Citation Nr: 21064735 Decision Date: 10/21/21 Archive Date: 10/21/21 DOCKET NO. 17-28 749A DATE: October 21, 2021 ORDER New and material evidence having been received, the appeal to reopen the claim of entitlement to service connection for a right knee disability is granted. Service connection for a right knee disability is denied. REMANDED Entitlement to a disability rating in excess of 10 percent for left knee chondromalacia patella and degenerative joint disease, status post arthroscopic patellar chondroplasty and arthroscopic partial medial meniscectomy and debridements, is remanded. Entitlement to a disability rating in excess of 10 percent for left knee instability/laxity from May 9, 2016 is remanded. Entitlement to a separate 10 percent disability rating for left knee instability/laxity prior to May 9, 2016 is remanded. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) prior to March 2, 2020 is remanded. FINDINGS OF FACT 1. A September 2013 rating decision denied the claim of entitlement to service connection for a right knee disability; the Veteran did not file a timely notice of disagreement, and no evidence was received within one year of the RO decision, nor were new, relevant service records received any time thereafter. 2. The evidence associated with the claims file subsequent to the September 2013 rating decision denying service connection for a right knee disability is not cumulative, relates to an unestablished fact necessary to substantiate the claim, and raises a reasonable possibility of substantiating the claim. 3. Symptoms of a right knee disability were not continuous or recurrent in service or since service separation; arthritis did not manifest to a compensable degree within one year of active service; and there is no medical nexus between the current right knee disability and either active service or a service-connected disability. CONCLUSIONS OF LAW 1. The September 2013 rating decision, which denied service connection for a right knee disability, became final. 38 U.S.C. § 7105(a); 38 C.F.R. §§ 20.302, 20.1103. 2. The evidence received subsequent to the September 2013 rating decision denying service connection for a right knee disability is new and material, and the claim of entitlement to service connection for a right knee disability is reopened. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. 3. The criteria for service connection for a right knee disability are not met. 38 U.S.C. §§ 101, 1101, 1110, 1112, 1113, 1153, 5103(a), 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.307, 3.309, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran, who is the Appellant in this case, had active service from May 1995 to August 1997. This matter comes before the Board of Veterans' Appeals (BVA or Board) from an October 2015 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). On her June 2017 VA Form 9, the Veteran requested a videoconference hearing before the Board. The hearing was scheduled for January 10, 2020, at the St. Petersburg, Florida RO, and notice of the hearing date and place was provided to both the Veteran and her representative. However, the Veteran did not report for the hearing, and no request for postponement was received and granted prior to the hearing date. Under 38 C.F.R. § 20.704(d), when a veteran fails to appear for a scheduled hearing and no request for postponement is received, the claim is processed as though the request for hearing had been withdrawn. Therefore, this case will be processed as though the request for a hearing was withdrawn, and the Board can now proceed to appellate review. New and Material Evidence 1. New and material evidence having been received, the appeal to reopen the claim of entitlement to service connection for a right knee disability is granted. In July 2012, the Veteran filed an initial claim for service connection for a right knee disability. The claim was denied in a September 2013 rating decision, in which the RO determined that there was no nexus between the right knee disability and active service. The Veteran did not file a timely notice of disagreement (NOD), and no evidence was received within one year of the September 2013 RO decision, nor were new, relevant service records received at any time thereafter. 38 C.F.R. § 3.156(b) and 3.156(c). Consequently, the September 2013 rating decision became final. See 38 U.S.C. § 7105; 38 C.F.R. §§ 20.302, 20.1103. Evidence added to the record since the time of the last final denial of the psychiatric disability claim in September 2013 includes the Veteran's statements that she believes her right knee disability was caused or aggravated by an altered gait due to the service-connected left knee disability, as well as private treatment records from 2014 which showed an altered gait. The Board finds that this evidence constitutes new and material evidence as it tends to support the existence of a medical nexus between the right knee disability and a service-connected disability, and the lack of a medical nexus between the claimed right knee disability and either active service or a service-connected disability has been the basis for the previous denial of the right knee disability claim. In this regard, the Board notes that the threshold for determining whether new and material evidence raises a reasonable possibility of substantiating a claim is "low." See Shade v. Shinseki, 24 Vet. App. 110, 117 (2010). Therefore, the Board finds that the evidence added to the record since the last final September 2013 denial of the right knee disability claim constitutes new and material evidence, and that the criteria under 38 C.F.R. § 3.156(a) have been satisfied; therefore, the claim of entitlement to service connection for a right knee disability is reopened. Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Establishing service connection generally requires (1) competent evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) competent evidence of a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). The United States Court of Appeals for Veterans Claims (Court) has held that "Congress specifically limits entitlement for service-connected disease or injury to cases where such incidents have resulted in a disability. In the absence of proof of a present disability there can be no valid claim." Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); see also Rabideau v. Derwinski, 2 Vet. App. 141, 143-44 (1992). Where a veteran who served for ninety days or more during a period of war (or during peacetime service after December 31, 1946) develops certain chronic diseases, such as arthritis, to a degree of 10 percent or more within one year from separation from service, such diseases may be presumed to have been incurred in service even though there is no evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. See 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. In this case, the medical evidence of record demonstrates right knee arthritis. Where the veteran asserts entitlement to service connection for a chronic disease but there is insufficient evidence of a diagnosis in service, service connection may be established under 38 C.F.R. § 3.303(b) by demonstrating a continuity of symptomatology since service or diagnosis within the presumptive period after service, but only if the chronic disease is listed under 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331, 1338-39 (Fed. Cir. 2013); 38 C.F.R. § 3.307 (service connection authorized for chronic diseases diagnosed within the presumptive period). However, for the reasons set forth below, the Veteran was not diagnosed with arthritis within one year of separation from service, nor has there been continuity of symptomatology. With specific regard to continuity of symptomatology, for the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. With chronic disease as such in service, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. If a condition, such as arthritis, noted during service is not shown to be chronic, then generally, a showing of continuity of symptoms after service is required for service connection. 38 C.F.R. § 3.303(b). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection may also be granted for a disability that is proximately due to or the result of a service-connected disability. See 38 C.F.R. § 3.310(a). When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. See 38 C.F.R. § 3.310(a); Harder v. Brown, 5 Vet. App. 183, 187 (1993). The controlling regulation has been interpreted to permit a grant of service connection not only for disability caused by a service-connected disability, but for the degree of disability resulting from aggravation of a non-service-connected disability by a service-connected disability. See Allen v. Brown, 7 Vet. App. 439, 448 (1995). In other words, service connection may be granted for a disability found to be proximately due to, or the result of, a service-connected disease or injury. To prevail on the issue of secondary service causation, the record must show (1) evidence of a current disability, (2) evidence of a service-connected disability, and (3) medical nexus evidence establishing a connection between the current disability and the service-connected disability. Wallin v. West, 11 Vet. App. 509, 512 (1998); Reiber v. Brown, 7 Vet. App. 513, 516-17 (1995). 2. Service connection for a right knee disability is denied. In this case, the Veteran has primarily contended that an altered gait due to her service-connected left knee disability caused or aggravated her current right knee disability. For the reasons discussed below, the Board finds that the weight of the evidence is against a grant of service connection for the right knee disability, either on a direct or secondary service connection basis. Reviewing the most relevant evidence of record, service treatment records are silent for any signs, symptoms, reports, findings, treatment, or diagnoses of a right knee disability. The Veteran, in fact, was discharged from active service due to her service-connected left knee disability, and there are extensive reports of examination of the left knee in service with no mention of any right knee problems. Following separation from service, the first documentation of right knee problems is in March 2000, when the Veteran reported bilateral knee pain. Bilateral crepitus was noted with pain to palpation, and she was diagnosed with chondromalacia of the bilateral knees. An August 2001 right knee x-ray study was normal. At an October 2001 VA orthopedic consultation, the Veteran reported bilateral knee pain, greater on the left. The orthopedist noted the normal x-ray study but diagnosed mild degenerative joint disease clinically. The Veteran was given Synvisc injections and knee braces. She continued to receive treatment for bilateral knee pain. A July 2013 private treatment record shows the Veteran reported right knee pain beginning 3 months prior. She denied any specific trauma to the right knee. She had a 1-year-old MRI study that showed chondromalacia, but the right knee had been fine until recently. An x-ray study was normal. The assessment was a right knee meniscal tear. In September 2013, she underwent surgical debridement of a lateral meniscal tear of the right knee. In December 2013, she underwent right knee biocartilage implantation with microfracture and tibial tubercle osteotomy for right knee chondral defect of the femoral trochlea. In an October 2015 report, a VA physician opined that the right knee disability was less likely than not caused or aggravated by the service-connected left knee disability. The examiner reasoned that the left knee conditions would not result in a severe antalgic gait for a prolonged period of years that would result in a shift of weight to the right lower extremity joints. Therefore, no extra weight burden or force transmission to the joints of the opposite, unaffected right lower extremity including the knee would occur. As a result, the examiner stated that the lack of extra stresses would not make the right knee predisposed to the development of the mechanical problems for which it had to be operated, citing to medical literature. The examiner further stated that the history of the Veteran as outlined in the August 2015 DBQ form demonstrated that she was not very active in her physical endeavors due to a limitation of walking or running. This information further illustrated that there would be less of a stress load on the right knee joint due to a favoring situation. Finally, the examiner stated that the August 2015 examination demonstrated that the right knee condition was stable and revealed no additional abnormalities than from what would be expected from its meniscectomy. Hence, no aggravation from the left knee was evident. The Veteran was afforded another VA knee examination in May 2016. The Veteran reported that her right knee discomfort started in approximately 1996 or 1997 as a result of compensating with her left knee. She indicated that her right knee discomfort gradually worsened over the years, and that she first received medical attention for her right knee approximately in 2001 or 2002, and was informed that she had chondromalacia patella in her right knee during that same timeframe. The May 2016 VA examiner opined that the Veteran's right knee disability (right knee chondromalacia patella, right knee DJD, s/p right knee arthroscopy with debridement of lateral meniscus and abrasion chondroplasty of femoral trochlea on 09/12/2013, and s/p right knee BioCartilage implantation with microfracture and tibial tubercle osteotomy on 09/12/2013 that has associated residuals) was less likely as not proximately due to or the result of or aggravated by injury to the service-connected left knee disability. The examiner reasoned that: (1) the right knee disability was not medically documented/identified until 2012, (2) the left knee injury occurred in 1995 with subsequent surgeries in 1996 and 2012, (3) scientific literature did not support the premise that a contralateral chondromalacia patella condition and/or contralateral knee surgical interventions increase risk of occurrence of chondromalacia patella of the opposite knee, and it was more likely than not that the Veteran's right knee condition (chondromalacia patella) was the result of the normal aging process, and (4) scientific literature did not support the premise that a contralateral chondromalacia patella condition and/or contralateral knee surgical interventions increase risk of occurrence of a meniscal tear and/or knee DJD of the opposite knee, and the etiology of the Veteran's right meniscal tear and/or right knee DJD were unknown. A March 2017 VA pain management note indicates that the Veteran was seen by orthopedics in May 2016, at which time x-rays showed no osseous injury or arthritis. Based on the evidence of record, lay and medical, the Board finds that there is no medical nexus between the current right knee disability and either active service or a service-connected disability. First, the weight of the evidence demonstrates that the Veteran's right knee disability was not continuous or recurrent in service. As noted above, service treatment records are entirely negative for any signs or symptoms of a right knee disability. The Board also finds that the preponderance of the evidence demonstrates that arthritis did not manifest to a compensable degree within one year of service separation. The preponderance of the evidence demonstrates no arthritis symptoms during the one-year period after service, and no diagnosis or findings of arthritis of any severity during the one-year post-service presumptive period. Indeed, as discussed above, the evidence does not demonstrate a diagnosis of arthritis until October 2001, and that diagnosis was based on clinical findings rather than imaging, which was and continues to be negative for arthritis. For these reasons, the Board finds that arthritis did not manifest to a compensable degree within one year of service separation; therefore, the presumptive provisions for arthritis are not applicable in this case. 38 C.F.R. §§ 3.307, 3.309. The Board next finds that the weight of the evidence demonstrates that symptoms of a right knee disability were not continuous or recurrent since separation from active service in August 1997. Following separation from service in August 1997, the evidence of record does not show any complaints, diagnosis, or treatment for a right knee disability until March 2000. The absence of post-service complaints, findings, diagnosis, or treatment for the claimed disability for two-and-a-half years after service separation is one factor that tends to weigh against a finding of continuous or recurrent symptoms of the claimed right knee disability after service separation. See Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006) (the lack of contemporaneous medical records is one fact the Board can consider and weigh against the other evidence, although the lack of such medical records does not, in and of itself, render the lay evidence not credible). Additional evidence demonstrating that symptoms of the claimed right knee disability have not been continuous or recurrent since service separation includes post-service treatment records from December 1998 and August 1999 indicating that the Veteran sought treatment for left knee pain but did not report, nor were there any findings of, right knee problems. These records provide highly probative evidence that she did not experience right knee symptoms continuously since active service, as it is expected that she would report right knee symptoms along with left knee symptoms in order to receive the best treatment. With regard to the Veteran's more recent assertions made in the context of the current disability claim of continuous or recurrent right knee symptoms since service, the Board finds that these more recent assertions are outweighed by the other, more contemporaneous, lay and medical evidence of record, both in service and after service, and are not reliable. See Charles v. Principi, 16 Vet. App. 370 (2002). The Board finds that the Veteran's assertions of continuous or recurrent right knee symptoms after service are not accurate because they are outweighed by other evidence of record that includes the more contemporaneous service treatment records, which are negative for any signs, reports, symptoms, findings, treatment, or diagnoses of a right knee disability; the December 1998 and August 1999 post-service treatment records showing reports of left but not right knee symptoms, as described above; and the lack of any documentation of reports or treatment for right knee symptoms for two-and-a-half years after service separation, also outlined above. As such, the Board does not find that the evidence sufficiently supports continuous or recurrent symptoms of a right knee disability since service so as to warrant a grant of service connection. Finally, the Board finds that the weight of the competent medical evidence weighs against a finding of a medical nexus between the current right knee disability and either active service or a service-connected disability. In this regard, the Board finds that the VA nexus opinions, discussed above, are the most probative evidence of record. The VA opinions are competent and probative medical evidence because they are factually accurate and are supported by adequate rationale. The VA examiners were informed of the pertinent evidence, reviewed the Veteran's claims file, and fully articulated the opinions in the reports, citing to specific medical evidence and medical literature. There are no contrary competent medical opinions of record, and the medical evidence of record does not otherwise suggest that there is an etiological relationship between the current right knee disability and either active service or a service-connected disability. The Board acknowledges the Veteran's contention made on her June 2017 VA Form 9 that the 2016 VA examiner relied on medical literature to form his opinion which did not take her specific circumstances into account. However, the 2016 VA examiner cited to specific treatment records and medical history in the rationale for his opinion, indicating that he did consider and address the Veteran's specific history in formulating his opinion; indeed, the examiner outlined a very extensive review of the Veteran's medical history earlier in the report. In addition, the 2015 VA examiner also specifically addressed the Veteran's contention that an altered gait due to her left knee disability caused or aggravated the right knee disability, explaining that the nature of the Veteran's left knee disability would not result in altered gait mechanics that would result in the type of disorders found in the right knee, and that her specific history indicated that her physical activity had been limited due to knee problems to a degree that would not result in additional stress on the right knee. Thus, the Board does not find the VA opinions to be inadequate. Moreover, the Board observes that the VA examiners' opinions are supported by the medical evidence of record. Namely, while the Veteran's gait was noted to be altered on several occasions in 2014 following her December 2013 right knee surgery, her gait has largely been observed to be normal (see, e.g., treatment records dated January 29, 2003, May 29, 2003, January 27, 2016, March 15, 2016, May 31, 2016, September 14, 2016, December 6, 2016, February 23, 2017, March 24, 2017, April 5, 2017, June 20, 2017, and September 4, 2018). These records also weigh against a finding that an altered gait caused or aggravated the right knee disability. The Board also acknowledges the January 2009 Board decision submitted by the Veteran wherein the Board granted service connection for a right knee disability as secondary to a service-connected left knee disability. In that case, the Board found that the right knee disability was caused by the service-connected left knee condition based, in part, on a private physician opinion stating that the veteran in that case overcompensated due to the left knee pain. In addition, there was evidence in that case that the veteran favored the right knee due to left knee pain, and even the VA examiner, who provided a negative nexus opinion, acknowledged that it was common for the contralateral knee to be affected. In contrast to the January 2009 Board decision, in this case, the VA examiners reviewed the Veteran's medical history and medical literature and concluded that the evidence and history did not support an etiological relationship between the left and right knee disabilities, and there are no favorable medical opinions of record. The VA opinions in this case which are unique to this particular Veteran are more persuasive than a Board decision pertaining to a different veteran. The Board acknowledges the belief of the Veteran that her right knee disability is related to her active service or to a service-connected disability. However, her statements alone do not establish a medical nexus. Indeed, while the Veteran is competent to provide evidence regarding matters that can be perceived by the senses, she has not been shown to be competent to render medical opinions on questions of etiology. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007)); see also Barr v. Nicholson, 21 Vet. App. 303 (2007) (lay testimony is competent to establish the presence of observable symptomatology). As such, as a layperson, she is without the appropriate medical training and expertise to offer an opinion on a medical matter, including the diagnosis, etiology, or causation of a specific disability. The question of diagnosis and causation, in this case, involves complex medical issues that the Veteran is not competent to address. Jandreau. Based on the evidence of record, the weight of the competent evidence demonstrates no relationship between the Veteran's claimed right knee disability and either her military service or a service-connected disability, including no credible evidence of continuous or recurrent symptoms of a right knee disability during active service, continuous or recurrent symptoms following service separation, or competent medical evidence establishing a link between the claimed right knee disability and either active service or a service-connected disability. Therefore, the Board finds that a weight of the lay and medical evidence that is of record is against the claim for service connection for the right knee disability and outweighs the Veteran's more recent contentions regarding in-service continuous or recurrent symptoms and continuous or recurrent post-service symptoms of a right knee disability. For these reasons, the claim must be denied. Because the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102. REASONS FOR REMAND 1. Entitlement to a disability rating in excess of 10 percent for left knee chondromalacia patella and degenerative joint disease, status post arthroscopic patellar chondroplasty and arthroscopic partial medial meniscectomy and debridements, is remanded. 2. Entitlement to a disability rating in excess of 10 percent for left knee instability/laxity from May 9, 2016 is remanded. 3. Entitlement to a separate 10 percent disability rating for left knee instability/laxity prior to May 9, 2016 is remanded. The Veteran filed a claim for an increased rating for her service-connected left knee chondromalacia patella and degenerative joint disease in May 2015. The October 2015 rating decision on appeal denied a rating in excess of 10 percent under the provisions of 38 C.F.R. § 4.71a, Diagnostic Code 5260 (limitation of flexion). During the course of this appeal, the RO granted a separate 10 percent disability rating for left knee instability/laxity under the provisions of 38 C.F.R. § 4.71a, Diagnostic Code 5257 (recurrent subluxation or lateral instability), effective from May 9, 2016, the date of the VA examination during which ligament testing demonstrated instability. Because the RO did not grant the separate rating for instability for the entire rating period on appeal, nor was the highest rating for instability awarded, the issues remaining on appeal have been characterized as they appear above. The Board finds that a remand is necessary to obtain a VA examination to assess the nature and severity of the left knee disability. The August 2015 and May 2016 VA knee examinations do not comply with the Court's more recent holdings regarding observing pain during active and passive range of motion and with weight-bearing and in non-weight-bearing status, and reporting or estimating range of motion during flare-ups and following repeated use over a period of time. See Correia v. McDonald, 28 Vet. App. 158 (2016); Sharp v. Shulkin, 29 Vet. App. 26 (2017). In Correia, 28 Vet. App. 158, the Court provided a precedential interpretation of the final sentence of 38 C.F.R. § 4.59 and held that VA examinations must, wherever possible, include range of motion testing of the pertinent joint for pain, as well as any paired joint, in active motion, passive motion, and in weight-bearing and non-weight-bearing. In Sharp, 29 Vet. App. 26, the Court held that before a VA examiner opines that he or she cannot offer an opinion as to additional functional loss during flare-ups without resorting to speculation based on the fact that the examination was not performed during a flare, the examiner must "elicit relevant information as to the veteran's flares or ask him to describe the additional functional loss, if any, he suffered during flares and then estimate the veteran's functional loss due to flares based on all the evidence of record, including the veteran's lay information, or explain why she could not do so." Id. In this case, the August 2015 VA examiner did not record whether or not there was pain in the left knee in non-weight-bearing status, nor did he provide an estimation of additional functional loss or loss of range of motion during flare-ups or following repeated use, stating that the Veteran reported varying degrees of additional limitation. The May 2016 VA examiner also did not record whether or not there was pain in the left knee in non-weight-bearing status, and, although the Veteran denied flare-ups at that examination, stated he was not able to estimate additional functional loss or loss of range of motion following repetitive use as the Veteran was not currently experiencing a flare-up. For these reasons, a new VA examination is necessary to assess the nature and severity of the left knee disability that complies with the Court's holdings in Correia and Sharp. 4. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) prior to March 2, 2020 is remanded. The issue of entitlement to a TDIU has been raised during the adjudicatory process of the underlying left knee disability. As such, it is part and parcel of the claim for benefits for the underlying left knee disability, and the Board has jurisdiction over it. See Rice v. Shinseki, 22 Vet. App. 447 (2009). In a June 2020 rating decision, the RO granted a TDIU effective from March 2, 2020. Because the award is not effective for the entire rating period on appeal (from May 29, 2015), the issue of entitlement to a TDIU prior to March 2, 2020 remains on appeal and is inextricably intertwined with the increased rating claim being remanded herein. The matters are REMANDED for the following action: 1. Afford the Veteran the opportunity to attend a VA examination to assess the current severity of his service-connected left knee disability. The claims file, to include a copy of this remand, should be made available to the examiner for review of the history in conjunction with the examination, and the examination report should reflect that such review was accomplished. The examiner must test the Veteran's active motion, passive motion, and identify whether or not there is pain with weight-bearing and without weight-bearing. Range of motion findings for active and passive motion should be recorded separately, even if they are the same, and the point at which painful motion begins should be clearly stated. A goniometer should be used for all range of motion testing. The examiner should also state whether the examination is taking place during a period of flare-up or following repeated use over time. If not, the examiner should ask the Veteran to describe the flare-ups he experiences, including: frequency, duration, characteristics, precipitating and alleviating factors, severity and/or extent of functional impairment he experiences during a flare-up of his knee symptoms and/or after repeated use over time. Based on the Veteran's lay statements and the other evidence of record, the examiner should provide an opinion estimating any additional degrees of limited motion caused by functional loss during a flare-up or after repeated use over time. If the examiner cannot estimate the degrees of additional range of motion loss during flare-ups or after repetitive use without resorting to speculation, the examiner should state whether the need to speculate is caused by a deficiency in the state of general medical knowledge (i.e., no one could respond given medical science and known facts) or by a deficiency in the record or the examiner (i.e., additional facts are required, or the examiner does not have the needed knowledge or training). The examiner should note that the VA CLINICIAN'S GUIDE requires the examiner to estimate the range of motion "per [the] Veteran." See VA CLINICIAN'S GUIDE at Ch. 11. 2. Once the development above has been completed, readjudicate the issues of entitlement to a disability rating in excess of 10 percent for left knee chondromalacia patella and degenerative joint disease, status post arthroscopic patellar chondroplasty and arthroscopic partial medial meniscectomy and debridements, to a disability rating in excess of 10 percent for left knee instability/laxity from May 9, 2016, to a separate 10 percent disability rating for left knee instability/laxity prior to May 9, 2016, and to a TDIU prior to March 2, 2020. Cynthia M. Bruce Veterans Law Judge Board of Veterans' Appeals Attorney for the Board T. Sherrard, 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.