Citation Nr: 21063002 Decision Date: 10/12/21 Archive Date: 10/12/21 DOCKET NO. 17-10 827A DATE: October 12, 2021 ORDER Entitlement to an initial disability rating in excess of 10 percent for left knee patellofemoral pain syndrome prior to December 1, 2017 and in excess of 30 percent for left knee total arthroplasty from February 1, 2019 (left ankle disability) is denied. REMANDED Entitlement to an initial disability rating in excess of 10 percent for a left ankle sprain with degenerative joint disease (left ankle disability) is remanded. FINDINGS OF FACT 1. From August 25, 2008 to November 30, 2017 there is painful range of motion in the left knee with flexion at most limited to 50 degrees, extension at most limited to 5 degrees, and dislocated semilunar cartilage without frequent episodes of locking. 2. From August 25, 2008 to November 30, 2017 the Veteran was in receipt of a separate rating for left knee subluxation. 3. From February 1, 2019, the Veteran's service-connected left knee total arthroplasty is manifested by pain, decreased motion, weakness, and limitation of CONCLUSIONS OF LAW 1. From August 25, 2008 to November 30, 2017, the criteria for an initial rating higher than 10 percent for left knee patellofemoral pain syndrome have not been met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5256, 5258, 5259, 5260, 5261, 5262, 5263. 2. From February 1, 2019, the criteria for an initial rating higher than 30 percent for left knee total arthroplasty have not been met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5055 (prior to and after February 7, 2021). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had honorable active duty service with the United States Air Force from October 1984 to May 1986. This case comes before the Board of Veterans' Appeals (Board) on appeal from an October 2010 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO) that granted service connection for a left knee disability and a left ankle disability, and assigned disability ratings of 10 percent and 0 percent, respectively, both effective as of August 25, 2008. In a February 2017 rating decision, the RO increased the evaluation of the Veteran's left ankle disability to 10 percent, effective as of August 25, 2008. In rating decision in April 2018 a 100 percent rating was assigned effective December 1, 2017 for a left knee total arthroplasty and a 30 percent rating was assigned from February 1, 2019. The Veteran testified at a hearing before a Veterans Law Judge (VLJ) in February 2015, that VLJ is no longer employed by the Board. The Veteran accepted the Board's offer of another hearing in light of the VLJ's departure, and he testified before the undersigned in June 2019. The Board notes that during the hearing, the undersigned explained that the Veteran's appeal at this point in time will be processed under the Legacy system. In August 2020 the Veteran requested a Board hearing regarding the proposed reduction of his left ankle disability rating. A rating decision in February 2021 continued the 10 percent for left ankle sprain with degenerative joint disease and a Report of General Information in February 2021 shows that the Veteran withdrew his request for a Board hearing as the rating for his left ankle disability remained at 10 percent. Lastly, the Veteran was last afforded a fully adequate VA examination for the left knee in November 2019. The Board recognizes that the United States Court of Appeals for Veterans Claims (Court) in Correia v. McDonald, 28 Vet. App. 158 (2016) emphasized that 38 C.F.R. § 4.59 requires that VA examinations include joint testing for pain on both active and passive motion, in weight-bearing and non-weight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint. The Board has also considered the holding in Sharp v. Shulkin, 29 Vet. App. 26 (2017), whereby the Court emphasized that case law and VA guidelines anticipate that VA examiners will offer opinions on the severity of flare-ups based on estimates derived from information procured from relevant sources, including lay statements of the Veteran. To the extent VA knee examinations prior to November 2019 may not be in complete compliance with Correia and Sharp, the Board finds that a remand for further development would serve no useful purpose as it is not feasible to expect an examiner to be able to provide retrospective opinions to address the concerns raised in Correia and Sharp. Issue 1: Entitlement to an initial disability rating in excess of 10 percent for left knee patellofemoral pain syndrome prior to December 1, 2017 and in excess of 30 percent for left knee total arthroplasty (left knee disability) from February 1, 2019. A disability rating is determined by the application of VA's Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. VA has a duty to acknowledge and consider all regulations that are potentially applicable through the assertions and issues raised in the record, and to explain the reasons and bases for its conclusions. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). 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 for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. The Board will consider whether separate ratings may be assigned for separate periods of time based on facts found, a practice known as "staged ratings," whether it is an initial rating case or not. Fenderson v. West, 12 Vet. App. 119, 126-27 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Rating factors for a disability of the musculoskeletal system include functional loss due to pain supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion, weakness, excess fatigability, incoordination, pain on movement, swelling, or atrophy. 38 C.F.R. §§ 4.40, 4.45; DeLuca v. Brown, 8 Vet. App. 202 (1995). In evaluating musculoskeletal disabilities, VA must determine whether pain could significantly limit functional ability during flare-ups, or when the joints are used repeatedly over a period of time. See DeLuca 8 Vet. App. at 206. Under 38 C.F.R. § 4.59, painful motion is a factor to be considered with any form of arthritis; however, 38 C.F.R. § 4.59 is not limited to disabilities involving arthritis. See Burton v. Shinseki, 25 Vet. App. 1 (2011). The Court has held that a higher rating can be based on "greater limitation of motion due to pain on use." See DeLuca 8 Vet. App. at 206. Any such functional loss must be "supported by adequate pathology and evidenced by the visible behavior of the claimant." 38 C.F.R. § 4.40. From August 25, 2008 to November 30, 2017 the Veteran's left knee disability was rated under Diagnostic Code 5260 for limitation of flexion of the knee. From February 1, 2019 onward the Veteran's left knee disability is rated under Diagnostic Code 5055. Normal range of motion of the knee is from zero degrees of extension to 140 degrees of flexion. 38 C.F.R. § 4.71, Plate II. Under Diagnostic Code 5260, limitation of flexion of the knee to 60 degrees warrants a noncompensable rating. Limitation of flexion of the knee to 45 degrees warrants a 10 percent rating. Limitation of flexion of the knee to 30 degrees warrants a 20 percent rating. And limitation of flexion of the knee to 15 degrees warrants a 30 percent rating. Under Diagnostic Code 5261, limitation of extension of the knee to 5 degrees warrants a zero or noncompensable rating. Limitation of extension of the knee to 10 degrees warrants a 10 percent rating. Limitation of extension of the knee to 15 degrees warrants a 20 percent rating. Limitation of extension of the knee to 20 degrees warrants a 30 percent rating. Limitation of extension of the knee to 30 degrees warrants a 40 percent rating and limitation of extension of the knee to 45 degrees warrants a 50 percent rating. Under Diagnostic Code 5256, a 30 percent rating is warranted for ankylosis of the knee with favorable angle in full extension, or in slight flexion between 0 degrees and 10 degrees. A 40 percent rating is warranted in flexion between 10 degrees and 20 degrees. Under Diagnostic Code 5258, a 20 percent rating is warranted for dislocation of semilunar cartilage with frequent episodes of "locking," pain, and effusion into the joint. 38 C.F.R. § 4.71a, Diagnostic Code 5258. Under Diagnostic Code 5259, a 10 percent rating is warranted for removal of semilunar cartilage that is symptomatic. Under Diagnostic Code 5262, a 10 percent rating is assigned for malunion of tibia and fibula with slight knee or ankle disability. A 20 percent evaluation is warranted for malunion with moderate knee or ankle disability. A 30 percent evaluation is warranted for malunion with marked knee or ankle disability. A 40 percent evaluation is assigned for nonunion of tibia and fibula, with loose motion requiring brace. Diagnostic Code 5055 provides for a total rating for the first year following implantation of a knee replacement (prosthesis); a 60 percent rating for chronic residuals consisting of severe painful motion or weakness in the affected extremity; an intermediate rating between 30 and 60 percent may be assigned for residual weakness, pain or limitation of motion by analogy to Diagnostic Codes 5256, 5261, or 5262. Diagnostic Code 5257 is the Code for recurrent subluxation or lateral instability. However, in the instant case the Veteran is in receipt of a separate rating for left knee subluxation that is not in appellate status. Thus, findings pertaining to subluxation and lateral instability and Diagnostic Code 5257 need not be considered. Similarly the Veteran is in receipt of a separate rating for left knee scarring that also is not in appellate status and will not be addressed. In VAOPGCPREC 23-97, VA's General Counsel held that a veteran who has arthritis and instability of the knee might be rated separately under Diagnostic Codes 5003 and 5257, provided that any separate rating must be based upon additional disability. When a knee disorder is already rated under Diagnostic Code 5257, the veteran must also have limitation of motion under Diagnostic Code 5260 or Diagnostic Code 5261 in order to obtain a separate rating for arthritis. In VAOPGCPREC 9-98, VA's General Counsel clarified that when a veteran has a knee disability evaluated under Diagnostic Code 5257, to warrant a separate rating for arthritis based on x-ray findings, the limitation of motion need not be compensable under Diagnostic Code 5260 or Diagnostic Code 5261; rather, such limited motion must at least meet the criteria for a zero-percent rating. A separate rating for arthritis could also be based on x-ray findings and painful motion under 38 C.F.R. § 4.59. The VA General Counsel also has held if the criteria for a compensable rating under Diagnostic Codes 5260 and 5261 are met, separate ratings can be assigned. VAOPGCPREC 9-2004. The Board notes that during the pendency of the appeal, the rating criteria for evaluating musculoskeletal disabilities under 38 C.F.R. § 4.71a were amended effective February 7, 2021. 85 Fed. Reg. 230 (Nov. 30, 2020). If a law or regulation changes during the course of a claim or an appeal, the version more favorable to the Veteran will apply, to the extent permitted by any stated effective date in the amendment in question. 38 U.S.C. § 5110(g). Diagnostic Codes 5256, 5258-5261, 5263 were not revised. Diagnostic Code 5257 was revised, however as discussed above it is not applicable in the instant case. Diagnostic Code 5262 for impairment of tibia and fibula was revised, however it is not applicable in the case at hand as the evidence discussed below does not show tibia and fibula impairment. Thus, the February 7, 2021 effective revision does not require further discussion. Although Diagnostic Code 5055 was revised, under the pre-amended criteria, a 100 percent rating was assigned for one year following implantation of a prosthesis. Under the post-amended criteria, this temporary 100 percent rating is available for four months following such implantation. As the Board is considering whether a higher rating is warranted for the Veteran's left knee total arthroplasty from February 1, 2019, the regulation changes effective February 7, 2021 do not affect the Board's analysis. From August 25, 2008 to December 1, 2017 the pertinent findings are summarized as follows. By way of history, in an October 2010 rating decision the RO granted service connection for left knee patellofemoral syndrome and assigned a 10 percent rating effective August 25, 2008, the date the Veteran's claim was received. Private medical records in May 2009 show that the range of motion in the left knee was zero degrees extension and 125 degrees of flexion. Stability tests were normal. The records show swelling in the left knee. The records in December 2009 report that x-ray evidence shows that the Veteran had degenerative arthritis in the left knee, chondromalacia, joint effusion, and Baker's cyst. In March 2010 the records show left knee effusion with left knee extending to zero degrees and flexion to 125 degrees. On VA examination in July 2010 left knee extension was zero degrees without pain, flexion was zero to 50 degrees without pain and 90 degrees with pain. Private medical records in October 2014 show that range of motion in the left knee was zero degrees extension to 135 degrees of flexion. In February 2015 range of motion in the left knee was zero to 135 degrees flexion. In March 2015 the Veteran underwent a left knee partial medial meniscectomy, patellar chondroplasty, and lateral release. In April 2015 the records show that range of motion of the knee was zero to 110 degrees. In June 2015 the records show that the Veteran had effusion and range of motion was from zero to 120 degrees. In December 2016 and September 2017 range of motion in the left knee was zero to 120 degrees. On VA knee examination in September 2015, the Veteran complained of left knee swelling and constant pain in his left knee. Physical examination shows flexion was 5 to 110 degrees and extension was 110 to 5 degrees with pain. The Veteran was able to perform repetitive use testing with at least three repetitions without additional function loss or range of motion after three repetitions. Pain, fatigue, weakness, and incoordination did not significantly limit functional ability with repeated use over a period of time. Muscle strength testing was normal and there was no ankylosis. Joint stability tests were normal. The examiner opined that the Veteran has not had recurrent patellar dislocation, shin splints, stress fractures, chronic exertional compartment syndrome or any other tibial and/or fibular impairment. The examiner noted that the Veteran had a meniscal tear in his left knee and scarring. Private medical records show that the Veteran in December 2017 underwent a total left knee arthroplasty. On VA knee Disability Benefits Questionnaire (DBQ) dated on December 29, 2017 the examiner noted that the Veteran had pain and swelling with a history of left meniscal tear that led to locking, pain, and effusion, however this examination was during the Veteran's convalescence period when the Veteran was in receipt of a temporary 100 percent rating and thus need not be further considered. In order to warrant a rating higher than 10 percent under Diagnostic Codes 5260 and 5261 there must be the functional equivalent of flexion to 30 degrees and extension to 15 degrees. Based on the evidence of record during the current appeal period discussed above, left knee flexion at most was limited to 50 degrees and left knee extension at most was limited to 5 degrees. Thus the evidence does not more nearly approximate a rating higher than 10 percent under Diagnostic Code 5260 and Diagnostic Code 5261 for the left knee. 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202 (1995). The Veteran does not contend nor does the other evidence show tibia and fibula involvement, or genu recurvatum in either knee, thus Diagnostic Codes 5262 and 5263 are thereby not applicable. As the evidence does not show ankylosis, Diagnostic Code 5256 is not applicable. The Board has also considered Diagnostic Code 5258 which provides for a 20 percent rating for dislocated semilunar cartilage with frequent episodes of locking, pain, and effusion into the joint as well as Diagnostic Code 5259 which provides for a 10 percent rating for the symptomatic removal of the semilunar cartilage. The Veteran from August 25, 2008 to December 1, 2017 complained of his knee locking, pain, and effusion. He also underwent a partial meniscectomy in March 2015 and had a meniscal tear in his left knee. However, in VAOGCPREC 9-98, VA's General Counsel found that limitation of motion is a relevant consideration under DC 5259. As limitation of motion is a relevant consideration under Diagnostic Code 5259, it is also a consideration under Diagnostic Code 5258, which provides a 20 percent rating for dislocated semilunar cartilage with frequent episodes of locking, pain and effusion. As the Veteran already is receiving a 10 percent rating for painful limitation of motion for the left knee under Diagnostic Code 5260 prior to February 1, 2019 a separate rating under Diagnostic Code 5259 is not warranted as it would amount to pyramiding, which is prohibited under 38 C.F.R. § 4.14. It follows that the assignment of separate ratings for the left knee under Diagnostic Code 5258 also would amount to pyramiding for the reasons discussed above. Further, the assignment of a particular diagnostic code is "completely dependent on the facts of a particular case" and the Board can choose the diagnostic code to apply so long as it is supported by reasons and bases as well as the evidence. Butts v. Brown, 5 Vet. App. 532, 538 (1993). It is permissible to switch diagnostic codes to reflect more accurately a claimant's current symptoms. See Read v. Shinseki, 651 F. 3d 1296, 1302 (Fed. Cir. 2011) (holding that service connection for a disability is not severed when the diagnostic code associated with it is changed to determine more accurately the benefit to which a veteran may be entitled). The left knee is rated 10 percent under Diagnostic 5260 from August 25, 2008 to February 1, 2019 under Diagnostic Code 5260. However, the evidence does not more nearly approximate the criteria for a 20 percent rating for the left knee under Diagnostic Code 5258 based on dislocated semilunar cartilage with frequent episodes of locking, pain, and effusion as there is a notation of a history of locking during a December 2017 DBQ examination during a period of convalescence, which does not rise to the level of frequent episodes of locking from August 25, 2008 to December 1, 2017. As to evidence from February 1, 2019 onward, on VA knee examination in November 2019, the Veteran stated that he experienced pain and numbness. The examiner noted that the Veteran complained of flare-ups as he stated that he had increased pain when he stood on concrete for more than one hour. Upon evaluation, flexion was zero to 125 degrees and extension was 125 to zero degrees. The examiner determined that range of motion did not contribute to functional loss and there was no pain on examination and pain with weight bearing. The examiner found that there was no additional loss of function after three repetitions with flexion being zero to 125 degrees and extension being 125 to zero degrees as a result of pain. The examiner indicated that while the Veteran was not being examined immediately after repetitive use over time, the examination was medically consistent with the Veteran's statements describing function loss with repetitive use over time. The examiner indicated that while the Veteran had pain, pain, weakness, fatigability or incoordination did not significantly limit functional ability with repeated use over a period of time and there was no change in range of motion. The examiner noted that the examination was not being conducted during a flare-up, however the examination was medically consistent with the Veteran's statements describing function loss during a flare-up. The examiner determined that while there was pain, pain, weakness, fatigability or incoordination did not significantly limit functional ability with flare-ups. The examiner found that there was no change in range of motion during a flare-up. Muscle strength was normal and there was no ankylosis in the left knee. The examiner indicated that the Veteran did not have tibial or fibular impairment. The examiner also determined that there were no current symptoms associated with a meniscal condition. The examiner found that there were no residuals associated with the total knee joint replacement in 2017. The examiner determined that there was no objective evidence of pain on non-weight bearing, passive range of motion was the same as active range of motion, and there was no objective evidence of pain on passive range of motion. The examiner noted that there was no additional functional loss in terms of additional degrees of limited motion. As for a rating higher than 30 percent, in the absence of evidence of ankylosis (immobility of the joint) in flexion between 10 degrees and 20 degrees, the criterion for a 40 percent rating under Diagnostic Code 5256 have not been met as the evidence does not suggest ankylosis. In the absence of evidence of extension limited to 30 degrees, considering functional loss due to pain and painful movement and that there is no additional functional loss due to pain, pain on movement, swelling, atrophy, fatigue, weakness, incoordination, to include during flare-ups and with repeated use the criterion for a 40 percent rating under Diagnostic Code 5261 have not been met as extension was zero degrees with pain. The criterion for a 40 percent rating under Diagnostic Code 5262 have not been met as there was no impairment of tibia and fibula. Notably, the November 2019 examiner found that there were no residuals associated with the total knee joint replacement in 2017. These findings are uncontroverted by the other competent evidence of record. In a statement received in February 2021, the Veteran contended that the issue for a rating higher than 10 percent for left knee patellofemoral pain syndrome prior to December 1, 2017 was remanded for further development and the RO never scheduled him for a VA examination. He stated that due to deterioration he had to have a total knee replacement in December 2017, which removed all evidence of his claim. As for a rating higher than 30 percent for the left knee since February 1, 2019 he disagreed with the rating as the surgery only relieved his instability and he continues to have daily chronic pain and swelling in his knee with the need to sleep with a pillow between his knees due to pain. The Board recognizes the Veteran's contentions and notes that he was afforded a VA knee examination in November 2019 as discussed above. To the extent that the Veteran is contending that an opinion regarding his left knee symptoms prior to December 1, 2017 needs to be obtained, the Board finds that a remand for further development would serve no useful purpose as it is not feasible to expect an examiner to be able to provide a retrospective opinion regarding the Veteran's left knee disability prior to December 1, 2017. The evidence of record prior to December 1, 2017 has been thoroughly considered in evaluating the Veteran's left knee disability. The Board also has considered the Veteran's statements that describe his left knee pain, swelling, and discomfort. The Veteran is certainly competent to describe his observations and the Board finds that his statements are credible. In this case, however, the objective medical findings by skilled professionals are more persuasive which, as discussed above, do not support a higher rating or additional separate ratings for the left knee. In essence, the lay evidence, while accepted as credible, does not provide a basis for a higher evaluation or any additional separate ratings. For these reasons, the preponderance of the evidence is against the claim for an initial disability rating in excess of 10 percent for left knee patellofemoral pain syndrome prior to December 1, 2017 and in excess of 30 percent for left knee total arthroplasty from February 1, 2019 and the benefit-of-the-doubt rule does not apply. 38 U.S.C. § 5107 (b). REASONS FOR REMAND Issue 2: Entitlement to an initial disability rating in excess of 10 percent for a left ankle sprain with degenerative joint disease (left ankle disability). In the October 2019 remand, the Board remanded the issue of entitlement to a higher rating for the left ankle disability in part for the Veteran to be afforded a VA examination and for the examiner to perform range of motion testing and for the examiner to address to what extent the Veteran experiences functional loss of his left ankle due to pain or any of the other symptoms during flare-ups or with repeated use. The VA examiner was asked to express any additional functional loss in terms of additional degrees of limited motion. On VA ankle examination in January 2020 the Veteran complained of flare-ups. As for flare-ups, the examiner checked the box indicating that there was no functional loss with flare-ups. The examiner also checked the box indicating that the examination was not being conducted during a flare-up and that the examination was neither medically consistent or inconsistent with the Veteran's statements describing function loss during a flare-up. In Sharp v. Shulkin, 29 Vet. App. 26 (2017), the Court held that a conclusion that the severity of additional functional impairment due to flare-ups cannot be made without resorting to speculation is inadequate if the examiner failed to obtain adequate information regarding flares-ups (e.g., frequency, duration, characteristics, severity) or functional loss by alternative means, including lay statements. As the October 2019 examiner failed to obtain adequate information regarding the Veteran's flare-ups, including from the Veteran's lay statements, the examination report did not comply with the requirements of Sharp nor with the October 2019 remand directives. Compliance with the Board's remand instructions is neither optional nor discretionary. See Stegall v. West, 11 Vet. App. 268, 271 (1998). Further, on the January 2020 VA ankle examination the examiner noted that there was no pain on examination. However, the Veteran in August 2020 contended that the January 2020 VA ankle examination was inadequate as the examiner did not test active or passive motion upon weight bearing and ignored his repeated complaints of ankle pain. Thus, the Veteran should be afforded a new VA examination that is in compliance with Sharp and adequately evaluates range of motion in the left ankle. By this remand, the Board makes no determination, express or implied, concerning the credibility of any statements or testimony on file. The matter is REMANDED for the following action: Schedule the Veteran for another VA examination by an appropriate medical professional to determine the severity of his left ankle disability. The examiner must be provided access to the electronic claims file. All necessary tests and studies, to include X-rays and range of motion studies, should be completed, and all clinical findings reported in detail. The examiner should: (a) Conduct range of motion testing in the left ankle, expressed in degrees in active motion, passive motion, weight-bearing, and non weight-bearing. The examiner must test the Veteran's movements of the left ankle that are painful on active use, passive use, in weight-bearing, and non-weight-bearing. The examiner is requested, to the extent possible, to provide estimates of range of motion if the Veteran asserts he is unable to perform range of motion testing due to pain. If the examiner is unable to conduct the required testing or concludes that the required testing is not necessary in this case, he or she must clearly explain why that is so. (b) Render specific findings as to whether, during the examination, there is objective evidence of pain on motion, weakness, excess fatigability, or incoordination associated with the left ankle. If pain on motion is observed, the VA examiner should indicate the point at which pain begins. In addition, the VA examiner should indicate whether, and to what extent, the Veteran experiences functional loss of his left ankle due to pain or any of the other symptoms during flare-ups or with repeated use. To the extent possible, the VA examiner should express any additional functional loss in terms of additional degrees of limited motion. The examiner must attempt to elicit information regarding the severity, frequency, and duration of any flare-ups, and the degree of functional loss during flare-ups. If it is not possible to provide a specific measurement, or an opinion regarding flare-ups, symptoms, or functional impairment without speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), or a deficiency in the record (additional facts are required). A complete rationale must be provided for all opinions offered. If an opinion cannot be offered without resort to mere speculation, the examiner must fully explain why this is the case and identify what additional evidence, if any, would allow for a more definitive opinion. 2. Afterwards, readjudicate the issue being remanded herein and provide the Veteran with the applicable criteria for evaluating musculoskeletal disabilities pertaining to the ankle under 38 C.F.R. § 4.71a effective February 7, 2021. Thomas H. O'Shay Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Mac, 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.