Citation Nr: 21062974 Decision Date: 10/12/21 Archive Date: 10/12/21 DOCKET NO. 10-19 066 DATE: October 12, 2021 ORDER A disability rating greater than 10 percent for right knee limitation of flexion is denied. A disability rating greater than 10 percent for left knee limitation of flexion is denied. An increased disability rating of 20 percent, but no higher, for right knee limitation of extension is granted, effective February 19, 2008. An increased disability rating of 20 percent, but no higher, for left knee limitation of extension is granted, effective February 19, 2008. A separate disability rating of 10 percent, but no higher, for right knee instability is granted, effective February 19, 2008. A separate disability rating of 10 percent, but no higher, for left knee instability is granted, effective February 19, 2008. Entitlement to an extraschedular rating for residuals of frostbite of the right foot is denied. Entitlement to an extraschedular rating for residuals of frostbite of the left foot is denied. REMANDED The following issues are remanded for further development: (1) entitlement to service connection for a low back disability, to include as secondary to residuals of frostbite, right and left knee disabilities, and/or a right shoulder disability; (2) entitlement to service connection to dizziness and loss of balance, to include as secondary to bilateral hearing loss and/or posttraumatic stress disorder (PTSD; and (3) entitlement to service connection for a respiratory condition, to include as secondary to PTSD. FINDINGS OF FACT 1. During the pendency of his claim, the Veteran's right knee disability has been manifested by painful motion during flexion, extension functionally limited to 15 degrees, and slight instability. However, at no time during the claim period was flexion limited to 30 degrees or less and extension was not limited to 20 degrees or less. 2. During the pendency of his claim, the Veteran's left knee disability has been manifested by painful motion during flexion, extension functionally limited to 15 degrees, and slight instability. However, at no time during the claim period was flexion limited to 30 degrees or less and extension was not limited to 20 degrees or less. 3. The Veteran is currently in receipt of maximum 30 percent schedular ratings for his service-connected frostbite residuals of both feet. While affiliated symptoms of difficulties with standing and walking are not contemplated by the diagnostic code used to assign his current 30 percent ratings, they are contemplated elsewhere in the rating schedule and have been compensated with the assignment of Veteran's knee disability ratings. CONCLUSIONS OF LAW 1. The criteria for a disability rating greater than 10 percent for limitation of flexion of the right knee are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.68, 4.71a, Diagnostic Codes 5010, 5260 (2020). 2. The criteria for a disability rating greater than 10 percent for limitation of flexion of the left knee are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.68, 4.71a, Diagnostic Codes 5010, 5260 (2020). 3. The criteria for an increased disability rating of 20 percent, but no higher, for limitation of extension of the right knee are met, effective February 19, 2008. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.400(o), 4.1, 4.2, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.68, 4.71a, Diagnostic Code 5261 (2020); Burton v. Shinseki, 25 Vet. App. 1 (2011); DeLuca v. Brown, 8 Vet. App. 202 (1995). 4. The criteria for an increased disability rating of 20 percent, but no higher, for limitation of extension of the left knee are met, effective February 19, 2008. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.400(o), 4.1, 4.2, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.68, 4.71a, Diagnostic Code 5261 (2020); Burton v. Shinseki, 25 Vet. App. 1 (2011); DeLuca v. Brown, 8 Vet. App. 202 (1995). 5. The criteria for a separate disability rating of disability rating of 10 percent, but no higher, for right knee instability are met, effective February 19, 2008. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.68, 4.71a, Diagnostic Code 5261 (2020); English v. Wilkie, 30 Vet. App. 347 (2018). 6. The criteria for a separate disability rating of disability rating of 10 percent, but no higher, for left knee instability are met, effective February 19, 2008. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.68, 4.71a, Diagnostic Code 5261 (2020); English v. Wilkie, 30 Vet. App. 347 (2018). 7. The criteria for a disability rating greater than 30 percent for frostbite residuals of the right foot on an extraschedular basis are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.14, 4.104, Diagnostic Code 7122; Long v. Wilkie, 33 Vet. App. 167 (2020). 8. The criteria for a disability rating greater than 30 percent for frostbite residuals of the left foot on an extraschedular basis are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.14, 4.104, Diagnostic Code 7122; Long v. Wilkie, 33 Vet. App. 167 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from July 1950 to July 1953 in the United States Army. His service included combat in the Korean conflict and participation in the atmospheric nuclear test program. He was awarded a Purple Heart Medal with First Bronze Oak Leaf Cluster. These matters are before the Board of Veterans' Appeals (Board) on appeal from an August 2008 rating decision of the Department of Veterans Affairs (VA) Regional Offices (RO) in Philadelphia, Pennsylvania. Jurisdiction of the Veteran's claims file currently resides with the St. Petersburg, Florida RO. In June 2016, the Veteran and his spouse testified at a Board hearing before the undersigned. A transcript of the hearing is of record. In February 2017, the Board first found that new and material evidence had been received to reopen the issues of service connection for bilateral hearing loss, a respiratory condition, and dizziness and loss of balance. Next, the Board found that new and material evidence had not been received to reopen the issues of service connection for obstructive sleep apnea, a sensitive nervous system, gout, and erectile dysfunction. The Board then denied assigning schedular ratings in excess of 30 percent for residuals of frostbite for both feet. Lastly, the Board remanded: (1) all of the reopened service connection issues; (2) service connection for left ankle and low back disabilities; (3) increased disability ratings for the right and left knee; and (4) entitlement to extraschedular ratings for residuals of frostbite. Thereafter, in a June 2017 rating decision, a VA RO granted the Veteran service connection for the left ankle as well as bilateral hearing loss. The Board finds that this grant of service connection constituted a full award of the benefits sought on appeal with respect to those issues. See Grantham v. Brown, 114 F.3d 1156, 1158-59 114 F.3d 1156, 1158-59 (Fed. Cir. 1997) (holding that where an appealed claim for service connection is granted during the pendency of the appeal, a second notice of disagreement must thereafter be timely filed to initiate appellate review of the claim concerning "downstream" issues, such as the compensation level assigned for the disability and the effective date); see also 38 C.F.R. § 19.20. Consequently, those issues are no longer before the Board. Then, in February 2020, the Board remanded the issues of entitlement to increased ratings for the right and left knees; entitlement to extraschedular ratings for frostbite residuals; and entitlement to service connection for a low back disability, dizziness and loss of balance, and a respiratory condition. The case has returned to the Board for appellate review. Increased Ratings for the Right and Left Knees In addressing the Veteran's claim for increased ratings for his knee disabilities, the Board first notes that, effective February 7, 2021, VA revised the criteria for evaluating disabilities of the musculoskeletal system. See Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 76453, 76464 (Nov. 30, 2020); Correction, 86 Fed. Reg. 8142, 8143 (Feb. 4, 2021). This amendment affected the diagnostic codes used to evaluate knee disabilities. VA's General Counsel has held that where a law or regulation changes during the pendency of a claim for a higher rating, the Board must first determine whether the revised version is more favorable to the veteran. In so doing, it may be necessary for the Board to apply both the old and new versions of the regulation. If the revised version of the regulation is more favorable, the retroactive reach of that regulation under 38 U.S.C. § 5110(g) can be no earlier than the effective date of that change. The Board must generally apply both the former and the revised versions of the regulation for the period prior and subsequent to the regulatory change, but an effective date based on the revised criteria may be no earlier than the date of the change. In the instant case, the Board finds the pre-amendment criteria more favorable to the Veteran. Accordingly, it will apply them for the entirety of the claim periodi.e., from February 8, 2009 onward. Turning to the relevant rating criteria for the knees, under the pre-amendment version of 38 C.F.R. § 4.71a, Diagnostic Code 5260, noncompensable, 10 percent, 20 percent, and 30 percent ratings were assigned for flexion limited to 60, 45, 30, and 15 degrees, respectively. Relatedly, in regard to limitation of extension, under the pre-amendment version of 38 C.F.R. § 4.71a, Diagnostic Code 5261, noncompensable, 10 percent, 20 percent, 30 percent, and 40 percent ratings were assigned for extension limited to 5, 10, 20, 30, and 30 degrees, respectively. Lastly, prior to the 2021 amendment to 38 C.F.R. § 4.71a, under Diagnostic Code 5257, disability ratings of 10, 20, and 30 percent were assigned for slight, moderate, or severe recurrent subluxation or lateral instability of the knee. In evaluating a disability based upon limitation of motionsuch as the kneeVA is to consider, in conjunction with the otherwise applicable diagnostic codes, any additional functional loss a 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, 204-7 (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 at issue. 38 C.F.R. § 4.40; Johnston v. Brown, 10 Vet. App. 80, 85 (1997). Additionally, the intent of the rating schedule is to recognize painful motion with joint or particular pathology as productive of disability. It is the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. The provisions of 38 C.F.R. § 4.59, which relate to painful motion, are not limited to arthritis and must be considered when raised by the veteran or when reasonably raised by the record. Burton v. Shinseki, 25 Vet. App. 1 (2011). In specific regard to rating disabilities of the knee, precedent opinions of VA's General Counsel have held that dual ratings may be given for a knee disorder, with one rating for instability (Diagnostic Code 5257) and one rating for arthritis with limitation of motion (Diagnostic Codes 5003 and 5010). VAOPGCPREC 9-98 (63 Fed. Reg. 56,704 (1998)) and 23-97 (62 Fed. Reg. 63,604 (1997)). Another such opinion held that separate ratings under Diagnostic Code 5260 (leg, limitation of flexion) and Diagnostic Code 5261 (leg, limitation of extension) may be assigned for disability of the same joint. VAOPGCPREC 9-2004 (69 Fed. Reg. 59988 (2004)). Further, in Lyles v. Shulkin, the Court of Appeals for Veterans Claims (Court) recently held that evaluation of a knee disability under the diagnostic codes for recurrent subluxation or instability; limitation of extension; or limitation of flexion does not preclude as a matter of law a separate evaluation of a meniscal disability under Diagnostic Code 5258 or 5259the diagnostic codes for removal or dislocation of semilunar cartilage. 29 Vet. App. 107, 115-16 (2017). Accordingly, considering the above, when evaluating the Veteran's left knee disability, the Board may assign separate ratings for: (1) recurrent subluxation or lateral instability; (2) limitation of flexion; (3) limitation of extension; and (4) symptoms associated with the dislocation or removal of semilunar cartilage. For rating purposes, normal range of motion in a knee joint is from 0 to 140 degrees. 38 C.F.R. § 4.71, Plate II. Here, the Veteran is currently in receipt of the following ratings for his service-connected right and left knee disabilities: (1) 10 percent under 38 C.F.R. § 4.71a, Diagnostic Code 5010 for limitation of flexion for the whole claim period; and (2) 20 percent under 38 C.F.R. § 4.71a, Diagnostic Code 5261 for limitation of extension from September 5, 2014 onward. After reviewing the evidence of record, the Board finds that disability ratings greater than 10 percent for limitation of flexion are not warranted. However, the Board does conclude that increased ratings of 20 percent for limitation of extension are warranted for the entire claim periodi.e., from February 19, 2008. Additionally, the Board finds that separate 10 percent ratings for right and left knee instability are warranted from February 19, 2008 are also warranted in the instant case. Accordingly, to this extent, the Board grants the Veteran's claim. Turing to the evidence of record, the Board notes that the Veteran was provided VA examinations concerning his knees in April 2021, June 2017, September 2014, and March 2008. In the February 2017 and February 2020 remands, the Board found the September 2014 and June 2017 VA examinations inadequate with respect to their findings concerning knee range of motion and additional loss of functionality during flare-ups. The Board does not disturb those findings at this time. In reviewing the VA examination reports of record, the Board notes that, in April 2021, the Veteran reported worsening bilateral knee pain with intermittent buckling of the right knee. On this occasion, the Veteran indicated that he did not experience flare-ups of either knee disability. However, he did report experiencing functional loss which he described as an inability to walk or stand for long periods. In evaluating the Veteran, the examiner stated that the Veteran did not have a history of frequent effusion of the knees. During initial range of motion testing, flexion of the right leg was limited to 95 degrees and extension was limited to 10 degrees. For the left leg, flexion was to 100 degrees and extension was to 10 degrees. The examiner indicated that active range of motion and passive range of motion testing produced identical results. The examiner then stated that, for both knees, there was no objective evidence of painful motion or crepitus. Following repetitive-use testing, the examiner opined that pain further limited right knee flexion to 90 degrees and left knee flexion to 95 degrees. The examiner then remarked that the Veteran's knee disabilities interfered with sitting, standing, and locomotion. Lastly, the examiner indicated that ankylosis was not present, but that the Veteran experienced persistent disability of the right knee. During another VA examination in June 2017, the Veteran again reported bilateral knee pain, which he described as severe and constant. On this occasion, the Veteran reported experiencing flare-ups, which he described as increased pain with increased walking or other movement. While the examination was determined to be inadequate with respect to range of motion testing, the June 2017 VA examiner remarked that ankylosis was not present and that the Veteran did not have joint instability of either knee. As mentioned previously, the Veteran was also provided a VA knee examination in September 2014. During the examination, the VA examiner remarked that the Veteran experienced the following functional impairments as a result of the Veteran's bilateral knee disabilities: less movement than normal; pain on movement; swelling; and disturbance of locomotion. Additionally, the examiner stated that joint instability was not demonstrated during objective testing of the knee and that ankylosis was not present. Finally, during a March 2008 VA examination, the Veteran reported symptoms of intermittent severe pain of the bilateral knees. The Veteran stated that he used a walker and cane as assistive devices and that he had difficulty with prolonged standing and walking, walking up and down stairs, climbing, and squatting. The examiner conducted both passive and active range of motion testing and reported that, for both passive and active motion, flexion was to 110 degrees and extension was to 0 degrees bilaterally. The examiner then remarked that painful motion was present between 100 and 110 degrees. Lastly, the examiner stated that there was no evidence of knee joint instability bilaterally and that the Veteran denied experiencing flare-ups. Separate from the VA knee examination reports of record, VA treatment records associated with the Veteran's claims file discuss the nature and severity of the Veteran's bilateral knee disabilities. Specifically, in November 2016, the Veteran reported to a VA emergency department seeking care for chronic bilateral knee pain. The Veteran stated that his knee pain was omnipresent, limited his ability to walk, and kept him awake up at night. The medical provider conducted a physical examination and reported no erythema, edema, bruising, or ligament instability. The provider did indicate that the Veteran presented with a valgus deformity and generalized tenderness. A few years earlier, in October 2013, the Veteran presented to a VA provider complaining of right knee pain only. The Veteran indicated that he used a wheelchair for ambulation. After completing a physical examination of the right knee, the provider stated that the Veteran had a bony enlargement and displayed pain during range of motion testing. However, the provider did not report this pain during range of motion testing in terms of degrees. In June 2013, the Veteran underwent a VA rheumatology consultation. The Veteran reported a history of chronic right knee pain and stated that his right knee would occasionally give out. Upon examination, the VA provider stated that the right knee was significant for bony enlargement, mild effusion, and painful range of motion. Comparatively, the provider stated that the left knee did not display any tenderness or effusion. In September 2011, the Veteran reported to his VA primary care provider with complaints of knee pain and knee instability. Following an evaluation, the Veteran was issued bilateral knee sleeves in October 2011. Prior to this September 2011 appointment, the Veteran underwent a VA orthopedic surgery consultation in July 2011. On this occasion, the Veteran reported right knee pain and stiffness. A physical examination indicated no effusion, ligamentous laxity, or loss of muscle strength. However, the provider indicated that right knee range of motion was abnormal, with flexion to 110 degrees and extension to 7 degrees. Separate from these VA records of medical treatment, the Veteran has also provided lay testimony during the claim period in regard to the nature and severity of his knee disabilities. Specifically, during the June 2016 Board hearing, the Veteran testified that when he is walking his knees will occasionally feel like they are out of place. See Hearing Tr. at 49. Additionally, in June 2011, the Veteran reported that his right knee buckled while walking. See June 2011 VA Emergency Room Nursing Note. Lastly, in February 2008, the Veteran reported symptoms of left knee aches and right knee instability, limiting his ability to walk and lift. From this evidence of record, the Board finds that entitlement to ratings greater than 10 percent for limitation of flexion are not warranted in the instant case. Indeed, at no point during the claim period was flexion limited to 30 degrees or less, which is necessary for the assignment of the next higher ratings of 20 percent under Diagnostic Code 5260. Accordingly, to this extent the Veteran's claim is denied. Comparatively, the Board does find that extension was limited to 10 degrees during claim period. While such evidence corresponds with ratings of 10 percent under Diagnostic Code 5261, the Board concludes that the Veteran's knee disabilities caused the functional impairments of disturbing locomotion and the ability to stand for long periods. In consideration of the holding of DeLucaand resolving reasonable doubt in favor of the Veteranthe Board finds that the criteria for increased ratings of 20 percent are warranted for the whole claim period under Diagnostic Code 5261i.e., from February 19, 2008 onward. See also 38 C.F.R. § 3.400(o). Accordingly, to this extent, the Veteran's claim is granted. Lastly, the Board finds that separate ratings of 10 percent are warranted for the entire claim period for right and left knee instability under 38 C.F.R. § 4.71a, Diagnostic Code 5257. In assigning these separate ratings, the Board notes that, in English v. Wilkie, the Court held that, unless explicitly contemplated, objective evidence of a symptom is not categorically more probative than lay evidence in determining whether to assign an increased rating. 30 Vet. App. 347, 353 (2018). In this case, the Veteran has provided subjective reports of knee instability intermittently throughout the claim period. The Board finds the Veteran to be credible in this regard and, accordingly, categorizes his bilateral knee instability as slight, warranting the assignment of separate 10 percent ratings under Diagnostic Code 5257 and English. The Board declines to assign the next higher ratings of 20 percent under Diagnostic Code 5257 as joint instability was not observed during any physical testing during the claim period. As such, the Board concludes that separate ratings greater than 10 percent for knee joint instability may not be assigned. Extraschedular Ratings for Frostbite Residuals of Both Feet In February 2017, the Board found that schedular ratings greater than 30 percent for residuals of frostbite of the right and left feet were not warranted. However, the Board then referred these increased rating issues to the Director of Compensation Service (Director) for extraschedular consideration pursuant to 38 C.F.R. § 3.321(b)(1). In making this determination, the Board indicated that, for referral purposes, the Veteran's symptom of difficulty with ambulation was not considered in the schedular criteria of Diagnostic Code 7122the diagnostic code under which the Veteran's maximum 30 percent ratings were assigned. Following the February 2017 referral, the Director found in October 2019 that an extraschedular rating for either foot was not warranted. However, the Board is not bound by the Director's determination. See Wages v. McDonald, 27 Vet. App. 233 (2015). Thereafter, in February 2020, the Board remanded the issues of entitlement to extraschedular ratings for frostbite residuals for a clarifying VA medical opinion. Specifically, the Board requested that a VA medical professional attempt to clarify whether the Veteran's symptoms of an inability to stand or walk for long periods were clearly attributable to his frostbite disabilities or to disabilities of the low back and ankles. The opinion requested by the Board in February 2020 was provided in July 2021. On this occasion, a VA medical professional opined that it was less likely than not that the Veteran's symptoms of an inability to stand or walk for long periods were solely attributable to the disabilities of frostbite residuals of both feet. In support of this opinion, the professional stated that the Veteran had several other conditions of the feetbilateral pes planus, bilateral plantar spurs, and hammertoesas well as other conditions impacting the lower extremitiesbilateral knee arthritis, bilateral ankle instability, bilateral ankle arthritis, and bilateral ankle ligament sprainsthat contributed to the Veteran's inability to stand or walk for long periods. Accordingly, the examiner concluded that it would be speculative to attribute the Veteran's concerns solely to the residuals of his frostbite injuries. In determining whether an extraschedular rating is warranted, the Board notes that the Court has established the following three-part test, based on 38 C.F.R. § 3.321(b)(1), for determining whether a claimant is entitled to an extraschedular rating: (1) the established schedular criteria must be inadequate to describe the severity and symptoms of the claimant's disability; (2) the case must present other indicia of an exceptional or unusual disability picture, such as marked interference with employment or frequent periods of hospitalization; and (3) the award of an extraschedular disability rating must be in the interest of justice. Thun v. Peake, 22 Vet. App. 111 (2008), aff'd, Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). In applying the steps outlined above, the Board acknowledges that recently, in Long v. Wilkie, the Court clarified how VA is to apply the first Thun stepi.e., whether the established schedular criteria are inadequate to describe the severity and symptoms of the disability at issue. 33 Vet. App. 167 (2020). The Court first stated that Thun's first step is not a "mechanical test that is satisfied whenever a veteran presents a symptom not expressly listed in the diagnostic code [at issue]." Id. at 173. The Court then specified that Thun is not a "more lenient, court-created, standard whereby anything not expressly listed in a diagnostic code is automatically deemed exceptional." With these foundational principles in mind, the Court held that Thun's first step centers on "whether the veteran's disability picture as a wholethat is, the full symptomatologypresents an impairment that is so exceptional that the rating schedule is not capable of assessing it in the first instance." Id. In providing a non-exhaustive list of guiding factors to address Thun's first step, the Court stated that determining whether a veteran's disability picture is exceptional "must be viewed in the context of all available rating tools and cannot be reduced to a mere comparison of a veteran's symptomatology with the language of a particular diagnostic code." Id. at 174 (citing Spellers v. Wilkie, 30 Vet. App. 211, 218 (2018)). The Board notes that the decision in Long was issued subsequent to the prior remands in this case in February 2017 and February 2020. While the Board previously found the symptoms of difficulty with standing for long periods and ambulating to not be contemplated by the rating criteria under Thun's first step, the holding in Long alters the Board's calculus in deciding whether extraschedular ratings are warranted. Specifically, when considering Long, the Board finds that the Veteran's symptoms of difficulty ambulating and standing for long periods are contemplated elsewhere in the rating schedule. Symptoms of difficulty ambulating and for standing for long periods may be considered to be functional impairments. In the above decision concerning the Veteran's knee increased rating claims, the Board awarded increased 20 percent ratings for limitation of extension of both knees under 38 C.F.R. § 4.71a, Diagnostic Code 5261, effective February 19, 2008. Although limitation of extension was limited to only 10 degrees for each leg during the claim period, the Board nevertheless assigned 20 percent ratings under Diagnostic Code 5261 in acknowledgement of the functional impairments of limitations in ambulation and standing, as warranted by the mandates of 38 C.F.R. § 4.40, 38 C.F.R. § 4.45, and DeLuca v. Brown, 8 Vet. App. 202, 204-7 (1995). Additionally, as the July 2021 VA medical professional indicated, it would be speculative to attribute the functional impairments of difficulty ambulating and standing for long periods solely to the service-connected disabilities of frostbite residuals. Rather, other disabilitiesincluding the service-connected disabilities of the kneescould also contribute to these functional impairments. Accordingly, as the functional impairments of difficulty ambulating and standing for long periods have been (1) already been attributed to the Veteran's right and left knee disabilities, and (2) addressed by the increased ratings of 20 percent under Diagnostic Code 5261 from February 19, 2008 onward, the Board finds Thun's first step has not been satisfied in the instant case as the Veteran's symptoms are adequately addressed by other tools in the rating schedule. Indeed, the Board concludes that the assignment of extraschedular ratings for residuals of frostbite of both feet is not warranted in this case as to do so under the current circumstances would violate the avoidance of pyramiding principle in 38 C.F.R. § 4.14 (indicating that the "evaluation of the same manifestation under different diagnoses" is to be avoided). Thus, the Veteran's claim is denied. REASONS FOR REMAND 1. Service Connection for a Low Back Disability In February 2020, the Board remanded the issue of service connection for a low back disability and requested that the Veteran be provided an additional VA medical opinion addressing whether any current low back disability (1) was incurred or caused by service; (2) was caused or aggravated by frostbite residuals of both feet; (3) was caused or aggravated by bilateral knee disability; or (4) was caused or aggravated by a right shoulder disability. Following the February 2020 Board remand, several VA medical opinions concerning the low back were associated with the Veteran's claims file in March 2020. However, the Board finds these opinions to be inadequate as they were conclusory. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). Accordingly, the Board remands this issue for additional VA medical opinions addressing both direct and secondary theories of entitlement. 2. Service Connection for Dizziness and Loss of Balance Similar to the low back, the Board finds that the issue of service connection for dizziness and loss of balance must be remanded for the provision of an additional VA medical opinion. Specifically, the Board finds that there has not been substantial compliance with the prior remand directives from February 2020. In February 2020, the Board requested that the Veteran be provided a medical opinion concerning the nature and etiology of his claim for service connection for a disability manifested by symptoms of dizziness and loss of balance. In providing this opinion, the selected VA clinician was to first identify whether the Veteran's reported symptoms were reflective of a distinguishable disability, to include a cardiovascular condition. Following the February 2020 remand, additional VA medical opinions were associated with the Veteran's claims file in March 2020. Although the VA clinician remarked that there was no history of a cardiovascular condition in service, the clinician did not identify whether the Veteran's reported symptoms of dizziness and loss of balance were reflective of a distinctive disability. Accordingly, the Board concludes that there was not substantial compliance with the February 2020 remand directives, warranting remand. See Stegall v. West, 11 Vet. App. 268 (1998) (finding that a remand by the Board confers on the Veteran the right to compliance with its remand orders). 3. Service Connection for a Respiratory Condition Lastly, the Board finds that remand is warranted regarding the issue of service connection for a respiratory disorder for the provision of an additional VA medical opinion. Specifically, in February 2020, the Board remanded this issue and directed the Agency of Original Jurisdiction (AOJ) to provide a VA medical opinion addressing (1) whether the Veteran had a current respiratory condition by diagnosis, and (2) if so, whether such condition was incurred in or caused by service, or were caused or aggravated by PTSD. Following the February 2020 remand, the requested VA medical opinion was provided in August 2020. While the August 2020 VA clinician addressed the questions posed in the February 2020 remand directives, the clinician provided similar rationales in support of the opinions concerning secondary service connection, contrary to the Court's holding in Atencio v. O'Rourke. 30 Vet. App. 74 (2018). Accordingly, the Board remands the issue of service connection for a respiratory condition for the provision of another VA medical opinion. The matters are REMANDED for the following action: 1. Forward the Veteran's claims file to an appropriate VA clinician for the issuance of a medical opinion regarding the nature and etiology of the Veteran's current low back disability. The clinician should review the Veteran's entire claims file and any relevant studies, tests, and evaluations deemed necessary should be performed. If the clinician determines that an examination is necessary, one should be provided. Thereafter, the clinician should address the following: (a.) Please state whether it is at least as likely as not (50 percent probability or more) that the Veteran's current low back disability was incurred in, caused by, or is otherwise related to service. In providing a response to part (a), please directly address the Veteran's contention that his back pain began in service and has continued to the present. (b.) Please state whether it is at least as likely as not (50 percent probability or more) that the Veteran's current low back disability was proximately caused by the Veteran's service-connected frostbite residuals of both feet. (c.) Please state whether it is at least as likely as not (50 percent probability or more) that the Veteran's low back disability was aggravated (worsened beyond natural progression) by the Veteran's service-connected frostbite residuals of both feet. (d.) Please state whether it is at least as likely as not (50 percent probability or more) that the Veteran's current low back disability was proximately caused by the Veteran's service-connected bilateral knee disabilities. (e.) Please state whether it is at least as likely as not (50 percent probability or more) that the Veteran's low back disability was aggravated (worsened beyond natural progression) by the Veteran's service-connected bilateral knee disabilities. (f.) Please state whether it is at least as likely as not (50 percent probability or more) that the Veteran's current low back disability was proximately caused by the Veteran's service-connected right shoulder disability. (g.) Please state whether it is at least as likely as not (50 percent probability or more) that the Veteran's low back disability was aggravated (worsened beyond natural progression) by the Veteran's service-connected right shoulder disability In providing responses to parts (c), (e), and (g), please note that aggravation may be substantiated by even a temporary worsening of the low back disability during the claim period. The clinician should consider medical and lay evidence dated both prior to and since the filing of the claim. The clinician must provide a complete rationale for any opinion rendered. If the examiner cannot provide an opinion without resorting to speculation, he or she should explain why an opinion cannot be provided (e.g., lack of sufficient information/evidence, the limits of medical knowledge, etc.). 2. Forward the Veteran's claims file to an appropriate VA clinician for the issuance of a medical opinion regarding the nature and etiology of the Veteran's reported symptoms of dizziness and loss of balance. The clinician should review the Veteran's entire claims file and any relevant studies, tests, and evaluations deemed necessary should be performed. If the clinician determines that an examination is necessary, one should be provided. Thereafter, the clinician should address the following: (a.) Please state whether it is at least as likely as not (50 percent probability or more) that the Veteran's reported symptoms of dizziness and loss of balance are reflective of a distinctive disability. (b.) If the symptoms are reflective of a distinctive disability identified in subsection (a), please state whether it is at least as likely as not (50 percent probability or more) that the disability was caused by, incurred in, or is otherwise related to service. (c.) If the symptoms are reflective of a distinctive disability identified in subsection (a), please state whether it is at least as likely as not (50 percent probability or more) that the disability was proximately caused by the Veteran's service-connected bilateral hearing loss. (d.) If the symptoms are reflective of a distinct disability identified in subsection (a), please state whether it is at least as likely as not (50 percent probability or more) that the disability was aggravated (worsened beyond natural progression) by the Veteran's service-connected bilateral hearing loss. (e.) If the symptoms are reflective of a distinguishable disability identified in subsection (a), please state whether it is at least as likely as not (50 percent probability or more) that the disability was proximately caused by the Veteran's service-connected PTSD. (f.) If the symptoms are reflective of a distinguishable disability identified in subsection (a), please state whether it is at least as likely as not (50 percent probability or more) that the disability was aggravated (worsened beyond natural progression) by the Veteran's service-connected PTSD. In providing responses to parts (d) and (f), please note that aggravation may be substantiated by even a temporary worsening of the disability during the claim period. The clinician should consider medical and lay evidence dated both prior to and since the filing of the claim. The clinician must provide a complete rationale for any opinion rendered. If the examiner cannot provide an opinion without resorting to speculation, he or she should explain why an opinion cannot be provided (e.g., lack of sufficient information/evidence, the limits of medical knowledge, etc.). 3. Forward the Veteran's claims file to an appropriate VA clinician for the issuance of a medical opinion regarding the nature and etiology of the Veteran's reported symptoms of shortness of breath, chest pain, and easy fatigability. The clinician should review the Veteran's entire claims file and any relevant studies, tests, and evaluations deemed necessary should be performed. If the clinician determines that an examination is necessary, one should be provided. Thereafter, the clinician should address the following: (a.) Please indicate whether the Veteran has a current respiratory condition by diagnosis. (b.) For each respiratory condition identified in part (a), please state whether it is at least as likely as not (50 percent probability or more) that the condition was caused by, incurred in, or is otherwise related to serviceto include exposure to radiation in service. (c.) If the Veteran does not have a current respiratory condition, please state whether it is at least as likely as not (50 percent probability or more) that the Veteran's reported symptoms of shortness of breath, chest pain, and easy fatigability are reflective of another type of distinct disability, to include a cardiovascular condition. (d.) If the symptoms are reflective of a distinguishable disability identified in subsection (c), please state whether it is at least as likely as not (50 percent probability or more) that the disability was caused by, incurred in, or is otherwise related to serviceto include exposure to radiation in service. (e.) If the symptoms are reflective of a distinguishable disability identified in subsection (c), please state whether it is at least as likely as not (50 percent probability or more) that the disability was proximately due to the Veteran's service-connected PTSD. (f.) If the symptoms are reflective of a distinguishable disability identified in subsection (c), please state whether it is at least as likely as not (50 percent probability or more) that the disability was aggravated (worsened beyond natural progression) by the Veteran's service-connected PTSD. In providing responses to parts (f), please note that aggravation may be substantiated by even a temporary worsening of the disability during the claim period (g.) If, in response to subsection (c), the symptoms of shortness of breath, chest pain, and easy fatigability are not reflective of a distinguishable disability, please state whether it is at least as likely as not (50 percent probability or more) that these symptoms cause functional impairment. (h.) If, in response to subsection (g), the symptoms cause functional impairment, please state whether it is at least as likely as not (50 percent probability or more) that the functional impairment is associated with the Veteran's service. (i.) If, in response to subsection (g), the symptoms cause functional impairment, please state whether it is at least as likely as not (50 percent probability or more) that the functional impairment was proximately caused by the Veteran's PTSD. (j.) If, in response to subsection (g), the symptoms cause functional impairment, please state whether it is at least as likely as not (50 percent probability or more) that the functional impairment was aggravated (worsened beyond natural progression) by the Veteran's service-connected PTSD. In providing a response to part (j), please note that aggravation may be substantiated by even a temporary worsening of the disability during the claim period The clinician should consider medical and lay evidence dated both prior to and since the filing of the claim. The clinician must provide a complete rationale for any opinion rendered. If the examiner cannot provide an opinion without resorting to speculation, he or she should explain why an opinion cannot be provided (e.g., lack of sufficient information/evidence, the limits of medical knowledge, etc.). S.C. KREMBS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board N.S. Pettine, 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.