Citation Nr: 21007937 Decision Date: 02/11/21 Archive Date: 02/11/21 DOCKET NO. 14-36 988 DATE: February 11, 2021 ORDER Entitlement to a rating in excess of 10 percent for residuals of a torn meniscus of the right knee is denied. Entitlement to a rating in excess of 10 percent for residuals of tibiotalar degenerative joint disease of the right ankle is denied. REMANDED Entitlement to service connection for a hip disorder is remanded. Entitlement to service connection for an acquired psychiatric disorder is remanded. FINDINGS OF FACT 1. Throughout the period on appeal, the Veteran’s residuals of a torn meniscus of the right knee manifested by painful motion, flexion that was limited to, at worst, 90 degrees and extension to zero degrees, at worst, even in contemplation of functional loss due to symptoms such as pain, fatigue, weakness, lack of endurance, or incoordination, or as a result of repetitive motion and/or flare-ups without recurrent subluxation, lateral instability, residuals of a meniscus condition, effusion, ankylosis, impairment of the tibia and fibula, or genu recurvatum. 2. Throughout the period on appeal, the Veteran’s residuals of tibiotalar degenerative joint disease of the right ankle manifested by, at most, moderate limitation of motion, even in contemplation of functional loss due to symptoms such as pain, fatigue, weakness, swelling, lack of endurance, or incoordination, or as a result of repetitive motion and/or flare-ups, without ankylosis of the ankle or subastragalar or tarsal joint, malunion of os calcis or astragalus, or an astragalectomy. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 10 percent for residuals of a torn meniscus of the right knee have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1—4.14, 4.27, 4.40, 4.59, 4.71a, Diagnostic Code 5260. 2. The criteria for a rating in excess of 10 percent for tibiotalar degenerative joint disease arthritis of the right ankle have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1—4.14, 4.27, 4.40, 4.59, 4.71a, Diagnostic Codes 5010, 5271. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from January 31, 1982 to May 25, 1982, and also from February 9, 2007 to June 2007. Aside from these periods of active duty service, the Veteran also has other service in the U.S. Army National Guard. See generally VADIR Information Report (rec’d July 24, 2020). This matter comes before the Board of Veterans’ Appeals (Board) on appeal of a March 2013 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Guaynabo, Puerto Rico. By way of background, the Veteran’s claims herein were previously remanded by the Board on September 18, 2018. See BVA Remand (Sept. 18, 2018). The Veteran was issued a Supplemental Statement of the Case (SSOC) on December 15, 2020. The Board accordingly reasserts jurisdiction. For the reasons to be discussed in respective parts below, the Board concludes that remands are required as to the Veteran’s claims for service connection for a hip disorder or a psychiatric disorder. The Board sincerely regrets additional delay that may be incurred upon remand; however, the Board cannot escape the conclusion that it is precluded from issuing those final determinations herein at this time. On the other hand, for reasons to be discussed in relevant parts below, the Board has reviewed the Veteran’s claims for increased ratings for his service-connected right knee and right ankle disorders; however, there is simply no evidence of record to suggest entitlement to any increased ratings. The Veteran is entitled to substantial compliance with all previous remand directives, see Stegall v. West, 11 Vet. App. 268, 271 (1998), and while the Board concludes that the Agency of Original Jurisdiction has supplied substantial compliance to the Veteran, the claims for increased ratings must be denied. This appeal has been advanced on the Board’s docket on account of good cause. 38 C.F.R. § 20.900(c). 38 U.S.C. § 7107(a)(2). Increased Rating Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities and are intended to represent the average impairment of earning capacity resulting from disability. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Disabilities must be reviewed in relation to their history. 38 C.F.R. § 4.1. Other applicable, general policy considerations are: interpreting reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating many accurately reflect the elements of disability, 38 C.F.R. § 4.2; resolving any reasonable doubt regarding the degree of disability in favor of the claimant, 38 C.F.R. § 4.3; where there is a questions as to which of two evaluations apply, assigning a higher of the two where the disability pictures more nearly approximates the criteria for the next higher rating, 38 C.F.R. § 4.7; and, evaluating functional impairment on the basis of lack of usefulness, and the effects of the disability upon the person’s ordinary activity, 38 C.F.R. § 4.10. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Separate evaluations may be assigned for separate periods of time based on the facts found, a practice known as “staged ratings.” 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). 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 the symptomatology of the other condition. 38 C.F.R. § 4.14; Esteban v. Brown, 6 Vet. App. 259, 262 (1994). A disability of the musculoskeletal system is primarily the inability, due to damage or inflammation in parts of the system, to perform normal working movements of the body with normal excursion, strength, speed, coordination and endurance. The functional loss may be due to absence of part or all of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or may be due to pain, supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part which becomes painful on use must be regarded as disabled. See DeLuca v. Brown, 8 Vet. App. 202 (1995); 38 C.F.R. § 4.40; see also 38 C.F.R. §§ 4.45, 4.59. 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). VA amended the criteria for rating musculoskeletal disabilities effective from February 7, 2021. These new regulations apply to all applications for benefits received by VA or that are pending before the Agency of Original Jurisdiction (AOJ) on or after February 7, 2021. Claims pending prior to the effective date will be considered under both old and new rating criteria, and whatever criteria is more favorable to the veteran will be applied. The Board may not apply a current regulation prior to its effective date, unless the regulation explicitly provides otherwise. Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). However, the Board is not precluded from applying prior versions of the applicable regulation to the period on or after the effective dates of the new regulation if the prior version was in effect during the pendency of the appeal. The Board notes that this instant claims was not pending before the AOJ on or after February 7, 2021 as the matters were docketed at the Board in January 2021. 1. Entitlement to a rating in excess of 10 percent for residuals of a torn meniscus of the right knee is denied. The Veteran generally contends that a higher rating is warranted for his right knee disorder. Specific argument in support of this appeal has not been presented. The Veteran’s right knee disorder was rated under Diagnostic Code 5262 (malunion tibia and fibula with slight knee disability) until prior to December 14, 2011, but under Diagnostic Code 5260 (limitation of flexion of leg) thereafter. The Veteran received a temporary total disability rating under 38 C.F.R. § 4.30 from August 17, 2007 until prior to October 1, 2007. As the Veteran is in receipt of a maximum disability rating for this service-connected disorder during that period on appeal. See Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (where the law, not the evidence, is dispositive, the appeal should be terminated for lack of legal merit or entitlement). Aside from that period of time, because higher ratings are available throughout the rest of the appellate period, the claim remains on appeal accordingly. See AB v. Brown, 6 Vet. App. 35 (1993). By way of background, the Veteran’s claim was remanded in September 2018, and the Board now reasserts jurisdiction of the matter. Disabilities of the knee are rated under Diagnostic Codes 5256 to 5263. 38 C.F.R. § 4.71a. Diagnostic Code 5260 provides that flexion of the leg limited to 15 degrees warrants a 30 percent rating; flexion limited to 30 degrees warrants a 20 percent rating; flexion limited to 45 degrees warrants a 10 percent rating; and flexion limited to 60 degrees warrants a zero percent (noncompensable) rating. 38 C.F.R. § 4.71a. Diagnostic Code 5261 provides that extension of the leg limited to 45 degrees warrants a 50 percent rating; extension limited to 30 degrees warrants a 40 percent rating; extension limited to 20 degrees warrants a 30 percent rating; extension limited to 15 degrees warrants a 20 percent rating; extension limited to 10 degrees warrants a 10 percent rating; extension limited to 5 degrees warrants a zero percent (noncompensable) rating. 38 C.F.R. § 4.71a. For comparison, normal range of motion of the knee is from zero degrees of extension to 140 degrees of flexion. See 38 C.F.R. § 4.71, Plate II. A 10 percent rating can also be assigned for the knee joint if there is painful motion without compensable limitation of motion. 38 C.F.R. §§ 4.59, 4.71a, Diagnostic Code 5003; see also Burton v. Shinseki, 25 Vet. App. 1 (2011) (holding that the applicability of 38 C.F.R. § 4.59 is not limited to arthritis claims). Recurrent subluxation and lateral instability of the knee warrants a 10, 20, or 30 percent rating if slight, moderate, or severe, respectively. 38 C.F.R. § 4.71a, Diagnostic Code 5257. When the knee disability affects the meniscus, a 20 percent rating is warranted when there is dislocated semilunar cartilage with frequent episodes of “locking,” pain, and effusion into the joint. 38 C.F.R. § 4.71a, Diagnostic Code 5258. A 10 percent rating is warranted when there has been removal of semilunar cartilage (e.g., meniscectomy) and current residual symptoms. 38 C.F.R. § 4.71a, Diagnostic Code 5259. Separate ratings can be assigned for the above knee disabilities (Diagnostic Codes 5257, 5258, 5259, 5260, and 5261) when none of the symptomatology overlaps and the separate rating is based on additional disabling symptomatology. See VAOPGCPREC 23-97, 62 Fed. Reg. 63,603 (1997); VAOPGCPREC 9-98, 63 Fed. Reg. 56,703 (1998); VAOPGCPREC 9-2004; 69 Fed. Reg. 59,988 (2004); Lyles v. Shulkin, 29 Vet. App. 107 (2017). Ratings can also be assigned for impairment of the tibia or fibula, removal of semilunar cartilage, genu recurvatum, or ankylosis of the knee. 38 C.F.R. § 4.71a, Diagnostic Codes 5256, 5259, 5262, 5263. By way of background, the Veteran’s knee was examined in May 2014. The claim was nonetheless remanded in September 2018 for a new examination in compliance with Correia v. McDonald, 28 Vet. App. 158 (2016) (instructing that VA orthopedic examinations should include testing for pain on both active and passive motion, in weight-bearing and non-weight-bearing (if applicable) and, if possible, with the range of the opposite undamaged joint), and Sharp v. Shulkin, 29 Vet. App. 26, 33 (2017) (outlining VA examiners’ obligation to elicit information regarding flare-ups of a musculoskeletal disability if the examination is not conducted during such a flare-up, and to use this information to characterize additional functional loss during flare-ups). This updated examination was performed in November 2019. The Board concludes that it is adequate; therefore, the Agency of Original Jurisdiction has afforded the Veteran substantial compliance with all previous remand directives. See Stegall v. West, 11 Vet. App. 268, 271 (1998). At the Veteran’s November 2019 examination, he denied flare-ups. See Sharp v. Shulkin, supra; VA Exam (Nov. 14, 2019), at Question No. 2b. The examiner supplied full Correia statements (about passive and active ranges of motion, weight-bearing and non-weight-bearing, between the affected joint and opposite unaffected joint), as was required in the last remand. See Correia v. McDonald, supra; VA Exam (Nov. 14, 2019), at Question No. 15. His right knee range of motion was measured as, at its most limited, from zero to 90 degrees flexion and from 90 to zero degrees extension on repetitive motion testing. See id. at Question No. 3c. Diagnostic Codes 5260 and 5261, respectively, do not yield any more advantageous ratings in excess of 10 percent. The examiner denied that the Veteran’s knee manifests in ankylosis, recurrent subluxation, or recurrent effusion, see id. at Questions Nos. 5, 6a, and 6c. Diagnostic Codes 5256 through 5259 do not yield any more advantageous ratings in excess of 10 percent either. There is no evidence of record to suggest that the Veteran has any more than a slight knee disability; therefore, Diagnostic Code 5262 does not appear to yield a more advantageous rating either. Finally, there is no evidence of record to suggest that the Veteran suffers from genu recurvatum; therefore, Diagnostic Code 5263 does not appear to yield a more advantageous rating either. Based on the foregoing, the evidence is against a finding that a rating in excess of 10 percent for the Veteran’s right knee limitation of flexion is warranted. Notably, flexion has been limited to at worst 90 degrees, and extension has been normal upon examination, to include after repetitive use, during flare ups, or as a result of other functional limitations. Given the above, even when considering the impact of knee pain on physical activities, higher or separate ratings are not warranted based on limitation of motion. 38 C.F.R. § 4.71a, Diagnostic Code 5260, 5261. The Board has considered the applicability of other potential diagnostic codes. As the evidence of record fails to ankylosis, impairment of the tibia or fibula, or genu recurvatum, the Veteran is not entitled to a higher or separate rating under 5256, 5262, or 5263, respectively, for his residuals of a torn meniscus of the right knee. Although the Veteran does have meniscus condition, the November 2019 VA examiner found that the only residual of that meniscal condition is arthralgia which is being rated herein. Therefore, a higher or separate rating under 5258 or 5259 is not warranted. The Board has considered whether there is any other schedular basis for further granting the above claim but has found none. The Board recognizes that it is the intent of the rating schedule to recognize actually painful, unstable or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. In this case, the Veteran is already assigned a 10 percent rating for his right knee under Diagnostic Code 5260, which is the minimum compensable rating allowable for the knee joint. The rating criteria reasonably describe the Veteran’s disability and his symptomatology. For all musculoskeletal disabilities, the rating schedule contemplates functional loss, which may be manifested by, for example, decreased or abnormal excursion, strength, speed, coordination, or endurance. 38 C.F.R. § 4.40; Mitchell v. Shinseki, 25 Vet. App. 32, 37 (2011). The Veteran’s knee disability has been manifested by symptoms of painful motion and limitation of flexion. The schedular rating criteria specifically provides ratings for painful arthritis (Diagnostic Codes 5003, 5257, 5258, 38 C.F.R. § 4.59) and limitation of motion (Diagnostic Code 5260), including motion limited to orthopedic factors such as pain, incoordination, weakness, and instability of station (38 C.F.R. §§ 4.40, 4.45, 4.59, DeLuca), which are incorporated into the schedular rating criteria. The Board acknowledges the Veteran’s occasional use of crutches, and that its use is not specifically noted in the rating criteria. However, the symptoms alleviated by the use of these devices are addressed. The medical record, particularly the VA examinations, describe the level of his disability when these devices are not in use and, as noted above, those symptoms are contemplated under the rating criteria. Cf. Jones v. Shinseki, 26 Vet. App. 56 (2012) (holding that the Board may not deny entitlement to a higher rating on the basis of relief provided by medication when the rating criteria does not specifically contemplate those effects). To the extent that the Veteran and contends that his right knee disorder is more severe than currently evaluated during any period on appeal, the Board observes that the Veteran, while competent to report symptoms, is not competent to report that his knee disabilities are of sufficient severity to warrant higher evaluations under VA’s rating schedule because such an opinion requires medical expertise (training in evaluating musculoskeletal impairment), which he has not been shown to possess. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007) (noting general competence to testify as to symptoms but not to provide medical diagnosis); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006); Charles v. Principi, 16 Vet. App. 370 (2002); Woehlaert v. Nicholson, 21 Vet. App. 456 (2007) (although the claimant is competent in certain situations to provide a diagnosis of a simple condition such as a broken leg or varicose veins, the claimant is not competent to provide evidence as to more complex medical questions). The Board has considered whether a staged rating under Hart, supra is appropriate; however, the Board finds that the remainder of his symptomatology has been stable throughout the appeal. Therefore, assigning a staged rating is not warranted. Further, the Veteran has not raised any other issues, nor have any other issues been reasonably raised by the record, with regard to such claim. Doucette v. Shulkin, 28 Vet. App. 366 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). Finally, the Board notes the ruling of the Court of Appeals for Veterans Claims (Court) in Rice v. Shinseki, 22 Vet. App. 447 (2009). In Rice, the Court held that a claim for a TDIU, either expressly raised by the Veteran or reasonably raised by the record, involves an attempt to obtain an appropriate rating for a disability and is part of the claim for an increased rating. In this case, the Veteran reported that he had retired from work in a November 2019 VA examination. The Veteran has not otherwise alleged, and the record does not suggest, that he is unable to obtain and maintain employment due to his right knee disorder. As such, Rice is inapplicable in this case. For all the foregoing reasons, there is no basis for any higher or separate rating at any point during the period on appeal. As the preponderance of the evidence is against a higher or separate rating, the benefit-of-the-doubt rule does not apply and the claim must be denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 2. Entitlement to a rating in excess of 10 percent for residuals of tibiotalar degenerative joint disease of the right ankle is denied. The Veteran generally contends that a higher rating is warranted for his right ankle disorder. Specific argument in support of this appeal has not been presented. The Veteran’s right ankle disorder is rated by analogy under Diagnostic Code 5010-5271 (tibiotalar degenerative joint disease and status postarthroscopic surgery, right ankle). This “built-up” Diagnostic Code reflects the rater’s attempt to arrive at the best criteria for rating a disability which does not specifically appear in the rating schedule. 38 C.F.R. § 4.27. Diagnostic Code 5010 refers to traumatic arthritis and is rated based upon limitation of motion of the affected part (in this case, for the Veteran’s right ankle; more specifically, either due to impairment of range of motion of the ankle [Diagnostic Code 5271]). The Veteran received a temporary total disability rating under 38 C.F.R. § 4.30 from December 14, 2009 until prior to February 1, 2010. As the Veteran is in receipt of a maximum disability rating for this service-connected disorder during that period on appeal. See Sabonis v. Brown, supra. Aside from that period of time, because higher ratings are available throughout the rest of the appellate period, the claim remains on appeal accordingly. See AB v. Brown, supra. By way of background, the Veteran’s claim was remanded in September 2018, and the Board now reasserts jurisdiction of the matter. The Veteran’s residuals of tibiotalar degenerative joint disease is rated under Diagnostic Code 5010-5271. 38 C.F.R. § 4.71a. A 10 percent rating is awarded for “moderate” limitation of motion; a 20 percent for “marked.” 38 C.F.R. § 4.71a, Diagnostic Code 5271. The normal range of motion in the ankle is 20 degrees of dorsiflexion and 45 degrees of plantar flexion. See 38 C.F.R. § 4.71, Plate II. Notably, the terms "moderate" and "marked" are not defined under VA regulations. Those terms also do not appear to have a generally accepted medical definition. Rather than applying a mechanical formula, the Board must evaluate all of 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 "moderate" by VA examiners and others, although 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. Under the revised diagnostic code, marked limitation of ankle motion constitutes less than five degrees of dorsiflexion or less than 10 degrees of plantar flexion while moderate limitation of ankle motion constitutes less than 15 degrees of dorsiflexion or less than 30 degrees of plantar flexion. Diagnostic Code 5010 directs a rating as degenerative arthritis, which is in rated in Diagnostic Code 5003. In Diagnostic Code 5003, a 10 percent rating is awarded with X-ray evidence of involvement of two or more major joints or two or more minor joint groups; a 20 percent rating is awarded when the disorder manifests in occasional incapacitating episodes. Under the amended diagnostic code, post-traumatic arthritis is to be rated as limitation of motion, dislocation or other specified instability under the affected joint. By way of background, the Veteran’s ankle was examined in May 2014. The claim was nonetheless remanded in September 2018 for a new examination in compliance with Correia v. McDonald, supra, and Sharp v. Shulkin, supra. This updated examination was performed in November 2019. The Board concludes that it is adequate; therefore, the Agency of Original Jurisdiction has afforded the Veteran substantial compliance with all previous remand directives. See Stegall v. West, 11 Vet. App. 268, 271 (1998). At the Veteran’s November 2019 examination, he denied flare-ups. See Sharp v. Shulkin, supra; VA Exam (Nov. 14, 2019), at Question No. 2b. The examiner supplied full Correia statements (about passive and active ranges of motion, weight-bearing and non-weight-bearing, between the affected joint and opposite unaffected joint), as was required in the last remand. See Correia v. McDonald, supra; VA Exam (Nov. 14, 2019), at Question No. 14. His right ankle range of motion was measured as, at its most limited, from 15 degrees dorsiflexion and 20 degrees plantar flexion. See id. at Question No. 3c. There is no evidence of record suggesting that his range of motion has ever been more limited than at that time. As a result, the Board concludes that the preponderance of the evidence of record suggests that the Veteran’s right ankle has only exhibit moderate limitation of motion; on the other hand, there is no evidence of record suggesting marked limitation of motion under the old criteria or the new criteria. Based on the foregoing, the evidence is against a finding that a rating in excess of 10 percent for the Veteran’s right ankle limitation of range of motion is warranted. 38 C.F.R. § 4.71a. The Board has considered whether there is any other schedular basis for further granting the above claim but has found none. The Board recognizes that it is the intent of the rating schedule to recognize actually painful, unstable or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. In this case, the Veteran is already assigned a 10 percent rating for his right ankle under Diagnostic Code 5271, which is the minimum compensable rating allowable for the ankle. Here, the rating criteria reasonably describe the Veteran’s disability and his symptomatology. For all musculoskeletal disabilities, the rating schedule contemplates functional loss, which may be manifested by, for example, decreased or abnormal excursion, strength, speed, coordination, or endurance. 38 C.F.R. § 4.40; Mitchell v. Shinseki, 25 Vet. App. 32, 37 (2011). The Veteran’s ankle disability has been manifested by symptoms of painful motion. The schedular rating criteria specifically provides ratings for painful traumatic arthritis (Diagnostic Code 5010) and limitation of motion (Diagnostic Code 5271), including motion limited to orthopedic factors such as pain, incoordination, weakness, and instability of station (38 C.F.R. §§ 4.40, 4.45, 4.59, DeLuca), which are incorporated into the schedular rating criteria. The Board acknowledges the Veteran’s occasional use of crutches, and that its use is not specifically noted in the rating criteria. However, the symptoms alleviated by the use of these devices are addressed. The medical record, particularly the VA examinations, describe the level of his disability when these devices are not in use and, as noted above, those symptoms are contemplated under the rating criteria. Cf. Jones v. Shinseki, supra. To the extent that the Veteran and contends that his right ankle disorder is more severe than currently evaluated during any period on appeal, the Board observes that the Veteran, while competent to report symptoms, is not competent to report that his knee disabilities are of sufficient severity to warrant higher evaluations under VA’s rating schedule because such an opinion requires medical expertise (training in evaluating musculoskeletal impairment), which he has not been shown to possess. See Davidson v. Shinseki, supra; See Jandreau v. Nicholson, supra; Buchanan v. Nicholson, supra; Charles v. Principi, supra; Woehlaert v. Nicholson, supra. The Board has considered whether a staged rating under Hart, supra is appropriate; however, the Board finds that the remainder of his symptomatology has been stable throughout the appeal. Therefore, assigning a staged rating is not warranted. Further, the Veteran has not raised any other issues, nor have any other issues been reasonably raised by the record, with regard to such claim. Doucette v. Shulkin, supra. Finally, the Board notes the ruling of the Court in Rice v. Shinseki, supra. In Rice, the Court held that a claim for a TDIU, either expressly raised by the Veteran or reasonably raised by the record, involves an attempt to obtain an appropriate rating for a disability and is part of the claim for an increased rating. In this case, the Veteran reported that he had retired from work in a November 2019 VA examination. The Veteran has not otherwise alleged, and the record does not suggest, that he is unable to obtain and maintain employment due to his right ankle disorder. As such, Rice is inapplicable in this case. For all the foregoing reasons, there is no basis for any higher or separate rating at any point during the period on appeal. As the preponderance of the evidence is against a higher or separate rating, the benefit-of-the-doubt rule does not apply and the claim must be denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, supra. REASONS FOR REMAND 1. Entitlement to service connection for a hip disorder is remanded. A VA examination is required when there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability, (2) evidence establishing that an event, injury, or disease occurred in service, or establishing certain diseases manifesting during an applicable presumptive period for which the claimant qualifies, and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the veteran’s service or with another service-connected disability, but (4) there is insufficient competent medical evidence on file for the Secretary to make a decision on the claim. McLendon v. Nicholson, 20 Vet. App. 79 (2006). See also 38 U.S.C. § 5103A(d)(2), 38 C.F.R. § 3.159(c)(4)(i).  The third prong, which requires that the evidence of record “indicate” that the claimed disability or symptoms “may be” associated with the established event, is a low threshold. McLendon, 20 Vet. App. at 83. The Veteran’s claim for service connection for a hip disorder was remanded in September 2018, so that the AOJ could associate medical treatment records with the Veteran’s claims file, including but not limited to an April 2018 referral to a radiologist for a magnetic imaging resonance scan, and any magnetic resonance imaging (MRI) results as to said hip pain. From this remand and the AOJ’s efforts in associating relevant medical records with the claims file, the Board notes that there is an indication that hip pain derives from “a fall while Patient was in military training.” See VA Treatment Records ( Apr. 13, 2018 ). As a result, the Board concludes that the Veteran is entitled to a VA examination to substantiate his claim, which he has not yet received for the claim of service connection for hip pain. See McLendon, supra. For this reason, this claim must be remanded. 2. Entitlement to service connection for an acquired psychiatric disorder is remanded. The Veteran’s claim for service connection for an acquired psychiatric disorder was remanded in September 2018 in order to ascertain the appropriate diagnosis/es, and to obtain full etiological opinions as to whether any applicable acquired psychiatric disorder is secondary to his service-connected right knee or right ankle disorder. A remand is required so that an addendum opinion can be obtained, because the Board concludes that the November 2019 psychiatric exam contains inadequate rationale. See VA Exam ( Nov. 26, 2019 ). The November 2019 examiner appears to conclude that the Veteran’s psychiatric disorder is not related to his service-connected right knee or right ankle disorder because the Veteran’s psychiatric treatment only started in 2013—more than six years after discharge and the effective date of those disorders. The Board concludes that this opinion is inadequate for basing a negative nexus opinion (i.e.: deeming that a disorder is not at least 50 percent likely attributable to service) solely based upon years without psychiatric treatment prior to diagnosis. See Dalton v. Nicholson, 21 Vet. App. 23 (2007) (an examination was inadequate where the examiner did not comment on a Veteran’s reports of in-service injury and instead relied on the absence of evidence in a Veteran’s service treatment records to provide a negative opinion). Furthermore, the examiner concluded that the psychiatric disorder has a different etiology from the knee and ankle disorders, but the examiner does not specify this alternative etiology. The Board cannot appropriately weigh this conclusion, because it is merely conclusory. See Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) (“[A] medical opinion must support its conclusion with an analysis the Board can consider and weight against contrary opinion”). Finally, as stated by the September 2018 Board remand, the November 2019 examiner was tasked with fully considering all theories of service connection for the Veteran’s claimed psychiatric disorder as secondary to the right knee or right ankle disorders. There is no opinion as to whether the Veteran’s acquired psychiatric disorder is secondarily aggravated beyond its natural progression by either of these service-connected disorders. El-Amin v. Shinseki, 26 Vet. App. 136, 140 (2013) (holding that findings of “not due to,” “not caused by,” and “not related to” a service-connected disability are insufficient to address the question of aggravation under 38 C.F.R. § 3.310(b)). Alternatively, the Board concludes that the Veteran is entitled to substantial compliance with all previous remand directives, see Stegall v. West, 11 Vet. App. 268, 271 (1998), and that to afford him substantial compliance, a remand is required to obtain an opinion as to secondary aggravation. The matters are REMANDED for the following action: 1. The Veteran should be given an opportunity to identify any outstanding private or VA treatment records relevant to the claims on appeal. After obtaining any necessary authorization from the Veteran, all outstanding records, to include any VA treatment records, should be obtained. For private treatment records, make at least two (2) attempts to obtain records from any identified sources. If any such records are unavailable, inform the Veteran and his attorney, and afford them an opportunity to submit any copies in their possession. For federal records, all reasonable attempts should be made to obtain such records. If any records cannot be obtained after reasonable efforts have been made, issue a formal determination that such records do not exist or that further efforts to obtain such records would be futile, which should be documented in the claims file. The Veteran must be notified of the attempts made and why further attempts would be futile, and allowed the opportunity to provide such records, as provided in 38 U.S.C. § 5103A(b)(2) and 38 C.F.R. § 3.159(e). 2. Following the receipt of outstanding records, schedule the Veteran for an examination by an appropriate clinician to determine the current nature and etiology of his claimed hip disorder. The entire record, to include a copy of this Remand, must be made available to and be reviewed by the examiner. Any indicated evaluations, studies, and tests should be conducted. The need for an in-person examination is left to the discretion of the examiner. The examiner should respond to the following questions: (A) Identify all current hip disorder(s) that have been present at any time since December 2011. (B) Is it at least as likely as not (more than 50 percent probability) that the Veteran’s hip disorder began in service, was caused by service, or is otherwise related to service? A rationale should be provided for all opinions offered. If it is not possible to provide a specific opinion regarding the above questions, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). The medical opinion must support the conclusions reached with an analysis that is adequate for the Board to consider and weigh against other evidence of record; medical opinions must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. If an opinion cannot be expressed without resort to speculation, ensure that the clinician so indicates and discusses why an opinion is not possible, to include whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. 3. Following the receipt of outstanding records, then return the claims file, to include a copy of this remand, to the November 2019 VA examiner for an addendum opinion. If the examiner who drafted the November 2019 opinion is unavailable, the opinion should be rendered by another appropriate medical professional. The need for another examination is left to the discretion of the medical professional offering the addendum opinion. The examiner is asked to answer the following questions: (A) With regards to the diagnosed acquired psychiatric disorder, the examiner should offer an opinion as to whether it was at least as likely as not (a 50 percent or higher probability) that such disorder was caused by his service connected residuals of a torn meniscus of the right knee and/or residuals of tibiotalar degenerative joint disease of the right ankle? (B) With regards to the diagnosed acquired psychiatric disorder, the examiner should offer an opinion as to whether it was at least as likely as not (a 50 percent or higher probability) that such disorder was aggravated by his service connected residuals of a torn meniscus of the right knee and/or residuals of tibiotalar degenerative joint disease of the right ankle? (Continued on the next page)   A rationale should be provided for all opinions offered. If it is not possible to provide a specific opinion regarding the above questions, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). The medical opinion must support the conclusions reached with an analysis that is adequate for the Board to consider and weigh against other evidence of record; medical opinions must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. If an opinion cannot be expressed without resort to speculation, ensure that the clinician so indicates and discusses why an opinion is not possible, to include whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. KRISTY L. ZADORA Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Michael B. Engle, 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.