Citation Nr: 21066794 Decision Date: 11/02/21 Archive Date: 11/02/21 DOCKET NO. 16-18 103 DATE: November 2, 2021 ORDER Prior to May 2, 2017, an evaluation of greater than 40 percent for spondylolysis L5-S1 and disc herniation L2-3 is denied. From May 2, 2017, an evaluation of greater than 50 percent for spondylolysis L5-S1 and disc herniation L2-3 is denied. From February 10, 2021, an evaluation of 20 percent disabling for left lower extremity radiculopathy associated with spondylolysis L5-S1, L2-3 disc herniation, is granted. From February 10, 2021, an evaluation of 20 percent disabling for right lower extremity radiculopathy associated with spondylolysis L5-S1, L2-3 disc herniation, is granted. A rating greater than 10 percent for osteoarthritis of the left knee is denied. REMANDED Entitlement to a rating greater than 10 percent for osteoarthritis of the right knee is remanded. Entitlement to a rating of total disability based on individual unemployability (TDIU) is remanded. FINDINGS OF FACT 1. Prior to May 2, 2017, the preponderance of evidence does not support that the Veteran's back disabilities manifested as causing unfavorable ankylosis of the thoracolumbar spine or its functional equivalent. 2. From May 2, 2017, the Veteran's back disability has manifested as ankylosis of the entire thoracolumbar spine, but not of the entire spine or its functional equivalent. 3. From February 10, 2021, the Veteran's left lower extremity radiculopathy has manifested as moderate, incomplete paralysis. 4. From February 10, 2021, the Veteran's right lower extremity radiculopathy has manifested as moderate, incomplete paralysis. 5. The preponderance of evidence supports a finding that the Veteran's left knee osteoarthritis condition manifests as reduced flexion and painful motion. CONCLUSIONS OF LAW 1. Prior to May 2, 2017, the criteria for a rating in excess of 40 percent for spondylolysis L5-S1 and disc herniation L2-3 are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Codes 5242-5240. 2. From May 2, 2017, the criteria for a rating in excess of 50 percent for spondylolysis L5-S1 and disc herniation L2-3 are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Codes 5242-5240. 3. From February 10, 2021, the criteria for a disability rating of 20 percent, but not higher, for left lower extremity radiculopathy (sciatic nerve) are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.124a, Diagnostic Code 8520. 4. From February 10, 2021, the criteria for a disability rating of 20 percent, but no higher, for right lower extremity radiculopathy (sciatic nerve) are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.124a, Diagnostic Code 8520. 5. The criteria for a rating in excess of 10 percent for osteoarthritis of the left knee are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Codes 5003-5260. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from January 1980 to December 1983. This appeal comes before the Board of Veterans' Appeals (Board) from a December 2014 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). This matter has previously come before the Board. In July 2019, the Board remanded these issues for new medical examinations to be conducted by VA which complied with the requirements of Correia v. McDonald, 28 Vet. App. 158 (2016) and Sharp v. Shulkin, 29 Vet. App. 26 (2017). The Veteran underwent a new examination of his knees in December 2019 and a new examination for his back in March 2021. Thus, the Board finds that its remand instructions were substantially complied with. Stegall v. West, 11 Vet. App. 268 (1998). In March 2021, the Veteran submitted correspondence to VA indicating he wished to discontinue further development actions associated with his claims on appeal. See March 2021 Correspondence. However, in June 2021, the Veteran's representative submitted an Appellate Brief discussing the increased ratings appeals for the Veteran's back and bilateral knee disabilities, indicating a desire to proceed with each claim. See June 2021 Appellate Brief (VSO IHP; Post Remand Brief; Attorney Brief). VA wrote the Veteran in July 2021 to attempt to clarify which appeal(s) he wished to withdraw, and which he wished to continue. The Veteran did not respond, and therefore the Board will proceed on a decision each of the issues on appeal. See 38 C.F.R. § 1955. The Board finds that the Veteran's claim for an increased evaluation for his lower back encompasses increased evaluation claims for his previously service-connected radiculopathy of bilateral lower extremities. See 38 C.F.R. § 3.155(d)(2) ("Once VA receives a complete claim, it must adjudicate entitlement to benefits for the claimed condition as well as entitlement to any additional benefits for complications of the claimed condition, including those identified by the rating criteria for that condition in the rating schedule."). 1. Prior to May 2, 2017, entitlement to an evaluation of greater than 40 percent for spondylolysis L5-S1 and disc herniation L2-3 is denied. The Veteran seeks an increased rating for his service-connected lower back disabilities, presently evaluated as 50 percent from May 2, 2017. Prior to May 2, 2017, the Veteran's back was rated as 40 percent disabling. Disability ratings are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities (rating schedule). See 38 U.S.C. § 1155; 38 C.F.R. § 4.1. If two ratings are potentially applicable, the higher rating will be assigned if the disability more nearly approximates the criteria required for that rating; otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability will be resolved in favor of the veteran. See 38 C.F.R. § 4.3. Where a veteran is appealing the rating for an already established service-connected condition, his present level of disability is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1995). A veteran is presumed to be seeking the maximum possible evaluation. AB v. Brown, 6 Vet. App. 35 (1993). Separate ratings can be assigned for separate periods of time based on the facts found a practice known as "staged" ratings. Here, the Veteran's ratings for his back conditions have been assigned in two stages. The Board will discuss each stage in turn. The Veteran's spondylolysis L5-S1 and disc herniation L2-3 are evaluated under 38 C.F.R. § 4.71a, Diagnostic Codes (DCs) 5242 and 5240, each of which follow the criteria listed in the General Rating Formula for Diseases and Injuries of the Spine (General Rating Formula). See 38 C.F.R. § 4.71a. Under the General Rating Formula, in pertinent part, a 40 percent rating is assigned for forward flexion of the thoracolumbar spine of 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is assigned for unfavorable ankylosis of the entire thoracolumbar spine. The maximum 100 percent rating is assigned for unfavorable ankylosis of entire spine. 38 C.F.R. § 4.71a. Any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, should be rated separately under an appropriate Diagnostic Code. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Note (1). Here, the Veteran is already in receipt of separate ratings for neurologic impairment of his lower extremities throughout the period on appeal. The Veteran's radiculopathy ratings will be discussed Unfavorable ankylosis is a condition in which the entire cervical spine, the entire thoracolumbar spine, or the entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching. Fixation of a spinal segment in neutral position (0 degrees) always represents favorable ankylosis. The rater is to round each range of motion measurement to the nearest five degrees. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Note (5). The Veteran submitted his claim for an increased rating for his back in August 2014. In the subsequent months, he submitted several lay statements including statements from his family members. Together, they generally asserted that the Veteran was experiencing worsening pain in his back, which precluded his ability to move and to perform daily activities. See September and November 2014 Correspondence (four documents) and October 2014 Buddy / Lay Statements (four documents). The Board finds these statements credible and probative as to the Veteran's functional loss due to his lower back condition. However, the Board is aware that none of the lay statements address the specific rating criteria in the Rating Schedule. In December 2014, the Veteran underwent a VA examination of his back. The examiner indicated review of the Veterans' complete claim file, and conducted an in-person examination. The examiner confirmed a diagnosis of degenerative joint disease of the lumbar spine, and additionally noted past diagnoses of spondylosis and spondylolisthesis. The Veteran demonstrated abnormal range of motion, as his back was limited from 0 to 70 degrees forward flexion (maximum 0 to 90), 0 to 10 degrees extension (maximum 0 to 30), right lateral flexion of 0 to 25 degrees (maximum 0 to 30), left lateral flexion 0 to 25 degrees (maximum 0 to 30). The Veteran showed full, normal range of lateral rotation from 0 to 30 degrees in both directions. The examiner wrote that the Veteran's abnormal range of motion contributed to functional loss due to back stiffness. Although the Veteran reported experiencing flare-ups, the examiner did not provide an estimate for further functional limitations due to those flare-ups. Ankylosis was not shown upon examination. Intravertebral disc syndrome (IVDS) was not shown. See December 2014 Compensation and Pension (C&P) Examination. The Board finds this evaluation to be highly probative as to the state of the Veteran's back at the time of examination. However, the Board is mindful that the examiner did not provide an estimate for range of motion during flare-ups and such will be factored into the weight given to this VA examination report. In March 2017, the Veteran underwent another in-person VA examination by a different examiner. She indicated review of the Veteran's complete claim file, and annotated diagnoses of spondylosis L5-S1 and L2-3 disc herniation. She documented the Veteran's reports of flare-ups after exertion, which caused the Veteran not to want to do anything and instead lay in bed. The frequency of those flare-ups was not documented. The Veteran's range of motion was observed to be abnormal, with forward flexion measured from 0 to 70 degrees, extension from 0 to 25 degrees, right lateral flexion from 0 to 25 degrees, left lateral flexion from 0 to 20 degrees, right lateral rotation from 0 to 20 degrees, and left lateral rotation from 0 to 20 degrees. The examiner also described observing pain upon examination, but she wrote that neither pain nor the reduced range of motion led to any functional loss. Pain was not observed upon weight bearing. Ankylosis and IVDS were not shown. See March 2017 C&P Examination. It should be noted that the Board has previously found this examination and the December 2014 examination to be inadequate for rating purposes as they did not comply with the requirements of Sharp v. Shulkin, 29 Vet. App. 26 (2017) and Correia v. McDonald, 28 Vet. App. 158 (2016). Nonetheless, in the present case, the question before the Board is whether the Veteran's back evaluation should be increased from 40 percent disabling. Under the General Rating Formula, a 50 percent evaluation or greater is not based on a range of motion measurement. Instead, an evaluation of 50 percent or higher requires a finding of ankylosis. Here, even though Sharp and Correia have not been strictly complied with, no evidence shows ankylosiseither favorable or unfavorableduring these examinations, or otherwise during this period on appeal. Thus, the VA examinations are highly probative to the question before the Board, as they specifically discuss an absence of ankylosis during that time and his functional impairment. The Veteran's 40 percent evaluation prior to May 2, 2017 is based upon his limited range of motion for his back. During this stage, the Veteran has been in receipt of the highest possible evaluation that can be based solely on reduced range of motion under the Rating Schedule. A review of the Veteran's medical treatment record does not show any indication of ankylosis during this stage. See generally VA Medical Treatment Record. The Board concludes that prior to May 2, 2017, the preponderance of evidence does not support that the Veteran's back disabilities manifested as causing unfavorable ankylosis of the thoracolumbar spine or the functional equivalent of ankylosis. See Chavis v. McDonough, 34 Vet. App. 1, 20. (2021) (holding that "application of §§ 4.40 and 4.45 permits consideration under the General Rating Formula of an evaluation based on ankylosis if a claimant's functional loss is consistent with that contemplated by ankylosisin other words, if it is the functional equivalent of ankylosis"). The May 2017 and 2014 VA examinations did not reflect ankylosis. These examinations also showed that the Veteran had movement in all directions, to include flexion (forward and lateral) and extension. Additionally, the Veteran had 5/5 muscle strength and no muscle atrophy at this examinations. The Board finds that the aforementioned competent evidence does not tend to support a finding of ankylosis or functional equivalent of ankylosis. Therefore, an evaluation higher than 40 percent is not warranted by the evidence of record during this stage on appeal. As the preponderance of evidence is against the claim during this stage, the benefit of the doubt doctrine is not for application, and the claim is denied. See 38 U.S.C. § 5107 (b); Gilbert v. Derwinski, 1 Vet. App. 49, 53-54 (1990). 2. From May 2, 2017, entitlement to an evaluation of greater than 50 percent for spondylolysis L5-S1 and disc herniation L2-3 is denied. On May 2, 2017, VA received from the Veteran a copy of an examination completed by a private physician on a standardized VA disability benefits questionnaire (DBQ) form. The doctor did not provide measurements of range of motion, explaining that such measurements could not be taken due to unfavorable ankylosis of the entire thoracolumbar spine, for which the Veteran needed fusion surgery. The doctor reiterated numerous times that the Veteran's condition manifested as unfavorable ankylosis of the entire thoracolumbar spine. See May 2017 VA Examination. In March 2021, the Veteran underwent another in-person VA examination. The examiner indicated review of the Veteran's complete claim file. The examiner documented the Veteran's accounts of back pain at a level of 9/10, describing sharp and burning pain which was worse with walking, standing, bending, twisting, sitting, and in cold weather. The Veteran described flare-ups 3-4 times per week which lasted all day, causing a burning and painful sensation in his back which was precipitated by movement or cold weather. The Veteran was experiencing a flare-up at the time of the examination. The examiner measured the Veteran's range of motion as limited in all directions, with forward flexion ending at 30 degrees, extension ending at 10 degrees, right and left lateral flexion each ending at 10 degrees, and right and left lateral rotation each ending at 10 degrees. The examiner did not conduct passive measurements, noting that such measurements were contraindicated due to the safety of both the Veteran and the examiner. The examiner observed that the measurements taken during that flare-up were consistent with the Veteran's descriptions of functional limitations. The examiner did not find evidence of ankylosis, but she did not comment on the previous examination which had identified unfavorable ankylosis of the entire thoracolumbar spine. IVDS was not shown. The Board finds this evaluation to be highly probative as it measured the Veteran's condition during a flare-up, and was based on a thorough evaluation using sound medical principles. The Board concludes that from May 2, 2017, the Veteran's back disability has manifested as ankylosis of the entire thoracolumbar spine, but not of the entire spine. Therefore, the present evaluation of 50 percent is appropriate. Although the VA examiner was silent as to any ankylosis during the March 2021 examination, the Veteran's private practitioner was abundantly clear that such ankylosis was the predominant factor in describing the Veteran's condition. The Board also finds persuasive that the 2021 VA examiner documented an extremely limited range of motion in the Veteran's back upon examination, but not ankylosis. The VA examiner's finding correspond to the private examiner's finding of ankylosis. Accordingly, these findings more nearly approximately the criteria for a 50 percent evaluationbased on unfavorable ankylosis of the thoracolumbar spine. The maximum evaluation of 100 percent is not warranted during this stage on appeal as the competent evidence does not tend to shows unfavorable ankylosis of the Veteran's entire spine or its functional equivalent. The 2021 VA examination report shows functional impact described as the Veteran would have difficulty walking, sitting, and standing due to pain. The examiner added that the functional impairment of the lower extremities (i.e., balance and propulsion) was not so diminished that he would be equally well served by an amputation with prosthesis. The Board finds such evidence does not tend to support a finding of the functional equivalent of unfavorable ankylosis of the entire spine. Thus, the preponderance of evidence weighs against a higher rating. See 38 U.S.C. § 5107(b). 3. From February 10, 2021, entitlement to an evaluation of 20 percent disabling for left lower extremity radiculopathy associated with spondylolysis L5-S1, L2-3 disc herniation, is granted. 4. From February 10, 2021, entitlement to an evaluation of 20 percent disabling for right lower extremity radiculopathy associated with spondylolysis L5-S1, L2-3 disc herniation, is granted. The Veteran's lower extremity radiculopathy, associated with his spondylolysis L5-S1 and L2-3 disc herniation disabilities, has been evaluated as 10 percent disabling in each leg since August 13, 2014. For the reasons that follow, the Board finds a 20 percent evaluation is warranted for each lower extremity from February 10, 2021. The Veteran's bilateral sciatic nerve radiculopathy is evaluated under 38 C.F.R. § 4.124a, DC 8520. Under DC 8520, a 10 percent evaluation is warranted for mild, incomplete paralysis. A 20 percent evaluation is warranted for moderate, incomplete paralysis. A 40 percent evaluation is warranted for moderately severe, incomplete paralysis. A 60 percent evaluation is warranted for severe, incomplete paralysis with marked muscular atrophy. The maximum evaluation of 80 percent is warranted for complete paralysis wherein the foot dangles and drops, no active involvement is possible of muscles below the knee, flexion of knee weakened or (very rarely) lost. See 38 C.F.R. § 4.124a, DC 8520. Generally, the Veteran's medical record shows an intermittent history of radicular pain and numbness in each of his lower extremities dating to as early as 2008. However, radiculopathy symptoms were not observed at the time of his VA examination in December 2014, nor at the private examination submitted by the Veteran, which was conducted in May 2017. See December 2014 C&P Examination; May 2017 VA Examination. At the Veteran's February 2021 VA examination for his lower back, the examiner found bilateral radiculopathy symptoms manifesting as pain radiating down his legs. The examiner indicated involvement of L4/L5/S1/S2/S3 nerve roots (sciatic nerve) in both legs. The examiner documented mild constant pain, moderate intermittent pain, mild paresthesias and/or dysesthesias, and mild numbness bilaterally. The examiner did not describe the overall severity of the Veteran's radiculopathy for either leg in terms of the rating criteria under DC 8520. However, resolving reasonable doubt in the Veteran's favor, the Board concludes that in this case, the examiner's indication of "moderate" intermittent pain (usually dull) in each leg demonstrates moderate, incomplete paralysis. Accordingly, a 20 percent evaluation is warranted for each lower extremity from February 10, 2021, which is the date the examination was conducted and the earliest showing of moderate, incomplete paralysis in the record. A higher evaluation of 40 or 60 percent is not warranted because the record does not show moderately severe or severe radiculopathy with marked muscular atrophy at any time during the period on appeal. In this regard, the Veteran did not have severe of constant pain, intermittent pain, numbness, or paresthesias and/or dysesthesias. The Veteran had active movement against some resistance (4/5) for left and right muscle strength and he did not have atrophy. The Board finds such evidence tends to weight against a finding of moderately severe (or worse incomplete paralysis of the left and right sciatic nerves. Therefore, from February 10, 2021, a 20 percent evaluation for left lower extremity radiculopathy is granted, and a 20 percent evaluation for right lower extremity radiculopathy is granted. 5. Entitlement to a rating greater than 10 percent for osteoarthritis of the left knee is denied. The Veteran seeks increased evaluations for his bilateral knee osteoarthritis, presently evaluated as 10 percent disabling for each knee under DCs 5003-5260. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires the use of an additional diagnostic code to identify the basis for the evaluation assigned; the additional code is shown after the hyphen. Disabilities of the knee joint, generally, are rated under diagnostic codes (DCs) 5256 through 5263. See 38 C.F.R. § 4.71a. In addition, there are special provisions for rating degenerative arthritis (to include osteoarthritis) under DC 5003. When there is painful motion of a major joint caused by degenerative arthritis that is detected on x-ray, such painful motion will be considered limited motion pursuant to 38 C.F.R. § 4.59. Painful motion is entitled to a minimum 10 percent rating, per joint, combined under DC 5003, even if there is no actual limitation of motion. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011); Lichtenfels v. Derwinski, 1 Vet. App. 484 (1991). Effective February 7, 2021, Diagnostic Code 5003 was revised as follows: Degenerative arthritis, other than post-traumatic: Degenerative arthritis established by X-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved (DC 5200, etc.). When however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under DC 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. In the absence of limitation of motion, with X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups, with occasional incapacitating exacerbations, a 20 percent disability rating is warranted. With X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups, a 10 percent disability rating is warranted. Note (1): The 20 percent and 10 percent ratings based on X-ray findings, above, will not be combined with ratings based on limitation of motion. Note (2): the 20 percent and 10 percent ratings based on X-ray findings, above, will not be utilized in rating conditions listed under DCs 5013 to 5024, inclusive. 38 C.F.R. Part 4, Schedule for Rating Disability: Musculoskeletal System and Muscle Injuries; Final Rule, correction, 85 Fed. Reg. 85523 (Dec. 29, 2020). Under DC 5260, a noncompensable evaluation is assigned for flexion limited to 60 degrees or less. A 10 percent rating is assigned for flexion limited to 45 degrees. A 20 percent rating is assigned for flexion limited to 30 degrees. A 30 percent rating is assigned for flexion limited to 15 degrees. Under DC 5261, a noncompensable evaluation is assigned for extension limited to 5 degrees or more. A 10 percent rating is assigned for extension limited to 10 degrees. A 20 percent rating is assigned for extension limited to 15 degrees. A 30 percent rating is assigned for extension limited to 20 degrees. A 40 percent rating is assigned for extension limited to 30 degrees. A 50 percent rating is assigned for extension limited to 45 degrees. Ankylosis is rated under DC 5256. DC 5257 (prior to February 7, 2021) covers "other impairment of the knee," and provides for 10, 20, or 30 percent ratings for recurrent subluxation or lateral instability that is, respectively, slight, moderate or severe. From February 7, 2021 onward, DC 5257 states that a 10 percent rating is assigned for a sprain, incomplete ligament tear or complete ligament tear causing persistent instability without prescribed assistive device or bracing for ambulation. A 20 percent rating is warranted when a) sprain, incomplete ligament tear, or repaired complete ligament tear causes persistent instability; or b) an unrepaired or failed repair of a complete ligament tear causes persistent instability. A prescribed assistive device or bracing for ambulation is required. A 30 percent rating requires unrepaired or failed repair of complete ligament tear causing persistent instability and a prescription for both an assistive device and bracing for ambulation. Under DC 5258, a 20 percent evaluation is assigned for semilunar, dislocated cartilage with frequent episodes of "locking" pain, and effusion into the joint. Under DC 5259, a 10 percent evaluation is assigned for symptomatic removal of semilunar cartilage. Impairment of the tibia and fibula is rated under DC 5262 and genu recurvatum is rated under DC 5263. The Veteran underwent an in-person VA examination of his knees in December 2014. The examiner indicated review of the complete claim file, and confirmed past diagnoses of osteoarthritis in each knee. The examiner documented the Veteran's reports of bilateral knee pain upon exertion and flare-ups during cold weather, which increased knee stiffness and pain. Both the Veteran's knees were measured to have full range of motion from 0 to 140 degrees flexion, and 140 to 0 degrees extension. However, the Board is mindful that the examiner did not estimate range of motion during flare-ups. The examiner wrote that the examination neither supported nor contradicted the Veteran's lay statements describing functional loss during flare-ups. The examiner documented that the Veteran was able to perform repetitive use testing in each knee with at least three repetitions, not resulting in additional functional loss or range of motion. Muscle strength testing showed normal strength bilaterally. There was no evidence of atrophy, ankylosis, recurrent subluxation, lateral instability, or recurrent effusion. Joint stability testing yielded normal results bilaterally. The examiner noted that the Veteran's bilateral osteoarthritis caused functional impact in his ability to perform occupational tasks such as standing, walking, lifting, sitting, etc. See December 2014 C&P Examination. The Board is mindful that this examination has previously been found not to satisfy the requirements of Sharp v. Shulkin, 29 Vet. App. 26 (2017) and Correia v. McDonald, 28 Vet. App. 158 (2016). However, it does not necessarily follow that the examination report is devoid of probative value. See Monzingo v. Shinseki, 26 Vet. App. 97, 107 (2012) (noting that, "even if a medical opinion is inadequate to decide a claim, it does not necessarily follow that the opinion is entitled to absolutely no probative weight"). Here, the examination's value is diminished by its failure to provide range of motion measurements and estimates under active and passive, weight-bearing and nonweight-bearing, and during flare-ups. However, the examiner's documentation of active medical conditions and the Veteran's lay statements remains sound and thus provides limited probative value. In December 2019, the Veteran underwent another in-person VA examination of his bilateral knees. The new examiner confirmed the previous diagnosis of bilateral knee arthritis, which caused aching pain, reduced range of motion, and decreased ability to walk. The examiner notated that the Veteran was experiencing a flare-up of his left knee, but not of his right knee, during the examination. Range of motion was measured from 0 to 120 degrees flexion in each knee, with an examiner's notation of "suboptimal effort." Extension was measured from 120 to 0 degrees in each knee. The same range was shown after observed repetitive use testing. No ankylosis was shown in either extremity. There was no evidence of recurrent subluxation or lateral instability. Joint stability testing yielded normal results. See December 2019 C&P Examination. With regard to the Veteran's left knee condition, the Board finds this examination to be highly probative, as it measured the Veteran's range of motion and described his functional limitation during an actual flare-up. The evidence supports a finding that the Veteran's left knee osteoarthritis condition manifests as reduced flexion and painful motion. Based solely upon the limited range of flexion to 120 degrees, a compensable rating would not be appropriate, as a 10 percent rating requires flexion to be limited to 60 degrees or less. However, when the limitation of motion of the specific joint or joint involved in an osteoarthritis rating is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011); Lichtenfels v. Derwinski, 1 Vet. App. 484 (1991). The knee is a major joint. 38 C.F.R. § 4.45. Therefore, based upon the limitation of flexion due to painful motion, a minimum 10 percent evaluation, as currently assigned, is warranted under DCs 5003-5260. 38 C.F.R. § 4.59 However, a higher evaluation of 20 percent is not appropriate based on the Veteran's limited range of motion, as the evidence does not show that the Veteran's range of motion is limited to 30 degrees or less flexion, or to 5 degrees or more extension. 38 C.F.R. §§ 5260, 5261. Although the Veteran may experience painful motion in extension, painful motion is already contemplated in his 10 percent evaluation under DCs 5003-5260 for the left knee joint, and thus a separate rating cannot be granted based on painful extension, as such would constitute unlawful pyramiding. 38 C.F.R. § 4.14. As ankylosis has not been shown, an evaluation under DC 5256 is not appropriate. Application of DC 5257 is not appropriate, as there is no evidence of recurrent subluxation or lateral instability per the 2014 and 2019 VA examination reports. DC 5258 contemplates dislocated semilunar cartilage, which is also not shown here, to include as noted at the 2019 VA examination. Evaluation under DC 5256 is not warranted as there is no tibia and fibula impairment shown. And evaluation under DC 5263 is not appropriate as there is not showing of genu recurvatum. Accordingly, the 10 percent evaluation afforded to the Veteran is appropriate. As the preponderance of evidence weighs against assignment of a higher rating, the benefit of the doubt doctrine is not for application and the claim for an increased rating for left knee osteoarthritis is denied. 38 U.S.C. § 5017(b); Gilbert v. Derwinski, 1 Vet. App. 49, 53-54 (1990). REASONS FOR REMAND 1. Entitlement to a rating greater than 10 percent for osteoarthritis of the right knee is remanded. As discussed above, the VA examination conducted in December 2019 was completed following a Board remand to address the requirements of Sharp v. Shulkin, 29 Vet. App. 26 (2017) and Correia v. McDonald, 28 Vet. App. 158 (2016). The Veteran reported that he was experiencing a flare-up in his left knee at the time of the new examination. However, the same was not true of his right knee. The examiner did not provide a range of motion estimate for the Veteran's right knee, and noted only that "using my medical knowledge and expertise, I have no basis to offer additional losses of function or motion with repeated use over time." The United States Court of Appeals for Veterans Claims (Court) has held that an examiner must obtain adequate information including frequency, duration, characteristics, severity, or functional loss regarding flare-ups in order to estimate functional loss during flare-ups. See Sharp, 29 Vet. App. at 36 (stating that a medical opinion that cannot be provided without resorting to speculation is adequate when it is clear that it is predicated on a lack of knowledge among the medical community at large, and not the insufficient knowledge of the specific examiner (quoting Jones v. Shinseki, 23 Vet. App. 382 (2010))). Such is not the case here, and hence, the Board finds that further development is necessary. 2. Entitlement to a rating of TDIU is remanded. The Veteran has submitted evidence of unemployability due to his service-connected disabilities. Specifically, in his Notice of Disagreement submitted in January 2015, the Veteran asserted that worsening back pain exacerbated his anger, depression and anxiety, requiring him to leave his job working for the city. In later correspondence in March 2017, the Veteran argued that because of his back disability alone, he was unable to make a good living and he felt he should be evaluated at 100 percent disabled. This evidence raises the issue of entitlement to a TDIU due to the service-connected conditions. Thus, the TDIU matter is now under the Board's jurisdiction as part and parcel of the appeal from the rating assigned for the underlying disability. Rice v. Shinseki, 22 Vet. App. 447, 453-54 (2009). The issue of TDIU has not been fully developed, and remand is therefore necessary. These matters are REMANDED for the following actions: 1. Schedule the Veteran for an examination to evaluate the level of disability of his right knee condition, including functional loss during flare-ups. The examiner should indicate review of the Veteran's complete claim file. (a.) Based upon a review of the medical records, lay statements submitted in support of the claim, and/or statements elicited from the Veteran during the examination, state whether the Veteran experiences flare ups of his service-connected right knee disability, and how he or she characterizes the additional functional loss during a flare. (b.) If the Veteran describes experiencing flare ups, identify the: a. frequency; b. duration; c. precipitating factors; and d. alleviating factors. e. Based upon the information elicited as a result of the foregoing, state whether it is at least as likely as not (50 percent probability or greater) that during a flare up range of motion of the right knee is additionally limited to 30 degrees. Please explain why or why not. A comprehensive rationale for all opinions is to be provided. If it is not possible to provide a specific measurement or estimate without speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). 2. Send appropriate notice to the Veteran regarding TDIU and complete any necessary development. This should include sending the Veteran an application form (VA Form 21-8940) and advising the Veteran of the necessity of notifying the AOJ of his employment history and his educational background for proper adjudication of this claim. Paul Sorisio Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Hermsdorfer, 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.