Citation Nr: A21020482 Decision Date: 12/23/21 Archive Date: 12/23/21 DOCKET NO. 191015-37848 DATE: December 23, 2021 ORDER Entitlement to service connection for bilateral hearing loss is denied. Entitlement to an evaluation in excess of 10 percent disabling for degenerative joint disease, left knee (flexion), is denied. Entitlement to an initial compensable evaluation for left knee limitation of extension is denied. Entitlement to an initial evaluation in excess of 20 percent disabling for instability of the left knee is denied. Entitlement to a separate, 20 percent evaluation for dislocated cartilage, with frequent episodes of "locking," pain, and effusion into the joint is granted. REMANDED Entitlement to service connection for right knee sprain is remanded. Entitlement to service connection for right shoulder stretched ligaments/torn tendons s/p surgery is remanded. FINDINGS OF FACT 1. The Veteran does not have a bilateral hearing loss disability for VA compensation purposes. 2. The Veteran's left knee has been manifested by limitation of flexion no worse than 50 degrees. 3. The Veteran's left knee has been manifested by limitation of extension no worse than 5 degrees. 4. The Veteran's left knee has been manifested by symptoms of moderate lateral instability. 5. The Veteran's left knee has been manifested by frequent episodes of "locking," pain, and effusion into the joint. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for bilateral hearing loss have not been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.385. 2. The criteria for entitlement to a 10 percent evaluation for degenerative joint disease, left knee (flexion), and no higher, have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71, 4.71a, Diagnostic Codes 5003-5260. 3. The criteria for a compensable evaluation for left knee limitation of extension have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71, 4.71a, Diagnostic Codes 5003-5261. 4. The criteria for entitlement to a 20 percent evaluation for left knee instability, and no higher, have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71, 4.71a, Diagnostic Codes 5003-5257. 5. The criteria for entitlement to a separate 20 percent rating for dislocated cartilage, with frequent episodes of "locking," pain, and effusion into the joint have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71, 4.71a, Diagnostic Code 5258. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty with the United States Navy from December 1979 to December 1999. This appeal to the Board of Veterans' Appeals (Board) was initiated from an August 2019 rating decision by the agency of original jurisdiction (AOJ) of the United States Department of Veterans Affairs (VA) under the Appeals Modernization Act (AMA). The issues of entitlement to service connection for hearing loss and right knee sprain were previously denied under a January 2001 rating decision; entitlement to service connection for right shoulder stretched ligaments/torn tendons s/p surgery was previously denied in a December 2014 rating decision. The August 2019 rating decision found that new and relevant evidence had been received to readjudicate these claims. This is a favorable finding by the agency of original jurisdiction (AOJ) and the Board will proceed to the address the claim on the merits. See 38 U.S.C. § 5104A; 38 C.F.R. § 3.104(c). In October 2019, the Veteran filed a VA Form 10182 Notice of Disagreement seeking review by the Board under the evidence submission docket. Under evidence submission, the Board considers evidence received through the date of the appealed decision, as well as any evidence received during the 90-day period following submission of the disagreement. 38 C.F.R. § 20.202. Remand is permitted only to correct pre-decisional errors or for any other error the correction of which raises a reasonable possibility of aiding in substantiating the claim. 38 C.F.R. § 20.802. Evidence was added to the claims file during a period when new evidence was not allowed. As the Board is deciding the claim of entitlement to service connection for bilateral hearing loss, it may not consider this evidence in its decision. 38 C.F.R. § 20.300. The Veteran may file a Supplemental Claim and submit or identify this evidence. 38 C.F.R. § 3.2501. If the evidence is new and relevant, VA will issue another decision on the claim, considering the new evidence in addition to the evidence previously considered. Id. Specific instructions for filing a Supplemental Claim are included with this decision. Although the Board is deciding increased evaluations for the Veteran's service-connected left knee, he has not made any allegations that this disability prevents him from working. Furthermore, the records indicate that as of June 2019, he was employed as an engineer. As such, consideration of total disability based on individual unemployability (TDIU) will not be inferred. Rice v. Shinseki, 22 Vet. App. 447 (2009). Service Connection for Bilateral Hearing Loss Service connection will be granted if it is shown that the Veteran suffers from a disability resulting from personal injury suffered or disease contracted in the line of duty, or for aggravation of a preexisting injury suffered or disease contracted in the line of duty, during active military service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. Disorders diagnosed after discharge will still be service connected if all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d); see also Combee v. Brown, 34 F.3d 1039, 1043 (Fed. Cir. 1994). To establish service connection on a direct basis, the record must contain competent evidence of: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). In the July 2019 rating decision, the AOJ made a favorable finding that the Veteran's military occupational specialty (MOS) was associated with a high probability of hazardous noise exposure. As such, exposure to hazardous noise exposure is established. The threshold for normal hearing is from 0 to 20 decibels, and higher threshold levels indicate some degree of hearing loss. Hensley v. Brown, 5 Vet. App. 155, 157 (1993). For purposes of applying the laws administered by VA, impaired hearing is considered a disability when: the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, 4000 Hertz is 40 decibels or greater; or when the auditory thresholds for at least three of those frequencies are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. See 38 C.F.R. § 3.385 The Veteran's service treatment records (STR's) show numerous audiometric tests completed during the Veteran's time in the military. Threshold shifts greater than 20 decibels were noted between several of the results, and the Veteran marked "hearing loss" on the report of medical history associated with his separation examination. However, hearing loss was not noted during service, including on the Veteran's separation examination. In May 2019 a private chiropractor relayed the information that the Veteran had been exposed to acoustic trauma in-service and that he has suffered from progressive bilateral hearing loss which he claims bothers him daily. He suggested that the Veteran receive a pure tone audiogram. In the July 2019 VA hearing loss examination, the examiner noted that the Veteran experiences symptoms associated with decreased hearing acuity, including the need to ask for repetitions, use of an amplifier on the telephone, and miscommunications with normal activity. In reviewing the STR's, the examiner noted that September 1996 audiometric results documented hearing loss in the right ear at 6000 Hertz, but all other identified results showed normal hearing. Upon testing, the objective results do not qualify as a hearing loss disability for VA purposes. Puretone thresholds in decibels for the right ear were measured at 25 decibels at 500 Hertz, 15 decibels at 1000 Hertz, 25 decibels at 2000 Hertz, 25 decibels at 3000 Hertz, and 30 decibels at 4000 Hertz. In the left ear, they were measured at 20 decibels at 500 Hertz, 20 decibels at 1000 Hertz, 30 decibels at 2000 Hertz, 25 decibels at 3000 Hertz, and 35 decibels at 4000 Hertz. Speech discrimination using the Maryland CNC word list was found to score 100 percent for both ears. This does not meet the VA requirements for hearing loss under 38 C.F.R. § 3.385. In conclusion, service connection for bilateral hearing loss is denied. As the preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine does not apply. 38 U.S.C. § 5107. Increased evaluations for left knee DJD (flexion), extension, and instability In November 2014, the Veteran provided a Statement in Support of Claim stating that, "Veteran is enclosing copy of a list of Doctors for which he is seeing or has seen to service as evidence, as well as medical notes." Accompanying this, the Veteran provided a list of several different medical providers. Although it does not appear that the AOJ has made any attempts to obtain these records, such does not constitute a pre-decisional error in this instance. Since these identified records were provided prior to the period on appeal, they are not relevant to the current evaluation. Disability evaluations are determined by the application of the facts presented to VA's Schedule for Rating Disabilities (Rating Schedule) at 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and the residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.321 (a), 4.1. In evaluating the severity of a particular disability, it is essential to consider its history. 38 C.F.R. § 4.1 (2018); Peyton v. Derwinski, 1 Vet. App. 282 (1991). Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary importance. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Separate evaluations may be assigned for separate periods of time based on the facts found. In other words, the evaluations may be staged. Staged ratings are appropriate for any rating claim when the factual findings show distinct time periods during the appeal period where the service-connected disability exhibits symptoms that would warrant different ratings. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). If the evidence for and against a claim is in equipoise, the claim will be granted. 38 C.F.R. § 4.3. A claim will be denied only if the preponderance of the evidence is against the claim. See 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 56 (1990). Any reasonable doubt regarding the degree of disability should be resolved in favor of the claimant. 38 C.F.R. § 4.3. Where there is a question as to which of two evaluations shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that evaluation. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Multiple diagnostic codes are potentially applicable to evaluation of the knees. The Veteran is currently rated 20 percent disabled under 5003-5257 for instability, 10 percent disabled under 5003-5260 for limitation of flexion, and noncompensable for limitation of extension under 5003-5261. Consideration of separate evaluation under Codes 5259 and 5258 involving meniscal injuries will be addressed in detail below. The rating criteria for evaluating musculoskeletal disabilities under 38 C.F.R. § 4.71a were amended, effective February 7, 2021. 85 Fed. Reg. 230 (Nov. 30, 2020). If a law or regulation changes during a claim or an appeal, the version more favorable to the Veteran will apply, to the extent permitted by any stated effective date in the amendment in question. 38 U.S.C. § 5110(g). Where the law or regulations governing a claim are changed while the claim is pending, the version most favorable to the claimant applies (from the effective date of the change), absent Congressional intent to the contrary. See Karnas v. Derwinski, 1 Vet. App. 308, 312-13 (1991). Codes 5003, 5260, and 5261 are the same before and after February 7, 2021 regarding their criteria. Codes 5258 and 5259 have not been amended. Code 5257, for subluxation and instability, has changed substantially and will be discussed further below. Code 5003 assigns a maximum 10 percent rating for radiographic evidence of arthritis in a single joint. 38 C.F.R. § 4.71a. As no higher rating is permitted than that currently assigned, no further discussion is warranted, other than consideration of ratings in addition to Code 5003. Under Code 5260, if flexion of the knee is limited to 60 degrees, a 0 percent rating is in order. For limitation to 45 degrees, a 10 percent rating is in order. If flexion of the knee is limited to 30 degrees, a 20 percent rating is warranted. If flexion of the knee is limited to 15 degrees, a 30 percent rating is assigned. 38 C.F.R. § 4.71a. A knee disability may also be rated based on extension under Diagnostic Code 5261. If extension of the knee is limited to 5 degrees, a 0 percent rating assigned. If extension is limited to 10 degrees, a 10 percent rating is in order. If limitation is to 15 degrees, a 20 percent rating is warranted. If extension of the knee is limited to 20 degrees, a 30 percent rating is in order. 38 C.F.R. § 4.71a. In evaluating any disability based on limitation of motion, VA must consider the actual degree of functional impairment imposed by pain, incoordination, weakness, fatigue, and lack of endurance with repetitive motion. 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202 (1995). Prior to February 7, 2021, Diagnostic Code 5257 provides a 10 percent rating for slight recurrent subluxation or lateral instability. A 20 percent rating is warranted for moderate recurrent subluxation or lateral instability. A 30 percent rating is warranted for severe recurrent subluxation or lateral instability. 38 C.F.R. § 4.71a. The words "intermediate" and "severe" or "slight" and "moderate" as used in the various Codes are not defined in the VA Schedule for Rating Disabilities. Rather than apply 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. It should also be noted that use of terminology such as "severe" by VA examiners and others, although not 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 regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6. Following February 7, 2021, the new rating criteria provides that for recurrent subluxation or lateral instability, 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. A 20 percent rating is warranted for one of the following: (a) Sprain, incomplete ligament tear, or repaired complete ligament tear causing persistent instability, and a medical provider prescribes a brace and/or assistive device (e.g., cane(s), crutch(es), walker) for ambulation 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 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. For patellar instability, 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. A 20 percent rating is warranted for a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription for one of the following: a brace, cane, or walker. 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. Note (1) to the criteria states that for patellar instability, the patellofemoral complex consists of the quadriceps tendon, the patella, and the patellar tendon. Note (2) states that 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). Codes 5258 and 5259 evaluate impairment of the semilunar cartilage, or menisci. Under 5258, a maximum 20 percent rating is warranted for dislocated semilunar cartilage with frequent episodes of locking, pain, and effusion into the joint. 38 C.F.R. § 4.71a., Diagnostic Code 5258. Symptoms due to the removal of the semilunar cartilage of either knee warrant a 10 percent rating, which is the maximum rating under the diagnostic code. 38 C.F.R. § 4.71a, Diagnostic Code 5259. Evidence In a May 2019 statement from a private chiropractor, the Veteran reported constant sub-patellar local tenderness, pain, instability, edema, and dysfunctional. He reported that he applies ice to his knees and takes over-the-counter medications which temporarily alleviates symptoms, but that he has painful limits and aggravation with daily tasks including carrying/lifting children, carrying/lifting groceries, going from sitting to standing, climbing stairs, getting dressing, sleeping, working in the yard, walking, sweeping, vacuuming, and exercising. Active range of motion was measured at 0 to 110 degrees on the left knee. The Veteran received a VA knee examination in August 2019. The Veteran described his current symptoms as dull aching pain with "loose-like" feelings and increased weakness, stiffness, and pain with physical activity. He further described swelling and popping and reported that the knee frequently gets locked up and gives out. Current treatment includes hot tub therapy about three times a week, medications including Aleve, Diclofenac and Lidocaine cream, and use of a brace while ambulating. The Veteran reported flare-ups, describing that at times he will wake up after turning a certain way in his sleep and notice that his knee is locked. Anytime he extends the knee or sits too long with it extended it will also lock. Such flare-ups occur 3 to 4 times (within an unspecified period), are moderate to severe, and last for hours at a time. The Veteran described functional loss in terms of his inability to run, knee, or squat using the knee, and his inability to elevate his leg up onto anything. Initial range of motion (ROM) measurements evidenced flexion from 5 to 50 degrees and extension from 50 to 5 degrees. The ROM itself was not found to contribute to functional loss, but pain was noted on both flexion and extension and causes functional loss. There was objective evidence of a palpable edema, crepitus, tenderness generalized entirely, considered worse over the lateral and medial joints. The severity of this was described as moderate. Pain with weight bearing was evidenced. There was objective evidence of pain on passive ROM testing and when the joint was used in non-weight bearing. The Veteran was able to perform repetitive-use testing with no additional loss of function or range of motion after three repetitions. The Veteran was not examined immediately after repetitive use over time, but the examination was medically consistent with the Veteran's statements describing functional loss with repetitive use over time. Pain, weakness, fatigability, or incoordination where not found to significantly limit functional ability with repeated use over a period, and the examiner was unable to describe in terms of ROM. Specifically, the examiner noted that "after review of the Veteran's records including the order request, DBQ, physical exam, reported history and subjective complaints, relevant evidence of record and using my medical knowledge and expertise, I have no basis to offer additional losses of function or motion with repeated use over time." The examiner provided the same responses regarding flare-ups. A reduction in muscle strength was noted, with rate strength 4/5 on flexion and 3/5 on extension. No muscle atrophy was found. No ankylosis was noted. No recurrent subluxation was identified. However, a history of lateral instability was found, and described as "moderate." There was a history of recurrent effusion described as palpable, swelling and effusion. Joint instability was tested, and the Veteran evidenced 2+ results on all testing, which measured anterior, posterior, medial, and lateral instability. The Veteran did not have recurrent patellar dislocation, "shin splints," stress fractures, chronic exertional compartment syndrome, or any other tibial or fibular impairment. However, a meniscus condition was identified, with frequent episodes of joint "locking," frequent episodes of joint pain, and frequent episodes of joint effusion. The examiner specifically noted that the Veteran has symptoms for a left meniscal-like injury with locking, effusion, and chronic pain. Regarding use of an assistive device, the Veteran uses a brace regularly. Diagnostic testing confirmed that the Veteran had degenerative arthritis. Furthermore, it was noted on this examination that the Veteran underwent an arthroscopic surgery in 2003/2004, with residuals described as pain, described range of motion, progressive arthritis, and effusion. A scar related to this surgery, for which the Veteran has already been service-connected, was identified. Separate private treatment records show that the Veteran underwent partial medial and lateral meniscectomies and lateral femoral chondroplasty in April 2004. Analysis After careful and thorough review of the evidence, the Board finds that the currently assigned 10 percent disability rating for flexion under Code 5260, noncompensable evaluation for extension under Code 5261, and 20 percent disability rating for instability under Code 5257 are appropriate; no higher evaluation is warranted. However, a separate, 20 percent evaluation under Code 5258 for frequent episodes of "locking," pain, and effusion into the joint is warranted. Regarding limitation of flexion, the 10 percent evaluation under Code 5260 accounts for flexion limited to 45 degrees. Testing revealed that motion was limited to no more than 50 degrees on flexion. To receive a higher 20 percent evaluation, flexion would need to be limited to 30 degrees. Regarding limitation of extension, a noncompensable evaluation under Code 5261 accounts for extension limited to 5 degrees, which is what has been evidenced on ROM testing. Compensable evaluation is warranted when extension is limited to 10 degrees. The examiner has specifically noted that additional losses of ROM would not be associated with repeated use over time and/or flare-ups. Therefore, even when considering additional functional impairment during flare-ups and periods of repeated use, the evidence does not reflect that the Veteran's flexion would be limited to 30 degrees or less, or extension limited to 10 degrees. Accordingly, higher ratings under Diagnostic Codes 5260 and 5261 are not warranted. In considering evaluation under Code 5257, the Veteran's instability is appropriately characterized as "moderate." Testing on examination resulted in positive instability testing and it was noted that the Veteran regularly uses a brace for ambulation. However, characterization as "severe," which would warrant a higher, 30 percent evaluation, is not shown. The instability was specifically described by the examiner as moderate. Also, while the Veteran regularly uses a brace, constant use of it was not evidenced. Additionally, the Board notes that the Veteran does not meet the criteria for a higher evaluation under the new criteria for Code 5257 for the period since February 7, 2021. Although the Veteran previously underwent an arthroscopic surgery for a torn meniscus, the evidence does not show that he has an unrepaired or failed repair of a complete ligament tear. Additionally, he does not have a diagnosed condition involving the patellofemoral complex. As such, the Board will maintain and continue the instability evaluation under the old criteria for Code 5257. The Board has determined that separate evaluation under Code 5258 is warranted. As noted previously, Codes 5258 and 5259 both pertain to impairment of the meniscus. Code 5258 affords a higher, 20 percent evaluation for cartilage, semilunar, dislocated, with frequent episodes of "locking," pain, and effusion into the joint. Code 5259 provides a 10 percent evaluation, compensating a Veteran after removal of the cartilage where it remains symptomatic. Here, although the Veteran previously underwent partial medial and lateral meniscectomies, his symptoms are aligned with Code 5258 and allow for award of this higher evaluation. Upon examination, each of the symptoms identified under this Code frequent episodes of joint "locking," frequent episodes of joint pain, and frequent episodes of joint effusion were identified. According, separate evaluation under Code 5258 is warranted. Code 5256 is utilized for evaluation of ankylosis or the functional equivalent. As there remains motion in the knee, this Code is not applicable. While evaluations under Code 5262 may be based in part upon knee disability, the underlying impairment must be related to damage to the bones of the lower leg. No tibia or fibula impairment is shown here. 38 C.F.R. § 4.71a. Accordingly, this Code is also not applicable. Code 5263 provides evaluation for genu recurvatum. The Veteran does not have a diagnosis for this, and the Code is not applicable. Therefore, a compensable evaluation under Code 5261 and evaluations higher than 10 percent under Code 5260 and 20 percent under Code 5257 are not warranted. However, a separate evaluation under Code 5258 is warranted. REASONS FOR REMAND Under the AMA, the Board does not have a duty to assist the Veteran in obtaining evidence in support of his claim. However, the Board is responsible for identifying duty to assist errors that were made by the AOJ prior to the rating decision on appeal. 38 C.F.R. § 3.159(c). Once identified, the Board must remand to the AOJ to correct pre-decisional duty to assist errors. 38 C.F.R. § 20.802(a). Service connection for right knee In determining whether the duty to assist requires that a VA medical examination be provided, or medical opinion obtained with respect to a veteran's claim for benefits, there are four factors for consideration. These four factors are: (1) whether there is competent evidence of a current disability or persistent or recurrent symptoms of a disability; (2) whether there is evidence establishing that an event, injury, or disease occurred in-service, or evidence establishing certain diseases manifesting during an applicable presumption period; (3) whether there is an indication that the disability or symptoms may be associated with the veteran's service or with another service-connected disability; and (4) whether there otherwise is sufficient competent medical evidence of record to make a decision on the claim. 38 U.S.C. § 5103A(d); 38 C.F.R. § 3.159(c)(4). The threshold for determining a possibility of a nexus to service is a low one. McLendon v. Nicholson, 20 Vet. App. 79 (2006). The Veteran's STR's document multiple in-service injuries to the Veteran's right knee. Medical treatment records from September 2013 show right knee pain. In the May 2019 report completed by the private chiropractor, the Veteran reported that his right knee began to be painful as a compensatory condition secondary to being on crutches for 8 weeks for his left knee injury. He reported current symptoms of pain and physical limitations in his right knee, including limited range of motion. The Board notes that the Veteran was previously afforded two VA knee examinations. However, they were completed to assess the severity of the Veteran's service-connected left knee disability. Accordingly, given that the low threshold for determining a possibility of a nexus to service under McLendon was met prior to the issuance of the August 2019 rating decision, a VA examination addressing the right knee should have been obtained. Service connection for right shoulder The Veteran has not been afforded a VA examination addressing his right shoulder condition. The Board finds that this constitutes a pre-decisional duty to assist error and requires remand. Here, the Veteran's federal and private treatment records show that he has had right shoulder surgery. In the May 2019 report completed by the private chiropractor, the Veteran said that he injured his shoulders while playing racquetball during physical training (PT), and that he continues experience symptoms including persistent pain, decreased mobility "grinding," crepitus, and dysfunction of the shoulders. The Veteran's STRs document that he received physical therapy (PT) for shoulder pain, although it is unclear whether this applied to both shoulders or just the left or right. Because the low threshold of McLendon was met prior to the issuance of the August 2019 rating decision on appeal, a VA examination should have been obtained. The Board has determined that the errors identified above were required to comply with the VA's duty to assist the Veteran and must be obtained upon remand. The matters are REMANDED for the following action: 1. Schedule the Veteran for a VA knee examination; the claims folder must be reviewed in conjunction with the examination. The examiner must identify all current disabilities of the right knee and then opine as to whether any such are at least as likely as not caused or aggravated by service. A full and complete rationale for all opinions expressed is required. 2. Schedule the Veteran for a VA shoulder examination; the claims folder must be reviewed in conjunction with the examination. The examiner must identify all current disabilities of the right shoulder and then opine as to whether any such are at least as likely as not caused or aggravated by service. A full and complete rationale for all opinions expressed is required. WILLIAM H. DONNELLY Veterans Law Judge Board of Veterans' Appeals Attorney for the Board S.P. Faris 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.