Citation Nr: 21074745 Decision Date: 12/16/21 Archive Date: 12/16/21 DOCKET NO. 14-19 509 DATE: December 16, 2021 ORDER Entitlement to a 30 percent rating, but no higher, for obstructive sleep apnea (previously rated as primary insomnia) for period prior to October 24, 2020 is granted. Entitlement to a rating in excess of 50 percent for obstructive sleep apnea (OSA) for the period after October 24, 2020 is denied. Entitlement to a 10 percent rating, but no higher, for right knee strain, limitation of flexion for the period prior to August 14, 2018 is granted. Entitlement to a rating in excess of 10 percent for right knee strain is denied. Entitlement to a 10 percent rating for right knee instability is granted. REMANDED Entitlement to a compensable rating for right shoulder bursitis is remanded. Entitlement to a compensable rating for left shoulder lesions and tears with bursitis prior to August 14, 2018, and in excess of 20 percent thereafter is remanded. Entitlement to a compensable rating for left wrist strain prior to August 14, 2018, and in excess of 10 percent thereafter is remanded. Entitlement to a compensable rating for right wrist strain prior to August 14, 2018, and in excess of 10 percent thereafter is remanded. FINDINGS OF FACT 1. During the period prior to October 24, 2020, the Veteran's symptoms of sleep trouble and persistent daytime fatigue were attributable to OSA but did not include a requirement for CPAP. 2. During the period after October 24, 2020, the Veteran's OSA was characterized by a requirement for CPAP and daytime fatigue but not by chronic respiratory failure, cor pulmonae or a requirement for tracheostomy. 3. During the entire period on appeal, the Veteran's right knee disability has been characterized by painful motion, flexion limited at worst and with consideration of pain to 95 degrees and by knee strain with recurrent instability. CONCLUSIONS OF LAW 1. The criteria for a 30 percent rating, but no higher, for OSA (previously rated as primary insomnia) for the period prior to October 24, 2020 have been met. 38 U.S.C. §§ 1155, 5107 (2018); 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.14, 4.97, Diagnostic Codes 6847, 9410 (2021). 2. The criteria for a rating in excess of 50 percent for OSA for the period after October 24, 2020 have not been met. 38 U.S.C. §§ 1155, 5107 (2018); 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.14, 4.97, Diagnostic Code 6847 (2021). 3. The criteria for a 10 percent rating for right knee strain limitation of flexion for the period prior to August 14, 2018 have been met. 38 U.S.C. §§ 1155, 5107 (2018); 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.14, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5260 (2021). 4. The criteria for a rating in excess of 10 percent for right knee strain limitation of flexion have not been met. 38 U.S.C. §§ 1155, 5107 (2018); 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.14, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5260 (2021). 5. The criteria for a 10 percent rating for right knee instability have been met. 38 U.S.C. §§ 1155, 5107 (2018); 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.14, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5257 (2021). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from May 2005 to June 2012. This matter came before the Board of Veterans Appeals (Board) on appeal from a July 2012 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified before the undersigned Veteran's Law Judge during an August 2017 hearing. The transcript of the hearing is of record. A January 2018 Board decision remanded all issues and a March 2021 Board decision denied an increased rating for bronchitis and remanded the remaining issues for further development. A December 2020 rating decision increased the rating for insomnia from 0 to 30 percent effective August 11, 2018 and changed the diagnosis to sleep apnea effective October 24, 2020, assigning a 50 percent rating. Because higher ratings for this disability are assignable during the relevant period, the issues remain on appeal. See AB v. Brown, 6 Vet. App. 35, 38 (1993). The March 2021 remand directives noted outstanding private treatment records regarding OSA, and asked the RO to contact the Veteran, request a completed authorization, and obtain any outstanding records. In accordance with the remand directive, the RO sent the request and authorization form in an April 2021 letter. However, the Veteran did not return a completed authorization form or otherwise respond to the request, and the record is silent for any indication that the request was not received, including in the August 2021 post-remand brief from the Veteran's representative. The Board notes that the duty to assist is not a one-way street. See Wood v. Derwinski, 1 Vet. App. 190. 192 (1991). While VA has a duty to assist the Veteran in the development of the claim, that duty is not limitless, and the Veteran must be prepared to cooperate with VA's efforts to obtain all relevant evidence. Olson v. Principi, 3 Vet. App. 480, 483 (1992). The Board therefore finds that the RO substantially complied with the remand directive and will proceed to adjudicate the issue based on the evidence of record. Increased Rating Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities. Individual disabilities are assigned separate diagnostic codes. See U.S.C. §1155; 38 C.F.R. § 4.1. When there is a question as to which of two evaluations applies, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for the rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. In evaluating the severity of a disability, it is essential to consider its history. 38 C.F.R. § 4.1; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Where entitlement to compensation has already been established and an increase in the rating is at issue, the present level of disability is of primary importance. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). That said, higher evaluations may be assigned for separate periods based on the facts found during the appeal period. See Fenderson v. West, 12 Vet. App. 119, 126 (1999). This practice is known as staged ratings. Id. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall resolve reasonable doubt in favor of the claimant. 38 U.S.C. § 5107; 39 C.F.R. §§ 3.102, 4.3; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 1. Entitlement to compensable rating for primary insomnia prior to August 11, 2018, and in excess of 30 percent for the period from August 11, 2018 to October 24, 2020 2. Entitlement to a rating in excess of 50 percent for OSA for the period after October 24, 2020 The Veteran contends that he is entitled to an increased rating for his sleep disability, which is rated as primary insomnia for the periods prior to October 24, 2020 and as OSA thereafter. The Board finds that a uniform 30 percent rating is warranted under DC 6847 for the entire period prior to October 24, 2020 but that a higher rating for the period after October 24, 2020 is not warranted. The Veteran's primary insomnia is rated under Diagnostic Code (DC) 9410 for the period prior to October 24, 200. Under the General Rating Formula for Mental Disorders, a noncompensable rating is assigned when a mental condition has been formally diagnosed, but symptoms are not severe enough to either require continuous medication, or to interfere with occupational and social functioning. A 10 percent rating is assigned when mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of occasional stress, or symptoms controlled by medication cause occupational and social impairment. A 30 percent rating is assigned when symptoms such as depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, or mild memory loss (such as forgetting names, directions, or recent events), cause occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and normal conversation). A 50 percent rating is assigned when symptoms such as flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; or difficulty in establishing and maintaining effective work and social relationships cause occupational and social impairment with reduced reliability and productivity. A 70 percent rating is assigned when symptoms such as suicidal ideation; obsessional rituals which interfere with routine activities; intermittently illogical, obscure, or irrelevant speech; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); or inability to establish and maintain effective relationships cause occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. A 100 percent rating is assigned for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; or memory loss for names of close relatives, own occupation, or own name. 38 C.F.R. § 41.30, DC 9410. During the period after October 24, 2020, the Veteran's sleep disability is rated as OSA under DC 6847. Under the DC, a noncompensable rating is warranted for asymptomatic OSA with documented sleep disorder breathing. A 30 percent rating is warranted for peristent daytime hypersomnolence. 50 percent rating is warranted for sleep apnea that requires the use of a breathing device such as a continuous airway pressure (CPAP) machine, and a 100 percent rating is warranted for chronic respiratory failure with carbon dioxide retention or cor pulmonae or; requires tracheostomy. 38 C.F.R. § 4.100, DC 6847. A March 2012 VA examination diagnosed primary insomnia. The examiner found that the symptoms were not severe enough to either interfere with occupational and social functional or to require continuous medication. The examiner noted the Veteran's reports of inconsistent sleep, with problems falling asleep at times for 3 hours. He also reported occasional drowsiness and fatigue. A May 2013 sleep study diagnosed mild OSA. The provider noted symptoms of gasping for air at night and daytime fatigue. The provider recommended a trial of Provent or breath-right nasal strips, noting that CPAP or an oral appliance could be considered as an alternative treatment. November 2016 private treatment records show that the Veteran woke with a feeling of panic and could not breathe. The provider found that it was a panic attack. The records are silent for discussion of OSA or use of CPAP. An August 2018 VA mental disorders examination diagnosed persistent insomnia disorder and found occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. The examiner found symptoms of anxiety, chronic sleep impairment and disturbances of motivation and mood. Memory, concentration, and attention were found to be intact, and affect was noted to be normal. The examiner found no thought impairments and speech was found to be within normal limits. The Veteran denied suicidal and homicidal ideation. A September 2020 VA opinion stated that the provider could not provide an opinion regarding OSA and its relationship to insomnia as she was a psychologist. As the provider stated that she did not have the expertise to provide an opinion, the Board assigns the opinion no probative weight. An October 2020 VA mental disorders examination diagnosed primary insomnia and noted the Veteran's reports of problems falling asleep and waking frequently as well as physical exhaustion. The Veteran reported treatment with over the counter sleep aids. The examiner found symptoms of chronic sleep impairment. An October 2020 VA opinion, noting the May 2013 sleep study, found that the Veterans symptoms beginning in March 2012 were likely due to undiagnosed OSA and that primary insomnia was subsumed under the current OSA diagnosis. An October 2020 VA sleep apnea examination diagnosed sleep apnea, noting the 2013 diagnosis. The examiner found that the Veteran required both continuous medication and CPAP but did not find cor pulmonae, carbon dioxide retention or a need for a tracheostomy. A November 2020 VA addendum opinion stated that the primary insomnia diagnosis had been removed as the Veteran's sleep issues were adequately accounted for by his diagnosis of OSA. The examiner noted that the Veteran did not meet the criteria for any other mental health disorder at that time and that the October 2020 VA examination showed worsening of the OSA. The examiner noted that the Veteran had sleep problems about half the time and was physically exhausted, irritable and had problems concentrating. The examiner opined that the Veteran's sleep issues appeared to be fully accounted for by the diagnosis of OSA. At the outset, the Board finds that the VA examinations and opinions, other than the September 2020 opinion, are adequate for appellate review. There is no evidence that the examiners were not competent or credible, and as the reports are based on the Veteran's statements, in-person examinations and the examiners' observations, the Board finds they are entitled to significant probative weight. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 30205 (2008). At the August 2017 Board hearing, the Veteran reported that he took an over the counter sleep aid a few times per week. He reported that he was prescribed medication to help him sleep in 2012 and 2013, but he only took medication occasionally as they made him feel "drugged up." He stated that it usually took him a couple of hours to fall asleep. The Board notes that the Veteran is competent to report lay observable symptoms such as trouble sleeping as well as the treatment he receives and assigns his statements significant probative weight. Moreover, the undersigned has had the opportunity to observe the Veteran and finds him to be credible. See Dalton v. Nicholson, 21 Vet. App. 23, 38 (2007); Caluza v. Brown, 7 Vet. App. 498, 511 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996). Period prior to October 24, 2020 The Veteran's sleep disorder is currently rated as primary insomnia under DC 9410 prior to October 24, 2020. It is rated as noncompensable for the period prior to August 11, 2018, and at 30 percent for the period from August 11, 2018 to October 24, 2020. Upon review of the above, the Board finds that the sleep disability should be rated as OSA under DC 6847, rather than under DC 9410, and that a uniform 30 percent rating, but no higher, is warranted for the entire period prior to October 24, 2020. The assignment of a particular diagnostic code is "completely dependent on the facts of a particular case." See Butts v. Brown, 5 Vet. App. 532, 538 (1993). One diagnostic code may be more appropriate than another based on such factors as an individual's relevant medical history, the diagnosis and demonstrated symptomatology. Any change in a diagnostic code by a VA adjudicator must be specifically explained. See Pernorio v. Derwinski, 2 Vet. App. 625, 629 (1992). Furthermore, the selection of diagnostic codes or applicable rating criteria is not protected and may be appropriately revised if the action does not result in the reduction of compensation. See 38 C.F.R. §§ 3.951, 3.957. Here, the competent evidence indicates that the Veteran's primary insomnia is properly rated as sleep apnea under DC 6847 and that a 30 percent rating is warranted for the entire period on appeal. First, the record indicates that the Veteran's insomnia symptoms have been attributable to sleep apnea during the entire period. The October 2020 opinion specifically found that the sleep symptoms could be attributed to OSA as far back as March 2012, when a VA examination first diagnosed primary insomnia. In addition, both the October 2020 and November 2020 VA opinions found that the OSA diagnosis fully accounted for the Veteran's sleep symptoms. A rating under DC 6847 is therefore supported by the Veteran's medical history. A rating under DC 6847 also better encompasses the Veteran's sleep symptoms. DC 6847 specifically considers both disordered breathing and daytime exhaustion and somnolence, which have been consistently reported by the Veteran throughout the period prior to October 24, 2020. The May 2013 sleep study also noted symptoms of daytime fatigue. Significantly, the March 2012 VA examiner did not find chronic sleep impairment as contemplated by the mental health criteria but did note drowsiness and fatigue associated with the Veteran's sleep problems. Under DC 6847, a 30 percent rating is warranted for OSA with persistent day-time hypersomnolence. The rating better encompasses the Veteran's total disability picture as it considers his symptoms of daytime fatigue and also is of benefit to the Veteran as it provides for a compensable evaluation for the entire period. A 30 percent rating under DC 6847 is therefore warranted for the entire period prior to October 24, 2020. The Board acknowledges that a 50 percent rating has been assigned under DC 6847 for the period beginning October 24, 2020 and has considered whether a 50 percent rating is warranted during the prior period. However, the record prior the October 24, 2020 is against finding that the Veteran's OSA required CPAP. The 2013 sleep study specifically noted that due to the mild nature of the Veteran's OSA, medication and breath right strips were recommended, and CPAP was noted as an alternative rather than a requirement. The Veteran's testimony in August 2017 also did not show a need for CPAP, as he reported only treatment with medications and stated that he took medication only intermittently. There is simply no indication in the record that CPAP was used or required prior to the October 2020 VA examination. Significantly, the November 2020 opinion found that the October 2020 examination showed a worsening of the Veteran's OSA, indicating that this was a higher level of severity than shown in the prior period. The Board therefore finds that the competent evidence from the period prior to October 24, 2020 does not support the conclusion that the Veteran's OSA required CPAP. A rating in excess of 30 percent is therefore not warranted under DC 6847. The record also does not show that the Veteran's overall disability picture more nearly approximates the frequency, severity, or duration of psychiatric symptoms required for a 50 percent disability evaluation under DC 9410. That is, the competent evidence of record does not show that the Veteran experiences: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. The August 2018 examiner found sleep impairment and anxiety, but memory, concentration, and attention were found to be intact, and affect and speech were found to be normal. While November 2016 records showed a panic attack, the record is silent for any indication, and the Veteran does not contend, that he had recurrent panic attacks, let alone panic attacks of the frequency contemplated by a 50 percent rating. A 50 percent rating is therefore not warranted under DC 9410 and a rating under the DC would provide no benefit to the Veteran. The Board has considered the requirement of 38 C.F.R. § 4.3 to resolve any reasonable doubt regarding the level of the Veteran's disability in his favor. The Board finds that the Veteran's overall picture more nearly approximates that of a 30 percent disability rating under DC 6847 during the period prior to October 24, 2020 and his symptoms do not more nearly reflect the frequency, severity, and duration of symptoms associated with the 50 percent rating under either DC 6847 or DC 9410. A rating in excess of 30 percent during the period prior to October 24, 2020 is therefore not warranted. Rating in excess of 50 percent after October 24, 2020 The Veteran's OSA is rated at 50 percent during the period after October 24, 2020. The Board finds that the competent evidence of record is against an evaluation above 50 percent for the period on appeal. Again, to warrant a 100 percent rating, the evidence would need to show chronic respiratory failure with carbon dioxide retention or cor pulmonae, or that the Veteran required tracheostomy. The record is silent for any indication, and the Veteran does not contend, that he has had chronic respiratory failure at any point during the period on appeal, and the October 2020 examiner found no cor pulmonae, carbon dioxide retention or need for a tracheostomy. Therefore, a rating above 50 percent is not warranted. Because OSA is specifically listed in the rating schedule, it may not be rated by analogy under a different DC. Copeland v. McDonald, 27 Vet. App. 333, 337 (2015). Therefore, no other DCs are potentially applicable which might afford a higher rating on an alternative basis. The preponderance of the evidence is against a rating above 50 percent for OSA for the period after October 24, 2020. As such, the benefit-of-the-doubt doctrine is inapplicable. 38 C.F.R. § 4.3. For these reasons, the claim is denied. 3. Entitlement to a compensable rating for right knee strain prior to August 14, 2018, and in excess of 10 percent thereafter The Veteran contends that he is entitled to a higher rating for his right knee disability, which is currently rated as noncompensable for the period prior to August 14, 2018, and as 10 percent disabling thereafter. For the reasons that follow, the Board concludes that a uniform rating of 10 percent, but no higher, is warranted for right knee limitation of flexion under DC 5260 for the entire period on appeal and that a 10 percent for right knee instability is also warranted. The Veteran's right knee disability has been rated under DC 5260 for limitation of flexion for the entire period on appeal. Included within 38 C.F.R. § 4.71a are multiple DCs that evaluate impairment resulting from knee disabilities, including DC 5256 (ankylosis), DC 5257 (other impairment, including recurrent subluxation or instability and patellar instability), DC 5258 (dislocated semilunar cartilage), DC 5259 (symptomatic removal of semilunar cartilage), DC 5260 (limitation of flexion), DC 5261 (limitation of extension), DC 5262 (impairment of the tibia and fibula), and DC 5263 (genu recurvatum). The criteria of DC 5256 pertain to ankylosis. Ankylosis refers to immobility and consolidation of a joint due to disease, injury, or surgical procedure. See Shipwash v. Brown, 8 Vet. App. 218, 221 (1995) (citing DORLAND'S ILLUSTRATED MEDICAL DICTIONARY 91 (27th ed. 1988)). Under DC 5257, ratings are assigned for recurrent subluxation or instability or for patellar instability. For recurrent subluxation or instability, a 10 percent rating 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 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 (e.g., cane(s), crutch(es), walker) for ambulation, or (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 rating 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 rating 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 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 warranted 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. 38 C.F.R. § 4.71a, Code 5257. Objective medical evidence is not required or favored over lay evidence in determining whether to assign a rating for lateral instability of the knee. English v. Wilkie, 30 Vet. App. 347 (2018). Under DC 5258, a 20 percent rating is warranted for dislocation of semilunar cartilage with frequent episodes of "locking," pain, and effusion into the joint. Under DC 5259, a 10 percent rating is warranted for symptomatic removal of semilunar cartilage. DCs 5260 and 5261 focus on limitation of motion of the knee. Normal range of motion of the knee is to zero degrees extension and to 140 degrees flexion. See 38 C.F.R. § 4.71a, Plate II. Under DC 5260, a noncompensable rating will be assigned for limitation of flexion of the leg to 60 degrees; a 10 percent rating will be assigned for limitation of flexion to 45 degrees; a 20 percent rating will be assigned for limitation of flexion to 30 degrees; and a 30 percent rating will be assigned for limitation of flexion to 15 degrees. 38 C.F.R. § 4.71a, DC 5260. Under DC 5261, a noncompensable rating will be assigned for limitation of extension of the leg to 5 degrees; a 10 percent rating will be assigned for limitation of extension of the leg to 10 degrees; a 20 percent rating will be assigned for limitation of extension of the leg to 15 degrees; a 30 percent rating will be assigned for limitation of extension of the leg to 20 degrees; a 40 percent rating will be assigned for limitation of extension of the leg to 30 degrees; and a 50 percent rating will be assigned for limitation of extension of the leg to 45 degrees. 38 C.F.R. § 4.71a, DC 5261. Separate ratings can be assigned for knee disabilities when none of the symptomatology overlaps and the separate rating is based on additional disabling symptomatology; this includes separate ratings based on limitation of flexion (Diagnostic Code 5260), limitation of extension (Diagnostic Code 5261), lateral instability or recurrent subluxation (Diagnostic Code 5257), and meniscal conditions (Diagnostic Codes 5258, 5259). See VAOPGCPREC 23-97, 62 Fed. Reg. 63,603 (1997); VAOPGCPREC 9-98, 63 Fed. Reg. 56,703 (1998); VAOPGCPREC 9-2004; 69 Fed. Reg. 59,988 (2004); Lyles v. Shulkin, 29 Vet. App. 107 (2017). The Board notes that the March 2021 Board decision found the August 2018 VA knee examination to be inadequate, and therefore will not address it herein. January 2009 service treatment records show that the Veteran sustained a patellar contusion, and subsequent x-rays showed no acute post-traumatic radiographic abnormality. February 2009 service treatment records show a diagnosis of knee sprain. A VA knee examination was provided in October 2013. The Board's review indicates that the examination did not include joint testing for pain on both active and passive motion, in weight-bearing and non-weight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint, as required under Correia v. McDonald, 28 Vet. App. 158, 166 (2016). As the examination did not include the testing required under Correia, it is inadequate, and the Board assigns it no probative weight. A December 2019 VA examination found flexion limited at worst to 100 degrees during flare ups. The examiner found extension to 0 degrees. The examiner did not find joint instability on testing. The examiner did not find any history of recurrent subluxation, lateral instability, or recurrent effusion. The examiner found that the Veteran had never had a meniscus condition. The examiner noted that x-rays did not show degenerative or traumatic arthritis. An April 2021 VA examination noted the Veteran's reports of sore, stiff, and painful knees limiting physical activity such as walking and running. The examiner found that flexion was limited at worst and with consideration of pain to 95 degrees during flare ups due to pain and fatigability. The examiner did not find pain on range of motion testing. The examiner found full range of extension to 0 degrees. The examiner found that there was no meniscal condition, crepitus, ankylosis or effusion in either knee. The examiner conducted stability testing in both knees and found that there was no patellar or other persistent instability. The Board finds the December 2019 and April 2021 VA examinations adequate for appellate review. There is no evidence that the examiners were not competent or credible, and as the reports are based on the Veteran's statements, in-person examination and the examiner's observations, the Board assigns them significant probative weight. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 30205 (2008). At the August 2017 Board hearing, the Veteran reported that he did not receive treatment for his right knee, but his symptoms had worsened, and he had pain and stiffness with activity. He also stated that he had two patellar injuries and could feel instability in his knee, which he noticed even when laying on his side. The Board notes that the Veteran is competent to report lay-observable symptoms such as pain and assigns his statements significant probative weight. Moreover, the undersigned has had the opportunity to observe the Veteran and finds him to be credible. See Dalton v. Nicholson, 21 Vet. App. 23, 38 (2007); Caluza v. Brown, 7 Vet. App. 498, 511 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996). Period prior to August 14, 2018 Again, the Veteran's right knee limitation of flexion is rated as noncompensable under DC 5260 for the period prior to August 14, 2018. The Board finds that a 10 percent rating, but no higher, is warranted. Again, a 10 percent rating is warranted under DC 5260 when knee flexion is limited to 45 degrees. Here, there is no indication that the Veteran's right knee flexion has ever been limited to the required degree. At worst, the competent evidence of record has shown flexion limited upon consideration of pain during flare ups to 95 degrees. However, under 38 C.F.R. § 4.59, a single compensable rating may be assigned where there is painful motion of the knee, even when the limitation of motion itself is noncompensable. As the October 2013 examination has been found to be inadequate, the only competent evidence of record during the period regarding the severity of the Veteran's disability is the Veteran's August 2017 testimony that he had pain and stiffness in his right knee. The evidence therefore supports a finding of painful motion during the period prior to August 14, 2018 and a 10 percent rating under DC 5260 is warranted. 38 C.F.R. § 4.59. Rating in excess of 10 percent As a 10 percent rating for right knee limitation of flexion has been assigned during the period prior to August 14, 2018, there is now a uniform 10 percent rating under DC 5260 for the entire period on appeal. To warrant a 20 percent rating under DC 5260, the evidence would need to show flexion was limited to 30 degrees. The Board finds that the record does not support the conclusion that the Veteran's right knee more closely approximated the severity of a 20 percent rating. There is simply no indication that flexion was limited to 30 or less at any point during the period on appeal. The April 2021 VA examiner found flexion limited at worst and with consideration of pain and fatigue to 95 degrees, well above the required degree. While the Veteran reported of knee pain and stiffness with activity when walking, his reports of pain were explicitly considered in the April 2021 findings of limited motion and are encompassed by the 10 percent rating already assigned. A rating in excess of 10 percent is therefore not warranted under DC 5260. The Board has also considered a rating are under DC 5261 for limitation of extension. However, the evidence does not show that extension was limited to 10 degrees or more at any point during the period after August 14, 2018, with extension to 0 degrees shown at both VA examinations of record. A rating under DC 5261 is therefore not warranted. The Veteran reported right knee instability at the August 2017 hearing, and the question of a rating for instability under DC 5257 must therefore also be considered. While there is no evidence of a diagnosis involving the patellofemoral complex as required for a rating for patellar instability, a 10 percent rating is also warranted under DC 5257 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. The Veteran is competent to report instability. Moreover, in evaluations for knee instability, medical evidence of instability is not required and medical evidence regarding knee instability is not categorically more probative than lay evidence. English v. Wilkie, 30 Vet. App. 347 (2018). Thus, a separate rating for knee instability may be premised on lay evidence alone and cannot be denied solely based on the lack of objective findings of instability. Id. Here, the record contains conflicting evidence regarding whether the Veteran has instability. Both the December 2019 and April 2021 VA examiners found no evidence of joint instability on testing. However, this evidence must be balanced against the competent lay evidence submitted at the August 2017 hearing, when the Veteran reported instability, including when laying down. Again, medical evidence regarding knee instability is not categorically more probative than lay evidence. This is particularly the case here as the examination reports are silent for any indication that the examiners considered the Veteran's reports of instability, which were already of record at the time of both examinations. The April 2021 examiner specifically stated that the Veteran did not report or have a history of knee instability and did not reconcile this finding with the existing evidence of record. As there is no indication that the examiners considered the evidence of instability, the Board assigns less weight to their findings that there was no history of instability. Therefore, resolving all doubt in favor of the Veteran, the Board finds that there was recurrent instability during the period, warranting a 10 percent rating under DC 5257. The Board has also considered a separate rating under DC 5258, as a separate rating may be warranted when there is dislocated semilunar cartilage with symptoms such as effusion and crepitus. See Lyles, supra. However, the evidence does not show that the Veteran had dislocated semilunar cartilage at any point during the period on appeal, so rating under this DC is not warranted. A rating is also not warranted under DC 5259 for symptomatic removal of semilunar cartilage, as the evidence does not show that the Veteran has had such a procedure. Further, there is no evidence of ankylosis, impairment of tibia and fibula, or genu recurvatum; therefore, separate ratings under DCs 5256, 5262, and 5263 are not warranted. The preponderance of the evidence is against a rating in excess of 10 percent for right knee limitation of flexion. As such, the benefit-of-the-doubt doctrine is inapplicable. 38 C.F.R. § 4.3. For these reasons, the claim is denied. REASONS FOR REMAND 1. Entitlement to a compensable rating for right shoulder bursitis Pursuant to the March 2021 Board remand, a VA shoulder examination was provided in May 2021. An opinion was then obtained to assess whether the Veteran's current right shoulder symptoms and limitation of motion were likely due to the service connected right shoulder disability. A June 2021 opinion found that the current symptoms were not due to the service connected disability. As a rationale, the provided stated that there was a lack of "objective medical evidence" confirming chronicity of right shoulder bursitis "on active duty" and ten years had passed since that time. Therefore, the provider concluded, the subsequent right shoulder surgery and current limitations could not be related to the service connected bursitis. The Board finds that the opinion inadequate for review as it appears to be based on an analysis of symptoms outside of the period on appeal and did not properly address the question of the current level of functional impairment associated with the service connected disability. Instead, the opinion focused on the question of whether symptoms of bursitis were shown during service, as would be appropriate if the issue before the Board was one of service connection. Notably, the phrase "active duty" is repeated multiple times and emphasized with all-capital letters in the opinion. However, in an increased rating claim the focus is not on symptoms in service but on the current level of functional impairment. Due to the focus on symptoms well before the period on appeal, the opinion did not properly address the nature of the current symptoms and the level of functional impairment associated with the already service connected disability. In addition, the provider's emphasis on the need for "objective medical evidence" to show chronicity of symptoms suggests that she improperly disregarded the competent lay evidence regarding symptoms such as shoulder pain due to a lack of contemporaneous medical evidence. For these reasons, the opinion is inadequate and remand for a new examination is required. 2. Entitlement to a compensable rating for left shoulder lesions and tears with bursitis prior to August 14, 2018, and in excess of 20 percent thereafter A new VA shoulder examination is ordered above as part of the required development for the right shoulder disability. As that examination is likely to produce information relevant to the issue of an increased rating for the left shoulder, this issue must also be remanded. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (two issues are "inextricably intertwined" when the adjudication of one issue could have "significant impact" on the other issue). 3. Entitlement to a compensable rating for left wrist strain prior to August 14, 2018, and in excess of 10 percent thereafter 4. Entitlement to a compensable rating for right wrist strain prior to August 14, 2018, and in excess of 10 percent thereafter The March 2021 Board decision requested a new VA wrist examination, which was provided in April 2021. However, the examination was unclear regarding whether the Veteran had pain on range of motion testing. The April 2021 examiner conducted range of motion of the right and left wrists. For both wrists, the examiner noted pain on palmar flexion in both active and passive range of motion testing. However, the examiner then provided a negative response for both wrists to the question regarding whether there was evidence of pain. The examination report is therefore internally inconsistent regarding whether the Veteran had pain on range of motion testing and remand for a new examination is required. The matters are REMANDED for the following action: 1. Schedule the Veteran for an appropriate VA examination to determine the current nature and severity of his right shoulder disability. The claim file should be made available to and reviewed by the examiner and the examination report should state a review of the file was completed. All findings should be reported in detail and the examiner should specifically address which current symptoms and functional impairments are associated with the service connected disability and explain the basis for those findings. The examiner should identify all right shoulder pathology found to be present. The examiner should conduct range of motion studies. The joints involved should be tested in both active and passive motion, in weight-bearing and non-weight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint. If the examiner is unable to conduct the required testing or concludes that the required testing is not necessary in this case, he or she should clearly explain why that is so. The examiner should describe any pain, weakened movement, excess fatigability, instability of station and incoordination present. If pain is noted, the point during range of motion at which pain starts must be clearly indicated. The examiner should also state whether the examination is taking place during a period of flare-up. If not, the examiner should ask the Veteran to describe the flare-ups he experiences, including: frequency, duration, characteristics, precipitating and alleviating factors, severity and/or extent of functional impairment he experiences during a flare-up of symptoms and/or after repeated use over time. Based on the Veteran's lay statements and the other evidence of record, the examiner should provide an opinion estimating any additional degrees of limited motion caused by functional loss during a flare-up or after repeated use over time. If the examiner cannot estimate the degrees of additional range of motion loss during flare-ups or after repetitive use without resorting to speculation, the examiner should state whether the need to speculate is caused by a deficiency in the state of general medical knowledge (i.e. no one could respond given medical science and the known facts) or by a deficiency in the record or the examiner (i.e. additional facts are required, or the examiner does not have the needed knowledge or training). 2. Schedule the Veteran for an appropriate VA examination to determine the current nature and severity of his bilateral wrist disabilities. The claim file should be made available to and reviewed by the examiner and the examination report should state a review of the file was completed. All findings should be reported in detail. The examiner should identify all left and right wrist pathology found to be present. The examiner should conduct range of motion studies. The joints involved should be tested in both active and passive motion, in weight-bearing and non-weight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint. If the examiner is unable to conduct the required testing or concludes that the required testing is not necessary in this case, he or she should clearly explain why that is so. The examiner should describe any pain, weakened movement, excess fatigability, instability of station and incoordination present. If pain is noted, the point during range of motion at which pain starts must be clearly indicated. The examiner should also state whether the examination is taking place during a period of flare-up. If not, the examiner should ask the Veteran to describe the flare-ups he experiences, including: frequency, duration, characteristics, precipitating and alleviating factors, severity and/or extent of functional impairment he experiences during a flare-up of symptoms and/or after repeated use over time. Based on the Veteran's lay statements and the other evidence of record, the examiner should provide an opinion estimating any additional degrees of limited motion caused by functional loss during a flare-up or after repeated use over time. If the examiner cannot estimate the degrees of additional range of motion loss during flare-ups or after repetitive use without resorting to speculation, the examiner should state whether the need to speculate is caused by a deficiency in the state of general medical knowledge (i.e. no one could respond given medical science and the known facts) or by a deficiency in the record or the examiner (i.e. additional facts are required, or the examiner does not have the needed knowledge or training). 3. If upon completion of the above action the appeal remains denied, the case should be returned to the Board after compliance with appellate procedures. E. I. VELEZ Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A. Arnold 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.