Citation Nr: 21072430 Decision Date: 12/03/21 Archive Date: 12/03/21 DOCKET NO. 12-41 849A DATE: December 3, 2021 ORDER Entitlement to an initial rating in excess of 10 percent for left knee disability prior to January 7, 2017, and in excess of 20 percent from that date is denied. A separate 10 percent rating for the period prior to January 7, 2017 for painful motion of the left knee is granted, subject to the laws and regulations governing the payment of monetary benefits. A separate 10 percent rating is granted for slight instability of the left knee from January 7, 2017, subject to the laws and regulations governing the payment of monetary benefits. REMANDED Entitlement to service connection for a right knee disability, to include as secondary to service-connected left knee disability is remanded. Entitlement to service connection for an inguinal hernia, to include as secondary to service-connected fractured deformity of the right pubis, right inferior and superior ramus is remanded. Entitlement to service connection for a scar on left groin, to include as secondary to inguinal hernia is remanded. FINDINGS OF FACT 1. Prior to January 7, 2017, the Veteran's left knee disability was manifested by symptomatic removal of semilunar cartilage, slight instability; limitation of flexion to 100 degrees, at worst and extension was normal. 2. Prior to January 7, 2017, the Veteran's left knee disability is manifested by pain, but noncompensable limitation of motion. 3. From January 7, 2017, the Veteran's left knee disability was manifested by semilunar cartilage, dislocated, with frequent episodes of "locking," pain, and effusion into the joint, limitation of flexion to 80 degrees, at worst. Extension was normal. 4. From January 7, 2017, the Veteran's the left knee disability was manifested by slight instability. CONCLUSIONS OF LAW 1. Prior to January 7, 2017, the criteria for a rating in excess of 10 percent for a left knee disability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5259-5257. 2. From January 7, 2017, the criteria for a rating in excess of 20 percent for a left knee disability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5003-5258. 3. Prior to January 7, 2017, the criteria for a 10 percent rating, but no higher, for left knee painful motion have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.321, 4.40, 4.59, 4.71a Diagnostic Code (Code) 5257. 4. From January 7, 2017, the criteria for a separate 10 percent rating for slight instability of the left knee have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.321, 4.40, 4.71a Diagnostic Code (Code) 5257. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from March 1977 to February 1978. The Board remanded these claims in June 2018. There has been substantial compliance with the remand in connection with claims decided here and the Board will proceed with adjudication. Stegall v. West, 11 Vet. App. 268 (1998). After the remand, the Agency of Original Jurisdiction (AOJ) assigned an earlier effective of October 10, 1978 for the award of service connection for a left knee disability and awarded entitlement to individual unemployability due to service-connected disabilities (TDIU), from November 16, 2012. See August 2021 rating decision. Those issues are no longer before the Board. Increased Rating The Veteran seeks a higher initial rating for his service-connected left knee disability which is rated as 10 percent disabling under 38 C.F.R. § 4.71a Code 5259-5257 from October 10, 1978 and as 20 percent disability under Code 5003-5258 from January 7, 2017. Disability ratings are determined by comparing the Veteran's symptoms with criteria listed in VA's Schedule for Rating Disabilities, which is based, as far as practically can be determined, on average impairment in earning capacity. Separate Codes identify the various disabilities. 38 C.F.R. Part 4. When rating a service-connected disability, the entire history must be borne in mind. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Disability of the musculoskeletal system is primarily the inability, due to damage or infection in the parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. In evaluating disabilities of the musculoskeletal system, it is necessary to consider, along with the schedular criteria, functional loss due to flare-ups of pain, fatigability, incoordination, pain on movement, and weakness. DeLuca v. Brown, 8 Vet. App. 202 (1995). Weakness is as important as limitation of motion, and a part which becomes painful on use must be regarded as seriously disabled. 38 C.F.R. § 4.40. Pain on movement, swelling, deformity or atrophy of disuse as well as instability of station, disturbance of locomotion, interference with sitting, standing and weight bearing are relevant considerations for determination of joint disabilities. See 38 C.F.R. § 4.45. These determinations are, if feasible, to be expressed in terms of the degree of additional loss-of-motion due to any weakened movement, excess fatigability, incoordination, flare-ups, or pain. Mitchell v. Shinseki, 25 Vet. App. 32 (2011). Under Code 5003, degenerative arthritis is rated based on limitation of motion under the appropriate diagnostic code for the specific joint involved. Where the limitation of motion is noncompensable under the appropriate diagnostic code a (maximum) 10 percent rating is for application for each such major joint or group of minor joints affected by limitation of motion to be combined, not added, under Code 5003. 38 C.F.R. § 4.71a. In the absence of limitation of motion, X-ray evidence of arthritis involving two or more major joints or two or more minor joint groups, will warrant a rating of 10 percent; in the absence of limitation of motion, X-ray evidence of arthritis involving two or more major joint groups with occasional incapacitating exacerbations will warrant a 20 percent rating. The above ratings are to be combined, not added under Code 5003. 38 C.F.R. § 4.71a, Diagnostic Code 5003, Note 1. At issue in this case is the Veteran's left knee. During the pendency of the Veteran's claim and appeal, the criteria for rating musculoskeletal disabilities were changed by an amendment to the rating schedule that became effective on February 7, 2021. 85 Fed. Reg. 76, 453 (November 30, 2020). The amendments provide that the Board should apply the criteria which are more favorable to the Veteran. The amended rating criteria, if favorable to the claim, can be applied only for periods from the effective date of the regulatory change; however, the old regulations will be considered for the periods both before and after the change was made. See VAOPGCPREC 3-2000, 65 Fed. Reg. 33,422 (2000); Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). The February 2021 changes to the rating criteria for the knee pertain to Diagnostic Code 5257 (instability) and Diagnostic Code 5262 (impairment of the tibia and fibula). The rest of the rating criteria for the knee are unchanged. Code 5258 provides a 20 percent evaluation for dislocation of semilunar cartilage with frequent episodes of "locking," pain, and effusion into the joint. Code 5259 provides a 10 percent evaluation for removal of semilunar cartilage that is symptomatic. Under Code 5260, which contemplates limitation of leg flexion, a 0 percent rating is warranted for flexion limited to 60 degrees; a 10 percent rating is warranted for flexion limited to 45 degrees; a 20 percent rating is warranted for flexion limited to 30 degrees; and a 30 percent rating is warranted for flexion limited to 15 degrees. 38 C.F.R. § 4.71a, Code 5260. Under Code 5261, which contemplates limitation of extension of the leg, a 0 percent rating is warranted for extension limited to 5 degrees; a 10 percent rating is warranted for extension limited to 10 degrees; a 20 percent rating is warranted for extension limited to 15 degrees; a 30 percent rating is warranted for extension limited to 20 degrees; a 40 percent rating is warranted for extension limited to 30 degrees; and a 50 percent rating is warranted for extension limited to 45 degrees. 38 C.F.R. § 4.71a, Code 5261. Separate ratings may also be assigned for limitation of flexion and limitation of extension of the same knee. Specifically, where a Veteran has both a compensable level of limitation of flexion and a compensable level of limitation of extension of the same leg, the limitations must be rated separately to adequately compensate for functional loss associated with injury to the leg. VAOPGCPREC 9-04 (Sept. 17, 2004), 69 Fed. Reg. 59990 (2005). A veteran who has arthritis and instability of the knee may be rated separately under Codes 5003 and 5257. Evaluation of a knee disability under both of those Codes does not amount to pyramiding. However, a separate rating must be based on additional compensable level of disability. 38 C.F.R. § 4.14; VAOPGCPREC 23-97 (July 1, 1997), 62 Fed. Reg. 63604 (1997); Esteban v. Brown, 6 Vet. App. 259 (1994). For VA compensation purposes, normal flexion of the knee is to 140 degrees, and normal extension is to zero degrees. 38 C.F.R. § 4.71a, Plate II. Code 5258 provides a 20 percent evaluation for dislocation of semilunar cartilage with frequent episodes of "locking," pain, and effusion into the joint. Code 5259 provides a 10 percent evaluation for removal of semilunar cartilage that is symptomatic. Under the older version of Code 5257, a 10 percent rating is available for slight recurrent subluxation or lateral instability. A 20 percent rating is assigned for moderate recurrent subluxation or lateral instability. A 30 percent rating is assigned for severe recurrent subluxation or lateral instability. 38 C.F.R. § 4.71a, Code 5257. Under Code 5257, as in effect after February 7, 2021, for recurrent subluxation or lateral instability, a 10 percent is warranted for sprain, incomplete ligament tear, or complete ligament tear (repaired, unrepaired, or failed repair) causing persistent instability, without a prescription from a medical provider for an assistive device (e.g., cane(s), crutch(es), walker) or bracing for ambulation. A 20 percent is warranted for one of the following: (a) Sprain, incomplete ligament tear, or repaired complete ligament tear causing persistent instability, and a medical provider prescribes a brace and/or assistive device (e.g., cane(s), crutch(es), walker) for ambulation. (b) Unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribes either an assistive device (e.g., cane(s), crutch(es), walker) or bracing for ambulation. A 30 percent is warranted for unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribes both an assistive device (e.g., cane(s), crutch(es), walker) and bracing for ambulation. For patellar instability, a 10 percent is warranted for a diagnosed condition involving the patellofemoral complex with recurrent instability (with or without history of surgical repair) that does not require a prescription from a medical provider for a brace, cane, or walker. A 20 percent 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 is warranted 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. In his October 1978 claim, the Veteran reported having weak knees. On January 1979 VA examination, the Veteran reported crepitus in his knees, and the examiner noted range of motion seemed normal. The examiner described his knees seemed healthy and strong. In a September 2009 VA treatment note, the Veteran reported chronic left knee pain, and a history of scope surgery for degenerative joint disease and a meniscus tear. On examination his left knee was unremarkable. In a March 2014 VA treatment note, the provider noted the Veteran had a history of left knee pain and underwent a left knee arthroscopic meniscus repair in 2007. A September 2014 VA knee examination diagnosed meniscal tear of the left knee. The examiner noted that surgery was performed in 1996. The Veteran reported he still had pain and stiffness mostly in the morning. The Veteran described his daily pain and stiffness lasted 1 to 2 hours which decreased range of motion, but reported that he had no true flare-ups. On range of motion, left knee flexion was to 100 degrees and extension was normal, with no objective evidence of painful motion. The Veteran was unable to complete repetitive use testing because he was not able to stand due to pelvic pain. The examiner noted the Veteran had functional impairment of less movement than normal, weakened movement, excess fatigability, pain on movement, and interference with sitting, standing, and weight-bearing. The examiner noted that pain, weakness, and fatigability could significantly limited functional ability after repeated use over time, but the examiner to assess additional loss of range of motion and the Veteran was unable to replicate the estimated limitation. The Veteran had tenderness or pain to palpation for the joint line or soft tissue of his left knee. On muscle strength testing left knee flexion and extension were rated as 4 out of 5. On joint stability testing left knee anterior instability was 1+; posterior instability was normal; and medial-lateral instability was 1+. The examiner found the Veteran's left knee instability was slight. There was no evidence or history of recurrent patellar subluxation or dislocation. He did not have or ever have shin splints. The examiner noted the Veteran had a meniscal tear and a meniscectomy on his left knee in 1996. The examiner had residuals of weakness, pain, and instability. The Veteran did not use any assistive devices as a normal mode of locomotion. The examiner found there was not functional impairment of his left knee so much so that no effective function remained other than that which would be equally well served by an amputation with prosthesis. The examiner opined that the Veteran's left knee condition impacted his ability to work. The examiner noted the Veteran was limited as he could walk for up to 10 minutes before need a break; he could walk for a total of 2 hours during an 8 hour day with the remaining time spent resting; he could sit or stand for up to 10 minutes before needing to change positions; and he could sit or stand for a total of 2 hours during an 8 hour day if he was able to change positions frequently. In an October 2014 rating decision, service connection was granted for meniscal tear with meniscotomy and instability, left knee, and a 10 percent rating assigned under Code 5257, effective March 17, 2014. A January 2017 VA examination noted diagnoses of left knee meniscal tear, osteoarthritis, and instability. The examiner noted that the new diagnosis of left knee arthritis represented a progression of his previously service-connected meniscectomy. The Veteran reported that his left knee swelled and that he had to have a couple of injections and aspirations, but it was still very painful. He reported he was treated by a private provider and he was told he needed bilateral knee replacement. He reported that he used pain patches. He reported he did not have flare-ups of his left knee condition. He reported having functional impairment as he had pain with walking, weight-bearing, and sitting. He reported that he constantly had to be in motion because of pain. On range of motion testing, left knee flexion was 10 degrees to 115 degrees, and extension was normal. Range of motion contributed to functional loss as it made it difficult for him to walk. Pain was noted on both flexion and extension that caused functional loss, but the examiner did not note were pain started and ended. The examiner noted that passive range of motion testing and range of motion in non-weightbearing could not be performed. There was evidence of pain with weight bearing and of crepitus. There was objective evidence of localized tenderness on palpation as there was moderate diffuse tenderness to all areas of the knee and patella, including popliteal fossa. The Veteran was unable to perform repetitive use testing with at least three repetitions because he had too much pain. The examiner noted he was not being examined immediately after repetitive use over time, but that the examination was medically consistent with the Veteran's statements describing functional loss with repetitive use over time. The examiner was unable to say without mere speculation as if pain, weakness, fatigability or incoordination significantly limited functional ability with repeated use over a period of time because he was not examined under those conditions. On muscle strength testing left knee flexion and extension were rated as 4 out of 5. He did not have muscle atrophy or ankylosis. The examiner noted the Veteran did not have a history of left knee recurrent subluxation or lateral instability. On joint stability testing, left knee anterior instability was normal, posterior instability was normal, medial instability was 1+, and lateral instability was 1+. The Veteran did not have an had never had shin splints. The Veteran had a meniscus condition of a meniscus tear with frequent episodes of joint locking, joint pain, and joint effusion. The examiner noted the Veteran had pain with walking, his knee locked when he tried to bend it, and he had several aspirations of fluid. The examiner noted the Veteran occasionally used crutches and regularly used a cane and walker to help him walk due to left knee pain. The examiner found there was not functional impairment of his left knee so much so that no effective function remained other than that which would be equally well served by an amputation with prosthesis. The examiner opined that the Veteran's left knee condition impacted his ability to perform any occupational task as he would have difficulty with work that required high impact activity, such as running or jumping and he would have difficulty with prolonged weight bearing. A February 2018 rating decision assigned an earlier effective date for the award for service connection for the left knee and the 10 percent rating was assigned effective August 26, 2013; a 20 percent rating for residuals of arthritis, status post meniscectomy of the left knee was granted under Code 5003-5258, effective January 7, 2017. At the March 2018 hearing, the Veteran testified that he was told he needed a left knee replacement, probably in another five to seven years. He testified that his knee was painful and had swelled during his last examination. He testified he had injections for pain, and that he wore a brace because his knee gave way and used a walker and cane. An August 2021 VA knee examination diagnosed left knee arthritis, status post meniscectomy. The Veteran reported that his left knee had hurt since his motorcycle accident during service. The examiner noted he had surgery on his left knee in the early 2000s and that he had had injections in his left knee over the prior few years. The examiner noted the Veteran had pain, in the right greater than the left and that he walked with a moderate limp. He reported that pain was much worse with prolonged walking, and described that he had been walking a previous day on his property and was fairly immobile for a few days afterwards. The examiner noted he was taking various pain medications and that he had worn braces in the past, but did not currently wear them. The Veteran did not report having flare-ups of a knee condition. He described functional impairment that walking was very difficult due to the pain. He reported that his right knee was unstable, but did not report that his left knee was unstable. On range of motion testing, left knee flexion was to 80 degrees and extension was normal. Pain was noted on flexion and extension that caused functional loss, but the endpoints were the same. Passive range of motion was the same as active range of motion. The examiner noted that range of motion contributed to functional loss because he had difficulty with squatting motions. There was no objective evidence of crepitus or objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue. The Veteran was able to perform repetitive-use testing with at least three repetitions with no additional loss of range of motion. The Veteran was not being examined immediately after repeated use over time, and the procured evidence, including statements from the Veteran, did not suggest pain, fatigability, weakness, lack of endurance, or incoordination which significantly limited functional ability with repeated use over time. The examiner noted there were no additional contributing factors to his left knee disability. The Veteran did not have muscle atrophy or ankylosis. On joint instability testing, there was no left knee recurrent subluxation or persistent instability or left knee ligament tear. The Veteran did not require a prescription by a medical provider for ambulation. The examiner noted the Veteran had a left knee meniscal tear and underwent meniscectomy in the early 2000s per his reporting. The examiner found there was not functional impairment of his left knee so much so that no effective function remained other than that which would be equally well served by an amputation with prosthesis. The examiner opined that the Veteran's knee conditions impacted his ability to perform any occupational task as he should not carry even mildly heavy loads, and could not ambulate or stand for prolonged periods of time. The August 2021 rating decision assigned an effective date of October 10, 1978 for the grant of service connection for the left knee disability. Pursuant to the Board's June 2018 remand directives, the Veteran was asked to identify any treatment for his left knee disability prior to January 2004 and provide information to enable VA to obtain those records. He did not provide the necessary authorization forms to obtain private treatment records. Accordingly, VA has been unable to obtain potentially relevant evidence. The "duty to assist is not always a one-way street," and a claimant has an obligation to provide VA information necessary to substantiate the claim. See Wood v. Derwinski, 1 Vet. App. 190 (1991). Based on the evidence of record, the Board concludes that a rating in excess of 10 percent is not warranted for the left knee instability rating prior to January 7, 2017 and a rating in excess of 20 percent is not warranted for the left knee disability from that date. A separate 10 percent rating is warranted for painful motion prior to January 7, 2017 and a separate 10 percent rating is warranted for left knee instability from January 7, 2017. For the period prior to January 7, 2017, an initial rating in excess of 10 percent is not warranted. During this period, the Veteran is rated under Code 5259-5257 for removal of systematic semilunar cartilage and instability of the left knee. A higher 20 percent rating is not warranted as during this period, the instability of the Veteran's left knee did not more closely approximate moderate in severity. On September 2014 VA examination, left knee anterior instability was 1+; posterior instability was normal; and medial-lateral instability was 1+. The September 2014 VA examiner found the Veteran's left knee instability was slight. A separate 10 percent rating is warranted for painful motion prior to January 7, 2017. See 38 C.F.R. § 4.59; Burton v. Shinseki, 25 Vet. App. 1 (2011). The Veteran complained of painful motion on examination in September 2009, March and September 2014 and January 2017. Separate compensable ratings are not warranted prior to January 7, 2017 as there is no compensable limitation of motion prior to that date. At worst left knee flexion was to 100 degrees and extension was to 0. For the period from January 7, 2017, a rating in excess of 20 percent is not warranted. During this period, the Veteran is rated under Code 5003-5258 for arthritis and semilunar dislocated cartilage. As the Veteran has limitation of motion throughout this period, in order for the Veteran to receive a rating higher than 20 percent, it must be based upon the criteria for limitation of motion provided for the knee rating criteria. 38 C.F.R. § 4.71a Code 5003. At worst, and with consideration of pain, his left knee flexion was to 80 degrees and left knee extension was to 0. Therefore, the Board finds that the criteria for a higher 30 percent rating under Code 5260, for limitation of flexion are not met or more closely approximated; flexion is not limited to 15 degrees, even with consideration of pain and flare-ups. The Board also finds that the criteria for a separate compensable rating under Code 5261, for limitation of extension, are not met. Extension has been normal throughout the appeal period. The Board also finds that a separate 10 percent rating is warranted for slight instability under the prior version of Code 5257 for the period from January 7, 2017. The old version of 5257 does not require objective medical evidence to assign rating for instability. English v. Wilkie, 30 Vet. App. 347 (2018). On January 2017 VA examination, the examiner diagnosed instability and on joint stability testing medial and lateral instability was 1+. A higher rating is not warranted as moderate instability of the Veteran's left knee was not shown because anterior and posterior instability were normal on January 2017 VA examination, and no instability was found on August 2021 VA examination. Additionally, a higher 20 rating is not warranted under the new criteria for Code 5257 as on August 2021 VA examination, the Veteran was not diagnosed with sprain or ligament tear of the left knee and there is no notation of any diagnosed condition involving the patellofemoral complex. In deciding the claims, the Board has also considered the Veteran's lay statements that his left knee disabilities are worse than currently evaluated. He is competent to report symptoms because this requires only personal knowledge as it comes to him through his senses. Layno v. Brown, 6 Vet. App. 465 (1994). He is not, however, competent to identify a specific level of disability of this disorder according to the appropriate diagnostic codes. Such competent evidence concerning the nature and extent of the Veteran's disabilities has been provided by the medical personnel who have examined him during the current appeal and who have rendered pertinent opinions in conjunction with the evaluations. The medical findings (as provided in the examination reports and the clinical records) directly address the criteria under which his disability is evaluated. As such, the Board finds these records to be more probative than the Veteran's subjective complaints of increased symptomatology. The Board has considered the doctrine of reasonable doubt but has determined that it is inapplicable, other than the grant of a separate rating for left knee instability from January 7, 2017 because otherwise the preponderance of the evidence is against higher ratings. 38 U.S.C. § 5107 (b); 38 C.F.R. §§ 4.3, 4.7, 4.71a. REASONS FOR REMAND Entitlement to service connection for a right knee disability, to include as secondary to service-connected left knee disability is remanded. The claim is remanded to obtain an opinion on whether the right knee disability is aggravated by the now service-connected left knee disability. An August 2021 VA examination included a negative opinion as to direct service connection because it was likely related to a 2014 fall from a ladder. Entitlement to service connection for an inguinal hernia, to include as secondary to service-connected fractured deformity of the right pubis, right inferior and superior ramus is remanded. Entitlement to service connection for a scar on left groin, to include as secondary to inguinal hernia is remanded. The claims are remanded because the August 2021 VA opinion is inadequate. The rationale for the negative opinion on secondary service connection was, in part, because the Veteran did not have any pelvic condition until 2014, which was after the development and repair of his hernias. Accordingly, the basis of that opinion is improper because under 38 C.F.R. § 3.310 (a), a primary disability need not be service-connected, or even diagnosed, at the time the secondary condition is incurred. Frost v. Shulkin, 29 Vet. App. 131 (2017). Accordingly, a new opinion is necessary. The claim for a scar on the left groin, as secondary to inguinal hernia must be remanded also because the issues are inextricably intertwined. On remand, updated treatment records should be obtained. See 38 C.F.R. § 3.159. See also Bell v. Derwinski, 2 Vet. App. 611 (1992). The matters are REMANDED for the following action: 1. Obtain the names and addresses of all medical care providers who treated the Veteran for any right knee, inguina hernia, or left groin scar complaints since service, not already associated with the record. After securing the necessary release, take all appropriate action to obtain these records, including any VA treatment records since July 2017. 2. After the completion of the above, obtain an addendum opinion from the VA examiner who provided August 2021 VA opinion, (or another appropriate provider if the August 2021 examiner is unavailable) to determine the nature and etiology of the Veteran's right knee disability. Copies of all pertinent records, including this remand, must be made available to the examiner for review. Based on the review of the record (and examination if needed), the examiner should answer the following: Is it at least as likely as not that the Veteran's right knee disability is (i) caused by or (ii) aggravated by (defined as any increase in disability) the Veteran's service-connected left knee disability? Why or why not? The examiner should specifically consider and discuss as necessary the Veteran's 2014 fall off of a ladder and whether such fall was due to his left knee disability. The examiner must explain the rationale for all opinions in detail, citing to supporting clinical data and/or medical literature, as appropriate. If an opinion cannot be provided, the examiner should indicate why. 3. After the completion of (1), obtain an addendum opinion from the VA examiner who provided August 2021 VA opinion, (or another appropriate provider if the August 2021 examiner is unavailable) to determine the nature and etiology of the Veteran's inguinal hernia. Copies of all pertinent records, including this remand, must be made available to the examiner for review. Based on the review of the record (and examination if needed), the examiner should answer the following: Is it at least as likely as not that the Veteran's inguinal hernia is (i) caused by or (ii) aggravated by (defined as any increase in disability) the Veteran's service-connected fracture deformity of the right pubis, right inferior and superior ramus? Why or why not? The fact that the inguinal hernia was diagnosed before the right hip disability cannot be the basis for a negative opinion. The examiner must explain the rationale for all opinions in detail, citing to supporting clinical data and/or medical literature, as appropriate. If an opinion cannot be provided, the examiner should indicate why. 4. Confirm that the VA medical opinions provided comports with this remand, specifically that the standard for the secondary aggravation opinion is any increase in disability, not the standard of beyond the natural progression as noted on the examination form itself. If not, get an addendum. M.E. Larkin Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Eric Struening 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.