Citation Nr: 21077159 Decision Date: 12/28/21 Archive Date: 12/28/21 DOCKET NO. 16-17 071 DATE: December 28, 2021 ORDER Entitlement to an increased disability evaluation of 20 percent for left knee instability is granted. Entitlement to an increased compensable disability evaluation of 10 percent for left knee limitation of flexion is granted. REMANDED Entitlement to service connection for right foot disorder is remanded. Entitlement to service connection for right hip disorder is remanded. Entitlement to service connection for left hip disorder is remanded. Entitlement to service connection for right hand disorder is remanded. Entitlement to service connection for left hand disorder is remanded. Entitlement to total disability evaluation based on individual unemployability, due to service-connected disabilities (TDIU), is remanded. FINDINGS OF FACT 1. For the time period on appeal, the left knee disorder more closely approximated moderate evidence of slight recurrent subluxation or lateral instability. 2. For the time period on appeal, the evidence shows left knee limitation of flexion does not more closely approximate flexion limited to less than 60 degrees, ankylosis, meniscal condition/surgery, including dislocated or removed cartilage, tibial and/or fibular impairment, removal of semilunar cartilage, or genu recurvatum, but nonetheless is manifest in painful motion during repeated use over time. CONCLUSIONS OF LAW 1. Resolving all reasonable doubt in the Veteran's favor, the criteria for a 20 percent disability rating for left knee disorder for the time period on appeal are met for the time period on appeal. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 4.1, 4.2, 4.3, 4.7, 4.40, 4.45 (2020), 4.71a, Diagnostic Codes 5003, 5010-5257, 5256, 5258, 5260, 5261, 5262 (2020, 2021). 2. Resolving all reasonable doubt in the Veteran's favor, the criteria for an increased disability rating for left knee limitation of flexion to 10 percent for the time period on appeal are met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 4.1, 4.2, 4.3, 4.7, 4.40, 4.45 (2020), 4.71a, Diagnostic Codes 5260, 5256, 5258, 5261, 5262 (2020, 2021). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from November 1979 to January 1984 and from January 1989 to September 1992. In November 2018, the Veteran testified at a videoconference Board hearing before a Veterans Law Judge who is no longer at the Board. The Veteran was notified of this by a September 2021 letter, which informed him of his right to request another hearing and advised him if he did not respond within 30 days, the Board would assume he does not want another hearing. As the Veteran did not respond within that period, the Board accordingly has proceeded with the appeal. The Board's April 2019 decision denied the claims now on appeal. The Veteran appealed part of the Board's decision to the Court of Appeals for Veterans Claims (Court), which in turn in February 2020 remanded the claims remaining on appeal to the Board for action consistent with the Joint Motion for Partial Remand (JMPR), agreed to and submitted by the parties. Specifically, the parties agree the Board did not discuss if the Veteran was entitled to a VA examination(s) to determine whether the reported arthritis in his right knee, right foot, bilateral hips, and bilateral hands is related to service and whether VA medical examinations are needed. In regard to the claim for an increased rating for left knee, the parties agree the Board did not adequately consider the Veteran's lay statements indicating he had left knee instability; whether the disorder worsened since the 2014 examination, as indicated in the record regarding the use of assistive devices; whether a separate rating for limitation of motion is warranted; whether evaluation should be made without considering ameliorative effects of pain medication; and whether there is entitlement to TDIU. The Board therefore remanded the claims on appeal in May 2020 for examinations. While the JMPR did reference "initial evaluation," the Board finds the appeal period starts with a June 2014 informal claim with a look back period to June 9, 2013, but not earlier. While a statement of the case was generated in August 2002, no appeal follows. The appeal period starts June 9, 2013. 38 C.F.R. § 3.400(o)(2). The Board will note here an April 2021 rating decision in fact granted a separate service-connection disability for left knee limitation of flexion at a noncompensable disability evaluation, effective November 12, 2020. The Board further notes that a May 2021 rating decision granted the claim for service connection for right knee disorder, originally associated with this appeal, and that claim therefore is no longer before the Board. Schedular Ratings Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (rating schedule), found in 38 C.F.R. Part 4. When a reasonable doubt arises regarding the degree of disability, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. 38 C.F.R. § 4.7. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Additionally, it is possible for a veteran to be awarded separate percentage evaluations for separate periods (staged ratings), based on the facts. See Fenderson v. West, 12 Vet. App. 119, 12627 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). The rating schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of, or incident to, military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. In considering the severity of a disability, it is essential to trace the medical history of the veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41; Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Where an increase in the disability rating is at issue, the present level of the veteran's disability is the primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, the relevant overall temporal focus for adjudicating an increased rating claim is on the evidence concerning the state of the disability from the time period one year before the claim was filed until VA makes a final decision on the claim. Hart v. Mansfield, 21 Vet. App. 505 (2007). The evaluation of the same disability under several diagnostic codes, known as "pyramiding," must be avoided; however, separate ratings may be assigned for distinct disabilities resulting from the same injury, so long as the symptomatology for one condition is not duplicative of or overlapping with the symptomatology of the other condition. 38 C.F.R. § 4.14. When evaluating musculoskeletal disabilities, VA, in addition to applying the schedular criteria, may assign a higher disability rating when the evidence demonstrates functional loss due to limited or excessive movement, pain, weakness, excessive fatigability, or incoordination, to include during flare-ups and with repeated use, if those factors are not considered in the rating criteria. See 38 C.F.R. §§ 4.40, 4.45, 4.59; see also DeLuca v. Brown, 8 Vet. App. 202, 204-07 (1995); Burton v. Shinseki, 25 Vet. App. 1, 5 (2011). Nonetheless, a disability rating higher than the minimum compensable rating is not assignable under any diagnostic code relating to range of motion where pain does not cause a compensable functional loss. Rather, the "pain must affect some aspect of 'the normal working movements of the body' such as 'excursion, strength, speed, coordination, and endurance,'" as defined in 38 C.F.R. § 4.40, before a higher rating may be assigned. See Mitchell v. Shinseki, 25 Vet. App. 32, 37 (2011) (noting that while "pain may cause a functional loss, pain itself does not constitute a functional loss," and, is therefore, not grounds for entitlement to a higher disability rating). Additionally, the intent of the rating schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. Thus, with or without degenerative arthritis, actually painful, unstable or malaligned joints, due to a healed injury, are recognized as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59; see also Burton v. Shinseki at 5 (holding that the provisions of 38 C.F.R. § 4.59 are not limited to disabilities involving arthritis). 1. Entitlement to an increased disability evaluation in excess of 10 percent for left knee disorder. 2. Entitlement to an increased disability evaluation for left knee limitation of flexion. The April 2021 rating decision granted a separate service-connection disability for left knee limitation of flexion at a noncompensable rating, effective November 12, 2020. No further separate rating was granted for limitation of extension. The Veteran is rated for a left knee disability with degenerative joint disease under the hyphenated diagnostic code, 5010-5257. Hyphenated codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned. 38 C.F.R. § 4.27. In this case, the Agency of Original Jurisdiction (AOJ) assigned a hyphenated diagnostic code to recognize traumatic arthritis (Diagnostic Code 5010) as the Veteran's underlying diagnosis and recurrent subluxation or lateral instability (Diagnostic Code 5257) as the pathology of the disorder. See 38 C.F.R. § 4.20. Some diagnostic codes in the rating schedule for knee disorder have been revised, effective February 7, 2021. The pre-revision version of Diagnostic Code 5010 directs the rater or adjudicator to rate traumatic arthritis as degenerative arthritis, the rating criteria for which are found under Diagnostic Code 5003. As it is, the pre-revision and revised versions of Diagnostic Code 5003 are identical, other than the revised version specifying the diagnostic code pertains to degenerative arthritis, "other than post-traumatic." The code states, when established by x-ray findings, degenerative arthritis will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. When limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each such major joint affected by limitation of motion to be "combined," not added together, under Diagnostic Code 5003. See 38 C.F.R. § 4.25. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm or satisfactory evidence of painful motion. In the absence of limitation of motion, a rating of 10 percent will be assigned with x-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups. A 20 percent rating is warranted with x-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups, with occasional incapacitating exacerbations. The above ratings will not be combined with ratings based on limitation of motion. 38 C.F.R. § 4.71a, Diagnostic Code 5003 (2020 and as revised, February 7, 2021). However, in its revised version, Diagnostic Code 5010 now refers to post-traumatic arthritis and the instruction to rate as degenerative arthritis under 5003 has been removed. Traumatic arthritis is now rated as "limitation of motion, dislocation, or other specified instability under the affected joint. If there are 2 or more joints affected, each rating shall be combined in accordance with §4.25." Diagnostic Code 5257 addresses knee instability. That diagnostic code, too, was revised, but the Board must look to both the pre-revision and revised versions for the benefit most advantageous to the Veteran. The pre-revision version of Diagnostic Code 5257 provides a 10 percent rating with evidence of slight recurrent subluxation or lateral instability of the knee, a 20 percent rating with moderate evidence of recurrent subluxation or lateral instability and a 30 percent rating will be assigned when such evidence of recurrent subluxation or lateral instability is severe. 38 C.F.R. § 4.71a, Diagnostic Code 5257. The Board will note at this point that descriptive words, such as "slight," "moderate" and "severe," as used in Diagnostic Code 5257, are not defined in the Rating Schedule. Therefore, rather than applying a mechanical formula, the Board must evaluate all the evidence to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6. The use of descriptive terminology by medical examiners, although an element of evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision. 38 U.S.C. § 7104 (a); 38 C.F.R. §§ 4.2, 4.6. The revisions to Diagnostic Code 5257, effective February 7, 2021, are extensive, now providing for recurrent knee subluxation or instability a 10-percent rating 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 available 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. Assignment of 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. If there is patellar instability, 10 percent is warranted for a diagnosed condition involving the patellofemoral complex with recurrent instability (with or without history of surgical repair) which does not require a prescription from a medical provider for a brace, cane or walker. 20 percent is available 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. 30 percent will be assigned for a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair which requires a prescription by a medical provider for a brace and either a cane or a walker. The following notes to the diagnostic code provide further explanation: Note (1): For patellar instability, the patellofemoral complex consists of the quadriceps tendon, the patella and the patellar tendon. Note (2): A surgical procedure that does not involve repair of one or more patellofemoral components which 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). Objective medical evidence is not required to establish lateral-knee instability under Diagnostic Code 5257 and such evidence therefore cannot be found categorically to be more probative than the Veteran's lay evidence regarding instability. See English v. Wilkie, 30 Vet. App. 347, 352-53 (2018). Additionally, in order to afford the Veteran every possible opportunity to attain the highest evaluation allowed under the regulations, the Board will also look to closely related or analogous diagnostic codes pertaining to the knee, both pre-revision and as revised, to determine if a higher evaluation might be available When presenting for the first time at VA for primary care in April 2014, the Veteran reported chronic pain in various body segments, to include knees, and added multiple areas including the knees also "lock up." The Veteran was afforded a December 2014 VA examination for knee and lower leg conditions, in which the examiner stated a 1980 diagnosis of internal derangement of the left knee. He noted the Veteran's report of worsening intermittent left knee locking pain and "giving way." On examination, range of motion measurements showed left knee flexion ending at 140 degrees and extension ending at 0 degrees, both with no objective evidence of painful motion. Measurements were the same after repetitive-use testing and the Veteran's reported there were no flare-ups. The examiner found pain, weakness, fatigability, or incoordination did not significantly limit functional ability. He added the Veteran was unable to duplicate any functional loss at the time of examination and reported pain does not cause any functional loss. The examiner further found no evidence or history of recurrent patellar subluxation/dislocation, joint stability tests, to include anterior instability (Lachman test), posterior instability (posterior drawer test) and medial-lateral instability tests produced normal results, he found no evidence or history of recurrent patellar subluxation/dislocation, no "shin splints" (medial tibial stress syndrome), stress fractures, chronic exertional compartment syndrome, or any other tibial and/or fibular impairment, and no meniscal conditions or surgical procedures for a meniscal condition. The Veteran reported he used no assistive devices. The examiner noted there were no available imaging studies which might document arthritis. In a December 2017 VA physical therapy note, left knee flexion was recorded ending at 125 degrees and extension at " 5 degrees." As directed in the Board's May 2020 Remand, the Veteran was afforded another VA examination for knee and lower-leg conditions, the examination report of which was signed and associated with the claims file in December 2020. The examiner diagnosed left knee residual of injury, with degenerative joint disease. The Veteran pain and worsening over the years, with current symptoms as knee pain, stiffness, difficulty with heavy lifting, prolonged standing, walking, light jogging, climbing stairs, and limited range of motion. The examiner found left knee range-of-motion flexion from 0 to 90 degrees and extension from 90 to 0 degrees. He further found there is evidence of pain with weight bearing. He added at the end of his report there is objective evidence of pain on left knee non-weight bearing testing and on left knee passive range of motion testing. Upon testing for repeated use over time, the examiner found pain and lack of endurance significantly limited functional ability, estimating left knee flexion would be reduced to 0 to 70 degrees and extension to 70 to 0 degrees. The Veteran reported left knee flare-ups are moderate, lasting several hours, precipitated by light jogging, prolonged standing or walking, repetitive bending, and climbing stairs, and alleviated by resting. Although, the examination was not conducted during a flare-up, the examiner estimated that pain and lack of endurance during a flare-up would lessen left knee flexion to 0 to 60 degrees and extension to 60 to 0 degrees. Additional relevant findings include there was no left-side ankylosis and no history of left-side recurrent subluxation or lateral instability. Left knee joint stability testing involving 4 separate tests for anterior instability, posterior instability, medial instability, and lateral instability produced normal results for each test. The examiner further found no past or current patellar dislocation, tibial and/or fibular impairment, meniscus condition, and no related surgical procedures, to include knee-joint replacement or meniscectomy. The Veteran reported he used no assistive devices. Although imaging studies were available, they documented arthritis only in the right knee. Although all VA examinations have shown normal stability testing, the Veteran has consistently reported left knee instability to his medical providers and examiners. For example, in the December 2014 VA examination for knee and lower-leg conditions, the Veteran reported worsening intermittent left knee locking pain and giving way. Additionally, numerous VA notes between January and October 2020 note the Veteran's current use of a walker. Lastly, in his November 2018 Board hearing testimony, the Veteran stated his left knee locks at times, specifically, every time he stays in a certain position too long. Ultimately, at a certain point, he could no longer bend over, he therefore could not perform his work tasks and he quit his employment. When questioned, the Veteran further testified that locking does not occur when walking; however, his knee will "give way" due to instability, causing him to lose balance, because the knee becomes too weak. Objective medical evidence is not required to establish lateral knee instability under Diagnostic Code 5257 and such evidence therefore cannot be found categorically to be more probative than the Veteran's lay evidence regarding instability. See English v. Wilkie, 30 Vet. App. 347, 352-53 (2018). The Veteran's testimony is wholly consistent with his reports to his treatment providers. Although never detected at the time of VA examinations, the record of the Veteran's reports supports there were repeated instances of locking and giving way, indicating at least intermittent instability. The Board has considered the rating criteria of Diagnostic Code 5010-5257 under the pre-revised versions and revised versions of the 2 diagnostic codes. The record does not show x-ray evidence of involvement of two or more major joints or two or more minor joint groups and the left knee is a single joint. However, as stated earlier, Diagnostic Code 5003, to which Diagnostic Code 5010 directs the rater, first requires rating by reference to the appropriate diagnostic codes for limitation of motion, which for knee would be limitation of flexion (Diagnostic Code 5260) and limitation of extension (Diagnostic Code 5261). Diagnostic Code 5261 provides a 5 percent rating when extension is limited to 5 degrees, 10 percent when limited to 10 degrees, when limited to 15 degrees a 20 percent rating will be assigned, when limited to 20 degrees a 30 percent rating is available, a 40 percent rating is warranted for limitation at 30 degrees, and when extension limited to 45 degrees a 50 percent rating will be assigned. 38 C.F.R.§4.71a, Diagnostic Code 5261. However, as the above summary of the record shows, findings in all VA examinations for left knee extension and during the course of treatment between November 1992 and December 2020 were invariably above the range of motion measurements required for a higher left knee rating based on limited extension. Before addressing Diagnostic Code 5260 (limitation of flexion), the Board again will note the Veteran is now service connected for left knee limitation of flexion at a noncompensable disability evaluation, effective November 12, 2020, the actual date the December 2020 examination was conducted. This disorder has received a noncompensable rating under Diagnostic Code 5010-5260 and the Board must presently address the issue of whether a higher rating is warranted under the rating criteria. Once again, higher ratings under the pre-revised version of Diagnostic Code 5010 for arthritis are not available, as the left knee is a single joint, but, as the revised version now rates traumatic arthritis as limitation of motion, dislocation or other specified instability under the affected joint, the April 2021 rating decision found flexion as the relevant limitation of motion, under Diagnostic Code 5260. That diagnostic code provides a noncompensable rating when flexion is limited to 60 degrees, a 10 percent rating when limited to 45 degrees, 20 percent when limited to 30 degrees, and the maximum 30 percent rating will be assigned when flexion is limited to 15 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5260. Normal flexion is from 0 to 140 degrees. 38 C.F.R. § 4.71, Plate II. However, as shown above in VA examinations and throughout the record of treatment, left knee flexion was never recorded ending at less than 60 degrees, for example, as estimated by the December 2020 VA examiner during reported flare-ups. The December 2020 VA examiner found on testing for repeated use over time pain and lack of endurance significantly limited functional ability. Therefore, as the intent of the rating schedule is to recognize painful motion of a joint or periarticular pathology as productive of disability, joints which are actually painful are recognized as entitled to at least the minimum compensable rating for the joint, with or without degenerative arthritis. 38 C.F.R. § 4.59; see also Burton v. Shinseki, 25 Vet. App. at 5 (holding that the provisions of 38 C.F.R. § 4.59 are not limited to disabilities involving arthritis). As such, although left knee limitation of flexion was never compensable at the 10 percent level, it manifested painful motion under 38 C.F.R. § 4.59 for the time period on appeal. Additionally, the Board assigns a 20 percent rating for left knee disorder, for the time period on appeal, for moderate evidence of left knee recurrent subluxation or lateral instability. The rating reflects the criteria of the pre-revision version of Diagnostic Code 5257 then in effect. The effective date is the date on which the VA examination which included the Veteran's reports of occasional left knee locking and popping was conducted. In light of the record overall in this stage of the appeal period, the Board, without more clinical findings or additional reports from the Veteran, cannot reasonably conclude a "severe" level of disability existed due to recurrent subluxation or lateral instability under the pre-revision version of Diagnostic Code 5257. Looking to additional related or analogous diagnostic codes, Diagnostic Code 5259 for removal of semilunar cartilage and Diagnostic Code 5263 for genu recurvatum (back-bending knee) has not been found to apply. Also, none of the examinations show findings of ankylosis (Diagnostic Code 5256), meniscal conditions/surgery, including dislocated semilunar cartilage with frequent episodes of "locking," pain, and effusion into the joint (Diagnostic Code 5258) and no tibial and/or fibular impairment (Diagnostic Code 5262), nor do treatment records show any such findings. Additionally, as the left knee is 1 major joint, the higher evaluation of 20 percent under Diagnostic Code 5003 is not available for degenerative arthritis unless the evidence shows x-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups, with occasional incapacitating exacerbations. The related Diagnostic Codes 5260 (limitation of flexion) and 5261 (limitation of extension) have been addressed above. The Board notes, based on the Veteran's reports, symptoms of functional loss due to left knee disorder were noted by the VA examiners, as well as changes affecting normal working movements, which were sufficiently reviewed, included in the examination findings and considered for the higher rating of 20 percent now assigned. See 38 C.F.R. §§ 4.40, 4.45, 4.59; see also DeLuca v. Brown, 8 Vet. App. at 204-07; Mitchell v. Shinseki, 25 Vet. App. at 37; Burton v. Shinseki, 25 Vet. App. at 5. Additionally, the Board has considered the evidence summarized above and evaluated the severity of his disorder without considering any ameliorative effects of his pain medication. Although the record consistently indicates the Veteran's need for pain medication and his numerous requests over the course of treatment for further prescriptions, the Board nonetheless discerns in the medical evidence no indication that the VA examiners and treatment providers were unable to make findings without full knowledge, as shown in the record, of what medications had been prescribed to the Veteran or that they would not have been able to recognize and distinguish medication effects which might otherwise have obscured their findings. See Jones v. Shinseki, 26 Vet. App. 56, 63 (2012). The Board has considered the benefit-of-the-doubt doctrine, however, where the Board has not ruled favorably to the extent sought on appeal, the Board does not perceive an approximate balance of positive and negative evidence. No further grant of benefits is warranted. 38 U.S.C. § 5107 (b); 38 C.F.R. § 4.3. REASONS FOR REMAND 3. Entitlement to service connection for right foot disorder. 4. Entitlement to service connection for right hip disorder. 5. Entitlement to service connection for left hip disorder. 6. Entitlement to service connection for right hand/fingers disorder. 7. Entitlement to service connection for left hand/fingers disorder. In its May 2020 Remand, the Board remanded these claims for a VA examination and opinions to determine if reported arthritis for each disorder is related to active service, consistent with the requirements of the February 2020 JMPR. The Board's opinion question for each disorder was whether the disorder is caused by or related to an event, injury or illness during active service or that arthritis of the joints was clinically demonstrated within one year of separation from active service. The Board also requested that all opinions rendered by the examiner be accompanied by a rationale, by which conclusions are supported with references to and discussion of findings on examination, to clinical findings in the medical evidence of record and/or to accepted medical literature. Additionally, the examiner was requested to discuss all lay evidence of the Veteran, with particular attention to his November 2018 Board hearing testimony. Each of the opinions rendered by the VA examiner, accompanying his December 2020 examinations for each disorder, stated osteoarthritis was not caused by or related active service or was clinically demonstrated within one year of separation from active service, as there are no medical records showing any diagnosis or treatment for each of the above disorders while the Veteran was still in service or within 1 year of separation. However, the December 2020 series of opinions was determined by the AOJ to be inadequate, as the examiner did not comply with the Remand directive to discuss the Veteran's lay evidence, particularly his November 2018 Board hearing testimony, as well as all his lay statements and reports to examiners and treatment providers. The Board further notes the opinions effectively do not address direct service connection. Upon further instruction from the AOJ to address the lay evidence of record, the examiner produced a series of addenda opinions in March 2021, in which he simply added words referencing, but not discussing, lay evidence, the hearing testimony and reports to treatment providers and stated the conclusion it is less likely the disorder was incurred "in during" service, as complaints for the condition did not manifest until many years after separation from service. Although the March 2021 series of addenda opinions now appears to address the question of direct service connection of the disorders, the Board finds these opinions, too, are inadequate, as they do not provide rationales by which conclusions are supported with references to and discussion of findings on examination, to clinical findings in the medical evidence of record and/or to accepted medical literature. The examiner did not in the least discuss the Veteran's lay evidence, the relevant details of which are set forth below in the Board's directives for the purpose of aiding a new VA examiner. As a Remand by the Board confers on a claimant, as a matter of law, the right to compliance with the Board's prior remand requests, those directives concerning the claims for service connection on appeal remain as yet unfulfilled. See Stegall v. West, 11 Vet. App. 268 (1998). For these reasons, the claims again are remanded for new VA opinions, adequate for VA purposes of adjudication. 8. Entitlement to TDIU. The parties to the JMPR agreed the Board should consider whether the Veteran is entitled to TDIU. That claim is considered part of the increased rating claim for left knee, now before the Board and therefore part of this appeal. See Rice v. Shinseki, 22 Vet. App. 447, 448 (2009). However, as a decision on the above-remanded service-connection claims would have a significant impact on any determination regarding TDIU, all issues therefore are inextricably intertwined, requiring the claim for TDIU be remanded as well. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991). The matters are REMANDED for the following action: 1. Contact the Veteran and/or his representative for information pertaining to any current treatment for right foot disorder, right hip disorder, left hip disorder, right hand/fingers disorder, and left hand/fingers disorder, as well as the same information for each of the Veteran's service-connected disorders, now to include left knee instability, at any VA facility and by any private treatment provider. Obtain any records of the above treatments not yet associated with the claims file and associate them with the claims file. The assistance of the Veteran and/or his representative should be requested in obtaining any records of recent treatment as indicated. All attempts to obtain records should be documented in the claims file. 2. Simultaneous to the above directive, proceed with all usual and appropriate notice to the Veteran and his representative of the development for the claim of TDIU, to include specific information concerning the opportunity to provide whatever supporting evidence they deem necessary. Provide the Veteran and his representative with a VA Form 21-8940, Veteran's Application for Increased Compensation Based on Unemployability, to substantiate the claim of TDIU, with instructions on how to complete the form and how, where and by what date to submit it. Proceed with all indicated development for the AOJ's consideration and adjudication of the issue of TDIU. 3. After all additional records have been obtained and associated with the claims file, but whether or not records are obtained, arrange for review of the claims file and a copy of this Remand, to include the above introductory text, to be made available to an examiner for producing findings for foot, hip and hand/fingers disorders, as well as arthritis as associated with those disorders. The complete electronic claims file must be made available to the examiner in conjunction with the review. The examiner should detail all findings. If the examiner deems new VA examinations to be necessary, arrange for those examinations. The examiner is requested to render separate opinions for right foot disorder, right hip disorder, left hip disorder, right hand/fingers disorder, and left hand/fingers disorder addressing the following: (a) Whether it is at least as likely as not (a 50 percent or greater probability) the Veteran's reported arthritis of his joints, to include as associated with the disorder, was incurred during active service or is caused by an event, injury or illness occurring in active service. (b) Whether it is at least as likely as not (a 50 percent or greater probability) the Veteran's reported arthritis of his joints, to include as associated with the disorder, is clinically demonstrated as manifesting within 1 year of separation from active service and possibly exhibits continuity of symptomatology to the present. (c) Whether it is at least as likely as not (a 50 percent or greater probability) the evidence of record supports the October 2018 medical statement and opinion of Dr. W.R.I. (associated with the file on November 16, 2018). The examiner should specifically discuss Dr. W.R.I.'s opinion as to (1) the in-service origins of the Veteran's arthritis and his assertion of confirmation of this through physical examination, medical history, x-rays, and laboratory tests, (2) the adequacy of his rationale, if any, as to this assertion and (3) any conflicts between Dr. W.R.I.'s opinion and the examiner's opinion. Each opinion rendered by the examiner must be accompanied by a rationale, by which conclusions are supported by references to and discussion of findings on examination, to clinical findings in the medical evidence of record and/or to accepted medical literature. The examiner is requested to comment on any relevant opinions found in the record. The examiner is also requested to discuss the Veteran's November 2018 Board hearing testimony, the Veteran's February 1993 correspondence, March 1993 correspondence, the June 1994, May 2001 and June 2014 Statements in Support of Claim, his wife's June 2014 lay statement, the Veteran's September 2015 correspondence, and the statement accompanying his April 2016 Veterans Appeals Form 9, as well as the Veteran's reports to treatment providers and VA examiners as they appear throughout the record. Specifically, discussion of the Veteran's lay evidence of record should include those portions of his November 2018 Board hearing testimony, in which he states he was informed that arthritis manifesting "years later" after active-service physical trauma nonetheless can be related to the original trauma. The Veteran further discussed this in the lay statement accompanying his April 2016 Veterans Appeals Form 9. The Veteran discussed this point in greater detail in his September 2015 correspondence statement, with references to studies and reports by The American Academy of Orthopaedic Surgeons and the Journal of the American Medical Association. He discusses it again in his June 2014 correspondence statement with details as to in-service trauma, such as a ritualistic initiation-like severe beating by his fellow service members and extremely hard-played tackle football games, in which further beatings were administered furtively at the conclusion of tackles in the pile-up of players. He recounts discussions with his physicians concerning the continuing effects of traumatic arthritis. As stated above, there are other lay statements of the Veteran, as well as his wife, and further numerous reports by the Veteran to treatment providers and VA examiners in the record. The Board further urges the examiner to note that opinions rendered without discussing such lay evidence of the Veteran and his wife as it pertains to the above service-connected claims will be deemed insufficient for VA adjudication purposes. 4. After any additional evidence is received and the above development or any other development indicated is completed, review the record. Adjudicate the claims, to include the TDIU claim. If the benefit sought is not granted in full, send the Veteran and his representative a Supplemental Statement of the Case and afford them a reasonable opportunity to respond before the record is returned to the Board. EMILY TAMLYN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board P. Franke, Associate Counsel The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.