Citation Nr: 21074512 Decision Date: 12/15/21 Archive Date: 12/15/21 DOCKET NO. 17-57 613 DATE: December 15, 2021 ORDER Entitlement to a rating in excess of 10 percent for degenerative arthritis of the right knee (right knee arthritis) is denied. Entitlement to a 10 percent rating, but no higher, from June 4, 2021, for degenerative arthritis of the right knee limitation of extension is granted. Entitlement to a rating in excess of 10 percent prior to June 4, 2021, and in excess of 20 percent thereafter for degenerative arthritis of the left knee (left knee arthritis) is denied. Entitlement to a 20 percent rating, but no higher, from July 29, 2020, for instability, degenerative arthritis, right knee (right knee instability) is granted. Entitlement to a 20 percent rating, but no higher, from July 29, 2020, for instability, degenerative arthritis, left knee (left knee instability) is granted. REMANDED Entitlement to service connection for bilateral carpal tunnel syndrome is remanded. FINDINGS OF FACT 1. The Veteran's right knee arthritis was not manifest by flexion limited to 30 degrees, ankylosis, cartilage, semilunar, dislocated with frequent episodes of locking, pain, and effusion into the joint, impairment of the tibia and fibula, or genu recurvatum. 2. From June 4, 2021, the Veteran had right knee limitation of extension to 10 degrees. 3. Prior to June 4, 2021, the Veteran's left knee arthritis was not manifest by flexion limited to 30 degrees, extension limited to 5 degrees, ankylosis, cartilage, semilunar, dislocated with frequent episodes of locking, pain, and effusion into the joint, impairment of the tibia and fibula, or genu recurvatum. 4. From June 4, 2021, the Veteran's left knee arthritis was not manifest by flexion limited to 15 degrees, extension limited to 5 degrees, ankylosis, cartilage, semilunar, dislocated with frequent episodes of locking, pain, and effusion into the joint, impairment of the tibia and fibula, or genu recurvatum. 5. From July 29, 2020, the Veteran's right knee instability was manifest by moderate instability. 6. From July 29, 2020, the Veteran's left knee instability was manifest by moderate instability. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 10 percent for right knee arthritis have not been met. 38 U.S.C. §§ 1155, 5107 (b) (2012); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5003-5260 (2020). 2. The criteria for a 10 percent rating, but no higher, from June 4, 2021, for degenerative arthritis of the right knee limitation of extension have been met. 38 U.S.C. §§ 1155, 5107 (b) (2012); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5261 (2020). 3. The criteria for a rating in excess of 10 percent prior to June 4, 2021, and in excess of 20 percent thereafter for left knee arthritis have not been met. 38 U.S.C. §§ 1155, 5107 (b); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5010-5260, 5003-5261 (2020). 4. The criteria for a 20 percent rating, but no higher, from July 29, 2020, for right knee instability have been met. 38 U.S.C. §§ 1155, 5107 (b); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5003-5257 (2020). 5. The criteria for a 20 percent rating, but no higher, from July 29, 2020, for left knee instability have been met. 38 U.S.C. §§ 1155, 5107 (b); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5003-5257. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from July 1973 to July 1976. This matter comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Roanoke, Virginia. The Veteran testified at a videoconference hearing before the undersigned Veterans Law Judge in January 2021. A transcript of the hearing is of record. The Board remanded this matter in June 2013, April 2014, July 2015, September 2016, and March 2021. However, regarding the issue of service connection for bilateral carpal tunnel syndrome, the Board finds that the RO is not in substantial compliance with the directives set forth in the March 2021 remand. See Stegall v. West, 11 Vet. App. 268, 271 (1998). The Board notes that in a June 2021 rating decision, the RO granted separate 10 percent ratings for instability of the Veteran's right and left knees effective June 4, 2021. The Board finds the ratings for instability of the right and left knees are part and parcel of the Veteran's claim for an increased rating for his right and left knee arthritis currently on appeal. Increased Rating Ratings are based on a schedule of reductions in earning capacity from specific injuries or combination of injuries. The ratings shall be based, as far as practicable, upon the average impairments of earning capacity resulting from such injuries in civil occupations. 38 U.S.C. § 1155. Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability. 38 C.F.R. § 4.1. 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. 38 C.F.R. § 4.7. When, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability such doubt will be resolved in favor of the claimant. 38 U.S.C. § 5107 (b); 38 C.F.R. §§ 3.102, 4.3. When evaluating joint disabilities rated on the basis of limitation of motion, VA must consider granting a higher rating in cases in which functional loss due to pain, weakness, excess fatigability, or incoordination is demonstrated, and those factors are not contemplated in the relevant rating criteria. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202 (1995). "Although pain may cause a functional loss, pain itself does not constitute functional loss." Mitchell v. Shinseki, 25 Vet. App. 32, 37 (2011) (emphasis in original). Painful motion is deemed to be limitation of motion and warrants the minimum compensable rating for the joint, even if there is no actual limitation of motion. 38 C.F.R. § 4.59; Lichtenfels v. Derwinski; 1 Vet. App. 484, 488 (1991). The provisions of 38 C.F.R. § 4.59 relating 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). The Board must also consider whether VA examiners have elicited information concerning the "severity, frequency, duration, or functional loss manifestations" of such flare-ups. Sharp v. Shulkin, 29 Vet. App. 26 (2017). The United States Court of Appeals for Veterans Claims (Court) also has issued the opinion of Correia v. McDonald, 28 Vet. App. 158 (2016), which clarifies additional requirements that VA examiners should address when assessing musculoskeletal disabilities, holding specifically, that the joints involved should be tested for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with the range of the opposite undamaged joint. During the pendency of the appeal, the rating criteria for evaluating musculoskeletal disabilities under 38 C.F.R. § 4.71a were amended effective February 7, 2021. 85 Fed. Reg. 76453 (Nov. 30, 2020) (to be codified as 38 C.F.R. § 4.71a). Prior to February 7, 2021, the Board will consider the old version of the diagnostic code only; however, for the period beginning February 7, 2021, the Board will consider both the old and amended version of the diagnostic code and rate based on whichever is most favorable to the Veteran. 1. Entitlement to a rating in excess of 10 percent for degenerative arthritis of the right knee (right knee arthritis), entitlement to a 10 percent rating, but no higher, from June 4, 2021, for degenerative arthritis of the right knee limitation of extension, entitlement to a rating in excess of 10 percent prior to June 4, 2021, and in excess of 20 percent thereafter for degenerative arthritis of the left knee (left knee arthritis), entitlement to a 20 percent rating, but no higher, from July 29, 2020, for instability, degenerative arthritis, right knee (right knee instability), entitlement to a 20 percent rating, but no higher, from July 29, 2020, for instability, degenerative arthritis, left knee (left knee instability) The Veteran seeks higher ratings for his right and left knee disabilities. The Veteran is currently in receipt of two separate disability ratings for his right and left knee. For the entire appeal period, the Veteran's right knee is in receipt of a 10 percent rating for limitation of flexion pursuant to Diagnostic Code 5003-5260. Prior to June 4, 2021, the Veteran's left knee is in receipt of a 10 percent rating for limitation of flexion pursuant to Diagnostic Code 5010-5260, and from June 4, 2021, the Veteran's left knee is in receipt of a 20 percent rating for limitation of extension pursuant to Diagnostic Code 5003-5261. Also, from June 4, 2021, the Veteran is in receipt of 10 percent ratings for instability for his right and left knees pursuant to Diagnostic Code 5003-5257. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the rating assigned. The additional code is shown after a hyphen. 38 C.F.R. § 4.27. In this case, Diagnostic Code 5260 pertains to limitation of flexion, Diagnostic Code 5261 pertains to limitation of extension, Diagnostic Code 5257 pertains to recurrent subluxation or lateral instability, Diagnostic Code 5010 refers to arthritis, due to trauma, substantiated by x-ray findings, which in turn is rated as arthritis, degenerative, and Diagnostic Code 5003 refers to degenerative arthritis established by x-ray findings, which in turn is rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. Disabilities of the knee are rated pursuant to 38 C.F.R. § 4.71a, Diagnostic Codes 5256-5263. Regarding the recent regulatory change, Diagnostic Code 5257 was the only Diagnostic Code revised that is applicable to this case. Diagnostic Code 5003 further provides that, where the limitation of motion of the joint is noncompensable under the appropriate diagnostic code, a rating of 10 percent will be assigned where a major joint is affected by limitation of motion objectively confirmed by findings such as swelling, muscle spasm, or painful motion. 38 C.F.R. § 4.71a, Diagnostic Code 5003. The knee is a major joint. 38 C.F.R. § 4.45. The Board notes the only change to Diagnostic Code 5003 is a change in the title to the code, indicating that the criteria apply to all types of degenerative arthritis rather than just to post-traumatic arthritis. Diagnostic Code 5010 may now be rated as limitation of motion, as before, or as dislocation or other specified instability of the affected joint. Diagnostic Code 5256 provides evaluations for ankylosis of the knee. Diagnostic Code 5257 provides evaluations for recurrent subluxation and lateral instability. Prior to the regulatory change, a 10 percent rating was warranted for slight instability, a 20 percent rating was warranted awarded for moderate instability, and a 30 percent rating was warranted for severe instability. The words "slight," "moderate," and "severe" are not defined in the VA Schedule for Rating Disabilities; rather than applying a mechanical formula, the Board must evaluate all of the evidence so that its decisions are equitable and just. See 38 C.F.R. § 4.6. Under the revised criteria, Diagnostic Code 5257 contains two sections for rating other impairment of the knee. The first is for recurrent subluxation or instability. The second is for patellar instability. Regarding recurrent subluxation and instability, a compensable rating requires persistent instability. Id.; see also 38 C.F.R. § 4.31. While "persistent" is not defined in the VA Schedule for Rating Disabilities, according to Merriam-Webster's Dictionary, "persistent" is defined as "continuing or inclined to persist in a course" with "continuing" defined as "constant" and "persist" defined as "to continue to exist." Merriam-Webster's Dictionary (merriam-webster.com/dictionary, accessed March 15, 2021). Under the revised criteria, a 10 percent rating is assigned 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 or bracing for ambulation. A 20 percent rating is assigned with 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 for ambulation, 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 assigned with unrepaired or failed repair of complete ligament tear which causes persistent instability and a medical provider prescribes both an assistive device (e.g., cane(s), crutch(es), walker) and bracing for ambulation. Regarding patellar instability, 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 warrants a 10 percent rating. A diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for a brace, cane, or walker warrants a 20 percent rating. 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 warrants a 30 percent rating, which is the highest allowable rating for patellar instability. The patellofemoral complex consists of the quadriceps tendon, the patella, and the patellar tendon. 85 Fed. Reg. 76453, 76463 (Nov. 30, 2020) (to be codified at 38 C.F.R. § 4.71a, Diagnostic Code 5257, Note (1)). 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). Id., Note (2). Diagnostic Code 5258 provides a 20 percent rating for dislocation of semilunar cartilage with frequent episodes of locking, pain, and effusion into the joint. Diagnostic Code 5259 provides a 10 percent rating for symptomatic removal of semilunar cartilage. Diagnostic Codes 5260 and 5261 provide the rating criteria for limitation of knee motion. 38 C.F.R. § 4.71a. Normal range of motion of the knee is from 0 to 140 degrees. 38 C.F.R. § 4.71a Plate II. Diagnostic Code 5260 provides that limitation of knee flexion to 60 degrees is rated as noncompensable; limitation of knee flexion to 45 degrees is rated as 10 percent disabling; and limitation of knee flexion to 30 degrees is rated as 20 percent disabling. Limitation of flexion to 15 degrees is rated as 30 percent disabling. Diagnostic Code 5261 provides that limitation of knee extension to 5 degrees is rated as noncompensable; limitation of knee extension to 10 degrees is rated as 10 percent disabling; limitation of knee extension to 15 degrees is rated as 20 percent disabling; limitation of knee extension to 20 degrees is rated as 30 percent disabling; limitation of knee extension to 30 degrees is rated as 40 percent disabling; and limitation of knee extension to 45 degrees is rated as 50 percent disabling. Diagnostic Code 5262 provides that malunion of the tibia and fibula with slight knee or ankle disability is rated as 10 percent disabling; with moderate knee or ankle disability is rated as 20 percent disabling; malunion of the tibia and fibula with marked knee or ankle disability is rated as 30 percent disabling. Nonunion of the tibia and fibula, with loose motion, requiring a brace, is rated as 40 percent disabling. 38 C.F.R. § 4.71a, Diagnostic Code 5262. Under the revised criteria, Diagnostic Code 5262 provides that malunion of the tibia and fibula should be evaluated under diagnostic codes 5256, 5257, 5260, or 5261 for the knee, or 5270 or 5271 for the ankle, whichever results in the highest evaluation. For medial tibial stress syndrome (MTSS), or shin splints, a zero percent rating is warranted for impairment requiring treatment less than 12 consecutive months, one or both lower extremities; a 10 percent rating is warranted for impairment requiring treatment for no less than 12 consecutive months, and unresponsive to either shoe orthotics or other conservative treatment, one or both lower extremities; a 20 percent rating is warranted for impairment requiring treatment for no less than 12 consecutive months, and unresponsive to surgery and either shoe orthotics or other conservative treatment, one lower extremity; and a 30 percent rating is warranted for impairment requiring treatment for no less than 12 consecutive months, and unresponsive to surgery and either shoe orthotics or other conservative treatment, both lower extremities. A 40 percent rating is warranted for nonunion of the tibia and fibula, with loose motion, requiring a brace. Diagnostic Code 5263 provides a 10 percent rating for acquired traumatic genu recurvatum, with objectively demonstrated weakness and insecurity in weight-bearing. VA's General Counsel has stated that when a knee disorder is rated under 38 C.F.R. § 4.71a, Diagnostic Code 5257 and an appellant also has limitation of knee motion which at least meets the criteria for a noncompensable evaluation under 38 C.F.R. § 4.71a, Diagnostic Code 5260 or 5261, separate evaluations may be assigned for arthritis with limitation of motion and for instability. However, General Counsel stated that if an appellant does not meet the criteria for a noncompensable rating under either Diagnostic Code 5260 or Diagnostic Code 5261, there is no additional disability for which a separate rating for arthritis may be assigned. VAOPGCPREC 23-97 (July 1, 1997), published at 62 Fed. Reg. 63,604 (1997). If a rating is assigned under the provisions for other knee impairment (38 C.F.R. § 4.71a, Code 5257), a separate 10 percent rating may be assigned where some limitation of motion, albeit noncompensable, has been demonstrated. See VAOPGCPREC 9-98, 63 Fed. Reg. 56,704 (1998). VA's General Counsel has also stated that separate ratings under Diagnostic Code 5260 (limitation of flexion of the leg) and Diagnostic Code 5261 (limitation of extension of the leg) may be assigned for disability of the same joint. VAOPGCPREC 9-04 (September 17, 2004), published at 69 Fed. Reg. 59,990 (2004). Prior to June 4, 2021 In a September 2006 VA treatment record, the Veteran complained of knee pain after playing basketball yesterday. He said pain medication for his finger helped with pain in his knees and chest. In a January 2007 VA treatment record, the Veteran's knee arthralgia was noted. In a July 2007 VA examination, it was noted that the Veteran suffered from bilateral osteoarthritis. The Veteran reported the following symptoms: weakness, stiffness, lack of endurance, and locking. There was no evidence of swelling, heat, redness, giving way, fatigability, or dislocation. The Veteran had pain in both knees on the right more than the left; the pain occurred constantly and was aching and sharp. The Veteran reported pain as 7 out of 10, which was elicited by physical activity and relieved by medication. He said his condition did not cause incapacitation and the treatment was Methadone and activity modification. Functional impairment was reported as pain with running, prolonged standing, and walking. The Veteran's gait was within normal limits and did not require an assistive device for ambulation. The examiner observed that on the right there was lateral pain with duck walk. There was no evidence of joint line or patellar facet tenderness, edema, effusion, weakness, tenderness, redness, heat, abnormal movement, guarding of movement and subluxation. On the left knee there was no evidence of edema, effusion, weakness, tenderness, redness, heat, subluxation, or guarding of movement. On both knees there was no locking pain, genu recurvatum, or crepitus. Range of motion for both knees was the following: flexion to 140 degrees and extension to 0 degrees. Joint function was not additional limited by pain, fatigue, weakness, lack of endurance, or incoordination after repetitive use. The anterior and posterior cruciate ligaments stability test, medial and lateral collateral ligaments stability test, and medial and lateral meniscus test of the knees were within normal limits. In a December 2008 VA treatment record, the Veteran complained of pain in his knees. On examination, the Veteran's knees had normal appearance and normal range of motion. There was no evidence of tenderness and the Veteran was offered resistance on examination, but there was no restriction noted on activity. The examiner noted "bending knee staking of shoe" and that the Veteran had a normal gait. In a September 2010 statement, the Veteran said that he could not run or do his regular physical exercise around the block. He said climbing stairs was difficult and when he had to bend down to pick things up off the floor it was hard for him to get back up. The Veteran said that if he sat in a low chair, he had to have help to get back up. In a February 2012 VA treatment record, the Veteran reported occasional pain in the knees. In a May 2014 VA examination, the Veteran complained of bilateral knee pain for many years. The Veteran did not report any flare ups. On examination, range of motion for both knees was the following: flexion to 140 degrees and extension to 0 degrees, with no objective evidence of painful motion. The Veteran was able to perform repetitive use testing with 3 repetitions without additional limitation in range of motion. There was no evidence of functional loss. There was also no evidence of tenderness or pain to palpation. The examiner did not find any history of recurrent patellar subluxation/dislocation. The examiner concluded that as far as additional loss of range of motion during flare ups or with repetitive use from pain, fatigue, or weakened movement, there was no medical manner to assess such a change in the exam other than to examine the Veteran during such a flare up or after such repetitive use. Therefore, to state what that change in range of motion might be without the benefit of such an additional exam would have no medical foundation and would be completely speculative. In a June 2014 VA treatment record, x-ray showed evidence for both knees of minimal osteoarthritic changes. In an August 2016 VA examination, the Veteran reported that his pain had worsened over the past few years and rated his pain as a 6 out of 10. Prolonged standing and walking increased pain and the Veteran reported that he used a knee brace. The Veteran reported flare ups and said that prolonged standing and walking increased pain and stiffness. The Veteran did not report any functional loss. On examination, range of motion to the right knee was normal with no pain noted on exam, or pain with weight bearing. There was also no evidence of localized tenderness or pain on palpation or evidence of crepitus. Left knee range of motion was flexion to 110 degrees and extension to 0 degrees. Range of motion itself did not contribute to functional loss and pain was noted at flexion. There was evidence of pain with weight bearing; however, there was no evidence of localized tenderness or pain on palpation or any evidence of crepitus. The Veteran was able to perform repetitive use testing with at least 3 repetitions without additional functional loss or range of motion. The Veteran was not examined immediately after repetitive use over time and the examiner determined that the examination was medically consistent with the Veteran's statements describing functional loss with repetitive use over time. The examiner stated that he was unable to say without mere speculation whether pain, weakness, fatigability, or incoordination significantly limited functional ability with repeated use over a period of time because this would have to be examined. The examiner made the same finding for flare ups. The examiner determined that there were no additional factors that contributed to the Veteran's right knee disability; however, the Veteran's left knee exhibited less movement than normal, disturbance of locomotion, interference with standing, pain, and stiffness. There was no evidence of muscle atrophy or ankylosis. There was no evidence of a history of recurrent subluxation, lateral instability, or recurrent effusion. It was noted that the Veteran used a brace regularly. In a November 2016 statement, the Veteran said that he could no longer run and had a hard time climbing stairs. He also said he walked with a cane to help him with his balance. In an August 2017 VA examination, the Veteran complained of right knee pain as a 6 out of 10 with prolonged standing and walking, as well as swelling by the end of the day. The Veteran did not report flare ups or functional loss. On examination, range of motion for both knees was normal. Pain was noted on exam at flexion but did not result in functional loss. There was no evidence of pain with weight bearing. There was evidence of localized tenderness or pain on palpation. There was also evidence of crepitus. Range of motion for the left knee was also normal. The Veteran was able to perform repetitive use testing with at least 3 repetitions that did not result in additional functional loss or range of motion. The Veteran was not examined immediately after repetitive use over time and the examiner determined 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 whether pain, weakness, fatigability, or incoordination significantly limited functional ability with repeated use over a period of time because this would have to be examined. Additional factors contributing to the Veteran's right knee disability was pain and additional factors for the Veteran's left knee disability was disturbance of locomotion and interference with standing. There was no evidence of muscle atrophy or ankylosis. There was also no evidence of history of recurrent subluxation or lateral instability. There was evidence of recurrent effusion as the Veteran reported daily swelling of both knees. The examiner noted that the Veteran did not use any assistive devices. In a May 2018 VA treatment record, the Veteran reported his medical condition, knee/back pain due to arthritis, limited his mobility and made him depressed. In a December 2019 VA treatment record, the Veteran was seen for left knee bracing and walking with a single tip cane. The Veteran demonstrated a slightly antalgic gait and reported pain as a 6 to 7 out of 10. In a July 2020 VA treatment record, the Veteran was seen for both of his knees. It was noted that the Veteran received injections in September, and that they worked well for 3 to 4 months. The Veteran reported issues with his left knee more than his right. The Veteran also reported increased pain, buckling, and giving out. He had a knee brace at home, which he used on occasion. The Veteran requested injections in both knees. At the January 2021 Board hearing, the Veteran testified that he used a cane and walker because he fell frequently. He said his knees would lock up and he was not stable without his assistive devices. The Veteran said that climbing more than 3 to 4 steps bothered him and that he also used a knee brace. He described balance and stability issues and asserted that his knees did not have much cushion and were bone on bone. In a March 2021 VA treatment record, the Veteran was seen for his bilateral knee osteoarthritis. He was last seen in February, when he was administered injections for his knees. The Veteran said the shot worked for the right knee very well; however, in the left knee it only provided minimal relief and he was currently experiencing all of his baseline symptoms including pain throughout the knee and buckling multiple times a day. The Veteran inquired about a total knee replacement. From June 4, 2021 At the June 2021 VA examination, the Veteran reported flare ups and described a tolerable constant pain level of 7 out of 10, which was contingent on the level of activity and weather, where this would then increase to a 10 out of 10. The Veteran took his over the counter pain medication, used cold packs, and rested. The Veteran said it took at least a day for the pain to resolve. The Veteran described functional loss as significant limitations in lifting, running, jumping, climbing, squatting, bending, pulling, pushing, distance walking, and prolonged standing and sitting. The Veteran had a history of instability or recurrent subluxation, which was described, based on the Veteran's reports, as both knees giving out on him at least 5 to 6 times a week and falls. Frequent effusion was also reported as the Veteran described both knees swelling up at least 4 to 5 times a month. On examination, range of motion was the following: right knee flexion to 110 and extension to 5 degrees; left knee flexion to 100 degrees and extension to 10 degrees. For both knees, limited range of motion impacted mobility, balance, and activity. Pain was exhibited at flexion and extension. Passive range of motion was the same as active range of motion. There was evidence of pain on weight-bearing, nonweight-bearing, active motion, and passive motion, on rest/non-movement; this pain caused functional loss. There was evidence of crepitus and localized tenderness or pain on palpation. Regarding the right knee, the Veteran was able to perform repetitive use testing with at least 3 repetitions which caused additional loss of range of motion at flexion to 100 degrees and extension to 10 degrees. Pain, fatigability, and lack of endurance caused additional loss. The Veteran was not examined immediately after repeated use over time and the examiner determined that pain, fatigability, and lack of endurance limited functional ability with repeated use over time. Range of motion was estimated at flexion to 100 degrees and extension to 10 degrees. The Veteran was not examined during a flare up and the examiner determined that pain limited functional ability with flare ups. Range of motion was estimated at flexion to 100 degrees and extension to 10 degrees. Additional factors contributing to the disability were interference with sitting and standing, disturbance of locomotion, less movement than normal, and instability of station. Regarding the left knee, the Veteran was able to perform repetitive use testing with at least 3 repetitions with additional loss of range of motion described as flexion to 90 degrees and extension to 15 degrees. Pain, fatigability, and lack of endurance caused additional loss. The Veteran was not examined immediately after repeated use over time and the examiner determined that pain, fatigability, and lack of endurance limited functional ability with repeated use over time. Range of motion was estimated at flexion to 90 degrees and extension to 15 degrees. The Veteran was not examined during a flare up and the examiner determined that pain limited functional ability with flare ups. Range of motion was estimated at flexion to 90 degrees and extension to 15 degrees. Additional factors contributing to the disability were interference with sitting and standing, disturbance of locomotion, less movement than normal, and instability of station. For both knees, there was no evidence of muscle atrophy or ankylosis. Both knees exhibited recurrent subluxation or persistent instability. There was no evidence of a ligament tear. The Veteran required a cane but there was no evidence of patellar instability or surgical repair of the knee for patellar instability. It was noted that the Veteran used a cane constantly. Overall, the Board finds that a separate 10 percent rating is warranted for right knee arthritis limitation of extension from June 4, 2021. However, a rating in excess of 10 percent for limitation of flexion is not warranted for the right knee. Additionally, the Board finds that a rating in excess of 10 percent prior to June 4, 2021, and in excess of 20 percent thereafter for left knee arthritis is not warranted. Lastly, the Board finds that the evidence shows the Veteran suffered from moderate instability of both knees prior to June 4, 2021. Therefore, a 20 percent rating, but no higher, is warranted from July 29, 2020, for left and right knee instability as this is the earliest medical record found noting instability reported by the Veteran. Regarding the separate 10 percent rating for right knee extension, the Board finds that the June 2021 VA examiner determined that during repeated use and flare ups, the Veteran's extension was limited to 10 degrees. Under Diagnostic Code 5261, this warrants a 10 percent rating. However, regarding limitation of flexion, the Veteran's right knee was limited to, at worst, 100 degrees. This does not support a higher 20 percent disability rating. Regarding the Veteran's left knee limitation of flexion, the Veteran had, at worst, flexion to 110 degrees prior to June 4, 2021, and from that date was to, at worst, 90 degrees. This does not support a higher 20 percent disability rating. Regarding the Veteran's limitation of extension, prior to June 4, 2021, extension was normal; however, from June 4, 2021, extension was to, at worst, 15 degrees. Therefore, the Veteran's left knee limitation of extension does not support a higher 30 percent rating. In coming to this conclusion, the Board acknowledges the Veteran's reports of pain when doing certain activities, such as going up stairs, and with prolonged standing and walking. However, the Board finds that such symptoms do not more nearly approximate flexion limited to 30 degrees for either knee, to warrant a higher 20 percent rating, or extension limited to 15 degrees or 20 degrees, for the right and left knee, respectively, to warrant a higher 20 and 30 percent rating. Finally, regarding instability in both knees, as stated above, the Board finds that the evidence shows from July 29, 2020, the Veteran had instability in both knees. Therefore, a 20 percent rating in both knees is warranted from that date. The Board finds that there is evidence of the Veteran reporting multiple falls due to his knees and instability. He also uses a cane, walker, and brace for stability. Thus, the evidence shows that the Veteran's suffers from moderate instability in both knees. However, the Board finds that a higher, 30 percent rating under the old criteria for severe instability is not warranted. The evidence did not consistently show objective evidence of bilateral joint instability, effusion, or locking. Therefore, a higher 30 percent rating is not warranted. The Board also finds that a higher rating is not warranted under the revised criteria for Diagnostic Code 5257. Since February 7, 2021, there is no evidence of record that the Veteran's instability is due to a sprain or ligament tear as is required for a higher rating. In this regard, the Veteran's service-connected bilateral knee disabilities include chondromalacia, and there is no evidence of record that these disabilities began as a ligament tear or a sprain. Additionally, a higher rating is also not warranted for patellar instability as the evidence does not show surgical repair involving the patellofemoral complex. In considering whether compensable ratings might be assigned for the service-connected left knee disability under other diagnostic codes, the Veteran has not reported locking, and there is no history of dislocated semilunar cartilage; an additional rating under DC 5258 is not warranted. The Board has considered additional diagnostic codes to see if the Veteran warrants separate higher ratings. However, there is no history of dislocated semilunar cartilage under Diagnostic Code 5258, meniscus surgery under Diagnostic Code 5259 pertaining to removal of symptomatic semilunar cartilage, ankylosis under Diagnostic Code 5256, impairment of the tibia or fibula under Diagnostic Code 5262, genu recurvatum under Diagnostic Code 5263. In light of the foregoing, the Board finds that a separate 10 percent rating is warranted for limitation of extension for the right knee. However, a rating in excess of 10 percent for limitation of flexion of the right knee is not warranted. Additionally, higher ratings for the Veteran's left knee limitation of flexion and extension are not warranted. However, 20 percent ratings are warranted from July 29, 2020, for bilateral knee instability. Neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Yancy v. McDonald, 27 Vet. App. 484, 495 (2016); Doucette v. Shulkin, 38 Vet. App. 366, 369-70 (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). REASONS FOR REMAND Entitlement to service connection for bilateral carpal tunnel syndrome is remanded. The Board is obligated by law to ensure that the RO complies with its directives; where the remand orders of the Board are not complied with, the Board errs as a matter of law when it fails to ensure compliance. Stegall, 11 Vet. App. 268. Regrettably, the Board finds that further remand is necessary in this case under Stegall. In the March 2021 remand, the Board directed that a VA opinion be obtained for the Veteran's bilateral carpal tunnel syndrome. The Board directed the examiner to discuss the May 1975 and May 1976 service treatment records showing complaints of bilateral wrist/hand pain. The Board also directed the examiner to discuss the Veteran's lay statements of his duties in service carrying ammunition crates and his continued symptomatology from separation of service to the present. In a June 2021 VA opinion, the examiner opined that the Veteran's bilateral carpal tunnel syndrome was less likely than not related to service. The examiner reasoned that the Veteran said that while in service in 1974, he was involved in an altercation, which resulted in lacerations to the right hand; he was treated for this injury. The Veteran denied any wrist injury during the altercation. Service treatment records showed that he was treated for the "swollen left wrist for 2 days" on May 7, 1975. The etiology for the swollen left wrist was unknown and the Veteran was treated with an Ace bandage to the wrist and analgesics. Subsequent medical records did not show any worsening or recurrence of the wrist condition. The examiner said that service treatment records again showed that he was treated for "right hand pain" and "loss of function of the right middle finger secondary to a jamming injury" on May 6, 1976. Subsequent review of the service treatment records did not reveal any progression, worsening, or recurrence of this condition. After leaving service, the Veteran worked as a food service worker for at least 2 years and then worked as a civilian artillery tester; at the same time he worked at a grocery store as a stock clerk. He said that he did some heavy lifting in both jobs. The examiner stated that the Veteran then worked as a golf course maintenance personnel until 2008 and then in 2009, was on disability from diabetes and did some volunteer bell ringer for the Salvation Army. The Veteran started to complain to his VA primary care provider of wrist pain in 2016. The Veteran was diagnosed with bilateral carpal tunnel syndrome in December 2016. The examiner further stated that the Veteran was also diagnosed with gout involving the right wrist and hand in January 2018, and continued to have attacks of gout to date. The examiner stated that the Veteran had an established diagnosis of diabetes, which was poorly controlled. Review of medical literature showed that carpal tunnel syndrome was caused by pressure on the median nerve. The carpal tunnel was a narrow passageway surrounded by bones and ligaments on the palm side of the hand. When the median nerve was compressed, the symptoms could include numbness, tingling, and weakness in the hand and arm. Anything that squeezed or irritated the median nerve in the carpal tunnel space may lead to carpal tunnel syndrome. A wrist fracture could narrow the carpal tunnel and irritated the nerve, as could the swelling and inflammation caused by rheumatoid arthritis. The examiner said that, overall, the Veteran's service treatment records did not show any injuries/fractures to the wrist joints. Review of medical literature showed that symptoms of carpal tunnel syndrome could be recurrent and progress to chronicity if not treated. Review of service treatment records did not show any recurrence, chronicity, or progression of the Veteran's "left wrist swelling" when he was in the service. The Veteran had an established diagnosis of non-service connected diabetes, which had been poorly controlled. Review of medial literature showed that diabetes was a risk factor in the development of carpal tunnel syndrome. Initially, the Board notes that the examiner did not consider the Veteran's lay statements of his duties in service carrying ammunition crates and his continued symptomatology from separation of service to the present. This is a Stegall violation. Additionally, the Board finds that the examiner partially based his opinion on a lack of contemporaneous records, which the Board reminded the examiner in the remand is not an absolute bar. Finally, the examiner said that the Veteran's diabetes was a risk factor for his carpal tunnel syndrome. However, the examiner did not provide an adequate opinion finding whether the Veteran's carpal tunnel syndrome was more likely than not caused or aggravated by his diabetes. Because of this, the Board cannot assume that the Veteran's carpal tunnel syndrome is in fact caused by his diabetes and not his in-service treatment and duties in service. Thus, on remand a new VA opinion, and/or VA examination if necessary, is needed to address the Board's March 2021 remand directives and provide an adequate opinion for a direct theory of entitlement. Additionally, the examiner must address the lay statements provided by the Veteran. Finally, if the Veteran's diabetes is the cause of his carpal tunnel syndrome, then the examiner must provide an adequate opinion. The matters are REMANDED for the following actions: 1. Obtain any outstanding VA or private treatment records. Request that the Veteran assist with locating these records, if possible. Associate these records with the claims file. 2. Then, obtain a VA opinion, or examination if necessary, from an adequate examiner to determine the etiology of the Veteran's bilateral carpal tunnel syndrome. The claims file and a copy of this remand must be made available for review. Following a review of the pertinent evidence, the examiner must determine the following: (a) Whether it is at least as likely as not (50 percent or greater probability) that the Veteran's bilateral carpal tunnel syndrome is related to service. (b) Whether it is at least as likely as not (50 percent or greater probability) that the Veteran's bilateral carpal tunnel syndrome is caused or aggravated by his diabetes. A clear rationale must be provided for all opinions expressed. The examiner must discuss the Veteran's lay statements including his duties in service as well as continuity of symptomatology. The examiner should note that a lack of contemporaneous records is not an absolute bar to service connection. If the examiner is unable to provide an opinion without resorting to mere speculation, then the examiner must state this and provide any information needed to make an opinion, if possible. 3. Thereafter, readjudicate the claim on appeal. If the benefit sought remains denied, issue the Veteran and his representative a supplemental statement of the case and provide a reasonable opportunity to respond before returning this matter to the Board for further appellate review. MICHAEL MARTIN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Brown, Saudiee 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.