Citation Nr: 21071560 Decision Date: 11/30/21 Archive Date: 11/30/21 DOCKET NO. 15-00 735 DATE: November 30, 2021 ORDER Prior to April 19, 2019, a rating higher than 10 percent for the right knee chondromalacia patella with noncompensable painful motion is denied. Beginning April 19, 2019, the 10 percent rating for right knee chondromalacia patella with noncompensable painful motion under Diagnostic Code 5003 is replaced with a 10 percent rating under Diagnostic Code 5261 for compensable limited extension. Beginning April 19, 2019, a rating higher than 10 percent for the right knee limited extension is denied. For the entire period on appeal, a separate rating of 10 percent for the right knee instability is granted. A compensable rating for the right knee scar is denied. REMANDED Entitlement to a rating higher than 10 percent for the traumatic brain injury (TBI) is remanded. FINDINGS OF FACT 1. Prior to April 19, 2019, the right knee did not more nearly manifest as flexion limited to 30 degrees or extension limited to 10 degrees to warrant a rating higher than 10 percent. 2. Beginning April 19, 2019, the 10 percent rating assigned for noncompensable painful motion under Diagnostic Code 5003-5260 is replaced with a 10 percent rating under DC 5261 for compensable limited extension to avoid the rule against pyramiding. 3. Beginning April 19, 2019, the right knee extension did not more nearly manifest as limited to 15 degrees or greater. 4. For the entire period on appeal, the right knee more nearly manifested slight instability, but did not more nearly manifest as moderate instability. 5. The right knee scars have not more nearly manifested as painful or unstable scars and do not cover an area of at least 144 square inches (929 sq. cm.) or greater. CONCLUSIONS OF LAW 1. Prior to April 19, 2019, a rating higher than 10 percent for chondromalacia patella with painful noncompensable limited motion have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.40, 4.45, 4.71a, Diagnostic Codes 5003, 5010, 5260. 2. Beginning April 19, 2019, the Board replaces the current 10 percent rating for right knee chondromalacia patella with noncompensable painful motion under Diagnostic Code 5003 with a 10 percent rating under DC 5261 for compensable limited extension. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.7, 4.14, 4.71a, DC 5261. 3. Beginning April 19, 2019, the criteria for a 10 percent rating, but no higher, for limited right knee extension have been met. 38 U.S.C. §§ 5107, 7104; 38 C.F.R. §§ 3.321, 4.1, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, DCs 5261. 4. For the entire period on appeal, the criteria are met for a separate 10 percent disability rating, but not higher, for slight instability of the right knee. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.14, 4.21, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5257. 5. The criteria for a compensable rating related to the right knee arthroscopy are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.118, Diagnostic Codes 7800-7805. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from January 2009 to January 2013. This matter comes on appeal before the Board of Veterans' Appeals (Board) from a December 2013 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). By way of procedural background, this matter was previously before the Board in June 2020. The Board denied a rating higher than 10 percent for the service-connected TBI and remanded the claim for a rating higher than 10 percent for the right knee chondromalacia patella for further development. The Veteran appealed the Board's June 2020 decision to the Court of Appeals for Veterans Claims (Court). The parties entered a joint motion for partial remand (JMPR), which was granted by the Court in June 2021. The Veteran only requested court review of the initial 10 percent rating for the TBI under Diagnostic Code 8045. He affirmatively dismissed his appeal to the Court as to an initial rating higher than 30 percent for headaches, an initial rating higher than 10 percent for tinnitus, and the denial of a separate rating for pineal cyst as secondary residuals of the TBI. See June 2021 JMPR. Therefore, those additional issues are no longer before the Board. The claim for a rating higher than 10 percent for the service-connected TBI has now been returned to the Board for further appellate consideration and will be addressed in the remand portion of this decision. After substantially complying with the Board's remand directives, the increased rating claim for the right knee chondromalacia patella has also been returned to the Board for further appellate consideration. While on remand, the RO granted a separate 10 percent rating for right knee limited extension, effective June 2, 2021 and a noncompensable rating for right knee surgical scars, effective September 18, 2019. In August 2018, the Veteran testified before the undersigned Veterans Law Judge (VLJ) via videoconference hearing. A copy of the hearing transcript is of record and has been reviewed. The VLJ complied with her duties as a hearing officer as outlined in Bryant v. Shinseki, 23 Vet. App. 488 (2010). The Veteran has not alleged there are any deficiencies in the Board hearing. Preliminary Matters The Board has limited the discussion below to the relevant evidence required to support its finding of fact and conclusion of law, as well as to the specific contentions regarding the case as raised directly by the Veteran and those reasonably raised by the record. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015); Robinson v. Peake, 21 Vet. App. 545, 552 (2008); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016). Pertinent Laws and Regulations for initial increased rating claims Disability ratings are determined by application of the criteria set forth in VA's Schedule for Rating Disabilities, which is based on average impairment of earning capacity. 38 U.S.C. § 1155; 38 C.F.R. Part 4. The Veteran's entire history is to be considered when making disability evaluations. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). "Staged" ratings are appropriate for any rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007); Fenderson v. West, 12 Vet. App. 119 (1999). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture 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 a degree of disability will be resolved in favor of the veteran. 38 C.F.R. § 4.3. When evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use and therefore, not be reflected on range-of-motion testing. 38 C.F.R. § 4.45 requires consideration also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Nonetheless, even when the background factors listed in § 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a (musculoskeletal system) or § 4.73 (muscle injury); a separate or higher rating under § 4.40 or 4.45 itself is not appropriate. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016) ("[I]t is clear that the guidance of § 4.40 is intended to be used in understanding the nature of the veteran's disability, after which a rating is determined based on the § 4.71a [or 4.73] criteria."). Moreover, the provisions of 38 C.F.R. § 4.59, which relate to painful motion, are not limited to arthritis, and must be considered when raised by the claimant or when reasonably raised by the record. Burton v. Shinseki, 25 Vet. App. 1 (2011). Pyramiding, that is the evaluation of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when evaluating a veteran's service-connected disability. 38 C.F.R. § 4.14. However, it is possible for a veteran to have separate and distinct manifestations from the same injury which would permit rating under several diagnostic codes; the critical element in permitting the assignment of several evaluations under various diagnostic codes is that none of the symptomatology for any one of the conditions is duplicative or overlapping with the symptomatology of the other condition. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). Neither the Rating Schedule nor the regulations provide definitions for descriptive words such as "slight," "moderate," or "severe." See Sellers v. Wilkie, 30 Vet. App. 157 (2018). Rather than applying a mechanical formula, the Board must instead evaluate all the evidence to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6. In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive and provide the reasons for its rejection of any material favorable to the claimant. Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994). A veteran is competent to report symptoms because this requires only personal knowledge, not medical expertise, as it comes through the senses. See Layno, 6 Vet. App. 465, 469. Lay testimony is competent to establish the presence of observable symptomatology, where the determination is not medical in nature and is capable of lay observation. Barr v. Nicholson, 21 Vet. App. 303 (2007). Lay evidence may establish a diagnosis of a simple medical condition, a contemporaneous medical diagnosis, or symptoms that later support a diagnosis by a medical professional. Jandreau, 492 F.3d 1372, 1377. When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with a veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. 1. Increased rating claim for the right knee chondromalacia patella The Veteran is currently assigned a 10 percent rating for painful, noncompensable limited flexion under DC 5260-5257 effective January 6, 2013, and a 10 percent rating under DC 5261, effective June 2, 2021. Hyphenated DCs are used when a rating under one DC requires use of an additional DC to identify the basis for the rating; the additional DC is shown after the hyphen. 38 C.F.R. § 4.27. Effective February 7, 2021, VA amended the rating criteria for disabilities of the knee and leg. DCs 5260 and 5261 were unchanged; however, DC 5257 was amended. VA's General Counsel has held that where a law or regulation changes during the pendency of a claim for a higher rating, the Board must first determine whether the revised version is more favorable to the veteran. In so doing, it may be necessary for the Board to apply both the old and new versions of the regulation. If the amended version of the regulation is more favorable, the retroactive reach of that regulation under 38 U.S.C. § 5110(g) can be no earlier than the effective date of the amendments. The Board must generally apply both the former and the revised versions of the regulation for the period prior and after the regulatory change, but an effective date based on the amended criteria may be no earlier than the date of the change. Turning now to the relevant codes, Diagnostic Code 5010 instructs the rater to rate traumatic arthritis as degenerative arthritis under Diagnostic Code 5003. Under Diagnostic Code 5003, arthritis established by X-ray findings is rated based on limitation of motion under the appropriate Diagnostic Codes for the specific joint or joints involved. 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 and not added, under Diagnostic Code 5003. For purpose of rating disability from arthritis, the knee is considered a major joint. 38 C.F.R. § 4.45(f). The diagnostic codes that focus on limitation of motion of the knee are Diagnostic Codes 5260 (limitation of flexion) and 5261 (limitation of extension). For rating purposes, normal range of motion in a knee joint is from 0 to 140 degrees. 38 C.F.R. § 4.71, Plate II. The Rating Schedule provides for ratings of 0, 10, 20, or 30 percent where there is limitation of flexion of the leg to 60, 45, 30, or 15 degrees, respectively, and for ratings of 0, 10, 20, 30, 40, or 50 percent for limitation of extension of the leg to 5, 10, 15, 20, 30, or 45 degrees, respectively. 38 C.F.R. § 4.71a, Diagnostic Codes 5260, 5261. VA's General Counsel has held that separate ratings are available for limitation of flexion and limitation of extension under Diagnostic Codes 5260 and 5261. VAOPGCPREC 9-2004 (2004). Pre-amended Diagnostic Code 5257 provides ratings of 10, 20, and 30 percent for recurrent subluxation or lateral instability of the knee, which is slight, moderate, or severe, respectively. 38 C.F.R. § 4.71a, Diagnostic Code 5257. Effective February 7, 2021, Diagnostic Code 5257 Effective February 7, 2021, Diagnostic Code 5257 provides ratings for both recurrent subluxation or instability of the knee and for patellar instability. As it pertains to recurrent subluxation or instability of the knee, Diagnostic Code 5257 provides a 10 percent rating for a 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 either (a) sprain, incomplete ligament tear, or repaired complete ligament tear causing persistent instability, and a medical provider prescribes a brace and/or assistive device, or (b) unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribes either an assistive device 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 and bracing for ambulation. As it pertains to patellar instability of the knee, Diagnostic Code 5257 provides a 10 percent rating 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 assigned 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): For patellar instability, the patellofemoral complex consists of the quadriceps tendon, the patella, and the patellar tendon. Note (2): 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). See DC 5257 (Effective February 7, 2021). Diagnostic Code 5258 provides a 20 percent rating may be assigned for dislocated semilunar cartilage with frequent episodes of "locking," pain, and effusion into the joint. Diagnostic Code 5259 provides for a 10 percent rating for symptomatic removal of the semilunar cartilage. Turning to the evidence, private treatment records, including physical therapy, was provided to the Veteran in 2011 and 2012 due to complaints of pain on motion, particularly when climbing stairs. In October 2012, the Veteran was seen by a private physician Dr. S.H., MD, who noted the Veteran's reports of right knee pain. In December 2013, the Veteran underwent a VA compensation examination for his service-connected right knee disability. The examiner reported that the Veteran had right knee pain and status post right tibia/fibula fracture, without residuals. The Veteran reported that his symptoms included swelling, pain, and a spontaneous burning sensation. The examiner noted that the Veteran did not have flare-ups that impacted the function of the right knee or lower leg. On range of motion testing, the Veteran's flexion and extension were normal. The Veteran was able to perform repetitive use testing with no additional loss of range of motion or functional impairment. The examiner further noted that there was no pain on palpation and no evidence of ankylosis. The Veteran's muscle strength, joint stability and medial-lateral instability were all noted as normal with no evidence of recurrent patella subluxation or dislocation. The examiner noted that the Veteran did not use an assistive device and did not have degenerative or traumatic arthritis. In April 2014, the Veteran reported to the VA medical center (VAMC) with symptoms of chronic knee pain. The Veteran expressed that he was unable to do workouts at the gym due to the pain he experienced during knee exercises. See VA outpatient reports dated March 2013 to April 2014. In May 2014, the Veteran was seen by a VA orthopedic surgeon. The surgeon noted that a slight retropatellar pop was present at about 10 to 15 degrees at a flexed position. No instability or effusion was noted. In July 2014, an MRI study revealed that the Veteran had patellar chondromalacia and a possible patellofemoral disease, for which he was referred for additional treatment. The Veteran was noted as having a history of chronic pain with chondromalacia. No instability or effusion issues were noted. See VAMC outpatient treatment records received October 2014. In August 2018, the Veteran was treated by private physician Dr. J.C.K. The Veteran reported that he still experienced constant, moderate to severe, throbbing, sharp pain primarily over the medial aspect as well as inferior to the patella. He further expressed that his knee buckled more frequently, at least 2 to 3 times per week, especially when he used the stairs. The Veteran then reported feeling popping and grinding in his knee. Dr. J.C.K noted that although the Veteran had pain, he was unable to take pain medication because of unrelated issues with his stomach. Finally, after receiving the Veteran's MRI results, Dr. J.C.K concluded that the Veteran had a contusion of the right knee and moderate to high-grade patellofemoral chondromalacia with small join effusion. Also, in August 2018, the Veteran testified before the Board that his knee would occasionally swell and become numb, and he experienced pain. The Veteran also noted that these symptoms limited his mobility as he felt pain when he extended his knee. He then recalled that his knee buckled randomly when he would walk. Furthermore, the Veteran recalled that he would experience excruciating pain when he attempted to move his knee during his last VA examination. During the hearing, the Veteran also challenged the adequacy of the December 2013 VA examination, which incorrectly expressed that he does not use assistive devices. Moreover, the Veteran explained that the examination report did not note his reports of painful motion during the examination. In September 2018, the Veteran submitted a Disability Benefits Questionnaire completed by Dr. J.C.K., who continued the Veteran's diagnosis of patellofemoral pain syndrome in the right knee. The physician then noted that the Veteran experienced pain during range of motion testing, on weight-bearing, and on palpation of joints or soft tissue. The contributing factors of the Veteran's disability were reported as weakened movement, pain on movement and interference with standing. Pain, weakness, fatigability, or incoordination were specifically reported as factors which significantly limit functional ability during flare-ups or repeated use over time. Next, the physician reported that diagnostic testing revealed that the Veteran has degenerative or traumatic arthritis and crepitus. Finally, the physician noted that the Veteran's disability interfered with his ability to complete work tasks. A private orthopedic surgeon evaluated the Veteran in January 2019. The Veteran had ongoing right knee pain since February 2012 following an injury in service. He was previously treated at VA with a knee brace and physical therapy. The Veteran presented wearing a IROM knee brace on the right knee, locked in full extension and ambulating with the crutches non-weight bearing. His pain was constant, moderate, throbbing, sharp, and localized to the medial aspect of the right knee. He "cannot comment on weakness or instability" as the right knee was currently non-weight bearing. He used ice as needed and was not taking pain medications. An x-ray study did not show osseous abnormalities in the right knee. On physical examination, the Veteran guarded the right knee. He had tenderness at the lateral facet, medial facet, and medial joint line. There was no swelling, ecchymosis, or significant deformity. Patellofemoral crepitus and positive grimace test were noted. Anterior drawer, lateral pivot, lateral pivot shift grind, Lachman's, posterior drawer test, external rotation-recurvatum, reverse, lateral pivot shift, and the sag testing were negative. The medial collateral ligament stress test in extension and lateral collateral ligament were trace positive. The medial collateral ligament stress test in flexion and lateral collateral ligament stress test in flexion were stable. On range of motion testing, the Veteran had to 5 degrees extension and 115 degrees of flexion. The medial McMurray's test and medially Steinman test were positive. The lateral Steinman and lateral McMurray's test were negative. Medically directed pressure at the lateral femoral epicondyle did not cause pain. There was mild effusion. Homan's sign was negative. There were multiple healed arthroscopic incisions. The impression was chondromalacia patella with a fracture of the medial tibial plateau. The physician noted the Veteran had ongoing right knee pain with increased frequency of instability. The Veteran's knee often gave out. A previous MRI scan showed a large area of bone marrow edema anterior and medially. It originally appeared that he had a stress reaction that was significant and at risk of developing a fracture. On follow up MRI scans, the Veteran had developed a medial tibial plateau fracture. Subsequently, a November 2018 MRI scan showed that the medial tibial fracture had resolved. However, the Veteran continued to have pain on the superior and inferior aspects of the patella and was still guarded on examination. The December 2018 MRI study showed subchondral fracture of the medial femoral condyle. This fracture occurred without injury or significant weight bearing. It was noted that due to the potential for osteoporosis due to the Veteran's diagnosis of Klinefelter's syndrome, he was referred to an endocrinologist for work up. The Board remanded the claim in March 2019 to obtain another VA examination based on the Veteran's testimony of worsening symptoms in the right knee. See August 2018 hearing transcript. April 2019 private treatment records showed the Veteran had right knee pain with weakness and gait disturbances. The Veteran had difficulty sleeping, standing for one hour, driving, transfers, walking between rooms, work, housework, school, hobbies, recreation, sports activities, squatting, and stairs. The Veteran had five scope incisions on the anterior knee with Steri strips. He was very guarded in the flexed knee posture. His pain was, at worst, a 10 on a 10 point pain scale with 10 being the most painful, and currently was an 8 out of 10. He had active range of motion in the right knee extension to 23 degrees and flexion to 60 degrees. The Veteran was wearing immobilizer brace on right knee. Additional April and May 2019 private treatment records reported the Veteran had right knee pain and gait disturbances with 90, 90, 118, 120, 125, 120, 120, 120, 128 degrees of flexion and 15, 10, 10, 10, 10, 10, 10, 10, and 5 degrees of extension. A May 2019 private postoperative right knee arthroscopy examination showed increased density consistent with calcium carbonate bone structure cement in the posterior medial tibial plateau region and in the central medial femoral condyle region. The increased density was in the region of the subchondral fractures. No other abnormality was noted. Surgical changes of the medial tibial plateau and medial fun loral condyle consistent with subchondroplasty were found. There was still clicking under the patella. In July 2019, the Veteran was examined at VA. He was in constant pain due to the 5 fractures of the femur and medial tibial plateau. It was not healing. On physical examination, there was no edema or effusion found. He had "limited right knee extension" but flexion was intact. He had right leg atrophy above the knee with pain on palpation on the medial right knee. He was referred to orthopedics. A July 2019 MRI study showed a normally aligned right knee. The Veteran reported having a recent MRI through a private provider, but those results had not been submitted to VA. Compared to a 2016 MRI study, there were new areas of sclerosis within the distal femur/medial tibial plateau. The right knee joint spaces were well maintained and stable. The Veteran was afforded a VA examination for the right knee in September 2019. The examiner, a nurse practitioner, noted the Veteran had been diagnosed with right knee chondromalacia in September 2012. Since then, the Veteran was unable to run and had fissures in his knee. He had an arthroscopic surgery on the right knee three months earlier because of multiple fractures in the medial tibial plateau and femur. Per the Veteran they filled his knee with "cement" to make it so he could walk on it again. His right knee buckled constantly, and he experienced pain when climbing stairs, squatting, or kneeling. The Veteran did not report flare-ups of the right knee or functional loss. The examiner was unable to report right knee initial range of motion or range of motion on repetitive use testing in degrees because the Veteran stated he was unable to move his knee due to pain. The examiner noted the Veteran was sitting comfortably on the edge of the examination table with his knee flexed at 90 degrees, walked unassisted with normal gait, and had full extension to 0 degrees. No pain was noted on examination in weight bearing. There was no objective evidence of localized tenderness or pain on palpation of the joint or associated tissue. The Veteran was not examined immediately after repeated use over time. The examination was neither medically consistent nor inconsistent with the Veteran's description of functional loss with repeated use over time. Pain weakness, fatigability, or incoordination did not significantly limit the right knee functional ability. Muscle strength was normal. No muscle atrophy, ankylosis, history of recurrent subluxation, history of lateral instability, history of recurrent effusion, or joint instability were found on examination. The Veteran had six well healed arthroscopic scars each measuring .05 centimeters x 0.1 centimeters. He did not use any assistive device for locomotion. The functional impairment of the right knee was not so severe that he would be equally well served by amputation and use of a prosthetic. Imaging studies had been performed but did not show arthritis. An October 2019 VA treatment record reported the Veteran's right knee gave out and caused him to brace himself by standing straight, injuring his back. A November 2019 consultation with a VA orthopedic surgeon noted the Veteran had right knee pain post sub-chondroplasty, likely meniscus with nerve irritation, flexion contracture, quad weakness, and possible reflex sympathetic dystrophy versus complex regional pain syndrome. A knee brace was prescribed. Another November 2019 MRI study showed no acute fracture, bone tear, or meniscus tear. The findings were consistent with installation of cement material in the knee. He had mild lateral patellar tilting and subluxation, and nonspecific band-like edema signal in the vastus medialis muscle distally. A June 2020 VA addendum medical opinion concluded that it was not possible to differentiate whether the reduced extension was due to the fixation or the right knee chondromalacia without resorting to speculation. The VA examiner also noted that osteoporosis, which could be caused by Klinefelter's syndrome, was ruled out in March 2019. In addition, the 2018 tibial plateau fracture was more likely caused by trauma, and not by alteration of gait or weight bearing related to the chondromalacia. The Veteran sought treatment from a private chiropractor primarily for his back disability between March 2019 to August 2021. The Veteran reported low back, middle back, right leg, and left leg pain that made it difficult to lift, walk, rise from sitting, almost any movement, and sleeping. An August 2020 VA examiner, a physician, noted the right knee chondromalacia had progressed or worsened. The Veteran reported he had arthroscopic surgery on his right knee on June 2019 due to the right knee condition, they had to fill his knee with "cement" to make it so he could walk on it again. The right knee "buckles constantly" and the pain was an 8 out of 10 on a 10-point pain scale when he climbed or descended stairs, squats, or kneeled. The Veteran had flare-ups during cold weather or after physical activity. His functional loss was being unable to kneel or squat. Initial active range of motion and passive motion testing measured flexion to 100 degrees and extension to 0 degrees. The abnormal range of motion contributed to functional loss as it caused difficulty bending down, walking for extended periods, and difficulty lifting objects. Pain was noted on examination in flexion and extension. There was no objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue. There was evidence of pain on weight bearing and on non-weight bearing. There were objective signs of crepitus. The Veteran was able to perform repetitive-use testing with at least three repetitions without additional loss of range of motion. Pain, fatigue, weakness, lack of endurance, and incoordination did not significantly cause functional loss. The Veteran was not being examined immediately following repeated use over time or during a flare up. The examination was neither medically consistent nor inconsistent with the Veteran's description of his functional loss in these circumstances. Pain, weakness, fatigability, or incoordination did not significantly limit functional ability with repeated use over time. The right knee range of motion with repeated use over time was estimated to be to 100 degrees of flexion and 0 degrees of extension. Pain, fatigue, weakness, and lack of endurance significantly limited his functional ability during a flare up. Range of motion during a flare up was estimated to be to 90 degrees of flexion and 0 degrees of extension. Additional contributing factors included instability of station, disturbance of locomotion, interference with sitting, and interference with standing. Muscle strength was normal in right knee flexion and extension. No muscle atrophy, ankylosis, history of subluxation, history of lateral instability, history of recurrent effusion, instability on objective testing, recurrent patellar dislocation, shin splints, stress fractures, chronic exertional compartment syndrome, or any other tibial or fibular impairment was found. The Veteran did not have a meniscal condition. The Veteran underwent a June 2019 arthroscopic surgery of the right knee. He had six well-healed scars on the right knee measuring 0.5 centimeters x 0.2 centimeters. The Veteran used a knee brace constantly and a cane regularly for locomotion. The Veteran's right knee disability was not so severe that an amputation and use of a prosthetic would equally well serve the Veteran. Imaging studies had been performed, but no degenerative or traumatic arthritis was found. The examiner noted the functional impact of the right knee chondromalacia was decreased range of motion, difficulty with prolonged sitting, difficulty walking, difficulty going up and down stairs, and that it impacted his ability to work. An October 2020 VA neurological examination and medical opinion indicated the Veteran denied tingling and numbness in his right lower extremity. He had right knee pain and swelling. The right knee buckled frequently and was tender to the touch. On physical examination, the Veteran guarded the right knee due to pain and tenderness at the medial and inferior aspect of his knee joint. He has several well healed arthroscopic scars around the medial and lateral knee joint from the recent arthroscopic surgery and the scars are non-tender. The knees are symmetrical but anteriorly, the right knee circumference was 43 centimeters, and the left knee circumference was 41 cm. There was no calf atrophy. The muscles in the calves were well toned. The Veteran worked for ADT in sales, and the job was not physically demanding and does not affect his right knee. The examiner concluded that neither the Veteran reported at the examination, nor the medical records showed, evidence of neurological symptoms relate to the right knee disability. The Veteran primarily indicated he had right knee pain, but he did not report any neurological signs, symptoms, or deficits in the right lower extremity. The Veteran was afforded another June 2021 VA examination for the right knee. The examiner, a physician, indicated that the Veteran had right knee chondromalacia patella and medial tibial plateau fractures with residuals of pain and limited range of motion. The Veteran reported his knee swelled and buckled at random. Pressure on the right knee increased the pain, he was unable to run or use an elliptical, he was unable to crawl or kneel, and he had difficulty climbing stairs. He underwent a right knee debridement in April 2019 and a fixation of medial femoral condyle using calcium carbonate for fixation, with residuals of pain and decreased range of motion. He was not taking any medications for the right knee disability. The Veteran had daily flare-ups of the right knee that lasted several minutes. The flare-up symptoms were described as intense pain. Precipitating factors for a flare-up was activity or climbing stairs. An alleviating factor was ice. The severity of the right knee disability was mild. The Veteran described his functional impairment during a flare-up as he was unable to walk, run, or climb stairs without increased pain. The Veteran had a history of instability or recurrent subluxation, which the Veteran described as random buckling of the right knee. The Veteran also reported a history of effusion, describing it as frequent random swelling. Initial active and passive range of motion testing showed he had flexion to 80 degrees and extension to 0 degrees with evidence of pain in both active and passive motion on flexion and extension. Limitation of motion was not specifically attributable to pain, weakness, fatigability, or incoordination. Pain was not noted in weight bearing or nonweight-bearing. Pain caused functional loss, including inability to walk, run, or climb stairs without increased pain. There was no objective evidence of crepitus. There was mild localized tenderness to palpation to the patella and associated soft tissues. The Veteran was able to perform repetitive use testing with at least three repetitions with no additional loss of function or loss of range of motion. The Veteran was not examined immediately following repeated use over time or during a flare-up. According to the Veteran, pain, fatigability, weakness, and lack of endurance significantly limited his functional ability with repeated use over time and during flare-ups. The estimated right knee range of motion after repeated use over time and during a flare-up was to 75 degrees flexion and 10 degrees extension. No additional contributing factors were found. The examiner did not find right knee muscle atrophy, ankylosis, recurrent subluxation, persistent instability, ligament tear or sprain, recurrent patellar instability, or a meniscal condition. The examiner also indicated that the Veteran did not require a prescription by a medical provider for a cane, walker, crutches, or braces. The Veteran did not currently have, and had never been diagnosed with, recurrent patellar dislocation, shin splints, stress fractures or any other tibial or fibular impairment. Under other pertinent physical findings, the examiner indicated that the Veteran had weight bearing flexion to 70 degrees and extension to 5 degrees. The Veteran did not use any assistive devices as a normal mode of locomotion. The right knee disability was not so severe that the Veteran would be equally well served by an amputation and use of a prosthetic. The examiner indicated the Veteran's functional impact was that he could not walk, stand, kneel, or squat. The examiner determined that the medial tibial plateau fractures with residuals of pain and limited range of motion were new conditions that were unrelated to the service-connected right knee chondromalacia patella. The examiner noted that the medial tibial plateau fractures were diagnosed in 2019, and they were more likely caused by trauma. The Veteran was in a motor vehicle accident in 2012. A September 2012 right knee MRI study was ordered based on a concern for a plateau fracture, but it was negative. Thus, it was less likely that the medial tibial plateau fractures were caused in service. As a procedural history, the RO initially rated the Veteran's right knee chondromalacia patella as noncompensable under Diagnostic Code 5257. This award was based on evidence of a right knee disability but with no symptoms. The Board awarded at least a 10 percent rating for the right knee disability for the entire appeal period based on painful motion under 38 C.F.R. § 4.59 for noncompensable painful motion of the right knee and remanded for an additional examination. On remand, the evidence showed the Veteran's right knee had worsened, and the right knee first met the criteria for a 10 percent rating for limited extension in the right knee. As a result, effective June 2, 2021, the RO awarded an additional separate 10 percent rating under DC 5261 for compensable limited flexion and continued the10 percent rating for instability with noncompensable painful limited flexion and changed the applicable Diagnostic Code from 5257 to 5260-5257. Changing the assigned Diagnostic Code 5260-5257 suggests that the right knee chondromalacia patella is rated based on noncompensable limitation of flexion with slight instability. 38 C.F.R. § 4.71a. There is no evidence at any time during the appellate period that the Veteran has experienced ankylosis, a condition affected the semilunar cartilage (meniscus), nonunion or malunion of the tibia and fibula, or genu recurvatum in the right knee. Thus, Diagnostic Codes 5256, 5258, 5259, 5262, and 5263 are not for application at any time during the appellate period. a) Appellate period prior to April 19, 2019 Prior to April 19, 2019, the right knee disability did not have compensable limitation of motion. However, as discussed by the Board in the June 2020 Board decision, a 10 percent rating was awarded based on painful noncompensable range of motion under 38 C.F.R. § 4.59 and Burton v. Shinseki, 25 Vet. App. at 1. However, a higher than 10 percent rating is not warranted, as there is no compensable flexion to 45 degrees or less or compensable extension to degrees or less to warrant higher rating. Prior to April 19, 2019, under the pre-amended Diagnostic Code 5257, the Board finds that, affording the Veteran the benefit of the doubt, the right knee slight instability warrants a separate 10 percent rating. Objective stability testing during this period on appeal has consistently found no instability; however, the Veteran has repeatedly reported that his right knee occasionally buckled and gave way. See e. g., July 2014 VA treatment record August 2018 private treatment record. Prior to February 7, 2021, Diagnostic Code 5257 did not require objective medical evidence of lateral instability for a rating to be assigned. See English v. Wilkie, 30 Vet. App. 347 (2018). Because the Veteran has competently and credibly reported right knee instability symptoms, the Board finds that a separate 10 percent rating is warranted for slight lateral instability for the rating period on appeal. However, the Veteran's knee instability is not more accurately described as moderate. The medical records do not specifically describe instability of the knee joint, and VA and private evaluations have consistently found that the knee joints are normal on all stability tests. The Board finds that knee instability that causes functional impairment but is undetectable on all forms of examination is best characterized as slight in nature. Thus, the Board awards a separate 10 percent rating for slight right knee instability prior to April 19, 2019. As there was no limitation on extension prior to April 19, 2019, a compensable rating under DC 5261 for limited extension does not apply to this period on appeal. In conclusion, prior to April 19, 2019, the Board finds that a 10 percent rating for painful, noncompensable loss of range of motion is warranted; nevertheless, the preponderance of the evidence is against the Veteran's claim for a rating higher than 10 percent for limited flexion or extension. Additionally, a separate 10 percent rating, but no higher, for right knee instability is warranted prior to April 19, 2019. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. Finally, the Board notes that neither the Veteran nor his representative have raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 69-70 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). b) Appellate period beginning April 19, 2019 While on remand the RO assigned a 10 percent rating for extension limited to 10 degrees, effective June 2, 2021. After reviewing the record, the Board finds that the first manifestation of limited extension to 10 degrees was April 19, 2019, and a 10 percent rating under Diagnostic Code 5261 is warranted on that date. As an initial matter, the Board acknowledges that the right knee limited extension could be due to the 2018 fracture of the tibial plateau, which was determined to not be caused the service-connected chondromalacia patella. Nevertheless, the June 2020 VA examiner also indicated that symptoms of the two right knee disabilities could not be differentiated. When symptoms of two conditions cannot be sufficiently distinguished, entitlement to the benefit sought is determined based on the overlapping symptoms, which are attributed in whole to the service-connected disability. 38 C.F.R. § 3.102; Mittleider v. West, 11 Vet. App. 181 (1998). Thus, the symptoms of the fracture of the tibial plateau will be attributed to the right knee chondromalacia. The Board acknowledges that on April 19, 2019, the right knee extension was measured to 15 degrees, which could warrant a 20 percent rating for the right knee. However, thereafter, the right knee extension was repeatedly limited to 10 degrees. Furthermore, he also had extension to 5 degrees and to 0 degrees (normal) after April 19, 2019. See, e.g., April 22, 2019, April 25, 2019, April 29, 2019, April 30, 2019, and May 2, 2019 private treatment records and June 2021 VA examination; but see May 28, 2019 private treatment records and August 2020 VA examination. While the Board acknowledges that there was a single measurement of limited extension to 15 degrees during the entire period on appeal, a single measurement is not an accurate description of the right knee functional impairment. The Board also notes that this single measurement of limited extension was found only a few days after he underwent arthroscopic surgery. Thus, based on the evidence as a whole and construing any reasonable doubt in favor of the Veteran, the right knee limited extension more nearly manifested as limited extension to 10 degrees beginning April 19, 2019. During the entire appeal period, the limitation of motion did not more nearly approximate extension limited to 15 degrees or more or flexion limited to 30 degrees or less, as needed for a 20 percent rating, even with consideration of the additional limitation due to pain, fatigability, weakness, and incoordination. Therefore, a disability rating higher than 10 percent is not warranted under either Diagnostic Codes 5260 or 5261 for limitation of extension or flexion. 38 C.F.R. § 4.71a. Nevertheless, because the Veteran is now in receipt of a 10 percent rating for painful limited extension, he cannot also be rated under Diagnostic Code 5003-5261 for noncompensable painful limitation of motion rated under Diagnostic Code 5003-5260. Assigning a separate rating under Diagnostic Code 5003-5260 and Diagnostic Codes 5261 would constitute pyramiding, as these diagnostic codes rate based on limitation of motion, including limitation of motion caused by pain. 38 C.F.R. § 4.14; Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). Thus, the 10 percent rating assigned prior to April 19, 2019 under Diagnostic Code 5003-5260 for noncompensable painful motion is discontinued and replaced with the 10 percent rating under Diagnostic Code 5261. The staged ratings assigned above for the Veteran's right knee chondromalacia patella have not resulted in an actual reduction of compensation payments to the Veteran, and no additional notice of the action was required. Tatum v. Shinseki, 24 Vet. App. 139 (2010). Beginning April 19, 2019, the Veteran also continued to experience slight instability of the right knee. Beginning April 19, 2019, objective stability testing during this period on appeal consistently found no instability; however, the Veteran repeatedly reported that his right knee occasionally buckled and gave way. See e. g., October 2019 VA treatment record, October 2020 private treatment record, and June 2021 VA examination. Nevertheless, the Veteran's knee instability did more nearly manifest as moderate instability. The medical records do not specifically describe instability of the knee joint, and VA and private evaluations have consistently found that the knee joints are normal on all stability tests. The Board finds that knee instability that causes functional impairment but is undetectable on all forms of examination is best characterized as slight in nature. Thus, the right knee instability was also slight during this period on appeal under the pre-amended Diagnostic Code 5257. The Board also considered whether a rating higher than 10 percent was warranted under the amended diagnostic code 5257, effective February 7, 2021. However, the record does not show that the Veteran was entitled to a rating higher than 10 percent for the service-connected right knee chondromalacia under the amended Diagnostic Code 5257. Specifically, the record does not show that the service-connected right knee disability involves the patellofemoral complex, as defined in Note (1) following Diagnostic Code 5257, or recurrent subluxation or instability due to a sprain or ligament tear in the right knee. In conclusion, beginning April 19, 2019, the Board finds that a 10 percent rating, but no higher, for painful, right knee extension limited to 10 degrees is warranted, the 10 percent rating under Diagnostic Code 5003-5260 for painful noncompensable range of motion is discontinued, and a 10 percent rating, but no higher, for slight right knee instability continues. The preponderance of the evidence is against the claim for a rating higher than 10 percent for limited flexion or extension and a preponderance of the evidence is against the claim for a rating higher than 10 percent for right knee instability. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. Finally, the Board notes that neither the Veteran nor his representative have raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 69-70 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). 2. A compensable rating for the right knee scar is denied. During the appellate period, the RO granted service connection for right knee scars associated with the service-connected chondromalacia patella and assigned a noncompensable rating, effective September 18, 2019. The Veteran's right knee scars is rated under Diagnostic Code 7802. Effective August 13, 2018, the rating criteria for scars were amended on August 13, 2018. These new regulations apply to all applications for benefits received by VA or that are pending before the agency of original jurisdiction on or after August 13, 2018. Claims pending prior to the effective date will be considered under both old and new rating criteria, and whatever criteria is more favorable to the veteran will be applied. The Board may not apply a current regulation prior to its effective date unless the regulation explicitly provides otherwise. Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). However, the Board is not precluded from applying prior versions of the applicable regulation to the period on or after the effective dates of the new regulation if the prior version was in effect during the pendency of the appeal. Prior to August 13, 2018, Diagnostic Code 7802, was for burn scar(s) or scar(s) due to other causes, not of the head, face, or neck, that were superficial and nonlinear. Under these criteria, a scar with an area or areas of 144 square inches (929 sq. cm.) or greater warrants a 10 percent rating. 38 C.F.R. § 4.118. Note 1 to Diagnostic Code 7802 instructed that a superficial scar was one not associated with underlying soft tissue damage. Id. Since August 13, 2018, Diagnostic Code 7802 is for burn scar(s) or scar(s) due to other causes, not of the head, face, or neck, that are not associated with underlying soft tissue damage. 38 C.F.R. § 4.118. Diagnostic Code 7802 was otherwise unchanged by the August 13, 2018, amendments. The Board finds that the preponderance of the evidence is against the assignment of a compensable evaluation under Diagnostic Code 7802 because the Veteran's right knee scars have not manifested by an area or areas of 144 square inches (929 sq. cm.) or greater. At worst, the medical evidence shows that he has multiple arthroscopic surgery scars on his right knee measuring from 1 x 0.2 centimeters each for four scars (total area of 0.8 centimeters squared) to 0.5 x 0.2 centimeters each for 6 scars (total area of .10 centimeters squared). See August 2020 and June 2021 VA examinations. The Board has also considered the other Diagnostic Codes pertaining to scars. However, the right knee scars are not of the head, face, or neck, are not deep and non-linear, and are not associated with underlying soft tissue damage. Moreover, the right knee scars are not unstable or painful. Therefore, Diagnostic Codes 7800, 7801, and 7804, both prior to and from August 13, 2018, are inapplicable. Finally, the evidence of record shows there are no other disabling effect(s) not considered in a rating provided under Diagnostic Codes 7800-04 as contemplated under both pre- and post-August 13, 2018, Diagnostic Code 7805. The Board acknowledges the one notation of tender scars in the May 2019 post-operative private treatment records. However, the Veteran had only recently undergone the April 17, 2019 arthroplasty of the right knee and the scars would not have been fully healed at this appointment. There are no other notations in the record, despite numerous physical examinations, that show the Veteran reported tender or painful scars. Thus, the Board finds that the right knee arthroscopy scars did not more nearly manifest as painful or unstable scars to warrant a compensable rating. The Veteran is competent to report observable symptoms, to include tender and painful right knee scars. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). However, he has not asserted, and the medical treatment records do not show, that the right knee scars have manifested by an area or areas of 144 square inches (929 sq. cm.) or greater and are not painful or unstable. In conclusion, the Board finds that the preponderance of the evidence is against the Veteran's claim for a compensable rating for right knee scars. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. REASONS FOR REMAND 1. Entitlement to a rating higher than 10 percent for the traumatic brain injury (TBI) is remanded. The Veteran contends that a rating higher than 10 percent is warranted for the TBI under two theories. First, the Veteran asserts that at least a level of 2 should be assigned to the facet applicable to memory, attention, concentration, and executive function based on January 2014 VA clinician's diagnosis of mild neurocognitive disorder due to a TBI. Furthermore, the Veteran also asserts that at least a level of 2 should be assigned to the subjective symptoms facet for three or more subjective symptoms that moderately interfere with work, instrumental activities of daily living, or work, family, or other close relationships. Examples of findings for this facet at the moderate level of impairment are marked fatigability, blurred or double vision, and headaches requiring rest periods during most days. See June 2021 brief. As to the first theory, in January 2014, a VA neuropsychologist diagnosed the Veteran with mild cognitive disorder and attributed it to the service-connected TBI. However, an October 2014 addendum opinion from a VA examiner, who previously examined the Veteran in December 2013, indicated the January 2014 neuropsychologist did not review the Veteran's service treatment records and her attribution of the cognitive impairment to a TBI was based on mere speculation. In the October 2014 VA examiner's opinion, there was no reason to change his assigment of the memory, attention, concentration, or executive function facet. In a subsequent September 2019 VA examination, the examiner selected the box to indicate the Veteran had mild neurocognitive disorder attributable to the TBI. The September 2019 VA examiner did not discuss the conflicting evidence of record or provide a rationale to support this conclusion. As there are conflicting opinions of record, on remand, a clarifying medical opinion should be obtained to determine whether the mild neurocognitive disorder is attributable to the service-connected TBI. As to the subjective symptoms facet, the Veteran contends that he experiences symptoms of dizziness, periods of blacking out/seizures, coordination problems, stuttering, slurring, blurry or double vision, ringing in his ears, headaches, sensitivity to light, sensitivity to sound, tingling and numbness in his upper and lower extremities, and memory deficits. See June 2021 brief. The Board notes that the Veteran is already in receipt of separate ratings for the headache disability secondary to the TBI disability, which has been rated based on his symptoms of headaches, sensitivity to light and sound, and blurry/double vision. He is also in receipt of a separate rating for tinnitus as a TBI residual, which is rated at 10 percent based on the ringing in his ears. The Veteran was specifically afforded an October 2020 VA examination to evaluate the lower extremity tingling and numbness as described in the August 2018 hearing. However, on examination, the Veteran denied these symptoms. The examiner concluded based on the Veteran's statements, the medical records, and the physical examination that he did not have neurological signs or symptoms in the right lower extremity. Nevertheless, the left lower extremity and the bilateral upper extremities were not evaluated in the context of the TBI claim. The medical and lay evidence of record is silent as to symptoms of stuttering, slurring, periods of blacking out or seizures, upper extremity tingling and numbness, and difficulty with coordination. As such, a VA examination is necessary to determine if the Veteran is experiencing these symptoms and if they are attributable to the service-connected TBI or another condition. The Veteran also reported dizziness in the August 2018 Board hearing and attributed it to the TBI. The medical records show the Veteran has repeatedly denied dizziness during the appellate period. See, e.g., March 2013, May 2013, April 2014, December 2015, and July 2019 treatment records. Nevertheless, as dizziness has not been evaluated, a VA examination is warranted to determine whether the Veteran experiences this symptom as a TBI residual. The matters are REMANDED for the following action: 1. Obtain any outstanding pertinent VA treatment records and associate them with the claims file. 2. Schedule the Veteran for an addition VA TBI examination with an appropriate clinician. After a complete review of the claims file the examiner should address the following: a) Elicit from the Veteran all his symptoms of the TBI. See June 2021 brief. b) Evaluate the Veteran's TBI symptoms under Diagnostic Code 8045. *Note the Veteran did not appeal the separate ratings assigned for the headaches and tinnitus disabilities as residuals of the TBI. He also did not appeal the denial of a separate rating for pineal cyst as a residual of the TBI. Thus, these issues are no longer on appeal. c) Provide an addendum opinion to clarify the conflicting medical opinions of record as to whether the mild neurocognitive disorder diagnosed in January 2014 is a residual of the service-connected TBI. See October 2013 VA examination, January 2014 VA neuropsychiatric evaluation, October 2014 VA addendum opinion, and September 2019 VA examination report. Whether an additional physical examination is necessary is left to the discretion of the Veteran. c) Provide an opinion as to whether each of the Veteran's subjective symptoms are attributable to the service-connected TBI or another condition. *Specific attention is directed to the Veteran's reports of dizziness, periods of blacking out/seizures, coordination problems, stuttering, slurring, tingling and numbness in the upper and lower extremities, memory deficits, headaches, sensitivity to light and sound, blurry/double vision, and ringing in the ears. See June 2021 brief. 3. Readjudicate the remanded claim on appeal. S. B. MAYS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board T. Harper, 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.