Citation Nr: 21065342 Decision Date: 10/25/21 Archive Date: 10/25/21 DOCKET NO. 15-11 290 DATE: October 25, 2021 ORDER Entitlement to service connection for left ankle lateral/collateral ligament sprain is granted. Entitlement to an initial rating higher than 10 percent for left knee strain is denied. REMANDED Entitlement to service connection for nasal disability is remanded. Entitlement to service connection for right wrist disability is remanded. Entitlement to service connection for residuals of traumatic brain injury (TBI), to include disability manifested by loss of consciousness, is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) due to service-connected disabilities, from June 11, 2007 through November 15, 2011, is remanded. FINDINGS OF FACT 1. The evidence is at least evenly balanced as to whether the Veteran's left ankle lateral/collateral ligament sprain began during active service. 2. Since the June 11, 2007 effective date of service connection, the Veteran's left knee strain has been manifested by knee pain with normal knee flexion (140 degrees) and extension (0 degrees), and there has been no significant additional loss of motion due to such factors as pain, weakness, lack of endurance, fatigability, and incoordination with repeated use over time and during flare ups. CONCLUSIONS OF LAW 1. With reasonable doubt resolved in favor of the Veteran, the criteria for service connection for left ankle lateral/collateral ligament sprain are met. 38 U.S.C. §§ 1110, 1154, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for an initial rating higher than 10 percent for left knee strain are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.10, 4.20, 4.21, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes (DC) 5256-5263 (in effect prior to and since February 7, 2021). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from November 2000 to November 2004. His awards include the Army Commendation Medal. These matters initially came before the Board of Veterans' Appeals (Board) from May 2016 and January 2018 rating decisions. The Veteran testified before the undersigned Veterans Law Judge (VLJ) at a May 2018 hearing and a transcript of the hearing is associated with his claims file. In July 2018, the Board remanded the issue of entitlement to a TDIU for readjudication by the agency of original jurisdiction (AOJ) and issuance of a supplemental statement of the case (SSOC). In April 2020, the AOJ awarded a TDIU, from November 7, 2013. In July 2020, the Board remanded the issues of entitlement to service connection for left ankle disability, residuals of TBI, nasal disability, and right wrist disability, entitlement to a higher initial rating for left knee strain, and entitlement to a TDIU prior to November 7, 2013 for further development. In December 2020, the AOJ assigned an effective date of November 16, 2011 for the award of a TDIU. The Board points out that the TDIU issue was raised as part and parcel of the Veteran's appeal for a higher initial rating for his service-connected left knee disability. Therefore, the period on appeal for the TDIU issue dates back to the June 11, 2007 effective date of service connection for left knee strain. Accordingly, the issue of entitlement to a TDIU, from June 11, 2007 through November 15, 2011, remains on appeal before the Board. See Harper v. Wilkie, 30 Vet. App. 345 (2018). In the July 2020 remand, the Board instructed the AOJ to, among other things, implement the Board's award of an earlier effective date for the award of service connection for left knee strain (to include the assignment of an initial disability rating), ask the Veteran to identify any outstanding treatment records and to complete the appropriate authorization form to allow VA to obtain any outstanding private medical records, and obtain the Veteran's outstanding VA treatment records. Pursuant to the Board's remand, the AOJ implemented the Board's award of an earlier effective date for the award of service connection for left knee strain and assigned an initial disability rating in a July 2020 rating decision. The Veteran was asked to identify any outstanding treatment records and to complete the appropriate authorization form to allow VA to obtain any outstanding private medical records by way of an October 2020 letter. Copies of the authorization forms (VA Forms 21-4142 and 21-4142a) were included with the letter. Also, all outstanding VA treatment records were obtained and associated with the claims file. Therefore, the AOJ substantially complied with the Board's pertinent remand instructions. See Dyment v. West, 13 Vet. App. 141, 146- 47 (1999); Stegall v. West, 11 Vet. App. 268 (1998). As a final preliminary matter, the Board points out that the Veteran had also perfected an appeal with regard to the issue of entitlement to service connection for erectile dysfunction, and the Board remanded this issue in July 2020 for further development. The AOJ awarded service connection for erectile dysfunction by way of a July 2021 rating decision, and thereby resolved the appeal as to this issue. I. Service Connection Service connection will be granted if the evidence demonstrates that current disability resulted from an injury suffered or disease contracted in active military, naval, or air service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Establishing service connection generally requires competent evidence of three things: (1) current disability; (2) in-service injury or disease; and (3) a relationship between the two. Saunders v. Wilkie, 886 F.3d 1356, 1361 (Fed. Cir. 2018). Consistent with this framework, service connection is warranted for a disease first diagnosed after service when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Entitlement to service connection for left ankle lateral/collateral ligament sprain The Veteran contends that he has current left ankle disability which had its onset in service. The Board finds, for the following reasons, that the Veteran has a current diagnosis of left ankle lateral/collateral ligament sprain, and that the evidence is at least evenly balanced as to whether this disability began during active service. A March 2021 VA ankle examination report shows that the Veteran has a current diagnosis of left ankle lateral/collateral ligament sprain. Therefore, current left ankle disability has been demonstrated. There is also evidence of left ankle problems during service and evidence of continuous symptoms in the years since service. In this regard, the Veteran has reported that he began to experience left ankle pain in service following treatment for left foot problems. As explained in the Board's July 2020 decision, the Veteran participated in combat/was exposed to incoming enemy fire while serving in Southwest Asia. Where a veteran engaged in combat, satisfactory lay evidence that an injury or disease was incurred in service will be accepted as sufficient proof of service connection where such evidence is consistent with the circumstances, conditions, or hardships of service. 38 U.S.C. § 1154 (b). The combat rules not only reduce the evidentiary burden for establishing in-service injury but allow a combat veteran to use "satisfactory lay or other evidence" to establish that he incurred the disability itself in service, even in cases where "there is no official record" that such injury or disability occurred. Reeves v. Shinseki, 682 F.3d 988, 998 (Fed. Cir. 2012). In this case, the Veteran's reports of left ankle problems in combat situations in service are satisfactory evidence and the reports are consistent with the circumstances of his service in Southwest Asia. There is no clear and convincing evidence to the contrary. Therefore, the presence of left ankle symptoms in service is established. Moreover, the Veteran's post-service medical records and lay statements indicate that his left ankle symptoms have continued in the years since service. The Veteran is competent to report continuous left ankle symptoms in the years since service. Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006). Also, there no evidence that explicitly contradicts the Veteran's reports and his reports are generally consistent with the evidence of record. Therefore, the Board concludes that his reports of continuous left ankle symptoms in the years since service are credible. In May 2021, the physician who conducted the March 2021 VA ankle examination reviewed the Veteran's claims file and opined that his claimed left ankle disability was not likely ("less likely than not"/"less than 50 percent probability") incurred in or caused by service. The physician reasoned that medical records revealed that the Veteran began having ankle issues in 2016, which was 12 years after service. Therefore, the claimed left ankle disability was not likely ("less likely than not") incurred in or caused by the claimed in-service injury, event, or illness. The May 2021 opinion is of little, if any, probative value because it is entirely based upon an inaccurate history. Specifically, the examiner reasoned that there was no evidence of any treatment for ankle problems until 2016. However, the Veteran's VA treatment records reveal that he was treated for chronic ankle pain as early as 2011. Therefore, the May 2021 opinion is based on an inaccurate history and is of little probative value. Monzingo v. Shinseki, 26 Vet. App. 97, 107 (2012) ("If the opinion is based on an inaccurate factual premise, then it is correct to discount it entirely") (citing Reonal v. Brown, 5 Vet. App. 458, 461 (1993)). Moreover, the May 2021 opinion is entirely based on the absence of clinical evidence of treatment for ankle problems for many years following service and does not take into account the Veteran's competent and credible reports of left ankle pain in service and continuous ankle symptoms in the years since service. In this regard, a medical opinion is inadequate if it is based solely on the absence of documentation in the record and does not take into account the Veteran's reports of symptoms and history (even if recorded in the course of the examination). Dalton v. Peake, 21 Vet. App. 23 (2007). This is particularly true in the case of a combat veteran. Congress enacted the combat statute because of its concern that combat veterans faced "major obstacle[s]" when seeking to assemble the medical records necessary to establish that they suffered an injury or disease while in service. Reeves, 682 F.3d at 998 (citing H.R. Rep. No. 1157, at 3 (1941)). In many instances, medical records do not survive combat conditions. Id. Moreover, due to the exigencies of battle, soldiers may not immediately seek medical treatment for combat-related injuries. Id. Thus, to the extent that the May 2021 opinion was based on a lack of report of ankle problems during service, this is precisely the reasoning that the combat law was designed to prevent. In sum, the evidence reflects that the Veteran experienced left ankle symptoms in service and that there have been continuous symptoms in the years since service. He has also been diagnosed as having current left ankle lateral/collateral ligament sprain. There is no adequate medical opinion contrary to a conclusion that the current left ankle lateral/collateral ligament sprain had its onset in service. Thus, the evidence is at least evenly balanced as to whether this disability had its onset in service. As the reasonable doubt created by this relative equipoise in the evidence must be resolved in favor of the Veteran, entitlement to service connection for left ankle lateral/collateral ligament sprain is warranted. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. See also Buchanan, 451 F.3d at 1335 ("[N]othing in the regulatory or statutory provisions [relating to evidence to be considered] require both medical and competent lay evidence; rather, they make clear that competent lay evidence can be sufficient in and of itself"). II. Higher Initial Rating Disability ratings are determined by the application of rating criteria set forth in the VA Schedule for Rating Disabilities (38 C.F.R. Part 4) based on the average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155. Where service connection has been granted and the assignment of an initial rating is disputed, separate ratings may be assigned for separate periods of time based on the facts found. In other words, the ratings may be "staged." Fenderson v. West, 12 Vet. App. 119, 125-126 (1999). If two ratings are potentially applicable, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. In view of the number of atypical instances it is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified. Findings sufficiently characteristic to identify the disease and the disability therefrom, and above all, coordination of rating with impairment of function will, however, be expected in all instances. 38 C.F.R. § 4.21. In evaluating a disability, the Board considers the current examination reports considering 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. Disabilities evaluated on the basis of limitation of motion require VA to apply the provisions of 38 C.F.R. §§ 4.40, 4.45, pertaining to functional impairment. The United States Court of Appeals for Veterans Claims (Court) has instructed that in applying these regulations VA should obtain examinations in which the examiner determines whether the disability is manifested by weakened movement, excess fatigability, incoordination, pain, or flare-ups. Such inquiry is not to be limited to muscles or nerves. These determinations are, if feasible, to be expressed in terms of the degree of additional range-of-motion loss due to any weakened movement, excess fatigability, incoordination, flare-ups, or pain. The examiner should also determine the point, if any, at which such factors cause functional impairment. Moreover, the joints involved should be tested for pain on both active and passive motion, in weight-bearing and non weight-bearing and, if possible, with the range of the opposite undamaged joint. Correia v. McDonald, 28 Vet. App. 158 (2016); Mitchell v. Shinseki, 25 Vet. App. 32, 43-4 (2011); DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Johnston v. Brown, 10 Vet. App. 80, 84-5 (1997); 38 C.F.R. § 4.59. 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. See Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 230 (Nov. 30, 2020). These amendments revised select diagnostic codes "to ensure that this portion of the rating schedule uses current medical terminology and provides detailed and updated criteria for the evaluation of musculoskeletal disabilities." Id. 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); see also Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). If the revised version of the regulation is more favorable, the implementation of that regulation under 38 U.S.C. § 5110 (g) can be no earlier than the effective date of that change. If the former version is more favorable, VA can apply the earlier version of the regulation for the period prior to, and from, the effective date of the change. 38 U.S.C. § 5110; Kuzma, 341 F. 3d 1327. Therefore, the Board will consider the Veteran's claim under the former criteria prior to February 7, 2021, and both the former and new rating criteria from February 7, 2021. The criteria that is more favorable to the Veteran will be applied. Entitlement to an initial rating higher than 10 percent for left knee strain As a preliminary matter, the Board notes that the Veteran's representative contended in an October 2021 statement that a December 2017 VA knee examination was inadequate because the examiner "confused 'repeated use over a period of time' with 'repetitive-use testing.'" Neither the Veteran nor his representative have specifically challenged the qualifications of the examiner who conducted the December 2017 examination and such a specific challenge is required to warrant further discussion of the examiner's competence. Francway v. Wilkie, 930 F.3d 1377, 1381 (Fed. Cir. 2019) ("whether an examiner is competent and whether he has rendered an adequate exam are two separate inquiries") (quoting Mathis v. McDonald, 834 F.3d 1347, 1351 (Fed. Cir. 2016) (Hughes, J., concurring in denial of rehearing en banc), modified on other grounds by Francway v. Wilkie, 940 F.3d 1304 (Fed. Cir. 2019)(en banc). Moreover, the December 2017 VA examination report is the product of an in-person examination, a review of the Veteran's treatment records, and consideration of his reported symptoms and history. In addition, the report sets forth detailed findings in a manner which allows for informed appellate review under applicable VA laws and regulations and the Board finds the examination to be sufficient for appellate review and of high probative value. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007); Stefl v. Nicholson, 21 Vet. App. 120, 124-25 (2007) (holding an examination is considered adequate when it is based on consideration of the appellant's prior medical history and examinations and also describes the disability in sufficient detail so that the Board's evaluation of the disability will be a fully informed one). Hence, the Board finds that the December 2017 knee examination report is adequate, and that this report, along with the other evidence of record, provides sufficient information for resolution of the appeal for a higher initial rating for left knee strain. Moreover, the December 2017 knee examination provided the findings necessary to properly rate the Veteran's left knee disability based upon an in-person examination, he has not reported any changes in his knee disability since that time, and the record does not otherwise suggest any changes. Palczewski v. Nicholson, 21 Vet. App. 174 (2007) (mere passage of time does not trigger need for a new VA examination, absent evidence of a change in the disability). Thus, a new VA examination for his left knee disability need not be conducted merely due to the passage of time since the last examination. The Veteran's left knee strain is rated under 38 C.F.R. § 4.71A, DC 5260 as limitation of knee flexion. Under DC 5260, both prior to and since the regulatory change, limitation of knee flexion is rated as follows: a 10 percent rating is warranted when it is limited to 45 degrees; a 20 percent rating is warranted when it is limited to 30 degrees; and a 30 percent rating is warranted when it is limited to 15 degrees. 38 C.F.R. § 4.71A, DC 5260. VA's General Counsel has held that separate ratings can be provided for limitation of knee extension and flexion. VAOPGCPREC 9-2004 ; 69 Fed. Reg. 59,990 (2004). Under DC 5261, both prior to and since the regulatory change, limitation of knee extension is rated as follows: a 10 percent rating is warranted when it is limited to 10 degrees; a 20 percent rating is warranted when it is limited to 15 degrees; a 30 percent rating is warranted when it is limited to 20 degrees; a 40 percent rating is warranted when it is limited to 30 degrees; and a 50 percent rating is warranted when it is limited to 45 degrees. 38 C.F.R. § 4.71A, DC 5261. For rating purposes, normal range of motion in a knee joint is from 0 to 140 degrees. 38 C.F.R. § 4.71, Plate II. Considering the pertinent evidence in light of the applicable rating criteria and considerations, the Board finds, for the following reasons, that the Veteran's left knee strain has not met or approximated the criteria for an initial rating higher than 10 percent at any time since the June 11, 2007 effective date of service connection. VA treatment records dated in February 2011, a December 2013 examination report from M.C. Dubinsky, MD, and the report of a November 2014 VA knee examination indicate that the Veteran experienced persistent intermittent left knee pain which affected his ambulation. The pain was located at the anterior, lateral, and posterior knee, occurred on a daily basis, was achy in nature, was up to 6/10 in severity, and was exacerbated with kneeling and squatting. There were no flare ups of knee symptoms. The Veteran was only able to sit for 15 to 20 minutes at a time before having to get up because of pain, he experienced difficulty with bending and stooping maneuvers, and his knee pain affected his ambulation, balance, and sleep. Examination revealed that the ranges of motion of the left knee were all normal. The Veteran was able to perform repetitive use testing and there was no change in the ranges of motion after repetitive testing. There was no pain with active motion, passive motion, or repetitive use testing of the knee, there was no pain when the knee was used in weight-bearing or non weight-bearing, and there was no localized tenderness or pain on palpation of the left knee joint/soft tissue. There was no functional loss of the left lower extremity attributable to the Veteran's left knee disability and there was no functional loss (not associated with limitation of motion) during flare ups or when the knee was used repeatedly over a period of time. Moreover, muscle strength associated with left knee flexion and extension was normal (5/5), there was no muscle atrophy, there was no ankylosis of the knee, there was no evidence or history of recurrent patellar subluxation, lateral instability, or effusion, and joint stability testing was all normal. The Veteran did not have any shin splints, stress fractures, Achilles tendonitis, Achilles tendon rupture, or malunion of the calcaneus (os calcis) or talus (astragalus), and he had not had a talectomy (astragalectomy). He did not have any meniscus (semilunar cartilage) condition or total knee joint replacement, there were no scars related to the Veteran's knee disability, and there were no other pertinent physical findings, complications, conditions, signs, or symptoms. He did not use any assistive devices as a normal mode of locomotion and there was no functional impairment of an extremity such that no effective function remained other than that which would have been equally well served by an amputation with prosthesis. The Veteran reported during a December 2017 VA knee examination that he experienced flare ups of left knee symptoms, during which there was intense throbbing. There was functional loss/impairment in that his left foot was unable to bend properly when he walked. The ranges of left and right knee motions were tested and the left knee ranges of motion were flexion to 140 degrees and extension to 0 degrees. There was pain associated with knee flexion and extension, but the pain did not result in/cause functional loss. There was no evidence of pain with weight bearing, objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue, or objective evidence of crepitus. The Veteran was able to perform repetitive use testing with at least three repetitions and there was no additional loss of function or range of motion after three repetitions. He was being examined immediately after repetitive use over time and during a flare up and the examiner specified that pain, weakness, fatigability, or incoordination did not significantly limit functional ability with repeated use over time or during flare ups. There were no additional factors contributing to disability. Moreover, muscle strength associated with left knee flexion and extension was normal (5/5) and there was no muscle atrophy or ankylosis. The Veteran did not have a history of any recurrent subluxation, lateral instability, or recurrent effusion, and knee stability testing was all normal. He did not have any recurrent patellar dislocation, shin splints (medial tibial stress syndrome), stress fractures, chronic exertional compartment syndrome, or any other tibial or fibular impairment. He did not have any meniscus condition, there were no scars related to his knee disability, and there were no other pertinent physical findings, complications, conditions, signs, or symptoms. The Veteran did not use any assistive devices as a normal mode of locomotion and there was no functional impairment of an extremity such that no effective function remained other than that which would have been equally well served by an amputation with prosthesis. The Veteran was diagnosed as having a left knee strain. This disability did not impact his ability to work. Moreover, the examiner noted that there was objective evidence of pain on passive range of motion testing, but no evidence of pain on non weight-bearing of the knee. The above evidence reflects that since the June 11, 2007 effective date of service connection, the Veteran has experienced left knee pain and that left knee flexion has been to 140 degrees and extension has been to 0 degrees. These findings, by themselves and without consideration of potential functional impairment, are contemplated by no more than a single 10 percent rating for painful left knee motion under DC 5260. With respect to functional impairment, there is pain associated with the Veteran's left knee disability. He did not report any flare ups during the November 2014 VA examination, but he reported during the December 2017 examination that there were flare ups of left knee symptoms, during which there was intense throbbing. There was no pain associated with knee motion during the November 2014 examination, the December 2017 examination report indicates that pain did not cause any functional loss, and there was no additional functional loss/impairment or range of motion loss following repetitive use testing during the November 2014 and December 2017 examinations. The examiner who conducted the November 2014 examination indicated that there was no functional loss of the left lower extremity attributable to the Veteran's left knee disability and there was no functional loss during flare ups or when the knee was used repeatedly over a period of time. Also, the examiner who conducted the December 2017 examination specified that the Veteran was being examined immediately after repetitive use over time and during a flare up, that pain, weakness, fatigability, and incoordination did not significantly limit functional ability with repeated use over a period of time or during a flare up, and that there were no additional factors contributing to disability. The Veteran is competent to report the symptoms associated with his service-connected left knee disability and the extent of his impairment following repetitive use and during flare ups, and the Board has no reason to challenge the credibility of his contentions. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); Buchanan, 451 F.3d at 1337. Regardless of the competent and credible reports of flare ups, pain, and other functional impairments, and despite the fact that painful motion has been documented, the preponderance of the evidence nonetheless supports the conclusion that the Veteran's knee symptoms have most closely approximated the criteria for at most a single 10 percent rating for painful knee motion under DC 5260 during the entire claim period. Specifically, the above evidence reflects that the flare ups and other functional impairments have not been so severe, frequent and/or prolonged to warrant the next higher percent ratings at any time during the claim period. A preponderance of the evidence shows that even considering pain, flare ups, and other functional factors, the Veteran's knee symptoms have not been shown to be so disabling to actually or effectively result in limitation of knee flexion more nearly approximating 30 degrees or limitation of knee extension more nearly approximating 10 degrees, which are the requirements for a 20 percent rating for limitation of knee flexion under DC 5260 and a compensable (10 percent) rating for limitation of knee extension under DC 5261, respectively. Overall, the Veteran's left knee strain has resulted in painful knee motion with noncompensable limitation of motion. Therefore, an initial rating higher than 10 percent for limitation of knee motion is not warranted at any time since the June 11, 2007 effective date of service connection under either the old or the revised regulations. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 4.7, 4.71A, DCs 5260-5261. Moreover, there is no evidence of knee ankylosis during the claim period. Ankylosis is defined in general as "immobility and consolidation of a joint due to disease, injury, or surgical procedure." Colayong v. West, 12 Vet. App. 524 (1999) (citing Dorland's Illustrated Medical Dictionary (28TH Ed. 1994) at 86). The Court has held that a veteran may be entitled to a rating based on ankylosis if he experiences the functional equivalent of ankylosis when considering the provisions of 38 C.F.R. §§ 4.40 and 4.45. Chavis v. McDonough, 34 Vet. App. 1, 23-24 (2021). In this case, the November 2014 and December 2017 examinations indicate that there was no actual knee ankylosis. Also, the Board finds that even considering knee pain and other functional factors, the Veteran has not experienced the functional equivalent of knee ankylosis at any time during the claim period. In other words, a preponderance of the evidence shows that even considering pain and other functional factors, the Veteran's knee symptoms have not been so disabling to actually or effectively result in immobility or fixation of the knee at any point in the ranges of knee motion. Therefore, a higher rating is not warranted on the basis of ankylosis/functional equivalent of ankylosis at any time during the claim period under either the old or the revised regulations. See 38 C.F.R. § 4.71A, DC 5256 (in effect prior to and since February 7, 2021). In his October 2021 statement, the Veteran's representative noted an April 2013 VA treatment record which indicates a history of impaired balance due to the Veteran's left knee disability. The representative contends that this suggests that a separate rating for knee instability is warranted. However, there is no evidence that the Veteran has ever reported any recurrent subluxation or instability of his left knee, the November 2014 and December 2017 examination reports indicate that there was no evidence or history of recurrent patellar subluxation or lateral instability and that knee stability testing was all normal, and the Veteran has not used any assistive device as a normal mode of locomotion due to his knee disability. Therefore, the Board finds that the preponderance of the evidence is against a finding of any recurrent subluxation or instability of the left knee, and a separate rating under DC 5257 is not warranted any time during the claim period, under either the old or the revised regulations. See 38 C.F.R. § 4.71A, DC 5257 (in effect prior to and since February 7, 2021). Also, there is no evidence of any cartilage impairment or removal, impairment of the tibia or fibula, or genu recurvatum at any time during the claim period. Therefore, separate/higher ratings are not warranted under DCs 5258-5259, 5262 or 5263 at any time since the effective date of service connection under either the old or the revised regulations. Lastly, in conjunction with the appeal for a higher initial rating for the service-connected left knee disability, no other related issues have been raised by the Veteran or his representative, and no other such issues have been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 369-70 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). REASONS FOR REMAND 1. Entitlement to service connection for nasal disability is remanded. The Veteran contends that he began to experience nasal disability (manifested by nasal discharge, scabs, and sores) in service during his exposure to burn pits and other environmental toxins in Southwest Asia and that such symptoms have continued in the years since service. He was afforded a VA examination in April 2016 and the examiner did not diagnose him as having any current nasal disability (to include any sinus disability). Also, the examiner opined that the Veteran's claimed nasal disability was not likely incurred in or caused by service. In the July 2020 remand, the Board explained that the April 2016 opinion is inadequate because it is essentially based on a finding that, other than a runny nose associated with upper respiratory infections, there was no evidence that any chronic nasal condition existed in service, immediately following the Veteran's separation from service, or in the intervening years. However, the examiner did not acknowledge or comment on the potential significance of the Veteran's treatment for increased sinus pressure in service in March 2004. Also, VA treatment records dated in February and March 2011 include references to a history of allergic rhinitis, nasal discharge, and headaches that were "most likely due to sinuses." Therefore, the Board instructed the AOJ to afford the Veteran a new examination to determine the nature and etiology of any current nasal disability. The examiner was instructed to opine whether any current nasal symptom experienced by the Veteran is a manifestation of an identifiable disability and, if so, to opine whether the disability is related to service. If any current nasal symptom was not a manifestation of an identifiable disability, the examiner was to opine whether the symptom represents an indication of a chronic disability resulting from an undiagnosed illness or a medically unexplained chronic multisymptom illness (MUCMI). Pursuant to the Board's July 2020 remand, a VA nasal examination was conducted in February 2021. The examiner did not diagnose the Veteran as having any current nasal disability and opined that his claimed nasal disability was not likely incurred in or caused by service. The examiner reasoned that there were three references of nasal symptoms with self-limited upper respiratory infections, which all occurred prior to his deployment to southwest Asia. There was no reference to any ear, nose, and throat (ENT) symptoms, the Veteran made a nasal symptom claim 11 years after discharge, and there was no treatment for nasal symptoms after deployment and exposure to burn pits. In August 2021, the February 2021 examiner reviewed the Veteran's claims file and provided an addendum opinion in order to address the increased sinus pressure in service in March 2004 and the VA treatment records dated in February and March 2011 which reference a history of allergic rhinitis, nasal discharge, and headaches that were "most likely due to sinuses." The examiner explained that there was no specific "sinus pressure" medical record evaluation in the Veteran's service treatment records and that "no nasal discharge" was actually reported. Also, despite the February and March 2011 references in the VA treatment records, there was no specific evaluation of any ENT condition and they were subjective medical records from a patient history which, unlike objective findings, could not be verified. The February and August 2021 opinions are inadequate because despite the examiner's assertion that there was no evidence of sinus pressure documented in the Veteran's service treatment records, a March 2004 service treatment record reflects that the Veteran reported a 2 to 3 day history of increased sinus pressure and drainage, and a history of allergies. The Veteran was diagnosed as having allergic rhinitis and was prescribed allergy medications. Moreover, the examiner's opinion is partially based on the absence of clinical evidence of treatment for nasal problems following service and the examiner did not adequately consider the Veteran's competent and credible reports of nasal symptoms in the years since service. Also, the February and August 2021 opinions do not address whether any of the Veteran's reported nasal symptoms are indicative of a chronic disability resulting from an undiagnosed illness or a MUCMI. In light of the above inadequacies of the February and August 2021 opinions, a remand is necessary to obtain a new medical opinion as to the nature of the Veteran's claimed nasal disability and whether any such disability is related to service. Also, the evidence indicates that there may be outstanding relevant VA treatment records. The most recent VA treatment records in the claims file are from the VA Greater Los Angeles Healthcare System (dated to July 2021), the VA Long Beach Healthcare System (dated to November 2020), and the VA Loma Linda Healthcare System (dated to May 2008). Any VA treatment records are within VA's constructive possession, and must be obtained regardless of their relevance as long as they are sufficiently identified. Sullivan v. McDonald, 815 F.3d 786, 793 (Fed. Cir. 2016) (VA has a duty to assist in obtaining sufficiently identified VA medical records regardless of their relevance). See also Jones v. Wilkie, 918 F.3d 922 (Fed. Cir. 2019) (confirming the holding in Sullivan). A remand is required to allow VA to obtain them. 2. Entitlement to service connection for right wrist disability and residuals of TBI (to include disability manifested by loss of consciousness) are remanded. As the record currently stands, there is no evidence of any current right wrist disability or residual of TBI that is not already service-connected. As additional treatment records are being sought upon remand which may document evidence of such disabilities, the claims of service connection for right wrist disability and residuals of TBI are being remanded as well. 3. Entitlement to a TDIU due to service-connected disabilities, from June 11, 2007 through November 15, 2011, is remanded. The Veteran most recently submitted a Veteran's Application for Increased Compensation Based on Unemployability form (VA Form 21-8940) in May 2018, on which he reported that he stopped working in November 2011. However, he and his representative appear to contend that he stopped working prior to this date and it is otherwise unclear as to the Veteran's employment history during the period from June 11, 2007 through November 15, 2011. Therefore, a remand is necessary to seek clarification from the Veteran as to his employment history during this period. Also, the AOJ should contact the Social Security Administration (SSA) and request the Veteran's earning statements from 2007 through 2011. Also, all outstanding VA treatment records should be secured upon remand. Finally, because the AOJ's implementation of the Board's award of service connection for left ankle lateral/collateral ligament sprain and a decision on the remanded service connection issues could significantly impact a decision on the issue of entitlement to a TDIU, the issues are inextricably intertwined. A remand of the claim for a TDIU is required. The matters are REMANDED for the following action: 1. Ask the Veteran to complete a VA Form 21-8940 and to report his education and complete employment history and earnings, especially for the period from June 11, 2007 through November 15, 2011. 2. The AOJ should contact the SSA and request the Veteran's earning statements for the period from 2007 through 2011. If the SSA informs the AOJ that it cannot provide earnings statements to VA without the Veteran's approval, the AOJ should undertake to obtain any documentation needed from the Veteran to enable the AOJ to obtain his SSA earning statements. 3. Ask the Veteran to identify the location and name of any VA or private medical facility where he has received treatment for nasal disability, right wrist disability, and residuals of TBI, to include the dates of any such treatment. Ask the Veteran to complete a VA Form 21-4142 for all records of his treatment for nasal disability, right wrist disability, and residuals of TBI from any sufficiently identified private treatment provider from whom records have not already been obtained. Make two requests for any authorized records, unless it is clear after the first request that a second request would be futile. 4. Obtain the Veteran's outstanding VA treatment records from the VA Greater Los Angeles Healthcare System for the period since July 2021; the VA Long Beach Healthcare System for the period since November 2020; the VA Loma Linda Healthcare System for the period since May 2008; and all such relevant records from any other sufficiently identified VA facility. 5. After all efforts have been exhausted to obtain and associate with the claims file any additional treatment records, obtain an addendum opinion from an appropriate clinician regarding the nature of any current nasal disability and whether any such disability is related to service. The clinician should answer all of the following questions: (a) Has the Veteran experienced rhinitis, sinusitis, and/or rhinosinusitis at any time since approximately December 2015? (b) Is it at least as likely as not that any identifiable nasal disability experienced by the Veteran since approximately December 2015 (1) began during service; OR (2) is related to an injury or disease during service, including the nasal and sinus symptoms documented in his service treatment records (including his treatment for increased sinus pressure and drainage on March 9, 2004, which was diagnosed as allergic rhinitis) and his reported nasal symptoms in service and exposure to burn pits and other environmental toxins in Southwest Asia? (c) Is it at least as likely as not that any identifiable nasal disability experienced by the Veteran since approximately December 2015 has at least a partially understood pathophysiology AND etiology? (d) Are any of the Veteran's reported nasal symptoms (including, but not limited to, nasal discharge, scabs, and sores) a symptom of an identifiable disability? If not, does any such symptom represent an objective indication of chronic disability resulting from (1) an undiagnosed illness; OR (2) a medically unexplained chronic multisymptom illness without conclusive pathophysiology OR etiology? For purposes of the above opinions, the clinician shall presume that any reports by the Veteran of nasal symptoms and exposure to burn pits and other environmental toxins in service and in the years since service are accurate The clinician must provide reasons for each opinion given. Jonathan Hager Veterans Law Judge Board of Veterans' Appeals Attorney for the Board B. Elwood, 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.