Citation Nr: 21070535 Decision Date: 11/24/21 Archive Date: 11/24/21 DOCKET NO. 17-15 775 DATE: November 24, 2021 ORDER Entitlement to an initial compensable disability rating for right eye corneal abrasion with corneal scar prior to February 8, 2021, is denied. Entitlement to an initial 10 percent disability rating for right eye corneal abrasion with corneal scar from February 8, 2021, forward, is granted, subject to the law and regulations governing the payment of monetary benefits. Entitlement to a compensable disability rating for hypertension is denied. REMANDED Entitlement to a disability rating in excess of 20 percent for left knee degenerative joint disease, status post patella fracture, with scars is remanded. Entitlement to a disability rating in excess of 10 percent prior to April 19, 2017, and from June 1, 2017, forward, for right knee osteoarthritis and chondromalacia is remanded. Entitlement to an initial disability rating in excess of 10 percent for left ankle sprain is remanded. Entitlement to an initial disability rating in excess of 20 percent for right ankle sprain is remanded. Entitlement to a disability rating in excess of 20 percent for lumbar spine degenerative arthritis remanded. Entitlement to a compensable disability rating for right thumb fracture residuals is remanded. FINDINGS OF FACT 1. The preponderance of the evidence weighs against a finding that the Veteran has had incapacitating episodes, impairment of visual field or muscle function, or scarring or disfigurement because of his right eye corneal abrasion with corneal scar. 2. Prior to February 8, 2021, the Veteran did not have decline in visual acuity; from February 8, 2021, the Veteran had had impairment of right eye corrected distance visual acuity of 20/100. 3. The preponderance of the evidence demonstrates that the Veteran's hypertension was not manifested by diastolic pressure predominantly 100 or more, or; systolic pressure predominantly 160 or more, or; the minimum evaluation with a history of diastolic pressure predominantly 100 or more requiring continuous medication for control. CONCLUSIONS OF LAW 1. The criteria for entitlement to an initial compensable rating for right eye corneal abrasion with corneal scar prior to February 8, 2021, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.2, 4.3, 4.6, 4.7, 4.79, Diagnostic Code 6009. 2. The criteria for entitlement to an initial 10 percent disability rating for right eye corneal abrasion with corneal scar from February 8, 2021, forward, have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.2, 4.3, 4.6, 4.7, 4.79, Diagnostic Code 6009. 3. The criteria for entitlement to a compensable disability for hypertension have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.2, 4.3, 4.6, 4.7, 4.104, Diagnostic Code 7101. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from July 1974 to September 1995. This matter comes before the Board of Veterans' Appeals (Board) on appeal from July 2016 rating decision. In January 2020, the Veteran testified before the undersigned Veterans Law Judge (VLJ) at a video-conference hearing. A transcript of that hearing is of record. The above issues were remanded by the Board in July 2020 and June 2021 for further development. Most recently, the issues were remanded to afford the Veteran an opportunity to authorize VA to obtain private treatment records. The Veteran was provided correspondence dated June 8, 2021, and July 22, 2021, prompting him to submit private treatment records. The Veteran was also provided VA Form 21-4142, Authorization to Disclose Information and VA Form 21-4142a, General Release for Medical Provider Information for him to authorize VA to obtain his private treatment records. The Veteran did not respond. The Board notes that thus far, the Veteran's failure to submit private treatment records has precluded the consideration of potentially favorable evidence. See Wood v. Derwinski, 1 Vet. App. 190, 193 (1991) (stating that the duty to assist is not always a one-way street, or a blind alley, and that a veteran must be prepared to cooperate with VA's efforts to provide an adequate medical examination and submit all the medical evidence supporting the claim). If a veteran wishes help, he cannot passively wait for it in circumstances where he may or should have evidence that is essential in obtaining the putative evidence. See id. As a result, the Board must adjudicate the claim based upon the evidence that is currently of record. Increased Disability Ratings VA has adopted a Schedule for Rating Disabilities to evaluate service-connected disabilities. 38 U.S.C. § 1155; 38 C.F.R. § 3.321; see generally, 38 C.F.R. § Part IV. The basis of disability evaluations is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life, including employment. 38 C.F.R. § 4.10. The percentage ratings in the Schedule for Rating Disabilities represent, as far as practicably can be determined, the average impairment in earning capacity resulting from service-connected diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the several grades of disability. 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities and the criteria for specific ratings. 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 rating. 38 C.F.R. § 4.7. Otherwise, the lower rating will be assigned. Id. All reasonable doubt regarding the degree of disability will be resolved in favor of the claimant. 38 C.F.R. § 4.3; see also 38 C.F.R. § 3.102. Separate ratings for distinct disabilities resulting from the same injury or disease can be assigned so long as the symptomatology for one condition is not "duplicative or overlapping with the symptomatology" of the other condition. See Amberman v. Shinseki, 570 F.3d 1377, 1381 (Fed. Cir. 2009); Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). However, the evaluation of the same disability or its manifestations under various diagnoses, which is known as pyramiding, is to be avoided. 38 C.F.R. § 4.14. Because the level of disability may have varied over the course of the claim, the rating may be "staged" higher or lower for segments of time during the period under review in accordance with such variations, to the extent the evidence shows distinct time periods where the service-connected disability has exhibited signs or symptoms that would warrant different ratings under the rating criteria. Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007); Fenderson v. West, 12 Vet. App. 119, 126 (1999). In initial-rating cases, where the appeal stems from a granted claim of service connection with respect to the initial evaluation assigned, VA assesses the level of disability from the effective date of service connection. See Fenderson, 12 Vet. App. at 126. A claimant is entitled to the benefit of the doubt when there is an approximate balance of positive and negative evidence on any issue material to the claim. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102 (providing, in pertinent part, that reasonable doubt will be resolved in favor of the claimant). When the evidence supports the claim, or is in relative equipoise, the claim will be granted. See Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990); see also Wise v. Shinseki, 26 Vet. App. 517, 532 (2014). If the preponderance of the evidence weighs against the claim, it must be denied. Alemany v. Brown, 9 Vet. App. 518, 519 (1996). 1. Entitlement to an initial compensable disability rating for right eye corneal abrasion with corneal scar is denied. 2. Entitlement to an initial 10 percent disability rating for right eye corneal abrasion with corneal scar from February 8, 2021, forward, is granted. The Veteran's right eye corneal abrasion with corneal scar is rated noncompensable under 38 C.F.R. § 4.79, Diagnostic Code 6009, for unhealed eye injury. During the pendency of the appeal, VA issued a final rule revising the portion of the VA Schedule for Rating Disabilities that addresses the organs of special sense and schedule of ratings-eye. 89 Fed. Reg. 15316 (Apr. 10, 2018). The final rule went into effect May 13, 2018. Where there is a change in the rating criteria during the appeal period, the Board will consider the claim in light of both the former and revised schedular rating criteria, although an increased evaluation based on the revised criteria cannot predate the effective date of the amendments. Under the former criteria, Diagnostic Code 6009 instructed to evaluate pursuant to the General Rating Formula for Diagnostic Codes 6000 through 6009. The General Rating Formula for Diagnostic Codes 6000 through 6009 instructs to evaluate on the basis of either visual impairment due to the particular condition or on incapacitating episodes, whichever results in a higher evaluation. Where incapacitating episodes have a total duration of at least 1 week, but less than 2 weeks, during the past 12 months, a 10 percent rating is warranted. Where incapacitating episodes have a total duration of at least 2 weeks, but less than 4 weeks, during the past 12 months, a 20 percent rating is warranted. Where incapacitating episodes have a total duration of at least 4 weeks, but less than 6 weeks, during the past 12 months, a 40 percent rating is warranted. Where incapacitating episodes have a total duration of at least 6 weeks during the past 12 months, a 60 percent rating is warranted. A Note following the General Rating Formula indicates that, for VA purposes, an incapacitating episode is a period of acute symptoms severe enough to require prescribed bed rest and treatment by a physician or other healthcare provider. Under the revised criteria, Diagnostic Code 6009 instructs to evaluate pursuant to the General Rating Formula for Diseases of the Eye. The General Rating Formal for Diseases of the Eye instructs to evaluate on the basis of either visual impairment due to a particular condition or on incapacitating episodes, whichever results in a higher evaluation. Where there are documented incapacitating episodes requiring at least 1 but less than 3 treatment visits for an eye condition during the past 12 months, a 10 percent rating is warranted. Where there are documented incapacitating episodes requiring at least 3 but less than 5 treatment visits for an eye condition during the past 12 months, a 20 percent rating is warranted. Where there are documented incapacitating episodes requiring at least 5 but less than 7 treatment visits for an eye condition during the past 12 months, a 40 percent rating is warranted. Where there are documented incapacitating episodes requiring 7 or more treatment visits for an eye condition during the past 12 months, a 60 percent rating is warranted. Note (1) indicates that, for the purposes of evaluations under 38 C.F.R. § 4.79, an incapacitating episode is an eye condition severe enough to require a clinic visit to a provider specifically for treatment purposes. Note (2) indicates that examples of treatment may include but are not limited to: systemic immunosuppressants or biologic agents; intravitreal or periocular injections; laser treatments; or other surgical interventions. Note (3) indicates that, for the purposes of evaluating visual impairment due to a particular condition, refer to 38 C.F.R. § 4.75-4.78 and to § 4.79, Diagnostic Codes 6061-6091. Both the former and revised criteria provide for consideration of visual impairment. The amendments made no substantive changes to how visual acuity is rated. With regard to visual field and muscle function examinations, the use of a Goldmann chart is no longer required. There are otherwise no substantive changes to how those types of visual impairment are rated. The evaluation of visual impairment is based on impairment of visual acuity (excluding developmental errors of refraction), visual field, and muscle function. 38 C.F.R. § 4.75(a). Examinations of visual impairment must be conducted by a licensed optometrist or ophthalmologist, and the examiner must identify the disease, injury, or other pathologic process for any visual impairment found. Id. § 4.75(b). Examinations of visual field or muscle function will be conducted only when medically indicated. Id. Evaluation of visual acuity is based on corrected distance vision with central fixation. 38 C.F.R. § 4.76(b)(1). The measurements for each eye are applied to the table for Impairment of Central Visual Acuity. Generally, the table is divided into steps corresponding to different levels of visual acuity for one eye, and each step is further divided into subsections of visual acuity for the other eye, with corresponding ratings. The rater will first locate the step that matches the visual acuity of the poorer eye. Within that step, the rater will then locate the subsection that matches the visual acuity of the better eye, which will produce the corresponding rating. Where a reported visual acuity is between two sequentially listed visual acuities, the visual acuity which permits the higher evaluation will be used. 38 C.F.R. § 4.76(c). Subject to the provisions of § 3.383(a), if visual impairment of only one eye is service connected, the visual acuity of the other eye will be considered to be 20/40 for purposes of evaluating the service-connected visual impairment. 38 C.F.R. § 4.75(c). The evaluation for visual impairment of one eye must not exceed 30 percent unless there is anatomical loss of the eye. Id. § 4.75(d). The evaluation for visual impairment of one eye should be combined with other disabilities of the same eye that are not based on visual impairment (e.g., disfigurement under DC 7800). 38 C.F.R. § 4.75(d). The table of Impairment of Central Visual Acuity encompasses Diagnostic Codes 6061-66. Diagnostic Code 6066 provides ratings where vision in one eye (the poorer eye) is 10/200 or better. Where the visual acuity in one eye (the poorer eye) is 20/100, the following ratings apply. A 50 percent rating is warranted where vision in the other eye is also 20/100. A 30 percent rating is warranted where vision in the other eye is 20/70. A 20 percent rating is warranted where vision in the other eye is 20/50. A 10 percent rating is warranted where vision in the other eye is 20/40. Evaluation of visual field is based on the remaining field of vision in each eye. The examiner must record the remaining visual field of at least 16 meridians 2212 degrees apart for each eye, even though only the visual field at eight principal meridians 45 degrees apart will be used for rating purposes. Id. The table of Ratings for Impairment of Visual Fields provides ratings for visual field loss. The first half of the table provides ratings based on loss of an entire half of field of vision in an eye. The second half of the table provides ratings based on the average concentric contraction of the visual field of each eye. To calculate average concentric contraction, the rater should add the remaining visual field (in degrees) at each of eight principal meridians 45 degrees apart and divide the sum by eight. 38 C.F.R. § 4.77(b). To determine the evaluation for visual impairment when both decreased visual acuity and visual field defect are present in one or both eyes and are service connected, separately evaluate the visual acuity and visual field defect (expressed as a level of visual acuity), and combine them under the provisions of § 4.25. 38 C.F.R. § 4.77(c). Evaluation of impairment of muscle function is based on the degree of diplopia. The examiner must record test results for the four major quadrants (upward, downward, and right and left lateral) and the central field (20 degrees or less). 38 C.F.R. § 4.78(a). To evaluate the Veteran's service-connected eye disability, he was afforded a June 2016 Eye Conditions Disability Benefits Questionnaire. The examination report states that the Veteran has right eye corneal scar and dry eye right eye greater than left eye. Concerning medical history, the Veteran reported vision in his right eye is blurry compared to his left eye. The Veteran's visual acuity on corrected distance was measured as 20/40 or better. He does not have a difference equal to two or more lines on the Snellen test type chart or its equivalent between distance and near-corrected vision, with near vision being worse. His pupils were 4 millimeters bilaterally, round and reactive to light, and there was not an afferent pupillary defect present. The June 2016 examination report states that the Veteran does not have anatomical loss, light perception only, or extremely poor vision or blindness in either eye. He does not have a corneal irregularity that results in severe irregular astigmatism. He does not have diplopia. The Veteran's right and left eye pressure were measured at 16. The examination report states that the slit lamp, external eye examination, and internal eye examination were normal. The June 2016 examination report indicates that the Veteran has a visual field defect and visual field testing was performed. The Veteran does not have loss of a visual field, scotoma, or legal blindness. He has bilateral dry eye that does not cause scarring of disfigurement. According to the examination report, the Veteran's scarring impacts best corrected visual acuity, which decreases visual acuity or causes visual impairment. Concerning scarring or disfigurement, the June 2016 examination report states that the Veteran does not have scarring or disfigurement attributable to any eye condition. During the past 12 months, the Veteran has not had any incapacitating episodes attributable to any eye condition. The Veteran's service-connected eye disability does not impact his ability to work. The Veteran was also afforded a February 2021 Eye Conditions Disability Benefits Questionnaire. The examination report states that the Veteran has diagnoses of corneal scar, right eye, and cataract, bilateral. The Veteran's cataract is not related to his corneal scar according to the examination report. The Veteran's current symptoms are noted as blurred vision. Regarding visual acuity, the Veteran had right eye 20/100 vision and left eye 20/20 or better vision on corrected distance. He does not have a difference equal to two or more lines on the Snellen test type chart or its equivalent between distance and near corrected vision, with near vision being worse. His pupils were 4 millimeters bilaterally, round and reactive to light, and there was not an afferent pupillary defect present. The February 2021 examination report states that the Veteran does not have anatomical loss, light perception only, or extremely poor vision or blindness in either eye. He does not have a corneal irregularity that results in severe irregular astigmatism. He does not have diplopia. The Veteran's right eye pressure was measured at 17 and his left eye pressure was measured at 18. The examination report states that the slit lamp and external eye examination showed bilateral cataract. His internal eye examination was normal. The February 2021 examination report provides that the Veteran does not have a documented visual field defect. He has a one-millimeter right eye corneal scar that causes a decrease in visual acuity or other visual impairment. He has bilateral preoperative cataract and aphakia or dislocation of the crystalline lens is not present. The Veteran's cataract causes a decrease in visual acuity or other visual impairment. He has not had any incapacitating episodes attributable to any eye condition in the past 12 months. Concerning functional impairment, he has difficulty driving to work. During the January 2020 hearing, the Veteran stated that he has not had any incapacitating episodes in the past 12 months. He further advised that his hearing worsened after his June 2016 examination, he has difficulty reading, and his vision is worse in his left eye than in his right eye. The Board finds that from February 8, 2021, the Veteran's right eye corneal abrasion with corneal scar warrants a 10 percent disability rating for visual impairment. 38 C.F.R. § 4.79. Diagnostic Code 6066. The February 2021 examination report measured the Veteran's right eye distance vision as 20/100. As the Veteran's left eye is not service-connected, it is considered to be 20/40 for purposes of evaluating the service-connected visual impairment. 38 C.F.R. § 4.75(c). Therefore, a 10 percent disability rating is warranted. 38 C.F.R. § 4.79. Diagnostic Code 6066. Prior to this date, the Veteran's visual acuity was measured as 20/40 or better, thus not warranting a compensable disability rating. Regarding a higher disability rating due to visual field or muscle function, the evidence does not demonstrate that the Veteran has a visual field deficit, diplopia, or other muscle function manifestations related to his right eye corneal abrasion with corneal scar. As such, a higher disability rating related to loss of visual field or muscle function are not warranted. The evidence also does not demonstrate that the Veteran's right eye corneal abrasion with corneal scar has resulted in incapacitating episodes. Regarding a higher disability rating based on scarring or disfigurement, the evidence from the June 2016 and February 2021 examination reports demonstrates that the only scarring or disfigurement was the cornea scarring. As such, a higher disability rating based on scarring or disfigurement is not warranted. In conclusion, as the Board finds that the preponderance of the evidence is against a compensable disability rating for right eye corneal abrasion with corneal scar prior to February 8, 2021, and in favor of the assignment of a 10 percent disability rating, but not higher, from February 8, 2021, forward. In finding the above, the Board finds the benefit of the doubt doctrine is not applicable. See 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 55. 3. Entitlement to a compensable disability rating for hypertension is denied. The Veteran's service-connected hypertension is rated under Diagnostic Code 7101. 38 C.F.R. § 4.104. Under Diagnostic Code 7101, a 10 percent disability is assigned for hypertensive vascular disease with diastolic pressure predominantly 100 or more or systolic pressure predominantly 160 or more. A 10 percent disability rating is also assigned when the individual has a history of diastolic pressure predominantly 100 or more and requires continuous medication for control. Id. A 20 percent disability rating is assigned when diastolic pressure is predominantly 110 or more, or systolic pressure predominantly 200 or more. Id. A 40 percent disability rating is assigned when diastolic pressure is predominantly 120 or more. Id. A maximum 60 percent disability rating is assigned when diastolic pressure is predominantly 130 or more is rated 60 percent disabling. Id. Hypertension or isolated systolic hypertension must be confirmed by readings taken two or more times on at least three different days. Id., Note (1). The term hypertension means that the diastolic blood pressure is predominantly 90 mm. or greater, and isolated systolic hypertension means that the systolic blood pressure is predominantly 160 mm. or greater with a diastolic blood pressure of less than 90 mm. Id.; but see Gill v. Shinseki, 26 Vet. App. 386, 391 (2013) (holding that the definition in Note (1), including the requirement that hypertension be confirmed by readings taken two or more times on at least three different days, pertains to establishing the diagnosis rather than evaluating the severity of hypertension under the rating criteria). The rating criteria for hypertension under Diagnostic Code 7101 contemplate the effects of medication. McCarroll v. McDonald, 28 Vet. App. 267, 271-73 (2016). The Veteran was afforded a July 2017 Hypertension Disability Benefits Questionnaire. The examination report states that the Veteran's treatment plan includes taking continuous medication for his hypertension. He does not have a history of diastolic blood pressure elevation to predominantly 100 or more. The Veteran's blood pressure, taken on July 11, 2017, demonstrates readings of 130/90, 130/90, and 150/80. The Veteran was afforded a February 2021 Hypertension Disability Benefits Questionnaire. The examination report states that the Veteran's treatment plan includes taking continuous medication for his hypertension and that he does not have a history of diastolic blood pressure elevation to predominantly 100 or more. The Veteran's blood pressure, taken on February 9, 2021, demonstrates readings of 162/96, 151/87, and 153/88. During the January 2020 hearing, the Veteran advised that he completed a blood pressure study and without medication, his systolic pressure was measured around 170 and his diastolic pressure was measured above 90. He stated that his medication keeps his blood pressure stable. The Board notes that the blood pressure study was completed in December 2014, prior to the period on appeal. The effective date of an award of increased compensation shall be the earliest date as of which it is ascertainable that an increase in disability had occurred, if the application is received within one year from such date; otherwise, it is the date of receipt of the claim. 38 U.S.C. § 5110(a), (b)(2); 38 C.F.R. § 3.400(o). Thus, the effective date of an award of increased compensation may be assigned no earlier than one year prior to the date of claim, if an ascertainable increase in disability is established during that period. 38 U.S.C. § 5110(a), (b)(2); 38 C.F.R. § 3.400(o); Hart, 21 Vet. App. at 509-10; Hazan v. Gober, 10 Vet. App. 511, 519 (1992). As the Veteran submitted his claim for an increased disability rating for hypertension in March 2016, the evidence from the blood pressure study cannot be considered. The evidence demonstrates that the Veteran requires continuous medication for control of his hypertension. However, while the Veteran's VA treatment records demonstrate intermittent findings of systolic pressure readings above 160, the evidence does not show readings predominantly 160 or more or diastolic pressure predominately 100 or more. In sum, the preponderance of the evidence weighs against assignment of a compensable disability rating for the Veteran's service-connected hypertension. Consequently, the benefit-of-the-doubt rule does not apply, and an increased disability rating is denied. See 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 55. REASONS FOR REMAND Unfortunately, the Veteran's claims for increased disability ratings must be remanded for further development. Although the Board sincerely regrets the additional delay, it is necessary to ensure that there is a complete record upon which to decide the Veteran's claims, so he is afforded every possible consideration. 1. Entitlement to a disability rating in excess of 20 percent for left knee degenerative joint disease, status post patella fracture, with scars is remanded. 2. Entitlement to a disability rating in excess of 10 percent prior to April 19, 2017, and from June 1, 2017, forward, for right knee osteoarthritis and chondromalacia is remanded. The Veteran was afforded an October 2017 Knee and Lower Leg Conditions Disability Benefits Questionnaire to determine the current severity of his service-connected disabilities. The Board finds the examination is inadequate. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate). As discussed below, the examiner did not provide an estimate concerning the additional loss of range of motion during a flare-up. Therefore, a retrospective medical opinion is necessary to capture the severity of the Veteran's left and right knee during the relevant time period. Sharp v. Shulkin, 29 Vet. App. 26 (2017); see also Chotta v. Peake, 22 Vet. App. 80 (2008) (when there is an absence of medical evidence during a certain period of time, a retroactive medical evaluation may be warranted). VA examiners are required to estimate the additional loss of range of motion during a flare-up based on all procurable information from the record, and the Veteran's own statements. Sharp, 29 Vet. App. at 34-35. If an estimate cannot be provided without resort to speculation, it must be clear whether this is due to a lack of knowledge among the medical community at large, or insufficient knowledge of the specific examiner. Id. at 36. The October 2017 examination report notes that the Veteran has flare-ups of his left knee that are described as severe, disturbs his sleep, and he can barely walk. The Veteran has right knee flare-ups hat are mild to intense pain without medication and he is unable to remain standing for long periods of time and walks with a limp. The October 2017 examination was not being performed during a flare-up. Further, the examination report demonstrates that the examiner was not able to state without mere speculation whether pain, weakness, fatigability, or incoordination significantly limit functional ability with flare-ups. The examiner was unable to provide such an estimation of additional loss of range of motion during flare-ups because the examiner was not having a flare-up on the date of the examination. It is not apparent why the examiner could not estimate additional functional loss or additional loss of range of motion based on the Veteran's statements describing the flare-ups, or why the available information in the file was not sufficient to permit such an estimate. 3. Entitlement to an initial disability rating in excess of 10 percent for left ankle sprain is remanded. 4. Entitlement to an initial disability rating in excess of 20 percent for right ankle sprain is remanded. The Veteran was afforded a May 2016 Ankle Conditions Disability Benefits Questionnaire to determine the current severity of his service-connected disabilities. The Board finds the examination is inadequate. See Barr, 21 Vet. App. at 312 (2007). Again, the examiner did not provide an estimate concerning the additional loss of range of motion during a flare-up. Therefore, a retrospective medical opinion is necessary to capture the severity of the Veteran's left and right ankle during the relevant time period. Sharp, 29 Vet. App. 26; see also Chotta, 22 Vet. App. 80. The May 2016 examination report states that the Veteran has flare-ups of the left and right ankle as emergency room visits. The May 2016 examination report states that the examination is not being conducted during a left ankle flare-up. While the examination report states that the examination is not being conducted during a right ankle flare-up, the examiner also noted that the Veteran reported having a flare-up during the examination. The examination report demonstrates that the Veteran's left ankle pain significantly limits functional ability with flare-ups. The examiner was not able to state without mere speculation whether pain, weakness, fatigability, or incoordination significantly limit functional ability with flare-ups for the right ankle. Regarding the Veteran's left ankle, the examiner was unable to describe functional loss in terms of range of motion loss, because it will depend on the type of activity performed and the severity of pain experienced. The examiner did not describe the Veteran's functional loss in terms of range of motion for his right ankle and it is unclear whether he was experiencing a flare-up during the examination. It is not apparent why the examiner could not provide such loss of range of motion or estimate additional functional loss or additional loss of range of motion based on the Veteran's statements describing the flare-ups, or why the available information in the file was not sufficient to permit such an estimate. 5. Entitlement to a disability rating in excess of 20 percent for lumbar spine degenerative arthritis remanded. The Veteran was afforded a May 2016 Back (Thoracolumbar Spine) Conditions Disability Benefits Questionnaire to determine the current severity of his service-connected disability. The Board finds the examination is inadequate. See Barr, 21 Vet. App. at 312 (2007). Again, the examiner did not provide an estimate concerning the additional loss of range of motion during a flare-up. Therefore, a retrospective medical opinion is necessary to capture the severity of the Veteran's back disability during the relevant time period. Sharp, 29 Vet. App. 26; see also Chotta, 22 Vet. App. 80. The May 2016 examination report states that the Veteran has flare-ups that render him almost unable to function. The May 2016 examination was not being performed during a flare-up. Further, the VA examination report demonstrates that the examiner advised that pain, fatigue, and weakness significantly limit functional ability with flare-ups. The examiner was unable to provide such an estimation of additional loss of range of motion during a flare-up because it depends on the activity performed at the severity of the pain experienced. It is not apparent why the examiner could not estimate additional functional loss or additional loss of range of motion based on the Veteran's statements describing the flare-ups, or why the available information in the file was not sufficient to permit such an estimate. 6. Entitlement to a compensable disability rating for right thumb fracture residuals is remanded. The Veteran was afforded a May 2016 Hand and Finger Conditions Disability Benefits Questionnaire to determine the current severity of his service-connected disability. The Board finds the examination is inadequate. See Barr, 21 Vet. App. at 312 (2007). Again, the examiner did not provide an estimate concerning the additional loss of range of motion during a flare-up. Therefore, a retrospective medical opinion is necessary to capture the severity of the Veteran's right thumb disability during the relevant time period. Sharp, 29 Vet. App. 26; see also Chotta, 22 Vet. App. 80. The May 2016 examination report states that the Veteran has flare-ups described as severe pain that could result in an emergency room visit if it not treated. The May 2016 examination was not being performed during a flare-up. Additionally, the examination report demonstrates that the examiner advised that pain and fatigue significantly limit functional ability with flare-ups. The examiner was unable to provide such an estimation of additional loss of range of motion during flare-ups because it depends on the activity performed at the severity of the pain experienced. It is not apparent why the examiner could not estimate additional functional loss or additional loss of range of motion based on the Veteran's statements describing the flare-ups, or why the available information in the file was not sufficient to permit such an estimate. The matters are REMANDED for the following action: 1. Obtain the Veteran's VA treatment records for the period from August 2021 to the present. 2. After the above development is completed, obtain a retrospective opinion concerning the Veteran's left knee degenerative joint disease, status post patella fracture, with scars and right knee osteoarthritis and chondromalacia from an appropriate examiner. The examiner must review the Veteran's claims folder. The examiner should provide a retrospective opinion, as best as can be ascertained from the Veteran's self-reports and clinical records and other evidence, including examination reports. The examiner is asked to provide an opinion estimating any additional degrees of limited motion caused by functional loss during a flare-up. The Veteran reported flare-ups on the October 2017 Knee and Lower Leg Conditions Disability Benefits Questionnaire If it is not possible to provide a specific measurement, or an opinion regarding flare-ups, symptoms, or functional impairment without speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). The complete rationale for all opinions expressed must be set forth by the examiner. 3. Obtain a retrospective opinion concerning the Veteran's left ankle sprain and right ankle sprain from an appropriate examiner. The examiner must review the Veteran's claims folder. The examiner should provide a retrospective opinion, as best as can be ascertained from the Veteran's self-reports and clinical records and other evidence, including examination reports. The examiner is asked to provide an opinion estimating any additional degrees of limited motion caused by functional loss during a flare-up. The Veteran reported flare-ups on the May 2016 Ankle Conditions Disability Benefits Questionnaire. If it is not possible to provide a specific measurement, or an opinion regarding flare-ups, symptoms, or functional impairment without speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). The complete rationale for all opinions expressed must be set forth by the examiner. 4. Obtain a retrospective opinion concerning the Veteran's lumbar spine degenerative arthritis from an appropriate examiner. The examiner must review the Veteran's claims folder. The examiner should provide a retrospective opinion, as best as can be ascertained from the Veteran's self-reports and clinical records and other evidence, including examination reports. The examiner is asked to provide an opinion estimating any additional degrees of limited motion caused by functional loss during a flare-up. The Veteran reported flare-ups on the May 2016 Back (Thoracolumbar Spine) Conditions Disability Benefits Questionnaire. If it is not possible to provide a specific measurement, or an opinion regarding flare-ups, symptoms, or functional impairment without speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). The complete rationale for all opinions expressed must be set forth by the examiner. 5. Obtain a retrospective opinion concerning the Veteran's right thumb fracture residuals from an appropriate examiner. The examiner must review the Veteran's claims folder. The examiner should provide a retrospective opinion, as best as can be ascertained from the Veteran's self-reports and clinical records and other evidence, including examination reports. The examiner is asked to provide an opinion estimating any additional degrees of limited motion caused by functional loss during a flare-up. The Veteran reported flare-ups on the May 2016 Hand and Finger Conditions Disability Benefits Questionnaire. If it is not possible to provide a specific measurement, or an opinion regarding flare-ups, symptoms, or functional impairment without speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). The complete rationale for all opinions expressed must be set forth by the examiner. Michael J. Skaltsounis Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Mussey, Sean 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.