Citation Nr: 21062993 Decision Date: 10/12/21 Archive Date: 10/12/21 DOCKET NO. 17-37 993 DATE: October 12, 2021 ORDER Entitlement to service connection for a hip disability is dismissed. Entitlement to an earlier effective date prior to February 10, 2015 for the award of an increased rating of 20 percent for a back disability is denied. Entitlement to an earlier effective date prior to February 10, 2015 for the award of an increased rating of 20 percent for a bilateral lower extremity disability is denied. Entitlement to service connection for a neck disability is denied. Entitlement to an increased rating in excess of 20 percent for a back disability is denied. Entitlement to an increased rating in excess of 20 percent for right lower extremity radiculopathy is denied. Entitlement to an increased rating in excess of 20 percent for left lower extremity radiculopathy is denied. REMANDED Entitlement to service connection for a sleep disability, to include sleep apnea, is remanded. Entitlement to service connection for a respiratory disability, to include an undiagnosed illness and asthma, is remanded. Entitlement to an increased rating in excess of 20 percent for a right knee disability is remanded. Entitlement to a total disability rating based on individual unemployability is remanded. FINDINGS OF FACT 1. Prior to the promulgation of a decision in the appeal, service connection for a hip disability was granted in a January 2020 rating decision. 2. There is no evidence in the record showing the Veteran's entitlement to an increased rating for his back arose prior to February 10, 2015. 3. There is no evidence in the record showing the Veteran's entitlement to an increased rating for his bilateral lower extremity radiculopathy arose prior to February 10, 2015. 4. The Veteran does not have a neck disability that was incurred in or due ot his time in service or that was caused by or aggravated by any of his service-connected disabilities. 5. The Veteran's back disability is not manifested by forward flexion to 30 degrees or less or by any form of ankylosis. 6. The Veteran's right lower extremity radiculopathy is not manifested by any nerve that is manifested by complete or severe incomplete paralysis. 7. The Veteran's left lower extremity radiculopathy is not manifested by any nerve that is manifested by complete or severe incomplete paralysis. CONCLUSIONS OF LAW 1. The criteria for dismissal of the appeal of entitlement to service connection for a hip disability have been met. 38 U.S.C. § 7105; 38 C.F.R. § 19.55, 20.204. 2. The criteria for an effective date prior to February 10, 2015 for the award of an increased rating of 20 percent for a back disability have been not met. 38 U.S.C. §§ 5107 (b); 38 C.F.R. §§ 3.155, 3.400. 3. The criteria for an effective date prior to February 10, 2015 for the award of an increased rating of 20 percent for a bilateral lower extremity disability have been not met. 38 U.S.C. §§ 5107 (b); 38 C.F.R. §§ 3.155, 3.400. 4. The criteria for service connection for a neck disability are not met. 38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.310. 5. The criteria for an increased rating in excess of 20 percent for a back disability are not met. 38 U.S.C. §§ 5107; 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.3, 4.7, 4.85, 4.97, Diagnostic Code (DC) 5242. 6. The criteria for a rating of 20 percent for right lower extremity radiculopathy are not met. 38 U.S.C. §§ 1155; 38 C.F.R. § 4.124a, DC 8520. 7. The criteria for a rating of 20 percent for left lower extremity radiculopathy are not met. 38 U.S.C. §§ 1155; 38 C.F.R. § 4.124a, DC 8520. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from January to April 2004 and from October 2005 to August 2007. These matters are on appeal from August 2015, September 2016, and July 2017 rating decisions by a Department of Veterans Affairs (VA) regional office (RO). These matters were previously before the Board and were remanded for further development in a November 2019 decision. The development has been completed and the matters are again before the Board. Dismissed Claim Regarding the Veteran's claim to service connection for a hip disability, the Veteran's claim was granted in a January 2020 rating decision. As the full benefit sought on appeal was granted, further appellate review is moot. See AB v. Brown, 6 Vet. App. 35, 38 (1993). Earlier Effective Date Claims In general, the effective date of an award based on an original claim or a claim reopened after final adjudication of compensation shall be fixed in accordance with the facts found, but shall not be earlier than the date of the receipt of the application. 38 U.S.C. § 5110 (a); 38 C.F.R. § 3.400. Generally, the effective date of an award of disability compensation based on an original claim shall be the date of receipt of the claim or the date entitlement arose, whichever is later. 38 U.S.C. § 5110 (a); 38 C.F.R. § 3.400. The effective date of an award of disability compensation based on a claim to reopen after a final disallowance shall be the date of receipt of the new claim or the date entitlement arose, whichever is later. 38 U.S.C. § 5110 (a); 38 C.F.R. § 3.400 (q)(ii), (r). The provisions of 38 C.F.R. § 3.400 (b)(2) allow for assignment of an effective date the day following separation from active service if a claim is received within one year after separation from service. With regard to the date of entitlement, the term "date entitlement arose" is not defined in the current statute or regulation. However, it is the date when the veteran met the requirements for the benefits sought, which is determined on a "facts found" basis. 38 U.S.C. § 5110 (a); McGrath v. Gober, 14 Vet. App. 28, 35 (2000). An effective date generally can be no earlier than the "facts found." DeLisio v. Shinseki, 25 Vet. App. 45 (2011). These "facts found" include the date the disability first manifested and the date entitlement to benefits was authorized by law and regulation. For instance, if a veteran filed a claim for benefits for a disability before he actually had the disability, the effective date for benefits can be no earlier than the date the disability first manifested. Ellington v. Peake, 541 F.3d 1364, 1369-70 (Fed. Cir. 2008). An effective date for an increased rating may be assigned later than the date of receipt of the claim, if the evidence shows that the increase in disability actually occurred after the claim was filed, but never earlier than the date of receipt of the claim for increase. In general, "date of receipt" means the date on which a claim, information or evidence was received in VA. 38 C.F.R. § 3.1 (r). A claim is "a formal or informal communication in writing requesting a determination of entitlement or evidencing a belief in entitlement to a benefit." 38 C.F.R. § 3.1 (p). Any communication or action, indicating intent to apply for one or more benefits under the laws administered by VA may be considered an informal claim. Such informal claim must identify the benefit sought. Upon receipt of an informal claim, if a formal claim has not been filed, an application form will be forwarded to the claimant for execution. 38 C.F.R. § 3.155 (a). The Veteran contends that he is entitled to the grant of a 20 percent rating for his back disability prior to February 10, 2015. The Veteran also contends he is entitled to the grant of his 20 percent rating for his bilateral lower extremity radiculopathy prior to February 10, 2015. The current effective date of February 10, 2015 is the date of the claim. The Board has considered whether there was a non-final claim that would allow for an earlier effective date, but found none. The Board notes the Veteran had previously been awarded service connection for these disabilities in a May 2009 rating decision. However, the Veteran did not perfect an appeal to this rating decision and therefore, it became final. The Board has also considered whether evidence received within the year prior to the date of the claim indicated the Veteran was entitled to this benefit prior to February 10, 2015. However, no records show that the Veteran's back and bilateral lower extremity radiculopathy warranted a higher rating prior to his current effective date. Therefore, an earlier effective date prior to February 10, 2015 for the award of increased ratings for back and bilateral lower extremity disabilities is denied. Service Connection Claim Generally, to prevail on a claim of service connection on the merits, there must be competent evidence of (1) a current disability, (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury, and (3) medical evidence or other competent evidence of a nexus between the claimed in-service disease or injury and the present disease or injury. See Hickson v. West, 12 Vet. App. 247 (1999); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). To establish service connection on a secondary basis, the evidence must 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. 38 C.F.R. § 3.310. The Veteran contends he has a neck disability that was incurred in or due to his time in service or that is proximately due to his service-connected back disability. The Veteran's record shows conflicting evidence as to whether he has been diagnosed with a neck disability with one examiner reporting a diagnosis and another saying the Veteran did not have a neck disability. Even if the Board is to grant the benefit of the doubt to the Veteran and assume he has been diagnosed with a neck disability, there are several other reasons why service connection cannot be granted. The Veteran's service treatment records (STRs) do not indicate any ongoing complaints or treatment for a neck disability. The Veteran had an examination for his neck in August 2016. The examiner noted the Veteran had a diagnosis of a cervical strain and IVDS. The Veteran said he had a one-year history of neck pain and numbness into his arms. The examiner opined it was less likely than not the Veteran's neck disability was aggravated by or caused by his back disability, saying there was no evidence the Veteran's back condition resulted in any increased strain or change in biomechanics such as to result in any cervical spine pathology. The Veteran had another examination for his neck in January 2020 in which the examiner reported the Veteran had not been diagnosed with a neck disability. The Veteran reported symptoms of pain in the base of his neck that would work itself upward. A February 2020 examiner opined the Veteran's neck condition was less likely than not incurred in or caused by his time in service. The examiner stated there was no record of a neck condition indicated during service and that the Veteran had not been diagnosed with such. The Veteran reported some symptoms in his neck, such as intermittent pulling pain, which indicated a mild muscle strain which "is typically acute in nature and is a result of something the Veteran did recently to strain the neck." The examiner opined the Veteran's complaints regarding his neck were less likely than not directly related to his time in service. Thus, even if the Veteran was diagnosed with a neck disability, multiple examiners have opined it was not due to or incurred during his time in service. Additionally, the most probative objective evidence, which includes examinations and medical treatment records, does not show the Veteran's neck disability is caused by or aggravated by his service-connected back disability or any of his other service-connected disabilities. Additionally, there is no evidence of a recurrent or ongoing neck problem while in service. Therefore, the claim will be denied. Increased Rating Claims Disability evaluations (ratings) 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 the 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. In evaluating a disability, the Board considers the current examination reports in light of the whole recorded history to ensure that the current rating accurately reflects the severity of the condition. The Board has a duty to acknowledge and consider all regulations that are potentially applicable. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). The medical as well as industrial history is to be considered, and a full description of the effects of the disability upon ordinary activity is also required. 38 C.F.R. §§ 4.1, 4.2, 4.10. Where entitlement to compensation already has been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). When evaluating joint disabilities rated on the basis of limitation of motion, VA must consider granting a higher rating in cases in which functional loss due to pain, weakness, excess fatigability, or incoordination is demonstrated, and those factors are not contemplated in the relevant rating criteria. See 38 C.F.R. §§ 4.40, 4.45, 4.59 (2016); DeLuca v. Brown, 8 Vet. App. 202 (1995). The Court has clarified that although pain may be a cause or manifestation of functional loss, limitation of motion due to pain is not necessarily rated at the same level as functional loss where motion is impeded. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011); cf. Powell v. West, 13 Vet. App. 31, 34 (1999); Hicks v. Brown, 8 Vet. App. 417, 421 (1995); Schafrath v. Derwinski, 1 Vet. App. 589, 592 (1991). Instead, the Mitchell Court explained that pursuant to 38 C.F.R. §§ 4.40 and 4.45, the possible manifestations of functional loss include decreased or abnormal excursion, strength, speed, coordination, or endurance, as well as less or more movement than is normal, weakened movement, excess fatigability, and pain on movement (as well as swelling, deformity, and atrophy) that affects stability, standing, and weight-bearing. See 38 C.F.R. §§ 4.40, 4.45. Thus, functional loss caused by pain must be rated at the same level as if the functional loss were caused by any of the other factors cited above. Thus, in evaluating the severity of a joint disability, VA must determine the overall functional impairment due to these factors. 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 claimant or when reasonably raised by the record. See Burton v. Shinseki, 25 Vet. App. 1 (2011). Moreover, the United States Court of Appeals for Veterans Claims (Court) in Southall-Norman v. McDonald, 28 Vet. App. 346, 352 (2016) held that the provisions of 38 C.F.R. § 4.59, which relate to painful motion, are not limited to the evaluation of musculoskeletal disabilities under Diagnostic Codes predicated on range of motion measurements. In Burton v. Shinseki, 25 Vet. App. 1 (2011), the Court held that 38 C.F.R. § 4.59 is not limited to disabilities involving arthritis. Furthermore, in Jones Shinseki, 26 Vet. App. 56, 61-63 (2012) the Court held that the Board may not deny entitlement to an increased rating on the basis of relief provided by medication when those effects are specifically contemplated by the rating criteria. The Board notes that there were changes to the rating criteria effective February 7, 2021. However, the Board notes that none of the rating criteria for the Veteran's back and radiculopathy claims were changed and the symptoms for rating criteria for the Veteran's claimed conditions remain unchanged. The Veteran contends his back disability is worse than indicated by his 20 percent disability rating. The Veteran's back is currently rated under DC 5242, DC 5242 provides that with or without such symptoms as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease, provides a 10 percent rating if forward flexion of the thoracolumbar spine is greater than 60 degrees but not greater than 85 degrees; or forward flexion the cervical spine greater than 30 degrees but not greater than 40 degrees; or combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or combined range of motion of the cervical spine greater than 170 degrees but not greater than 335 degrees; or muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or vertebral body fracture with loss of 50 percent or more of the height. A 20 percent rating is warranted if forward flexion of the thoracolumbar spine is greater than 30 degrees but not greater than 60 degrees, if the combined range of motion of the thoracolumbar spine is not greater than 120 degrees, or guarding severe enough to result in an abnormal gait, or abnormal spinal contour such as scoliosis, reversed lordosis or abnormal kyphosis; a 40 percent rating if forward flexion of the thoracolumbar spine being 30 degrees or less, or favorable ankylosis of the entire thoracolumbar spine; a 50 percent rating if there is unfavorable ankylosis of the entire thoracolumbar spine; and 100 percent rating if there is unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a, Diagnostic Code 5235-5242. Note (1) also articulates that neurologic abnormalities, including, but not limited to, bowel or bladder impairment, should be evaluated separately, under an appropriate diagnostic code. A 40 percent rating is warranted for forward flexion of the thoracolumbar spine 30 degrees or less or favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is warranted for unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent rating is warranted for unfavorable ankylosis of the entire spine. Normal back motion is flexion to 90 degrees, extension to 30 degrees, right and left lateral flexion to 30 degrees, and right and left rotation to 30 degrees. 38 C.F.R. § 4.71a, Plate V. The Veteran's bilateral lower extremity radiculopathy is rated under DC 8620. The Veteran's current disability rating is 20 percent for each extremity. DC 8620 provides that mild incomplete paralysis is rated 10 percent disabling; moderate incomplete paralysis is rated 20 percent disabling; moderately severe incomplete paralysis is rated 40 percent disabling; and severe incomplete paralysis, with marked muscular atrophy, is rated 60 percent disabling. Complete paralysis of the sciatic nerve, the foot dangles and drops, no active movement possible of muscles below the knee, flexion of knee weakened or (very rarely) lost, is rated 80 percent disabling. 38 C.F.R. § 4.124a. Words such as "severe," "moderate," and "mild" are not defined in the Rating Schedule. Rather than applying a mechanical formula, VA must evaluate all evidence, to the end that decisions will be equitable and just. 38 C.F.R. § 4.6. The term "incomplete paralysis," with this and other peripheral nerve injuries, indicates a degree of lost or impaired function substantially less than the type picture for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree of impairment. The ratings for the peripheral nerves are for unilateral involvement; when bilateral, the ratings are combined with application of the bilateral factor. 38 C.F.R. § 4.124a. The Veteran had an examination of his back in June 2015. The Veteran said that his back pain had worsened and that it woke him up at night. The Veteran also reported pain and numbness in his legs. The Veteran said that he could hardly get around, had to crawl at times, and that both prolonged sitting and standing aggravated his pain. The examiner found the Veteran's forward flexion was to 45 degrees and that this loss of range of motion led to functional loss due to pain. The examiner found the Veteran had guarding and muscle spasm resulting in abnormal gait or spinal contour. The examiner also found the Veteran had moderate radiculopathy in both of his lower extremities, but with no ankylosis in his back. The veteran was found to have IVDS but with no episodes of acute IVDS that required bedrest in the past 12 months. The examiner also reported the Veteran's conditions did impact his ability to work due to prolonged sitting and standing. The Veteran had another examination in August 2016. The examiner noted the Veteran's surgical intervention which helped some in decreasing back pain. The examiner also acknowledged the Veteran's ongoing problems with radiculopathy. The Veteran did report flare ups during which he had increased pain, decreased range of motion, difficulty with prolonged weight bearing and high impact activities. The Veteran's forward flexion was to 75 degrees with decreased range of motion leading to functional loss. The Veteran did have objective evidence of localized pain and tenderness and after repetitive use, the Veteran's forward flexion was decreased to 70 degrees. The examiner said the Veteran did not have muscle spasm or guarding. The examiner reported the Veteran had mild bilateral lower extremity radiculopathy but no ankylosis. The Veteran did have IVDS which led to less than a week of bedrest post operation in June 2016. The Veteran had another examination in January 2020. The Veteran said that he has pain at a three out of a 10 with constant aching in his legs and 10 out of 10 pain in his back. The Veteran had functional loss in the form of trouble with bending over, climbing ladders, and anything that put too much pressure on his legs. The Veteran's forward flexion was to 45 degrees with range of motion leading to functional loss. After repetitive use testing, there was no additional loss of range of motion. The Veteran's testing was consistent with the Veteran's description of functional loss with repetitive use testing over time which would result in further limitation of forward flexion to 40 degrees. During a flare up, the examiner opined the Veteran's forward flexion would be further limited to 35 degrees. The Veteran did not have muscle spasm or guarding, with no muscle atrophy. The Veteran did have radiculopathy that was mild in both lower extremities. The Veteran did have IVDS but did not have any acute signs or symptoms that led to prescribed bedrest by a physician in the past 12 months. The Veteran did not use assistive devices. The Veteran also had an examination specifically for his radiculopathy in January 2020. The Veteran said he had numbness and tingling in his legs, in particular his right leg. The examiner found the Veteran had moderate right lower extremity and mild left lower extremity paresthesias and moderate right lower extremity and mild left lower extremity numbness. The Veteran's strength was normal. The Veteran's gait was normal. The examiner found the Veteran had mild incomplete paralysis of his bilateral lower extremity sciatic nerves and mild incomplete paralysis of his popliteal nerve, mild incomplete paralysis of his superficial peroneal nerve, mild incomplete paralysis of his anterior tibial nerve, mild incomplete paralysis of his tibial nerve, mild incomplete paralysis of his posterior tibial nerve. The Veteran's treatment records show he has been seen for his back and radiculopathy and has often been in pain, made worse by increased activity with shooting pain into his legs. (See e.g. September 2015 treatment records.) Throughout the years, the Veteran reported continued back pain and radiculopathy, in particular, right leg numbness. (See e.g. January, July 2016, April 2017, June 2019 treatment records.) April 2018 imaging showed mild scoliosis but no facture or significant degenerative changes. The Veteran's back clearly still causes him pain and discomfort. However, the Veteran's record does not indicate he has ankylosis, favorable or unfavorable. Even at its worst during a flare up, the Veteran's forward flexion was limited to 35 degrees, which does not warrant a higher, 40 percent rating. The Veteran has had multiple examinations, all of which have indicated the Veteran does not have ankylosis or restriction of range of motion severe enough to warrant a higher rating. Similarly, the Veteran's radiculopathy clearly continues to be a problem for him, especially in his right lower extremity. However, as discussed above, the Veteran's radiculopathy has been noted to be mild or moderate by several examiners. The Veteran's medical treatment records, while showing that his radiculopathy is still a problem, does not indicate that his radiculopathy has been determined to be severe by any medical examiner. The Veteran's treatment records have noted that he has received epidural injections to help with pain in his legs and back, pain has already been contemplated as a symptom in the reduction of range of motion and in the severity of his radiculopathy. The Veteran's record, while showing he had numbness and tingling in his lower extremities, the Board finds this does not rise to a severe level as the record does not indicate he had lost all feeling, was unable to use his lower extremities on a daily basis for a significant period of time, or was unable to have active movement in his feet. The Board notes the Veteran had multiple nerves that are involved in his lower extremity radiculopathy. The Board has considered all relevant diagnostic codes to determine whether changing the Veteran's DC would result in a higher evaluation. However, no such possibility exists based on the evidence. Additionally, the awarding of separate ratings under each relevant diagnostic code would constitute impermissible pyramiding. Esteban v. Brown, 6 Vet. App. 259 (1994); 38 C.F.R. § 4.14. Consequently, the Veteran is not entitled to separate ratings under separate diagnostic codes for each affected nerve. Neither the Veteran nor his representative has not identified any other rating criteria that would provide a higher rating or an additional rating. However, the potential applications of various provisions of Title 38 of the Code of Federal Regulations (2016) have been considered as required by the holding of the Court in Schafrath v. Derwinski, 1 Vet. App. 589, 593 (1991). Regarding the claims above, the Board acknowledges the Veteran's statements that his conditions continue to affect his daily life and still causes symptoms and pain and his contention that his neck disability was incurred in or due to his time in service or is otherwise related to his service-connected disabilities. However, while the Veteran is competent to report the symptoms of his disability, he is not competent to opine on matters requiring medical knowledge, such as determining the nature, etiology, or severity of his complex medical condition or what rating is should get. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Therefore, the Board lends more weight to the examinations, medical records, and objective records on file and has weighed them as discussed above and discussed the relative probative value of each. The Board also finds the VA examinations, when combined and looked at as a whole, to be adequate as the examiners reviewed the Veteran's file, saw him in person, accounted for his statements as well as his medical history, and offered opinions backed by detailed explanations. It is important for the Veteran to understand that the most probative medical evidence of record provides evidence against these claims that the Board cannot, unfortunately, ignore, outweighing the Veteran's belief that he is entitled to service connection for his neck disability or higher disability ratings. This does not mean that the Veteran's service-connected disabilities do not cause him problems; clearly, his conditions are quite serious. The only question is the degree. Regarding all the above, the Board has considered the applicability of the benefit of the doubt doctrine. Because the preponderance of the evidence is against the Veteran's claim, the benefit of the doubt doctrine does not apply. See 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 55-57(1990). REASONS FOR REMAND Sleep Apnea and Respiratory Disability Claims A remand is warranted for the Veteran's claims to service connection for a sleep disability, to include sleep apnea, and service connection for a respiratory disability. A remand is also warranted in the Veteran's claim to an increased rating for his right knee disability and his claim to a TDIU. The Veteran has been diagnosed with sleep apnea. (See e.g. February 2020 sleep study.) A January 2020 examiner said the Veteran's respiratory condition was not directly related to his time in service. In February 2020, an examiner opined the Veteran's respiratory condition and sleep apnea were less likely than not caused by his time in service or aggravated by his back disability. The examiner explained the etiology of the Veteran's sleep apnea and noted that obesity is a major risk factor for sleep apnea. However, this examiner did not offer an opinion as to whether the Veteran's obesity was an intermediary step between his service-connected musculoskeletal disabilities and his currently diagnosed respiratory and sleep disabilities. The Veteran has been diagnosed with asthma. In July 2020, an examiner opined the Veteran's condition was a diagnosable chronic multi-symptom illness with a partially explained etiology and opined it was less likely than not due to the Veteran's service in Southwest Asia. The Veteran has said that his service-connected musculoskeletal disabilities caused his obesity, which, in turn, has caused his sleep apnea and respiratory disability. While obesity alone is not a compensable disability for VA purposes, it can serve as an intermediate step to establish service connection for another condition. Walsh v. Wilkie, 32 Vet. App. 300, 306-07 (2020). Therefore, a remand is required in order to address this theory of entitlement. Right Knee Disability The Veteran last had an examination for his right knee in August 2016, more than five years ago. In Correia v. McDonald, 28 Vet. App. 158 (2016), the United States Court of Appeals for Veterans Claims (Court) held that to be adequate, a VA examination of the joints must, wherever possible, include the results of the range of motion testing described in the final sentence of 38 C.F.R. § 4.59 (2017). The final sentence of section 38 C.F.R. § 4.59 (2017) directs that the 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. Additionally, a Court decision addressed what constitutes an adequate explanation for an examiner's inability to estimate motion loss in terms of degrees during periods of flare-ups. Sharp v. Shulkin, No. 16-1385 (Vet. App. Sept. 6, 2017). In Sharp, the Court held that a VA examiner must attempt to elicit information from the record and the Veteran regarding the severity, frequency, duration, or functional loss manifestations during flare-ups before determining that an estimate of motion loss in terms of degrees could not be given. It also held that any inability to furnish such an estimate must be predicated on a lack of medical knowledge among the medical community at large, rather than insufficient knowledge by the individual examiner. Thus, the Board finds another, contemporaneous examination is warranted. Snuffer v. Gober, 10 Vet. App. 400, 403 (1997). TDIU Claim The Veteran has also claimed that his service-connected disabilities rendered him unemployable. This matter is inextricably intertwined with the other issues being remanded and will therefore also be remanded. Harris v. Derwinski, 1 Vet. App. 180, 183 (1991). The matters are REMANDED for the following action: 1. The AOJ should obtain the Veteran's outstanding medical records and associate them with the claims file. If possible, the Veteran should submit any pertinent new evidence regarding the condition at issue in order to expedite the claim. 2. Send the Veteran the appropriate form to elicit current employment information. 3. Schedule the Veteran for an appropriate examination for his 1) sleep disability and his 2) respiratory disability. For each disability, the examiner should opine as to the following: (a) The examiner should clearly state what diagnoses the Veteran has. (b) Whether the Veteran's disability was at least as likely as not incurred in and due to his time in service. (c) Whether the Veteran's disability is proximately due to any of his service-connected disabilities. (d) Whether the Veteran's disability is aggravated by any of his service-connected disabilities, including his psychiatric disability and the medication he takes for it. NOTE: "Aggravation" does not mean a permanent worsening. Any temporary or incremental worsening is sufficient for a finding of "aggravation." (e) Is it at least as likely as not (i.e., a 50 percent or greater probability) that the Veteran's obesity has been caused by any of his service-connected disabilities? (f) Is there any medical reason to accept or reject the proposition that had the Veteran not had musculoskeletal disabilities, he would not be obese? (g) Is it at least as likely as not (i.e., a 50 percent or greater probability) that the Veteran's obesity has been aggravated (increased in severity) by any of his service-connected disabilities? (h) If, and only if, the Veteran's obesity is deemed to have been caused or aggravated by his service-connected disabilities, please explain whether it is at least as likely as not the Veteran's obesity proximately caused or aggravated his sleep disability or his respiratory disability. The VA examiner should also note that the Veteran's obesity is not a disease or disability for VA benefits purposes; however, it may act as an intermediate step between a service-connected disability and a current disability that may be service-connected on a secondary basis. A full rationale is to be provided for all stated medical opinions. If an opinion cannot be made without resort to speculation, the examiner should provide an explanation as to why this is so and note what, if any, additional evidence would permit such an opinion to be made. Any and all opinions should be supported by an explanation that accounts for the Veteran's statements and the objective evidence of record. 4. Schedule the Veteran for an appropriate examination to determine the severity of his right knee disability. The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran's disability under the rating criteria. To the extent possible, the examiner should identify any symptoms and functional impairments due to the Veteran's disability and discuss the effect on any occupational functioning and activities of daily living. The examiner should account for the Veteran's statements about his symptoms, including the instability of his knee and it "giving way." The examiner should explain in detail any opinion provided. 5. After undertaking any other appropriate development deemed necessary, readjudicate the issues on appeal based on the additional evidence of record. If the determinations remain adverse to the Veteran, he and his representative must be provided with a supplemental statement of the case. An appropriate period of time must then be allowed for a response before the record is returned to the Board for further review. John J. Crowley Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A. Snoparsky 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.