Citation Nr: 21008627 Decision Date: 02/17/21 Archive Date: 02/17/21 DOCKET NO. 14-24 609A DATE: February 17, 2021 ORDER Entitlement to an evaluation of 20 percent, but no higher, for a left shoulder disability is granted. Entitlement to an initial evaluation in excess of 10 percent for left ulnar neuropathy is denied prior to March 13, 2018. Entitlement to an initial evaluation of 20 percent, but no higher, is warranted for left ulnar neuropathy from March 13, 2018. REMANDED Entitlement to service connection for a right knee disability, to include as secondary to service-connected left knee disability, is remanded. Entitlement to service connection for bilateral carpal tunnel syndrome is remanded. Entitlement to an evaluation in excess of 20 percent for a lumbar spine disability is remanded. Entitlement to increased evaluations for a left knee disability is remanded. Entitlement an evaluation in excess of 10 percent prior to March 1, 2018, and in excess of 50 percent thereafter for an acquired psychiatric disorder is remanded. Entitlement to an evaluation in excess of 10 percent for left vastis lateralis tendon tear with tibial tuberosity is remanded. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is remanded. Entitlement to an evaluation in excess of 10 percent for migraine headaches is remanded. FINDINGS OF FACT 1. Prior to March 13, 2018, the evidence of record reflects the left shoulder disability manifested in painful motion of the shoulder and slight limitation of motion of the arm. 2. Beginning March 13, 2018, the record indicates the left shoulder disability manifested in limitation of motion of the arm to shoulder level. 3. The left ulnar neuropathy manifested in pain, sensation of weakness, and decreased sensation to light touch, indicating a mild level of incomplete paralysis prior to March 13, 2018. 4. As of March 13, 2018, the left ulnar neuropathy manifested in pain, decreased sensation to light touch and mild to moderate decreased grip and pinch strength, indicating a moderate level of incomplete paralysis. CONCLUSIONS OF LAW 1. The criteria for an evaluation of 20 percent, but no higher, for a left shoulder disability have been met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 3.102, 4.1-4.10, 4.59, 4.71a, Diagnostic Code 5201-5010. 2. The criteria for an evaluation in excess of 10 percent for left ulnar neuropathy prior to March 13, 2018 have not been met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 3.102, 4.1-4.10, 4.124a, Diagnostic Code 8516. 3. The criteria for an evaluation of 20 percent, but no higher, for left ulnar neuropathy from March 13, 2018 have been met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 3.102, 4.1-4.10, 4.124a, Diagnostic Code 8516. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty with the United States Army from November 1980 to March 1987. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from November 2011, April 2012, and November 2015 rating decisions issued by a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified before the undersigned Veterans Law Judge (VLJ) at a hearing in January 2017. This case was previously before the Board in February 2018 and April 2019, when it was remanded for development. The case has been returned to the Board for further appellate review. 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. When there is a question as to which of two ratings apply, VA will assign the higher of the two where the disability picture more nearly approximates the criteria for the next higher rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Disabilities must be viewed in relation to their entire history. 38 C.F.R. § 4.1. VA is required to interpret reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability. 38 C.F.R. § 4.2. Any reasonable doubt regarding the degree of disability will be resolved in favor of the claimant. 38 C.F.R. § 4.3. VA is also required to evaluate functional impairment on the basis of lack of usefulness and the effects of the disabilities upon the claimant’s ordinary activity. 38 C.F.R. § 4.10; see generally Schafarth v. Derwinski, 1 Vet. App. 589 (1991). Disability of the musculoskeletal system is primarily the inability, due to damage or inflammation of parts of the system, to perform the normal working movements of the body with normal excursion, strength, coordination, and endurance. 38 C.F.R. §4.40. The functional loss may be due to the loss of part or all of the necessary bones, joints, and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or it may be due to pain, and evidenced by visible behavior of the claimant undertaking the motion. Id. Weakness is as important as limitation of motion, and a body part which becomes painful on use must be regarded as seriously disabled. 38 C.F.R. §§ 4.40, 4.45; see also DeLuca v. Brown, 8 Vet. App. 202 (1995). For disabilities evaluated on the basis of limitation of motion, VA is required to apply the provisions of sections 4.40 and 4.45 pertaining to functional impairment. DeLuca, 8 Vet. App. at 207-08. In applying these regulations, VA must obtain examinations in which the examiner determines whether the disability was manifested by pain, weakened movement, excess fatigability, incoordination, and flare-ups which resulted in functional loss. These determinations, if feasible, should be expressed in terms of the degree of additional range-of-motion loss due to those factors. DeLuca, 8 Vet. App. at 207-08; see also Mitchell v. Shinseki, 25 Vet. App. 32 (2011). Functional loss of a joint can give rise to a higher schedular rating, to include if such functional loss is due to pain, but pain itself does not rise to the level of functional loss contemplated by VA regulations. See Mitchell, 25 Vet. App. at 37-38. Finally, painful motion is an important factor of disability with any form of arthritis. 38 C.F.R. § 4.59. The intent of the rating schedule is to recognize painful motion with joint or periarticular pathology as productive of disability; actually painful, unstable, or malaligned joints, due to healed injury, are entitled to at least the minimum compensable rating for the joint. Id. 1. Entitlement to an evaluation in excess of 10 percent for a left shoulder disability The Veteran’s left shoulder disability is current rated as 10 percent disabling under Diagnostic Code (DC) 5201-5010, indicating arthritis of the shoulder limiting motion of the arm. The shoulder and arm codes distinguish between the major, or dominant, extremity and the minor, or non-dominant, extremity. 38 C.F.R §§ 4.69, 4.71a. The evidence shows the Veteran to be right-hand dominant. Diagnostic Code 5201 governs limitation of motion of the arm. Where the arm’s range of motion is limited to shoulder level, a 20 percent rating is assigned to either a major or minor extremity. Limitation of motion of the arm from midway between the side and shoulder level also warrants a 20 percent evaluation for a minor extremity. Limitation of motion to 25 degrees from the side warrants a 30 percent evaluation for a minor extremity. The Board notes an update to the regulations went into effect on February 7, 2021; however, the update does not substantively change this particular diagnostic code, but clarifies “shoulder level” as flexion and/or abduction limited to 90 degrees, and “midway between the side and shoulder level” as flexion and/or abduction limited to 45 degrees. The Veteran’s VA records reflect complaints of pain throughout the period on appeal. Other than as noted below, the VA treatment records do not contain treatment for the left shoulder or reports of functional loss. None of the private treatment records in the claims file pertain to the Veteran’s left shoulder, nor is there any indication the Veteran ever sought treatment for his shoulder with a private provider. In January 2011, the Veteran attended a VA joints examination. The examiner noted instability, pain, stiffness, weakness, incoordination, and decreased speed of joint motion in the left shoulder. The Veteran reported locking episodes several times a year, but denied dislocation, subluxation, effusion, and flare-ups. The examiner noted the left shoulder disability did not affect the motion of the joint, and the range of motion testing resulted in a full range of motion (180 degrees in flexion and abduction, and 90 degrees in internal and external rotation), with objective evidence of pain noted on active motion. There was no objective evidence of pain noted following repetitive motion, and no change to the range of motion measurements. In May 2014, the Veteran sought treatment for increased left shoulder pain. The VA physician noted tenderness to the skin over the upper trapezius out of proportion to any visible reason, and no visibly obvious deformity or redness. The Veteran did not permit the physician to perform a full physical evaluation of the left shoulder for fear of pain. The Veteran attended a physical therapy consultation for the left shoulder pain in July 2014, where he reported discomfort with active movements and all activities of daily living. The physical therapist measured the active range of motion to be 30 degrees in flexion and abduction, and 50 degrees in external and internal rotation, noting the Veteran demonstrated submaximal effort. The passive range of motion was measured to be 150 degrees in flexion and abduction, and 60 degrees in external rotation. The Board notes this treatment record does not indicate whether a goniometer was used to measure these ranges of motion. See 38 C.F.R. § 4.46. The physical therapist also noted decreased muscle strength in the left shoulder. The Veteran declined a course of physical therapy and requested instead a home exercise program. In November 2014, the Veteran attended an orthopedic surgery consultation for his left shoulder. The VA surgeon noted the left shoulder was stable and did not lock or catch. The surgeon measured the range of motion to be 150 degrees in flexion and 45 degrees in external rotation, noting no pain at 90 degrees in abduction. Again, the Board notes this treatment record does not indicate whether a goniometer was used to measure the range of motion. See 38 C.F.R. § 4.46. The surgeon noted no pain or weakness against resistance in external and internal rotation. The surgeon did not propose surgery to treat the left shoulder, recommending instead continued pain management. In March 2018, the Veteran attended another VA examination, at which he reported difficulty reaching or lifting overhead with his left arm. He also reported that he cannot drive more than a short distance because his left shoulder begins to hurt when his left hand is on the steering wheel. The range of motion of the left shoulder was measured to be 70 degrees in flexion; 60 degrees in abduction; and 10 degrees in internal and external rotation. Pain was noted in all ranges of motion. Muscle strength testing revealed normal results in the left shoulder. The Board notes the Veteran reported flare-ups with weather changes during which he tries not to use his left arm; the examiner declined to opine as to additional limitation of range of motion during flare-ups. In August 2019, the Veteran was afforded a third VA examination, at which he reported flare-ups of increased pain with prolonged use of the shoulder. He also reported difficulty picking up objects with his left hand and arm, and the examiner noted he would have difficulty lifting, carrying, pushing, and pulling heavy objects, as well as with completing overhead tasks. The range of motion of the left shoulder was measured to be 90 degrees in flexion and abduction; 90 degrees in external rotation and 45 degrees in internal rotation. Pain was noted in all ranges of motion, and muscle strength testing revealed slightly decreased strength in the left shoulder. The examiner opined that there would be no additional limitation to range of motion during a flare-up. Ankylosis; recurrent dislocation; malunion, fibrous union, or nonunion of the humerus; flail shoulder; and impairment of the clavicle or scapula were not noted in the left shoulder at any point during the period on appeal. After review of the evidence of record, the Board finds an increase is warranted to 20 percent for the entire appeal period. Prior to March 13, 2018, the record reflects reports of pain in the left shoulder, and objective evidence of pain on active motion noted at the January 2011 examination. The Veteran’s active range of motion at the July 2014 physical therapy consultation was only 30 degrees in flexion and abduction, which would be considered less than midway between the side and shoulder level; however, the physical therapist opined the Veteran gave submaximal effort on active motion, and the passive range of motion at the same visit was 150 degrees in flexion and abduction. The Board notes the general disparity between the active and passive ranges of motion, as well as the physical therapist’s opinion of submaximal effort on active motion and the similarity of the passive range of motion measurements to those made in November 2014 by the orthopedic surgeon. The Board finds that these records tend to indicate a range of motion above shoulder level, rather than limited to shoulder level or below. Nonetheless, the Board finds that a 20 percent rating for painful limited motion of the left shoulder is warranted under the provisions of 38 C.F.R. § 4.59. The Veteran has competently and credibly reported throughout the appeal period that he experiences painful motion in his left shoulder and painful motion has been observed on examination. The minimum compensable rating for the shoulder is warranted based on the presence of painful limited motion under the provisions of 38 C.F.R. § 4.59. See Sowers v. McDonald, 27 Vet. App. 472, 481-82 (2016) (noting that while there is a 10 percent rating available for the shoulder across all diagnostic codes, a 20 percent rating is the minimum compensable rating for the shoulder for limitation of motion). Beginning March 13, 2018, the record reflects more severe limitation of motion of the left arm. Flexion was measured to be 70 degrees at the March 2018 examination and 90 degrees (shoulder level) at the August 2019 examination; abduction was noted to be 60 degrees in March 2018 and 90 degrees in August 2019. Therefore, a 20 percent rating under DC 5201 is warranted for limitation of motion to shoulder level. A higher evaluation is not warranted for this period. Although the Veteran reported flare-ups at both the March 2018 and August 2019 examinations, the descriptions of these flare-ups indicate the Veteran experiences increased pain but not additional functional limitation. The March 2018 VA examiner failed to estimate whether the flare-ups caused any additional range of motion loss; the Veteran reported favoring his right arm over his left during flare-ups, but did not indicate that he was unable to lift his right arm more than 25 degrees from his side, which would approximate the criteria for the next higher rating. This analysis does not change with the clarifications made to the rating schedule in the February 2021 update to the rating criteria. As noted above, ankylosis; recurrent dislocation; malunion, fibrous union, or nonunion of the humerus; flail shoulder; and impairment of the clavicle or scapula were not clinically noted in the left shoulder at any point during the period on appeal. Therefore, the other diagnostic codes relevant to the shoulder and arm are not for application in this case, and no higher evaluations are available under other diagnostic codes for either portion of the period on appeal. See 38 C.F.R. § 4.71a, DCs 5200, 5202, 5203. In conclusion, the Board finds a 20 percent evaluation, but no higher, is warranted for the period on appeal. 2. Entitlement to an initial evaluation in excess of 10 percent for left ulnar neuropathy The Veteran’s left ulnar neuropathy has been rated using DC 8516 for paralysis of the ulnar nerve. 38 C.F.R. § 4.124a. As noted above, the evidence of record indicates the Veteran’s dominant hand is his right hand, so the minor ratings apply to the left ulnar neuropathy. Diagnostic Code 8516 provides that 10, 20, and 30 percent ratings are assigned to a non-dominant extremity depending on whether the incomplete paralysis of the nerve is mild, moderate, or severe, respectively. Complete paralysis of the ulnar nerve, which is described as the “griffin claw” deformity due to flexor contraction of the ring and little fingers, warrants a 50 percent rating. The term “incomplete paralysis” indicates a degree of lost or impaired function substantially less than the type pictured for complete paralysis given with each nerve. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. 38 C.F.R. § 4.124a. The words “mild,” “moderate,” and “severe,” as used in the various diagnostic codes, are not defined in the rating schedule. The use of these terms by VA examiners and others, although an element of evidence to be considered by the Board, is not dispositive of an issue. 38 C.F.R. §§ 4.2, 4.6. 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. Here, the Veteran was granted service connection for left ulnar neuropathy in a December 2009 rating decision, and submitted his claim for a TDIU, which triggered this appeal of the evaluation of the left ulnar neuropathy, in October 2010. Therefore, the Board will review the evaluation from the effective date of service connection, June 16, 2009. The Veteran’s VA treatment records show that he is followed for left ulnar neuropathy throughout the appeal period, but do not contain specific complaints of ulnar neuropathy symptoms other than as specifically noted below. In December 2009, the Veteran attended a VA examination, at which he reported numbness and weakness in his left hand, increased by repetitive tasks, and that he dropped objects frequently. The examiner noted dexterity was intact in the left hand. There was a mild decrease in strength of pushing, pulling, and twisting, and diminished sensation to light touch in the fourth and fifth digits. Grip strength in the left hand was noted to be slightly decreased as well, measuring 4+ out of 5. The examiner opined that most of the Veteran’s hand complaints were due to the neuropathy rather than to the service-connected residuals of a fourth metacarpal fracture. At a January 2011 VA examination, the Veteran reported no issues since the December 2009 examination, and that the symptoms had improved. The Veteran denied dysesthesias, and testing in response to vibration, pinprick, position sense, and light touch was all normal. Muscle strength was noted to be slightly decreased, with the Veteran able to perform active movement against some resistance, although the examiner noted unreliable and inconsistent results, and the muscle strength was also slightly decreased in the right upper extremity. In May 2014, the Veteran underwent an environmental agents evaluation at VA, where he described pain in his neck that radiates down to his left shoulder and elbow. In February 2015, the Veteran attended another VA examination, at which he reported numbness, stiffness, and shooting pain, as well as reduced control of his left hand. He reported that sometimes his left arm from the elbow to the hand “just dies,” and that he has to be careful what he picks up, as he might drop it. The Veteran endorsed moderate intermittent pain and numbness, and mild paresthesias. Slightly decreased grip strength and pinch strength was noted, with the Veteran able to perform active movement against some resistance. The examiner opined that the decreased motor strength results were due to suboptimal effort on the Veteran’s part and were not useful for diagnostic purposes. The examiner noted the motor strength results were in contrast to the Veteran displaying strength and intrinsic hand motion within normal limits when asked to spread his fingers out to look for fasciculation. The examiner also noted the Veteran was independent in removing and replacing the hand splints he wore for the non-service-connected carpal tunnel syndrome, and that he was able to point and gesticulate during normal conversation with his left hand. Sensory testing was all normal, and the examiner noted mild incomplete paralysis of the ulnar nerve. The examiner noted the condition is based on subjective symptoms reported by the Veteran, and opined that the subjective complaints were out of proportion to the objective examination findings. On March 13, 2018, the Veteran attended another VA examination, at which he complained of a weakened grip. The Veteran endorsed moderate intermittent pain, paresthesias, and numbness in his left upper extremity. Muscle strength was normal in the extremity, except for decreased grip and pinch strength, with the Veteran able to perform active movement against some resistance. Decreased sensation to light touch was noted in the left forearm and hand, in the left ulnar distribution distal to the elbow. The examiner noted moderate incomplete paralysis of the ulnar nerve. After review of the record, the Board finds that an increased evaluation is warranted in this case, from March 13, 2018. First, the Board notes the December 2009, January 2011, and February 2015 VA examinations all describe a disability that is mild in severity. At the first two examinations, the Veteran did not complain of pain, only numbness and weakness, and his grip strength was noted to be slightly decreased. However, the January 2011 examiner opined that the results of the muscle strength testing were unreliable, and that both upper extremities reflected the same degree of weakness. In May 2014, the Veteran began reporting pain associated with the left ulnar neuropathy. At the February 2015 VA examination, he reported functional impairment due to his neuropathy symptoms, including loss of left hand control and grip strength. However, the February 2015 examiner opined that the Veteran’s subjective complaints were out of proportion to the objective examination findings, and that the clinical findings of decreased motor strength were not reliable for diagnostic purposes. The examiner specifically pointed out that the hand movements the Veteran easily did during other parts of the examination demonstrated hand strength and motion within normal limits, as opposed to the grip strength he demonstrated upon motor strength testing. The examiner indicated that this demonstrated the Veteran was not giving full effort when his grip strength was tested and that the grip strength test results were not reliable for diagnostic purposes. Therefore, the Board finds the left ulnar neuropathy symptoms include pain and sensation of weakness but not reduced grip strength. The March 2018 VA examination documents complaints reflecting increased severity of the neuropathy symptoms. After resolving the benefit of reasonable doubt in favor of the Veteran, the Board finds that the Veteran had moderate incomplete paralysis of the ulnar nerve as of the date of this examination, based on the examiner’s description of the incomplete paralysis as moderate, and the clinical findings from the March 2018 examination which demonstrate decreased grip and pinch strength. Although the previous examiners had found the Veteran’s efforts when grip and pinch strength were tested, the March 2018 examiner did not make a similar finding. Therefore, after resolving the benefit of reasonable doubt in favor of the Veteran, the Board finds that a 20 percent rating is warranted for left ulnar neuropathy as of March 13, 2018. At no point, however, have severe symptoms of left ulnar neuropathy been demonstrated, given that the Veteran has had only slight to moderate symptoms, based both on his own description and based on the observations of the clinical examiners. Thus, a rating in excess of 20 percent is not warranted. REASONS FOR REMAND 1. Entitlement to service connection for a right knee disability, to include as secondary to service-connected left knee disability, is remanded. The April 2019 Board remand found the November 2015 VA opinion regarding secondary service connection for the right knee to be inadequate. In August 2020, a VA examiner opined that the right knee disability is not related to service, because the arthroscopic surgery to remove foreign bodies from the right knee occurred more than ten years after separating. The examiner further opined that the right knee disability is not caused by the service-connected left knee arthritis, because the right knee is a separate entity unrelated to the left knee, and a review of medical literature failed to demonstrate a causal relationship. The examiner also opined that the service-connected left knee disability did not aggravate the right knee disability, again because the knees are not related entities. The examiner gave the same rationale for opinions regarding secondary service connection to the lumbar spine disability and the scars of the left knee. As these opinions do not consider the Veteran’s particular circumstances in arriving at the negative nexus conclusions, they are inadequate, and another remand is necessary. 2. Entitlement to service connection for bilateral carpal tunnel syndrome is remanded. The August 2019 VA examination identified a diagnosis of bilateral carpal tunnel syndrome. The VA examiner opined that the carpal tunnel syndrome is likely not proximately due to the service-connected residuals of a fracture of the left fourth metacarpal or the ulnar neuropathy of the left upper extremity, as carpal tunnel involves neural entrapment on the median nerve, and the hand and ulnar nerve are not involved. The examiner noted that an injury of the left hand would not account for bilateral carpal tunnel syndrome, but did not consider the service-connected residuals of a fracture to the right fifth digit. Further, the examiner did not consider whether the carpal tunnel syndrome is caused or aggravated by the Veteran’s service-connected left shoulder disability. Therefore, this opinion is incomplete, and a remand is necessary for an adequate opinion addressing all aspects of the Veteran’s claim. 3. Entitlement to an evaluation in excess of 20 percent for a lumbar spine disability is remanded. The Board notes that in July 2020, the Veteran complained of chronic knee and low back pain affecting his mobility, and reported that he was only able to perform approximately 30 to 40 percent of his regular activities due to the pain. Because it appears that the lumbar spine disability has worsened since the last evaluation, a new VA examination is necessary to determine the current severity of the Veteran’s left knee disability. See Palczewski v. Nicholson, 21 Vet. App. 174, 181-82 (2007); Snuffer v. Gober, 10 Vet. App. 400, 403 (1997). 4. Entitlement to increased evaluations for a left knee disability is remanded. In July 2020, the Veteran indicated in various statements that his left knee disability may have increased in severity; however, in the August 2020 VA knee examination, the Veteran declined to perform active range of motion testing on the left knee due to fear of pain. Although the Veteran provided descriptive reports of his left knee pain and the examiner was able to perform passive range of motion testing, on remand the RO should attempt to obtain an examination in compliance with Correia in order to provide the Veteran with every opportunity to substantiate his claim for an increased rating. See Correia v. McDonald, 28 Vet. App. 158, 168-70 (2017) (VA examination of the joints must, wherever possible, include results of range of motion testing for pain in both active and passive motion, in weight-bearing and non-weight-bearing). 5. Entitlement to an evaluation in excess of 10 percent for left vastis lateralis tendon tear with tibial tuberosity is remanded. The evaluation of the left thigh disability encompasses impairment of extension of the knee. Therefore, evidence obtained in the new knee examination will be relevant to this issue. Any adjudication involving the extension of the left knee is further intertwined with the evaluation of the left thigh, as the left knee is also currently evaluated based on limitation of extension, and there is a risk of pyramiding where these evaluations are not undertaken together. See 38 C.F.R. § 4.14. As the evaluation of the left thigh is intertwined with the left knee issue remanded above, it is also remanded at this time. See Henderson v. West, 12 Vet. App. 11, 20 (1998); Harris v. Derwinski, 1 Vet. App. 180, 183 (1991). 6. Entitlement an evaluation in excess of 10 percent prior to March 1, 2018, and in excess of 50 percent thereafter for an acquired psychiatric disorder is remanded. The RO issued a supplemental statement of the case discussing the evaluations for the psychiatric disorder in April 2020. Then, in July 2020, the Veteran attended a VA psychiatric examination. Since this examination, the RO has not readjudicated the Veteran’s claim for an increased evaluation, and a remand is therefore necessary to issue a supplemental statement of the case considering this new, VA generated evidence. 7. Entitlement to a TDIU is remanded. The Veteran’s claim for a TDIU is also intertwined with the issues above, as the Veteran does not meet the schedular percentage requirements for a TDIU throughout the entire appeal period and any increase awarded may affect his eligibility for a TDIU on a schedular basis. See Henderson, 12 Vet. App. at 20; Harris, 1 Vet. App. at 183. On remand, further development of the TDIU claim is needed. A November 2010 email from the VA vocational rehabilitation program indicates the Veteran entered employment in the cosmetology field on November 1, 2008, and did not return to the program thereafter. On his application for a TDIU, the Veteran reported he applied for work as a cosmetologist in October 2008 as a part of the program, but was diagnosed with carpal tunnel syndrome shortly after completing the vocational rehabilitation program. He also reported that he left the cosmetology business because of his left knee, left thigh, and back disabilities, depression, and carpal tunnel syndrome. The RO should seek to clarify whether the Veteran worked as a cosmetologist for any period of time, either with the salon where he reported applying for work or for himself. 8. Entitlement to an evaluation in excess of 10 percent for tension headaches is remanded. As discussed in the February 2018 Board remand, interference with employment is a primary rating consideration under the applicable criteria for evaluating the Veteran’s service-connected tension headaches. Therefore, any evidence developed with regard to a TDIU is potentially relevant to the rating assigned for the tension headaches, making this issue inextricably intertwined with the TDIU issue remanded above. See Henderson, 12 Vet. App. at 20; Harris, 1 Vet. App. at 183. The matters are REMANDED for the following action: 1. Attempt to determine whether the Veteran worked after March 2007, his reported last date of employment, particularly as a cosmetologist beginning in October or November 2008, or in any other capacity thereafter. Take any further steps the AOJ deems necessary to fully develop the Veteran’s TDIU claim. 2. Schedule the Veteran for an examination with an appropriate clinician to determine whether the current right knee disability is related to the Veteran’s military service and to determine the current severity of the left knee disability. The knees should be tested in both active and passive motion, in weight-bearing and non-weight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint. If the examiner is unable to conduct the required testing or concludes that the required testing is not necessary in this case, he or she should clearly explain why that is so. The examiner should describe any pain, weakened movement, excess fatigability, instability of station and incoordination present in the left knee. The examiner should also state whether the examination is taking place during a period of flare-up. If not, the examiner should ask the Veteran to describe the flare-ups he experiences, including: frequency, duration, characteristics, precipitating and alleviating factors, severity and/or extent of functional impairment he experiences during a flare-up of symptoms and/or after repeated use over time. Based on the Veteran’s lay statements and the other evidence of record, the examiner should provide an opinion estimating any additional degrees of limited motion in the left knee caused by functional loss during a flare-up or after repeated use over time. If the examiner cannot estimate the degrees of additional range of motion loss during flare-ups or after repetitive use without resorting to speculation, the examiner should state whether the need to speculate is caused by a deficiency in the state of general medical knowledge (i.e. no one could respond given medical science and the known facts) or by a deficiency in the record or the examiner (i.e. additional facts are required, or the examiner does not have the needed knowledge or training). Following review of the claims file and examination of the Veteran, the examiner should opine whether it is at least as likely as not (50 percent or greater probability) that the right knee disability began in or is otherwise caused by the Veteran’s active service. The examiner should also opine whether it is at least as likely as not (50 percent or greater probability) that the right knee disability is (a) caused by; or (b) aggravated (i.e., worsened beyond the normal progression of the disease) by the Veteran’s service-connected lumbar disability and/or left knee disability, to include any gait changes caused by the service-connected disabilities. If aggravation is found, the examiner must attempt to establish a baseline level of severity of the right knee disability prior to aggravation by the service-connected disabilities. Please note, causation and aggravation are separate concepts and must be addressed independently. In providing the requested opinions, the examiner should specifically address the Veteran’s lay statements regarding ongoing right knee pain since onset. The examiner should address any other pertinent evidence of record. All findings must be reported in detail and all opinions must be accompanied by a clear rationale. If any of the above issues cannot be resolved without resorting to speculation, then a detailed medical explanation as to why this is so must be provided. 3. Forward the claims file to an appropriate clinician to determine whether the current right and left carpal tunnel syndrome is related to the Veteran’s military service. If the examiner determines that an additional in-person examination is required, one should be scheduled. Following review of the claims file and, if indicated, examination of the Veteran, the examiner should opine whether it is at least as likely as not (50 percent or greater probability) that the carpal tunnel syndrome began in or is otherwise caused by the Veteran’s active service. The examiner should also opine whether it is at least as likely as not (50 percent or greater probability) that the carpal tunnel syndrome is (a) caused by; or (b) aggravated (i.e., worsened beyond the normal progression of the disease) by the Veteran’s service-connected disabilities, to include residuals of fractures to the right fifth digit and to the left fourth metacarpal, left shoulder impingement with osteoarthritis, and/or ulnar neuropathy of the left upper extremity. If aggravation is found, the examiner must attempt to establish a baseline level of severity of the carpal tunnel syndrome prior to aggravation by the service-connected disabilities. Please note, causation and aggravation are separate concepts and must be addressed independently. The examiner should specifically address the Veteran’s lay statements regarding ongoing symptoms since onset. The examiner should address any other pertinent evidence of record. All findings must be reported in detail and all opinions must be accompanied by a clear rationale. If any of the above issues cannot be resolved without resorting to speculation, then a detailed medical explanation as to why this is so must be provided. 4. Schedule the Veteran for an examination with an appropriate clinician to determine the current severity of the Veteran’s service-connected lumbar spine disability. The claims file should be made available to and reviewed by the examiner and all necessary tests should be performed. All findings should be reported in detail. The joints involved should be tested in both active and passive motion, in weight-bearing and non-weight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint. If the examiner is unable to conduct the required testing or concludes that the required testing is not necessary in this case, he or she should clearly explain why that is so. The examiner should describe any pain, weakened movement, excess fatigability, instability of station and incoordination present. The examiner should also state whether the examination is taking place during a period of flare-up. If not, the examiner must ask the Veteran to describe the flare-ups he experiences, including: frequency, duration, characteristics, precipitating and alleviating factors, severity and/or extent of functional impairment he experiences during a flare-up of symptoms and/or after repeated use over time. Based on the Veteran’s lay statements and the other evidence of record, the examiner should provide an opinion estimating any additional degrees of limited motion caused by functional loss during a flare-up or after repeated use over time. If the examiner cannot estimate the degrees of additional range of motion loss during flare-ups or after repetitive use without resorting to speculation, the examiner should state whether the need to speculate is caused by a deficiency in the state of general medical knowledge (i.e. no one could respond given medical science and the known facts) or by a deficiency in the record or the examiner (i.e. additional facts are required, or the examiner does not have the needed knowledge or training).   5. Then, review the claims file, to include consideration of all additional evidence relevant to the acquired psychiatric disorder claim that has been received since the most recent supplemental statement of the case in April 2020. Readjudicate the Veteran’s claims for entitlement to increased evaluations for an acquired psychiatric disorder. If the benefits sought remain denied, furnish the Veteran and his representative with a supplemental statement of the case. M. HYLAND Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board K. Josey, 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.