Citation Nr: 21065792 Decision Date: 10/27/21 Archive Date: 10/27/21 DOCKET NO. 10-24 641 DATE: October 27, 2021 ORDER Entitlement to a 20 percent rating for service-connected left knee Osgood-Schlatter disease is granted for the entire appeal period. REMANDED Entitlement to service connection for sinusitis is remanded. Entitlement to service connection for headaches is remanded. Entitlement to a total disability rating based upon individual unemployability (TDIU) is remanded. FINDING OF FACT For the entire appeal period, the Veteran's service-connected left knee Osgood-Schlatter disease has been manifested by painful motion limited to, at worst, 30 degrees flexion to 0 degrees of extension when considering functional impairment on use or during flares. CONCLUSION OF LAW The criteria for a 20 percent rating for service-connected left knee Osgood-Schlatter disease have been met for the entire appeal period. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, DCs 5260, 5261. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served honorably on active duty with the United States Air Force from October 1971 to October 1975. This case comes before the Board of Veterans' Appeals (Board) on appeal from a March 2015 rating decision and a December 2020 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) (hereinafter agency of original jurisdiction (AOJ)). A Board hearing was held before an Acting Veterans Law Judge (AVLJ) in August 2011. That AVLJ no longer works for the Board. A Board hearing was held before another Veterans Law Judge (VLJ) in July 2018. The hearing addressed the issues of entitlement to service connection for sinusitis, entitlement to a rating in excess of 10 percent for a left knee injury, and entitlement to service connection for headaches. A transcript of the hearing is of record. In July 2019, the Veteran was afforded another Board hearing and provided testimony before another VLJ. A transcript of the proceeding is associated with the record. By letter dated January 27, 2021, the Veteran was offered the opportunity for another hearing before a third VLJ who would be on a panel to ultimately decide his case. He did not request another hearing. The Board further notes that the AOJ has not documented compliance with the prior Board remand directive to search for VA clinic records since 1981. The AOJ initiated this request electronically in June 2020. However, the Board finds that the missing VA records are not pertinent to the increased rating claim for left knee disability. 1. Entitlement to a higher rating for service-connected left knee Osgood-Schlatter disease Disability evaluations are determined by the application of the facts presented to VA's Schedule for Rating Disabilities (Rating Schedule) at 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 the residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.321(a), 4.1. Separate diagnostic codes identify various disabilities and the criteria for specific ratings. Relevant regulations do not require that all cases show all findings specified by the Schedule; however, findings sufficient to identify the disease and the resulting disability and, above all, coordination of the rating with impairment of function will be expected in all cases. 38 C.F.R. §§ 4.7, 4.21. If two disability evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining will be resolved in favor of the veteran. 38 C.F.R. § 4.3. In establishing an appropriate initial assignment of a disability rating, the proper scope of evidence includes all medical evidence submitted in support of the veteran's claim. Fenderson v. West, 12 Vet. App. 119 (1999). In cases where an assigned disability rating has been challenged or appealed, it is possible for a veteran to receive a staged rating. A staged rating is an award of separate percentage evaluations for separate periods, based on the facts found during the appeal period. Id. at 126-28; see also Hart v. Mansfield, 21 Vet. App. 505 (2007) (in determining the present level of a disability for any increased evaluation claim, the Board must consider staged ratings). Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. Functional loss may be due to the absence or deformity of structures or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior in undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. § 4.40. In determining the appropriate evaluation for musculoskeletal disabilities, particular attention is focused on functional loss of use of the affected part. Under 38 C.F.R. § 4.40, functional loss may be due to pain, supported by adequate pathology and evidenced by visible behavior on motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. Under 38 C.F.R. § 4.45, factors of joint disability include increased or limited motion, weakness, fatigability, or painful movement, swelling, deformity or disuse atrophy. Under 38 C.F.R. § 4.59, painful motion is an important factor of joint disability and actually painful joints are entitled to at least the minimum compensable rating for the joint. This regulation also requires that, whenever possible, the joints involved are 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. See Correia v. McDonald, 28 Vet. App. 158, 168 (2016). Where functional loss is alleged due to pain upon motion, the provisions of 38 C.F.R. § 4.40 and § 4.45 must be considered. DeLuca v. Brown, 8 Vet. App. 202, 207-08 (1995). Within this context, a finding of functional loss due to pain must be supported by adequate pathology and evidenced by the visible behavior of the claimant. Johnston v. Brown, 10 Vet. App. 80, 85 (1997). Pain itself does not rise to the level of functional loss as contemplated by § 4.40 and § 4.45 but may result in functional loss only if it limits the ability to perform the normal working movements of the body with normal excursion, strength, coordination or endurance. Mitchell v. Shinseki, 25 Vet. App. 32, 43 (2011). The intent of the Rating Schedule is to recognize actually painful, unstable or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. For the period on appeal, the Veteran's left knee disorder is rated as follows: 10 percent disabled for left knee Osgood-Schlatter disease, effective March 16, 1998 to November 17, 2020, and 20 percent disabled thereafter. Included within 38 C.F.R. § 4.71a are multiple diagnostic codes (DC)s that evaluate impairment resulting from service-connected knee disorders, including DC 5256 (ankylosis), DC 5257 (other impairment, including recurrent subluxation or lateral instability), DC 5258 (dislocated semilunar cartilage), DC 5259 (symptomatic removal of semilunar cartilage), DC 5260 (limitation of flexion), DC 5261 (limitation of extension), DC 5262 (impairment of the tibia and fibula), and DC 5263 (genu recurvatum). Under DC 5260, a noncompensable rating is assigned when flexion of the leg is limited to 60 degrees; a 10 percent rating is assigned when flexion is limited to 45 degrees; a 20 percent rating is assigned when flexion is limited to 30 degrees; and a 30 percent rating is assigned when flexion is limited to 15 degrees. 38 C.F.R. § 4.71a, DC 5260. Under DC 5261, a noncompensable rating is assigned when extension of the leg is limited to 5 degrees; a 10 percent rating is assigned when extension is limited to 10 degrees; a 20 percent rating is assigned when extension is limited to 15 degrees; a 30 percent rating is assigned when extension is limited to 20 degrees; a 40 percent rating is warranted for extension limited to 30 degrees; and a 50 percent rating is assigned when extension is limited to 45 degrees. 38 C.F.R. § 4.71a, DC 5261. Under DC 5257, which evaluates recurrent subluxation or lateral instability of a knee, and assigns a 10 percent disabling for a slight impairment, 20 percent disabling for a moderate impairment, and 30 percent disabling for a severe impairment. Under DC 5258, a maximum 20 percent rating is warranted for semilunar cartilage, dislocated, with frequent episodes of "locking", pain, and effusion into the joint. Lastly, under DC 5259, a maximum 10 percent rating is warranted for removal of semilunar cartilage that is symptomatic. Separate ratings under DCs 5260 and 5261 may be assigned for disability of the same knee joint. See VAOPGCPREC 9-2004. Additionally, for a knee disability already rated under DCs 5260 and/or 5261, a claimant would have additional disability justifying a separate rating if there is instability and/or subluxation of the knee joint under DC 5257. See generally VAOPGCPREC 23-97. Furthermore, the rating criteria do not preclude separate ratings for meniscal injury under DCs 5258 and 5259 where there are separate ratings for limitation of motion under DCs 5260 and/or 5261, or instability under DCs 5257. Lyles v. Shulkin, 29 Vet. App. 107 (2017). The normal range of knee motion is 140 degrees of flexion and zero degrees of extension. 38 C.F.R. § 4.71, Plate II. The terms "slight," "moderate," "moderately severe," and "severe" are not defined in the Rating Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6. The use of terminology such as "slight" or "moderate" by VA examiners and others, although an element of evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. For the musculoskeletal system and muscle injuries, the applicable rating criteria, found at 38 C.F.R. § 4.71a, were amended effective February 7, 2021. The old rating criteria applies to rating periods prior to February 7, 2021; however, whichever set of criteria is more favorable applies to periods after February 7, 2021, if the claim was pending prior to this date. See Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). As the Veteran's claim was pending prior to this date, the more favorable criteria will apply. Under the new rating criteria for DC 5257, other impairments of the knee are rated under either recurrent subluxation or instability, or patellar instability. Under recurrent subluxation or instability, a 10 percent rating is warranted for sprain, incomplete ligament tear, or complete ligament tear (repaired, unrepaired, or failed repair) causing persistent instability, without a prescription from a medical provider for an assistive device (e.g., cane(s), crutch(es), walker) or bracing for ambulation. A 20 percent rating is warranted for one of the following: (a) Sprain, incomplete ligament tear, or repaired complete ligament tear causing persistent instability, and a medical provider prescribes a brace and/or assistive device (e.g., cane(s), crutch(es), walker) for ambulation; or, (b) Unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribes either an assistive device (e.g., cane(s), crutch(es), walker) or bracing for ambulation. A 30 percent rating is warranted for unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribes both an assistive device (e.g., cane(s), crutch(es), walker) and bracing for ambulation. Under patellar instability, a 10 percent rating is warranted for a diagnosed condition involving the patellofemoral complex with recurrent instability (with or without history of surgical repair) that does not require a prescription from a medical provider for a brace, cane, or walker. A 20 percent rating is warranted for a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for one of the following: A brace, cane, or walker. A 30 percent rating is warranted for a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for a brace and either a cane or a walker. Note 1 indicates for patellar instability, the patellofemoral complex consists of the quadriceps tendon, the patella, and the patellar tendon. Note 2 indicates that a surgical procedure that does not involve repair of one or more patellofemoral components that contribute to the underlying instability shall not qualify as surgical repair for patellar instability (including, but not limited to, arthroscopy to remove loose bodies and joint aspiration. After thoroughly reviewing the evidence of record, the Board finds that a uniform 20 percent rating for left knee Osgood-Schlatter disease is warranted for the entire appeal period. The Veteran first became service-connected for left knee Osgood-Schlatter disease following a July 1981 rating decision. The AOJ awarded a 0 percent disability rating for this condition, effective June 18, 1980. In March 1998, the Veteran filed an increased rating claim, requesting an increased evaluation of the service-connected left knee condition. In June 1998, the AOJ awarded a 10 percent disability rating for this condition, effective March 16, 1998, the date in which he filed the increased rating claim. In February 2001, the Veteran filed an increased rating claim, contending that his left knee condition warranted a higher disability rating. In February 2003, the AOJ continued the Veteran's 10 percent disability rating for his left knee condition. In June 2004, the Veteran filed an increased rating claim, contending that his left knee condition warranted a higher disability rating. In November 2004, the AOJ continued the Veteran's 10 percent disability rating for his left knee condition. The Veteran did not appeal this rating decision. The Veteran filed the current claim for an increased rating in January 2009. He reported being unable to stand for prolonged periods of time due to his left knee and also being unable fully extend his knee. The Veteran was provided a VA examination in March 2009. During the examination, the Veteran described experiencing symptoms of chronic left knee pain, which affected his occupation as a barber. Also, it was noted that the Veteran wore an elastic brace for his knee four times a week. Further, the stated that he had knee flares-up two times per week, which lasted for two days. And he took medication for his knee pain and flare-ups. Upon examination, the Veteran's left knee range of motion (ROM) was reported as follows: flexion of 0 to 130 degrees; and extension of 130 to 0 degrees. Additionally, the examiner reported that flexion caused some discomfort posterior to the patella. However, the patellar movement was noted as normal. Also, no laxity, effusion, redness, scarring, crepitus, and instability were found. Additionally, the Veteran reported missing work due to his knee disability. Additionally, in conjunction with the March 2009 VA examination, an x-ray was conducted, and minimal medial joint compartment narrowing was reported. However, the remaining joint spaces were normally maintained, no joint effusion was seen. Also, an ununited anterior tibial tubercle was seen, but was reported as "probably a normal variant." In August 2009, the Veteran's VA treatment records note continued complaints of left knee pain and a discussion of trying a knee brace for pain. The Veteran noted that he had some sense of improvement with using a knee wrap but found that sometimes it would get too tight and cause discomfort. In December 2009, the Veteran submitted a definition of Osgood-Schlatter disease being an inflammation of the bone, cartilage and/or tendon at the top of the shinbone, where the tendon to from the kneecap (patella) attaches. He submitted an additional statement wherein he reported that his left knee "slips and flops from time to time." He also had pain and swelling with morning leg cramps. During an August 2011 Board hearing, the Veteran testified that his career as a barber required prolonged standing, which caused problems with his left knee. Further, he explained that at the end of the week his knee usually began to swell, which required him to leave work and go home to take medication. Also, he described experiencing flare-ups "usually every weekend." And he was unable to do yard work because of his left knee. He reported being prescribed hydrocortisone which had a side-effect of affecting his vision and preventing good job performance. He described favoring his left knee while walking. The Veteran's treatment records note complaints of increased pain in the left knee. He was prescribed hydrocodone for pain. In October 2015, the Veteran was provided a VA examination. During the examination, the Veteran noted experiencing daily pain and wearing a brace and using a cane occasionally. Also, he reported that could stand for 5 hours, walk 100 yards, and avoided stairs. And he reported flare-ups after prolonged standing, which were resolved with motrin. The Veteran's left knee ROM was reported as follows: flexion of 0 to 120 degrees and extension of 120 to 0 degrees. Pain that caused functional loss was noted on flexion of the left knee. There was no change in ROM after repetitive use, and no additionally functional loss was noted. The examiner noted that ROM loss could not be described during flare-ups without mere speculation because the Veteran was not experiencing a flare-up at the time of the exam. Lastly, no meniscal conditions, instability, ankylosis, or crepitus were noted during the examination. In June 2017, the Veteran was provided an additional VA examination. During the examination, the Veteran noted experiencing daily pain and episodic swelling. Further, he stated that he wore a brace, could walk half a mile, sit for 1 hour, stand for 10 minutes, and avoided repetitive squatting. And that repetitive squatting caused increased pain. The Veteran's left knee ROM was reported as follows: flexion of 0 to 100 degrees and extension of 100 to 0 degrees. Pain that caused functional loss was noted on flexion of the left knee. A change in ROM after repetitive use could not be determined during the examination, but an increase in pain was found. Mild medial discomfort was noted upon examination. And objective evidence of crepitus and degenerative arthritis were noted. The examiner noted that ROM loss could not be described during flare-ups because the Veteran was not experiencing a flare-up at the time of the exam. Lastly, no meniscal conditions, patellar conditions, instability, or ankylosis were noted during the examination. X-ray examination was described as showing an unfused apophysis. VA clinic records in 2017 included the Veteran's description of left knee pain mostly with walking. Examination was significant for antalgic gain on the left, tenderness over the lateral joint line and anterior knee, tight muscles, and limited ROM. There was no laxity. He was advised to continue walking with a knee brace with future consideration of a steroid injection if symptoms did not improve. A magnetic resonance imaging (MRI) scan was ordered to evaluate for a lateral meniscal tear. However, there were scheduling difficulties and an MRI was not performed. During a July 2018 Board hearing, the Veteran testified that his left knee condition, which caused pain and swelling, had impacted his career as a barber. The pain and swelling in his knee required him to leave early from work a couple of days a week and had caused him to limit the number of days a week he could work. And due to the time off, he had taken a pay cut. Further, he explained that the symptoms associated with his left knee disability continued to worsen as he aged. Also, he described taking medication to control his symptoms, and during flare-ups his ROM was decreased beyond his normal limited ROM. Also, it was noted that the Veteran used a cane for mobility. The Veteran's August 2018 VA treatment records note that the Veteran requested a replacement knee brace for his left knee pain. The Veteran's treatment records continued to note chronic left knee pain, as well as chronically altered gait mechanics. VA treatment records in 2019 reflect that the Veteran underwent physical therapy for his right knee. He described left knee pain with prolonged walking and sitting , the Veteran's VA treatment records note a physical therapy consult. At that time, the Veteran's left knee ROM was reported as flexion of 0 to 116 degrees and extension of 116 to 0 degrees. Also, it was reported that the Veteran wore a hinged knee brace and used a cane. Normal joint play in both knees were reported. At that time, the treating physical therapist recommended avoiding stairs and inclines to allow the inflammation to decrease. During a July 2019 Board hearing, the Veteran testified that his knee condition, which caused pain and swelling, had required him to cut back his workload to two days a week. Further, he explained that the longer he stood on his left knee, the worse the pain and swelling became. And his ability to walk, which helped control his blood pressure, had been impacted. Also, the Veteran stated that his left knee was painful to bend, and that he wore a knee brace and used a cane on a daily basis. In May 2020, the Veteran reported that his left knee and right hip pain rendered him unable to continue working extended hours as a barber. In November 2020, the Veteran was provided an additional VA examination. During the examination, the Veteran noted experiencing constant and consistent knee pain, as well as stiffness in his left knee, which have worsened over time. Further, he stated that he experienced moderate flare-ups weekly, which lasted 2-3 days. The flare-ups were precipitated by prolonged standing or walking, and were alleviated by rest, Epsom salt baths, and pain medications. Also, he reported that his left knee pain caused difficulty standing, walking, or running for long periods of time. The Veteran's left ROM was reported as follows: flexion of 0 to 60 degrees and extension of 0 to 60 degrees. Pain, which caused functional loss, was noted during the examination. After observed repetitive use, the Veteran's left knee ROM was decreased to flexion of 0 to 50 degrees and extension of 50 to 0 degrees, and additional loss of function due to pain and lack of endurance was found. And ROM after repeated use over time was reported as flexion of 0 to 40 degrees and extension of 40 to 0 degrees, with additional loss of function due to pain and lack of endurance. During flare-ups, the Veteran's ROM was estimated as flexion of 0 to 30 degrees and extension of 30 to 0 degrees. Regular use of a knee brace and cane was reported, as well as occasional use of a walker. And the examiner confirmed the Veteran's diagnosis of Osgood-Schlatter disease. Lastly, no meniscal conditions, patellar conditions, instability, crepitus, or ankylosis were noted during the examination In December 2020, the AOJ increased the Veteran's rating for left knee disability to 20 percent disabling, under DC 5010-5260, effective November 17, 2020, the date of the most recent VA examination. At the outset, the Board notes that the Veteran's initial 10 percent rating was awarded in a June 1998 rating decision citing the criteria for a 10 percent evaluation for painful or limited motion of a major joint. However, the AOJ provided an ambiguous diagnostic code of DC "5010-5257." It is clear from the record that the Veteran had been rated on painful but noncompensable left knee joint motion and not instability. Regarding the Veteran's left knee motion loss, prior to November 17, 2020, the Veteran's ROM has been measured as 0-130 degrees (2009), 0-120 degrees (2015), 0-100 degrees (2017), and 0-116 degrees (2019). These findings fall short of the criteria for a compensable rating for loss of extension which requires a 10-degree limitation or loss of flexion which requires a 45-degree limitation. Following November 17, 2020, the Veteran's left knee range of motion loss more closely aligned with the presently assigned 20 percent disability rating under DC 5260, as his ROM was reported at 0-30 degrees during flare-ups, which occurred multiple times a week and last 2-3 days. See 38 C.F.R. § 4.71a, DC 5260 (a 20 percent rating is assigned when flexion is limited to 30 degrees). However, prior to the November 2020 VA examination, the Veteran consistently described increased functional impairment and increased pain of the left knee on use, particularly with prolonged walking and standing which interfered with his vocation as a barber. In 2009, the Veteran reported flares occurring twice per week which lasted 2 days in duration thus, 4 days a week he experienced a flare of symptomatology. In 2018, the Veteran self-described that his ROM was decreased beyond his normal baseline during flares. Additionally, he reported joint line tenderness, swelling, leg cramps, tight muscles, and stiffness. Unfortunately, the VA examinations prior to November 2020 were inadequate for rating purposes when evaluating the extent of motion loss during flares. See Sharp v. Shulkin, 29 Vet. App. 26 (2017) (noting that the Clinician's Guide instructs examiners to obtain information regarding the extent of functional impairment of flares from the Veteran, and estimate functional loss during flares based upon entirety of the record including the Veteran provided information). Resolving reasonable doubt in favor of the Veteran, the Board finds that the loss of flexion to 30 degrees during flares found on VA examination in November 2020 has been present for the entire appeal period. As such, a uniform 20 percent rating for limitation of flexion under DC 5260 is granted for the entire appeal period. However, even when considering functional impairment on use or during flares, the lay and medical evidence does not demonstrate that the Veteran has met, or more nearly approximated, loss of flexion to 15 degrees or loss of extension to 10 degrees. As such, a higher rating under DC 5260, or a separate compensable rating under DC 5261, is not warranted for any time during the appeal period. As for possible left knee instability, the old criteria evaluate instability in terms of "mild," "moderate," and "severe." Slight has been defined as small of its kind or in amount. https://www.merriam-webster.com/dictionary/slight. Moderate has been defined as not violent, severe, or intense. https://www.merriam-webster.com/dictionary/slight. Severe has been defined as "of a great degree." https://www.merriam-webster.com/dictionary/severe. The Veteran has been issued a left knee brace which is potential evidence of instability. However, the record establishes that the Veteran has been prescribed the knee brace to assist with swelling and pain, and the 2009, 2015, 2017, and 2020 VA examinations found no clinical evidence of actual left knee instability or subluxation. On one occasion, the Veteran described that his left knee "slips and flops from time to time." However, throughout the entire appeal period, there is no further Veteran description of any left knee instability or subluxation. Overall, the Board finds that the lay and medical evidence does not demonstrate left knee instability even to a slight degree for any time during the appeal period. As such, a separate compensable rating under the old criteria of DC 5257 is not warranted. The Veteran has no history of sprain, incomplete ligament tear, or complete ligament tear. He has provided a definition of Osgood-Schlatter disease as an inflammation of the bone, cartilage and/or tendon at the top of the shinbone, where the tendon to from the kneecap (patella) attaches. Assuming arguendo this meets the definition of a diagnosed condition involving the patellofemoral complex, the Board finds that a separate rating under the new criteria of DC 5257 is not warranted as the lay and medical evidence does not establish "recurrent" instability. Recurrent has been defined as returning or happening time after time. https://www.merriam-webster.com/dictionary/recurrent. As noted above, on one occasion, the Veteran described that his left knee "slips and flops from time to time." However, throughout the entire appeal period, there is no further Veteran description of any left knee instability, or subluxation and all clinic evaluations found no actual left knee instability and the prescribed knee brace was due to symptomatology of pain and swelling. The Board finds that the lay and medical evidence does not establish "recurrent" left knee instability. As such, a separate rating under the new criteria of DC 5257 is not warranted. The Veteran has no history of meniscal surgery, or a diagnosed dislocation of semilunar cartilage. On one occasion in 2017, the possibility of a meniscal tear was entertained based on symptoms of antalgic gain, tenderness over the lateral joint line and anterior knee, tight muscles, and limited ROM. However, the VA examinations and clinic setting evaluations before and after 2017 did not disclose any meniscal condition and there has been no lay or medical evidence of frequent episodes of "locking." As such, a separate rating under DC 5258 or DC 5259 is not warranted. The Board also finds that ankylosis, or functional ankylosis, has not been present at any time during the appeal period. Ankylosis is an objective finding or symptom and not a diagnosis. Chavis v. McDonough, 34 Vet. App. 1 (2021). Notably, multiple definitions of "ankylosis" were discussed in Chavis including general medical dictionary definitions as follows: "[i]mmobility and consolidation of a joint due to disease, injury, or surgical procedure" (citing DORLAND'S ILLUSTRATED MEDICAL DICTIONARY 94 (33rd ed. 2019)), "[s]tiffening or fixation of a joint as the result of a disease process, with fibrous or bony union across the joint" (citing STEADMAN'S MEDICAL DICTIONARY 95 (28th ed. 2006)) and "[a] stiffening or immobilization of a joint as a result of injury, disease, or surgical intervention" (citing CHURCHILL'S ILLUSTRATED MEDICAL DICTIONARY 91 (1989). The Court noted that VA had previously defined ankylosis as "bony fixation." The radiographic evidence does not demonstrate bony fixation, joint consolidation or fibrous or bony union of the left knee joint for any time during the appeal period. The Veteran has described left knee stiffness and limitation of motion, but even during flares he has not described no movement and there was no medical description of functional ankylosis even during flares or repetitive use. The Board finds notes that a March 2009 x-ray was interpreted as showing an ununited anterior tibial tubercle which was "probably a normal variant." A tubercle is a small or rounded eminence on a bone. See DORLAND'S ILLUSTRATED MEDICAL DICTIONARY 1755 (28th Ed. 1994). This does not represent malunion or nonunion of the tibia and fibula. As such, the criteria of DC 5262 do not apply. REASONS FOR REMAND 1. Entitlement to service connection for sinusitis is remanded. 2. Entitlement to service connection for headaches is remanded. 3. Entitlement to a TDIU is remanded. The Board's December 2018 remand directives instructed the AOJ to attempt to obtain records of treatment at the Little Rock VA Medical Center dating back to 1976. Currently, only records dating back to 1997 are available. In a September 2019 letter, the AOJ wrote, "[r]ecords were received dating back to 1981 but no further. Records from 7/18/1972 to 1981 were not located." Unfortunately, records dating back to 1981 have not been associated with the claims file, even though they were apparently scanned into VISTA. See, e.g., CAPRI record dated September 20, 2018 entitled Regional Office Request noting scanned document attached to this note and, "Click on Tools, click on VistA Imaging Display." See 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); Bell v. Derwinski, 2 Vet. App. 611, 613 (1992) (holding that VA treatment records are considered within VA's constructive possession). Therefore, remand is warranted to ensure these outstanding records are associated with the claims file for review. Finally, because a decision on the remanded issues of entitlement to service connection for sinusitis and headaches could significantly impact a decision on the issue of TDIU, the issues are inextricably intertwined. A remand of the claim for TDIU is required. The matters are REMANDED for the following actions: 1. Associate with the claims folder updated VA treatment records. 2. Obtain and associate with the claims file any outstanding VA medical treatment records, to include treatment records from prior to 1997. Records dating back to at least 1981 are apparently available, but thus far have not been added to the claims file for viewing. See, e.g., CAPRI record dated September 20, 2018 entitled Regional Office Request noting scanned document attached to this note and, "Click on Tools, click on VistA Imaging Display." T. MAINELLI Veterans Law Judge Board of Veterans' Appeals L. CHU Veterans Law Judge Board of Veterans' Appeals MICHAEL A. HERMAN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Patrick C. Brady, Associate 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.