Citation Nr: 21005446 Decision Date: 02/01/21 Archive Date: 02/01/21 DOCKET NO. 15-43 386 DATE: February 1, 2021 ORDER Entitlement to a 10 percent rating, but no higher, for left femur fracture with limitation of extension is granted from May 31, 2013. Entitlement to an initial 10 percent rating, but no higher, for left femur fracture with limitation of flexion is granted. Entitlement to a separate 20 percent rating, but no higher, for left femur fracture with residual thigh impairment is granted from May 31, 2013. Entitlement to an initial rating in excess of 10 percent for residuals of a left foot injury prior to September 23, 2019 is denied. Entitlement to an initial 20 percent rating, but no higher, for residuals of a left foot injury is granted from September 23, 2019. Entitlement to an initial rating in excess of 70 percent for posttraumatic stress disorder (PTSD) is denied. Entitlement to a total disability rating based on individual unemployability (TDIU) is granted from May 6, 2013. REMANDED Entitlement to a rating in excess of 10 percent prior to September 23, 2019 for lumbar spine degenerative arthritis with intervertebral disc syndrome (lumbar spine disability) and in excess of 20 percent thereafter is remanded. Entitlement to a rating in excess of 10 percent for right knee strain is remanded. Entitlement to a rating in excess of 10 percent for left knee strain with limitation of flexion is remanded. Entitlement to an initial compensable rating for left knee strain with limitation of extension is remanded. FINDINGS OF FACT 1. When considering pain, flare-ups, and corresponding functional impairment, the Veteran’s left femur fracture has more nearly approximated limitation of extension to 5 degrees, noncompensable but painful limitation of flexion, and limitation of abduction with motion lost beyond 10 degrees throughout the appeal period. 2. Prior to September 23, 2019, the Veteran’s left foot injury was manifested by no more than moderate residuals. 3. Since September 23, 2019, the Veteran’s left foot injury has been manifested by moderately severe residuals. 4. The Veteran’s PTSD has been manifested by no more than occupational and social impairment with deficiencies in most areas throughout the appeal period. 5. Since January 21, 2015, the Veteran’s service-connected PTSD, lumbar spine, bilateral knee, left femur, and left foot disabilities have rendered him unable to secure or follow a substantially gainful occupation. CONCLUSIONS OF LAW 1. The criteria for a 10 percent rating, but no higher, for left femur fracture with limitation of extension are met from May 31, 2013. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.10, 4.40, 4.45, 4.71a, Diagnostic Code (DC) 5251. 2. The criteria for an initial 10 percent rating, but no higher, for left femur fracture with limitation of flexion are met from May 31, 2013. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.10, 4.40, 4.45, 4.71a, DC 5252. 3. The criteria for a separate 20 percent rating, but no higher, for left femur fracture with residual thigh impairment are met from May 31, 2013. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.10, 4.40, 4.45, 4.71a, DCs 5299-5253. 4. The criteria for an initial rating in excess of 10 percent for residuals of a left foot injury prior to September 23, 2019 are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.10, 4.40, 4.45, 4.71a, DC 5284. 5. The criteria for an initial 20 percent rating, but no higher, for residuals of a left foot injury are met from September 23, 2019. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.10, 4.40, 4.45, 4.71a, DC 5284. 6. The criteria for an initial rating in excess of 70 percent for PTSD are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.130, DC 9411. 7. The criteria for entitlement to a TDIU are met from May 6, 2013. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.340, 3.341, 4.3, 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from January 1992 to May 1992 and from April 1994 to June 1998. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a June 2014 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). The Board remanded the claims for further development in November 2018. Notably, during the pendency of this appeal, a July 2020 rating decision increased the Veteran’s lumbar spine disability rating to 20 percent, effective September 23, 2019. Thus, the issue has been recharacterized accordingly. Increased Ratings Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. The percentage ratings represent, as far as can practicably be determined, the average impairment in earning capacity in civil occupations. 38 U.S.C. § 1155. The disability must be viewed in relation to its history. 38 C.F.R. § 4.1. If two disability ratings are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Reasonable doubt as to the degree of disability will be resolved in favor of the claimant. 38 C.F.R. § 4.3. When evaluating joint disabilities rated on the basis of limitation of motion, VA must consider granting a higher rating in cases in which functional loss due to pain, weakness, excess fatigability, or incoordination is demonstrated, and those factors are not contemplated in the relevant rating criteria. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202 (1995). The United States Court of Appeals for Veterans Claims (Court) later clarified that although pain may be a cause or manifestation of functional loss, limitation of motion due to pain is not necessarily rated at the same level as functional loss where motion is impeded. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011); cf. Powell v. West, 13 Vet. App. 31, 34 (1999); Hicks v. Brown, 8 Vet. App. 417, 421 (1995); Schafrath v. Derwinski, 1 Vet. App. 589, 592 (1991). Instead, the Mitchell Court explained that pursuant to 38 C.F.R. §§ 4.40 and 4.45, the possible manifestations of functional loss include decreased or abnormal excursion, strength, speed, coordination, or endurance, as well as less or more movement than is normal, weakened movement, excess fatigability, and pain on movement (as well as swelling, deformity, and atrophy) that affects stability, standing, and weight-bearing. See 38 C.F.R. §§ 4.40, 4.45. Thus, functional loss caused by pain must be rated at the same level as if the functional loss were caused by any of the other factors cited above. In evaluating the severity of a joint disability, VA must determine the overall functional impairment due to these factors. 1. Entitlement to a 10 percent rating, but no higher, for left femur fracture with limitation of extension is granted from May 31, 2013. 2. Entitlement to an initial 10 percent rating, but no higher, for left femur fracture with limitation of flexion is granted from May 31, 2013. 3. Entitlement to a 20 percent rating, but no higher, for left femur fracture with residual thigh impairment is granted from May 31, 2013. By way of background, a September 2010 rating decision awarded service connection for a left femur disability and assigned a 10 percent rating under DC 5255, effective August 26, 2009. A November 2010 rating decision awarded service connection for left hip bursitis associated with the left femur disability and assigned a 10 percent rating under DC 5019, effective August 26, 2009. In June 2014, a rating decision awarded service connection for limitation of flexion of the left femur and assigned a noncompensable rating under 5252, effective May 31, 2013, and combined left hip bursitis with the left femur disability and reevaluated the rating under DCs 5251-5255, based on limitation of extension. A July 2020 rating decision recharacterized the left femur disability, evaluating it under DCs 5251, 5252, and 5253, and increased the noncompensable rating under DC 5251 to 10 percent, as well as the 10 percent rating under DC 5253 to 20 percent, both effective from September 23, 2019. The current appeal period before the Board begins on May 31, 2013, the date VA received the Veteran’s claim for an increased rating, plus the one-year “look back” period. Gaston v. Shinseki, 605 F.3d 979, 982 (Fed. Cir. 2010). As a preliminary matter, the Board notes that although the Veteran presented for VA examinations in April 2014 and June 2014, the most recent September 2019 VA examination is the only examination that is compliant with the requirements set forth by Correia v. McDonald, 28 Vet. App. 158 (2016) and Sharp v. Shulkin, 29 Vet. App. 26, 33 (2017). Accordingly, only the September 2019 VA examination report will be utilized for evaluation of the Veteran’s left femur disability based on range of motion, as it is the only adequate examination of record. In this regard, the Board emphasizes that the prior non-compliant examinations show range of motion findings less favorable than those in the September 2019 VA examination report. Thus, there is no prejudice to the Veteran in not considering these examinations to rate his disability based on limitation of motion and DeLuca factors. The Veteran’s left femur fracture is currently rated pursuant to DCs, 5251, 5252, and 5253. DC 5251 provides a maximum 10 percent rating for limitation of extension of the thigh limited to 5 degrees. 38 C.F.R. § 4.71a, DC 5251. DC 5252 provides ratings for limitation of flexion of the thigh. A 10 percent rating is assigned for flexion limited to 45 degrees; a 20 percent rating is assigned for flexion limited to 30 degrees; a 30 percent rating is assigned for flexion limited to 20 degrees; and a maximum 40 percent rating is assigned for flexion limited to 10 degrees. 38 C.F.R. § 4.71a, DC 5252. DC 5253 evaluates impairment of the thigh, and provides a 10 percent rating for limitation of rotation (affected left cannot toe-out more than 15 degrees), or for limitation of adduction (cannot cross legs); and a maximum 20 percent rating for limitation of abduction, for motion lost beyond 10 degrees. 38 C.F.R. § 4.71a, DC 5253. On VA examination in September 2019, the Veteran endorsed constant left hip pain, as well as severe and daily flare-ups. Left hip range of motion showed flexion limited to 110 degrees, extension limited to 5 degrees, abduction limited to 20 degrees, and adduction limited to 10 degrees, external rotation to 30 degrees and internal rotation to 25 degrees, with evidence of pain causing functional loss, but no additional loss of motion upon repetition. The examiner noted the Veteran was not experiencing a flare-up at the time of the examination but indicated that left hip pain would cause additional functional loss, describing left hip flexion to 50 degrees, extension to 5 degrees, abduction to 10 degrees, and adduction, external and internal rotation to 15 degrees during flare-ups. Muscle strength testing was normal and there was no evidence of muscle atrophy, ankylosis, or any other symptoms. The Veteran’s constant use of a cane on ambulation for stability was noted. The examiner described the functional impact of the Veteran’s condition as causing pain on weight-bearing, pain on ambulation, decreased speed and endurance of ambulation secondary to pain, impaired kneeling and squatting due to pain, and decreased stability and coordination of ambulation. The Board finds that, when considering DeLuca factors, the Veteran’s left femur has been productive of painful but noncompensable limitation of flexion, thereby warranting a separate 10 percent rating, but no higher, under DC 5252. 38 C.F.R. § 4.59; Burton v. Shinseki, 25 Vet. App. 1, 4-5 (2011); see also Sowers v. McDonald, 27 Vet. App. 472, 480 (2016); Petitti v. McDonald, 27 Vet. App. 415, 428-29 (2015) (a compensable rating is warranted for joint pain pursuant to 38 C.F.R. § 4.59 for orthopedic disabilities rated under diagnostic codes containing a 10 percent rating, and the criteria for such a rating can be satisfied with lay and other non-medical evidence). The examiner’s finding of extension limited to 5 degrees is consistent with the 10 percent rating that the Veteran has already been assigned under DC 5251, as is the 20 percent rating assigned under DC 5253 for abduction with range of motion lost beyond 10 degrees. However, based on the Veteran’s competent and credible reports of limited left hip motion and pain and affording him the benefit of the doubt, the Board will extend the 10 percent for limitation of extension and extension and 20 percent for impairment of the thigh based on limitation of abduction to the beginning of the appeal period, or May 31, 2013. In this regard, there is no pertinent evidence demonstrating an ascertainable increase in disability to allow for assignment of the ratings within the one-year look-back period. As 10 percent and 20 percent are the maximum ratings available under DCs 5251 and 5253, respectively, higher ratings are not available. Regarding DC 5252, absent any compensable limitation of motion, a rating in excess of 10 percent cannot be assigned. The Board has considered whether higher or separate ratings are warranted under alternate diagnostic codes pertaining to the hip and thigh. However, there is no indication of ankylosis of the hip, flail hip joint, or impairment of the femur in the competent evidence of record. See September 2019 VA examination report. Accordingly, ratings under DCs 5250, 5254, and 5255 are not warranted. The Veteran’s associated left femur scar will not be discussed herein, as the issue has already been adjudicated in the prior November 2018 decision. 4. Entitlement to an initial rating in excess of 10 percent for residuals of a left foot injury prior to September 23, 2019 is denied. 5. Entitlement to an initial 20 percent rating, but no higher, for residuals of a left foot injury is granted from September 23, 2019. The Veteran’s left foot injury residuals are rated under DC 5284, which provides ratings for other foot injuries. Pursuant to DC 5284, a 10 percent rating is warranted for moderate symptoms; a 20 percent rating is warranted for moderately severe symptoms; a 30 percent rating is warranted for severe symptoms. A following note states that a 40 percent rating should be assigned for actual loss of use of the foot. 38 C.F.R. § 4.71a, DC 5284. Prior to September 23, 2019, a rating in excess of 10 percent is not warranted. In this regard, on VA examination in April 2014, the Veteran reported having continued residuals from an in-service left foot injury while playing volleyball. The examiner assessed moderate severity of the left foot and indicated there were no other pertinent findings. VA treatment records show the Veteran’s reports of left foot pain. See June 2016, June 2017, and December 2017 VA treatment records. The Board equates “moderate” with average and “moderately severe” as between average and serious. Here, given the examiner’s assessment of “moderate” symptomatology, coupled with the handful of complaints in the VA treatment records, the Board finds there is no evidence of demonstrative of moderately severe or severe left foot symptomology, or actual loss of the left foot, and a rating higher than 10 percent is precluded for this period. Beginning September 23, 2019, an increased 20 percent rating is warranted. On that date, during his VA examination, the Veteran reported the inability to bend his two small toes, as well as flare-ups consisting of sharp pain in his toes and difficulty with walking. The examiner noted the left foot exhibited functional loss during flare-ups or after repetitive use over time, describing symptoms of pain on weight bearing, pain on ambulation, decreased speed of ambulation due to pain, and decreased endurance of ambulation due to pain. The examiner indicated that the severity of the Veteran’s status-post left foot injury was moderate and found that the diagnosis had progressed to include ankylosis of the fourth and fifth phalanges with tenosynovitis and heel spurring. In considering the worsening progression of the Veteran’s left foot injury, as well as the examiner’s assessment of functional impairment due to painful flare-ups, the Board finds that the Veteran’s left foot injury has more closely approximated moderately severe residuals in support of a 20 percent rating. Although the Veteran’s left foot symptoms interfere with weight-bearing and ambulation, he is nonetheless able to perform such functions, and the record does not demonstrate actual loss of the foot or suggest that his functional impairments following repetitive use or during flare ups have been so severe, frequent, and/or prolonged to warrant a rating higher than 20 percent. In other words, even considering functional impairment due to pain and other factors, the Veteran’s symptoms have not been shown to be so disabling as to actually or effectively result in more than moderately severe limitation of foot function. Therefore, a rating in excess of 20 percent is not warranted. The Board has considered whether higher or separate ratings are warranted under alternate diagnostic codes pertaining to the foot. However, there is no evidence of weak foot, claw foot, anterior metatarsalgia, hallux valgus, hallux rigidus, hammer toe or malunion or nonunion of the tarsal or metatarsal bones. Therefore, ratings under DCs 5277-5283 are precluded. Furthermore, since the Veteran’s pes planus and plantar fascitis have been determined not connected to service, a rating under DC 5276 is also not available. 6. Entitlement to an initial rating in excess of 70 percent for PTSD is denied. The Veteran’s PTSD is currently rated at 70 percent disabling pursuant to 38 C.F.R. § 4.130, DC 9411, which is rated under the General Rating Formula for Mental Disorders. A 70 percent rating is assigned when there is occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; 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 work-like setting); inability to establish and maintain effective relationships. 38 C.F.R. § 4.130, DC 9411. A 100 percent rating is warranted if there is 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; memory loss for names of close relatives, own occupation, or own name. Id. When determining the appropriate disability evaluation to assign, the Board’s primary consideration is a veteran’s symptoms, but it must also make findings as to how those symptoms impact a veteran’s occupational and social impairment. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 118 (Fed. Cir. 2013); Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). Initially, the Board notes that the Veteran is also diagnosed with nonservice-connected other specified bipolar related disorder. See April 2014 VA examination report. The evidence of record does not sufficiently distinguish the symptoms of this disorder from his service-connected PTSD. Thus, the Board’s instant discussion attributes all the Veteran’s mental health symptoms to his PTSD. Mittleider v. West, 11 Vet. App. 181, 182 (1998). Upon review of the totality of the record, a rating in excess of 70 percent is not warranted at any point during the appeal period, as the Veteran’s symptoms are not of such a severity or frequency to result in total occupational and social impairment to warrant a higher 100 percent rating. Rather, the Board finds his PTSD produces deficiencies in most areas due to such symptoms as depressed mood, anxiety, suspiciousness, avoidance, chronic sleep impairment, nightmares, flashbacks, irritability, disturbances of motivation and mood, flattened affect, impairment of short and long term memory, difficulty in adapting to stressful circumstances, inability to establish and maintain effective relationships, obsessional rituals that interfere with routine activities and panic attacks. Notably, none of the examiners found that the Veteran was totally occupationally and socially impaired. See April 2014 and September 2019 VA examination reports and November 2015 Disability Benefits Questionnaire (DBQ). As to social impairment, the Veteran has endorsed social isolation, poor tolerance for public places, and diminished interest and participation in activities. However, the Board notes that the Veteran described an enjoyable family life and overall good family relationships, including good relations with his extended family, despite a somewhat strained relationship with is older child. See April 2014 and September 2019 VA examination reports. Thus, the evidence does not show he has total social impairment due to PTSD. Moreover, any current social impairments, to include his limited social relationships, mood swings, and irritability are adequately considered by his currently assigned 70 percent rating. As to occupational impairment, the record indicates symptoms causing difficulty in adapting to stressful circumstances, including work or a worklike setting, as well as difficulty in establishing and maintaining effective work and social relationships. The Board notes that the Veteran has been awarded a TDIU throughout the period on appeal due to his service-connected psychiatric and physical impairments, which is discussed below. The Board acknowledges that the April 2014 VA examination report and November 2015 DBQ shows memory loss consistent with a 100 percent rating. While there is evidence of memory and concentration problems, the preponderance of his symptoms and their severity, frequency, and duration more closely approximate the symptoms contemplated by a 70 percent rating. 38 C.F.R. § 4.7. Furthermore, the Board notes that the November 2015 DBQ indicates an intermittent inability to perform activities of daily living. The Veteran endorsed difficulties maintaining his hygiene, stating that he showers two to three times a week and that his wife reminds him to shave and get his haircut. In this regard, the record shows the Veteran’s appearance to be appropriate and within normal limits at all times. It also was noted that the Veteran’s wife does the grocery shopping, meal preparation, and manages the finances, whereas the Veteran reported the ability to grocery shop, albeit once a month, in addition to doing chores and yard work during the April 2014 VA examination. Nonetheless, the November 2015 DBQ examiner found the Veteran capable of managing his financial affairs and concluded that the Veteran’s symptomatology was consistent with occupational and social impairment with deficiencies in most areas, and the evidence is otherwise consistent with a 70 percent disability rating. There is also indication of persistent delusions or hallucinations in the November 2015 DBQ, with a report of overt hallucinations. However, this finding is not supported by the histories documented in the treatment records, which consistently reflect normal thought content and processes and are negative for any delusions, preoccupations, and hallucinations. As hallucinations were endorsed only once during the appeal period, they have not been persistent in order to warrant a higher rating. Moreover, the evidence shows normal speech and communication skills, good eye contact, as well as cooperative behavior, and the Veteran has been oriented at all times. There has been no indication of grossly inappropriate behavior, unprovoked periods of violence, or persistent danger of hurting self or others at any point during the appeal period. See e.g. August 2015, February 2016, June 2018, and March 2020 VA treatment records. There are no other symptoms throughout the appeal period reflective of total social and occupational impairment. In conclusion, the Board finds the Veteran’s PTSD symptoms throughout the entire appeal period have been manifested by no more than occupational and social impairment with deficiencies in most areas and are characteristic of the criteria considered by a 70 percent disability rating. The evidence of record does not support a finding that the Veteran has exhibited total occupational and social impairment, as he has never demonstrated symptoms of similar severity, frequency, or duration as to those contemplated by the 100 percent criteria. Thus, for reasons outlined above, a rating in excess of 70 percent is denied. 7. Entitlement to a total TDIU is granted from May 6, 2013. A total disability rating may be assigned, where the schedular rating is less than total, when the disabled person is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities. 38 C.F.R. § 4.16. Service connection is currently in effect for PTSD, a lumbar spine disability, a left femur disability, a bilateral knee disability, a left foot disability, bilateral lower extremity radiculopathy, and scars, for a combined rating of 80 percent from May 6, 2013. Thus, the Veteran meets the criteria for consideration of a TDIU on a schedular basis for the entire appeal period beginning May 6, 2013. 38 C.F.R. § 4.16(a). Accordingly, what remains to be determined is whether the functional impairment associated with his disabilities is of such nature and severity as to preclude substantially gainful employment. The determination as to whether a veteran can secure or follow a substantially gainful occupation includes an economic component and a noneconomic component. The economic component means that a veteran must not receive income from employment outside of a protected environment that exceeds the poverty threshold for one person. The noneconomic component requires consideration of a veteran’s ability to secure or follow substantially gainful employment, including factors such as the veteran’s history of education, skill, and training, as well as his or her ability to perform the physical and mental activities required by the occupation in question. See Ray v. Wilkie, 31 Vet. App. 58, 73 (2019). The record contains varying accounts as to when the Veteran was last employed. The Veteran reports that he last worked full time in April 2000, and that the most he earned in a year was $24,000. See September 2019 VA Form 21-8940. However, he indicated that he has not worked since 2003 but also reported working for his father’s construction business until 2008-2009. See April 2014 VA examination report and May 2016 private opinion. The Veteran’s representative states that the Veteran has not worked since February 27, 2008. See October 2020 appellate brief. Despite these inconsistent reports, the Board finds that the economic component of entitlement to a TDIU are met because the record shows that the Veteran has not been employed during the appeal period. Regarding the noneconomic component, the Veteran reported completing two years of college with no other education or training. See September 2019 VA Form 21-8940. He indicates that his service-connected mental and physical disabilities prohibit him from working. The evidence of record indicates that the Veteran is unemployable due to his service-connected orthopedic disabilities, as the April 2014 and September 2019 VA examiners determined that the Veteran’s lumbar spine, bilateral knee, left femur, and left foot disabilities impacted his ability to work. In this regard, the April 2014 examiner indicated that such service-connected disabilities resulted in problems with squatting, bending over, heaving lifting, pushing/pulling, as well as prolonged walking and standing, whereas the September 2019 examiner noted symptoms such as pain on prolonged sitting and standing, decreased speed and endurance of ambulation, decreased downward reach, pain on weight bearing, pain on ambulation, impaired kneeling and squatting, and decreased stability and coordination of ambulation, that impacted the Veteran’s ability to perform occupational tasks. Regarding PTSD, the record also indicates the Veteran is not able to follow a substantially gainful occupation due to symptoms including depressed mood, anxiety, suspiciousness, disturbances of motivation and mood, chronic sleep impairment, near-continuous panic or depression affecting the ability to function independently, appropriately and effectively, memory loss and impairment of memory, difficulty adapting to stressful circumstances, including work or a worklike setting, and difficulty/inability to establish and maintain effective work and social relationships. See April 2014 and September 2019 VA examination reports, and November 2015 DBQ. Notably, the November 2015 DBQ examiner opined that the Veteran would not be able to sustain the stress from a competitive work environment or be expected to engage in gainful activity due to his PTSD, noting that the Veteran’s fatigue and memory problems would be a safety issue in the workplace and affect his employment. Similarly, in a May 2016 private opinion, vocational consultant S.B. stated that the Veteran had a combination of physical and emotional conditions that interact in terms of severity level, with the major area of limitations appearing to be mental and physical activity involved in sustaining work, which was extremely limiting for the Veteran. After considering all the evidence, S.B. concluded that the Veteran was “totally and permanently precluded from performing work at a substantial gainful level” due to the severity of his service-connected PTSD and orthopedic disabilities. Given the Veteran’s educational and occupational background and the above-cited medical evidence of record, the Board finds that the Veteran has been unable to secure or maintain a substantially gainful occupation due to his service-connected PTSD, lumbar spine, bilateral knee, left femur, and left foot disabilities. Accordingly, a TDIU is established for the entire appeal period, from May 6, 2013. REASONS FOR REMAND 8. Entitlement to a rating in excess of 10 percent prior to September 23, 2019 for lumbar spine disability and in excess of 20 percent thereafter is remanded. 9. Entitlement to a rating in excess of 10 percent for right knee strain is remanded. 10. Entitlement to a rating in excess of 10 percent for left knee strain with limitation of flexion is remanded. 11. Entitlement to an initial compensable rating for left knee strain with limitation of extension is remanded. The Veteran was afforded VA examinations in connection with his service-connected lumbar spine and bilateral knee disabilities in April 2014 and September 2019. However, these examinations do not adequately address the Veteran’s reported flare-ups. See Sharp v. Shulkin, 29 Vet. App. 26, 33 (2017). The April 2014 VA examiner stated he was unable to estimate additional functional loss during a flare-up in degrees of range of motion, as he was not observing the Veteran during a flare-up, and the Board finds the basis for this conclusion is insufficient. The September 2019 VA examiner indicated that pain significantly limited functional ability with flare-ups, as well as with repeated use over time. However, the described additional functional loss in terms of range of motion during a flare-up are exactly the same measurements recorded for the initial range of motion findings, not during a flare-up. The Board finds it inconsistent that the examiner indicated significantly-limiting functional loss during flare-ups but failed to adequately estimate this loss in terms of range of motion. Given these seemingly contradictory findings, an addendum opinion is necessary on remand. Any outstanding treatment records should also be secured. The matters are REMANDED for the following action: 1. Obtain all outstanding VA treatment records. 2. With any necessary assistance from the Veteran, obtain any outstanding relevant private treatment records. 3. Then obtain an addendum opinion from an examiner other than the April 2014 and September 2019 VA examiners, addressing the severity of the Veteran’s lumbar spine and bilateral knee disabilities during a flare-up. The claims file should be made available to the examiner. No additional examination of the Veteran is necessary, unless the examiner indicates otherwise. Following a review of the claims file, to include the April 2014 and September 2019 VA examination reports, and the Veteran’s description of flare-ups therein, the examiner should provide an opinion describing functional impairments of the Veteran’s (1) lumbar spine, (2) right knee, and (3) left knee due to flare-ups, accounting for pain, incoordination, weakened movement, and excess fatigability on use, and, to the extent possible, report such impairment in terms of additional degrees of limitation of motion. If unable to provide such an opinion without resorting to speculation, please provide a rationale for this conclusion, with specific consideration of the instructions in the VA Clinician’s Guide to estimate, “per [the] veteran,” what extent, if any, flare-ups affect functional impairment. The examiner must include a discussion of any specific facts that cannot be determined if unable to opine without speculation (e.g. lack of sufficient information/evidence, the limits of medical knowledge, etc.). Noting that the Veteran was not examined during a flare-up will not suffice. A complete rationale shall be given for all opinions and conclusions expressed. S. BUSH Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board S.S. Mahoney 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.