of 10 percent for left knee instability is denied. 4. From June 26, 2017, entitlement to a disability rating of 20 percent for left knee instability is granted. As there is considerable overlap in the applicable evidence for the Veteran’s claims, the Board will discuss them together. Legal Criteria The Veteran’s left knee lateral instability is rated 10 percent, effective October 15, 2009, under DC 5257. 38 C.F.R. § 4.71a, DC 5257. Diagnostic Code 5257 provides ratings based on other impairments of the knee, to include recurrent subluxation or lateral instability. A 10 percent rating is warranted for slight recurrent subluxation or lateral instability. A 20 percent rating is warranted for moderate recurrent subluxation or lateral instability. The maximum 30 percent rating is warranted for severe recurrent subluxation or lateral instability. 38 C.F.R. § 4.71a. The terms “mild,” “moderate,” and “severe” are not defined in the Rating Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are “equitable and just.” 38 C.F.R. § 4.6. Factual Background Prior to June 26, 2017 In an October 2010 VA examination report, the Veteran was diagnosed with ligamentous laxity and degenerative joint disease (DJD) of the left knee. The Veteran reported left knee pain on a daily basis accompanied by locking and occasional instability along with swelling. During the examination, a moderate degree of both pain and laxity was noted on both varus and valgus stress. The knee was stable to the Lachman's test and drawer testing. In a June 2012 VA examination report, joint stability testing of the left knee for anterior instability (Lachman test), posterior instability (posterior drawer test), and medial-lateral instability (application of valgus/varus pressure to the knee in extension and 30 degrees of flexion), produced normal results. The Veteran had no history of recurrent patellar subluxation but used a knee brace occasionally. Imaging studies were performed, and no evidence of patellar subluxation was found. Based on the above, the probative medical evidence indicates that prior to June 26, 2017, a disability rating in excess of 10 percent for left knee instability is not warranted. 38 C.F.R. § 4.71a, DC 5257. There is no competent and credible evidence at any point prior to June 26, 2017 that characterized the Veteran’s symptoms as moderate recurrent subluxation or lateral instability. Id. Although the Board acknowledges the report of moderate laxity with varus and valgus stress from the October 2010 VA examination, the Board finds it significant that there was no finding of instability upon testing during the June 2012 VA examination. Rather, overall, her left knee instability symptoms are more closely approximated as slight. Id. Because of this, prior to June 26, 2017, a disability rating in excess of 10 percent for left knee instability is not warranted. From June 26, 2017 In a June 2017 VA examination report, the Veteran was diagnosed with left knee instability and patellofemoral pain syndrome. She reported episodes of her left knee giving out and her falling down. The VA examiner noted that the Veteran was not able to perform left knee joint stability testing because of increased pain. The Veteran used a knee brace occasionally. The Veteran’s left knee prevented her from driving due to pain and giving out. She noted that she was unable to walk more than 10 minutes or stand in one position for long periods of time because of pain and knee instability. In an October 2018 VA examination report, the Veteran was diagnosed with left knee instability. She reported constant left knee pain that was exacerbated by prolonged standing and walking. The Veteran noted frequent swelling of her left knee with overuse and that it gave way at times. The Veteran had no history of recurrent subluxation and slight history of lateral instability in her left knee. She had no recurrent effusion. Left knee joint instability testing was normal. The Veteran reported that she used a knee brace occasionally. In a February 2020 VA examination report, the Veteran was diagnosed with left knee instability. She had no history of recurrent subluxation. The VA examiner noted that the Veteran had a history of moderate lateral instability. Left knee joint stability test was indicated but the Veteran was unable to perform it because of observed and verbalized pain. The examination was stopped. The Veteran reported that she used a knee brace regularly. The Board notes that throughout the appeal period, the Veteran received medical treatment for her left knee. These treatment reports did not evaluate the nature, extent, and severity of her left knee instability. While not discussed specifically, the Board has reviewed them and taken them into consideration. Analysis In the June 2017 examination report, the Veteran reported episodes of her left knee giving out and that she fell down frequently. She was unable to perform joint stability tests. The October 2018 examination report characterized her left knee instability as slight and joint stability testing was normal. In the February 2020 examination report, the Veteran’s left knee lateral instability was characterized as moderate and she was again unable to perform joint knee stability testing. When analyzing the Veteran’s knee symptoms over the course of this period, the Board finds that the October 2018 examination results are an outlier compared to the earlier June 2017 VA examination report and the later February 2020 VA examination report. Based on this evidence, prior to June 26, 2017, the Veteran’s left knee lateral instability was characterized as slight. It was not characterized as moderate. 38 C.F.R. § 4.71a, DC 5257. From June 26, 2017, affording the Veteran the benefit of the doubt, the Board finds that her left knee lateral instability more nearly approximates moderate symptoms. Id. At no point during the appeal period has her left knee lateral instability been characterized as severe. Id. The Board finds that the December 2010, June 2012, June 2017, October 2018, and February 2020 VA examination reports, describing the Veteran’s left knee symptoms, to be the most probative evidence of record because the examiners reviewed the claims file and provided detailed rationales. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). While the Veteran and the other lay statements of record from her family and friends are competent (qualified) to observe her left knee instability symptoms, they do not have the training or credentials to determine the current nature, extent, and severity of those symptoms, as reflected by the applicable diagnostic criteria. Additionally, the Veteran and the other laypersons do not have the training or credentials to determine the proper disability evaluations concerning her left knee instability. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Because of this, the preponderance of the evidence is against a finding that the Veteran’s left knee instability warrants a rating in excess of 10 prior to June 26, 2017. A rating of 20 percent is warranted from June 26, 2017, but no higher. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102. Neither the Veteran nor her representative have raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366 (2017). REASONS FOR REMAND 1. Entitlement to an initial rating in excess of 10 percent for left knee degenerative joint disease (DJD) is remanded. In the August 2019 remand, the Board ordered the RO to test the Veteran’s active motion, passive motion, and pain with weight-bearing and without weight-bearing. Specifically, the examiner was ordered to include range of motion measurements in active motion, passive motion, with weight-bearing, and without weight-bearing. Additionally, the examiner was also ordered to address whether a meniscal condition was present, and if not, to specifically comment on a January 2018 VA treatment note suggesting that the Veteran’s symptoms were suggestive of a medial meniscus tear. In the subsequent February 2020 VA examination report, the examiner did not measure the Veteran’s range of motion in passive motion, with weight-bearing, and without weight-bearing. The examiner also did not comment on the January 2018 VA treatment note. Because of this, a new VA examination is necessary to evaluate the Veteran’s service-connected left knee DJD and to determine the current nature, extent, and severity of the disability. See Stegall v. West, 11 Vet. App. 268, 271 (1998). 2. Entitlement to a TDIU is remanded In Rice v. Shinseki, 22 Vet. App. 447 (2009), the United States Court of Appeals for Veterans Claims (Court) held that a TDIU claim is part of a claim for a higher rating when such claim is raised by the record or asserted by the Veteran. The Court further held that when evidence of unemployability is submitted during the pendency of a claim for an increased evaluation, the claim for TDIU is part and parcel of the claim for benefits for the underlying disability. Id. In the February 2020 VA examination report, the Veteran noted that she was no longer employed and had difficulty working in predominantly male dominated environments because of her PTSD symptoms. Because the Veteran is no longer working, the TDIU claim has been recognized as part and parcel of the increased rating appeal and is before the Board. The Board finds that a remand is warranted to allow the Veteran an opportunity to complete and return a VA Form 21-8940, Veteran's Application for Increased Compensation Based on Unemployability. Additionally, the Board finds that an opinion should be obtained as to the combined effects of the Veteran's service-connected disabilities. See Geib v. Shinseki, 733 F.3d 1350 (Fed. Cir. 2013); Floore v. Shinseki, 26 Vet. App. 376 (2013). The matters are REMANDED for the following actions: 1. Provide the Veteran and her representative with appropriate notice regarding the issue of entitlement to a TDIU, to include requesting that she complete and return a VA Form 21-8940 and any other necessary forms. All action necessitated by the Veteran’s response must be accomplished. 2. Schedule the Veteran for a VA examination to determine the current severity of her service-connected left knee DJD and ensure that she is notified of the date and time of such at her most recent address of record. The claims file must be made available to the examiner for review in connection with the examination. All indicated tests and studies must be performed in accordance with the pertinent Disability Benefits Questionnaires for this disability, and all findings should be set forth in detail. The examiner should identify all complications and symptoms attributable to the Veteran’s service-connected left knee in accordance with the rating criteria. The examiner must test the Veteran’s active motion, passive motion, and pain with weight-bearing and without weight-bearing and must include range of motion measurements in active motion, passive motion, with weight-bearing, and without weight-bearing unless such testing is not practicable or feasible. If such testing is not practicable or feasible, the examiner should explain why this is so. The examiner should also address whether a meniscal condition is present and, if no meniscal condition is determined to be present, should specifically comment on a January 2018 VA treatment note suggesting that the Veteran’s symptoms are suggestive of a medial meniscus tear. (Continued on the next page)   3. Forward the Veteran's claims file to an appropriate medical professional to obtain an opinion commenting on the effects of the combination of the Veteran's service-connected disabilities on her ability to secure and follow gainful employment. In rendering this "combined effects" opinion, the examiner should review the claims file and take into consideration the Veteran's level of education, special training, and previous work experience, but not age or any impairment caused by nonservice-connected disabilities. To the extent possible, there should be one opinion as to the combined effects of PTSD; degenerative disc desiccation, L5-S1; radiculopathy of the right and left lower extremities; degenerative joint disease of the right knee; degenerative joint disease of the left knee; and instability of the left knee; and not multiple opinions addressing each individual disability. K.C. SPRAGINS Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Abrams, 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.