Citation Nr: 21008835 Decision Date: 02/18/21 Archive Date: 02/18/21 DOCKET NO. 09-32 379A DATE: February 18, 2021 ISSUES 1. Entitlement to service connection for aortic atherosclerosis, to include as due to service-connected disabilities. 2. Entitlement to service connection for a kidney disorder (claimed as kidney cyst), to include as due to service-connected disabilities. 3. Entitlement to service connection for bladder cysts, to include as due to service-connected disabilities. 4. Entitlement to an initial compensable disability rating for the period prior to February 15, 2012, and in excess of 20 percent thereafter, for service-connected residuals of an abdominal exploratory laparotomy for ruptured small intestine and repair (an abdominal disability). 5. Entitlement to a disability rating in excess of 10 percent for the period prior to December 7, 2020, and in excess of 20 percent thereafter, for service-connected right knee anterior cruciate ligament reconstruction with degenerative joint disease (a right knee disability). 6. Entitlement to a disability rating in excess of 10 percent for the period prior to December 7, 2020, and in excess of 20 percent thereafter, for service-connected complete rupture of the medial head of the left triceps (left triceps disability). 7. Entitlement to an initial compensable disability rating for service-connected left leg length discrepancy. ORDER Entitlement to an initial compensable disability rating for the period prior to February 15, 2012, and in excess of 20 percent thereafter, for service-connected residuals of an abdominal exploratory laparotomy for ruptured small intestine and repair (an abdominal disability) is denied. Entitlement to a disability rating in excess of 20 percent for the period from December 7, 2020, for service-connected right knee anterior cruciate ligament reconstruction with degenerative joint disease (a right knee disability) is denied. REMANDED Entitlement to service connection for aortic atherosclerosis, to include as due to service-connected disabilities is remanded. Entitlement to service connection for a kidney disorder (claimed as kidney cyst), to include as due to service-connected disabilities is remanded. Entitlement to service connection for bladder cysts, to include as due to service-connected disabilities is remanded. Entitlement to a disability rating in excess of 10 percent for the period prior to December 7, 2020, for service-connected right knee anterior cruciate ligament reconstruction with degenerative joint disease (a right knee disability) is remanded. Entitlement to a disability rating in excess of 10 percent for the period prior to December 7, 2020, and in excess of 20 percent thereafter, for service-connected complete rupture of the medial head of the left triceps (left triceps disability) is remanded. Entitlement to an initial compensable disability rating for service-connected left leg length discrepancy is remanded. FINDINGS OF FACT 1. For the period prior to February 15, 2012, the Veteran’s service-connected residuals of an abdominal exploratory laparotomy for ruptured small intestine and repair (abdominal disability) has not been manifested by symptoms of diarrhea, anemia and an inability to gain weight, and as such, the requirements for a compensable evaluation are not met. 2. For the period from February 15, 2012, the Veteran’s service-connected residuals of an abdominal exploratory laparotomy for ruptured small intestine and repair (abdominal disability) has been manifested by symptoms of constipation and an inability to gain weight. 3. For the period from December 7, 2020, the Veteran’s service-connected right knee anterior cruciate ligament reconstruction with degenerative joint disease (right knee disability) is manifested by symptoms of mild pain, flexion and extension range of motion measurements from 30 to 0 degrees respectively, and full muscle strength. CONCLUSIONS OF LAW 1. For the period prior to February 15, 2012, the criteria for an initial compensable disability rating for service-connected residuals of an abdominal exploratory laparotomy for ruptured small intestine and repair (an abdominal disability) have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.114, Diagnostic Code 7328. 2. For the period from February 15, 2012, the criteria for a disability rating in excess of 20 percent for service-connected residuals of an abdominal exploratory laparotomy for ruptured small intestine and repair (an abdominal disability) have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.114, Diagnostic Code 7328. 3. For the period from December 7, 2020, the criteria for a disability rating in excess of 20 percent for the right knee disability have not been met or approximated. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.321, 4.1, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5260-5003. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the Army from January 1986 to July 1989 and from January 1990 to June 2007. The Veteran is a recipient of the Combat Infantryman Badge and the Purple Heart, among others. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from September 2007 and August 2015 rating decisions, issued by a Department of Veterans Affairs (VA) Regional Office (RO) which denied entitlement to the benefits currently sought on appeal. By way of background, the Veteran submitted a claim for each of the above disabilities, as well as entitlement to service connection for urinary incontinence and service connection for a left elbow disorder, which were subsequently denied in a September 2007 rating decision. The Veteran filed a Notice of Disagreement (NOD) in October 2007, however immediate action was not taken by the RO. The Veteran’s outstanding claims were remanded by the Board in September 2014 pursuant to Manlicon v. West, 12 Vet. App. 238 (1999), as the RO had not responded to the Veteran’s October 2007 NOD. The Veteran was then issued subsequent rating decision in August 2015 for his claims of entitlement to service connection only, and upon the claims returning to the Board in October 2015, the Board found that substantial compliance had not occurred with the Board’s September 2014 remand directives, insofar as each of the Veteran’s claims were not addressed. See Stegall v. West, 11 Vet. App. 268, 271 (1998). The Veteran’s claims for entitlement to service connection for urinary incontinence and the left elbow disorder were subsequently granted and are no longer currently on appeal. Following that additional development, in May 2019 the Board remanded the issues as cited above for further development and adjudication. Upon review of the Veteran’s claim file, the Board finds that there has been substantial compliance with the Board’s remand directives as it relates to the service-connected left leg discrepancy, left triceps, right knee and abdominal disabilities, as well as the claims of entitlement to service connection for a kidney disorder. See Stegall v. West, 11 Vet. App. 268, 271 (1998); Barr v. Nicholson, 21 Vet. App. 303, 307 (2007). There has not been substantial compliance with the Board’s remand directives as it relates to the Veteran’s claims of entitlement to service connection for aortic atherosclerosis and for bladders cysts, each to include as due to service-connected disabilities. See Stegall, Id. In December 2020 the RO increased the disability ratings of the Veteran’s service-connected right knee disability and his service-connected left triceps disability to 20 percent each. The Board notes that the grant of increased ratings during the course of an appeal does not affect the pendency of that appeal. AB v. Brown, 6 Vet. App. 35 (1993). As the Veteran is presumed to be seeking the maximum allowable benefit and the maximum benefit has not yet been awarded, the claim is still in controversy and on appeal. Id. Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C. §§ 5102, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). The Veteran in this case has not referred to any deficiencies in either the duties to notify or assist; therefore, the Board may proceed to the merits of the claim. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015, cert denied, U.S.C. Oct.3, 2016) (holding that “the Board’s obligation to read filings in a liberal manner does not require the Board....to search the record and address procedural arguments when the [appellant] fails to raise them before the Board”); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to an appellant’s failure to raise a duty to assist argument before the Board). The Board has reviewed all of the evidence in the Veteran’s claims file. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the Veteran or obtained on his behalf be discussed in detail. Rather, the Board’s analysis below will focus specifically on what evidence is needed to substantiate the claim and what the evidence in the claims file shows, or fails to show, with respect to the claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-130 (2000). 1. Entitlement to an initial compensable disability rating for the period prior to February 15, 2012, and in excess of 20 percent thereafter, for service-connected residuals of an abdominal exploratory laparotomy for ruptured small intestine and repair (an abdominal disability). The Veteran has claimed that his abdominal disability is worse than currently rated. Disability evaluations are determined by the application of the facts presented to VA’s Schedule for Rating Disabilities (Rating Schedule) at 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and the residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.321 (a), 4.1. In evaluating the severity of a particular disability, it is essential to consider its history. 38 C.F.R. § 4.1; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary importance. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). That said, higher evaluations may be assigned for separate periods based on the facts found during the appeal period. See Fenderson v. West, 12 Vet. App. 119, 126 (1999). This practice is known as staged ratings. Id. VA is required to give due consideration to all pertinent medical and lay evidence in evaluating a claim for disability benefits. 38 U.S.C. § 1154 (a). Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). If the evidence for and against a claim is in equipoise, the claim will be granted. 38 C.F.R. § 4.3. A claim will be denied only if the preponderance of the evidence is against the claim. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 56 (1990). Any reasonable doubt regarding the degree of disability should be resolved in favor of the claimant. 38 C.F.R. § 4.3. Where there is a question as to which of two evaluations shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that evaluation. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. The Veteran’s abdominal disability is rated under Diagnostic Code (DC) 7328. Under DC 7328, “Intestine, small, resection of,” a 20 percent rating is given when the condition is symptomatic with diarrhea, anemia and inability to gain weight. A 40 percent rating is given when there is definite interference with absorption and nutrition, manifested by impairment of health objectively supported by examination findings including definite weight loss. A 60 percent rating, the highest rating available under DC 7328, is given when there is marked interference with absorption and nutrition, manifested by severe impairment of health objectively supported by examination findings including material weight loss. 38 C.F.R. § 4.114 at DC 7328. Importantly, in every instance where the schedule does not provide a zero percent evaluation for a diagnostic code, a zero percent evaluation shall be assigned when the requirements for a compensable evaluation are not met. 38 C.F.R. § 4.31. The Veteran was in receipt of a noncompensable disability rating prior to February 15, 2012, and the RO increased his disability rating from that date forward to 20 percent. As noted above, since the Veteran is presumed to be seeking the maximum allowable benefit and the maximum benefit has not yet been awarded, the claim is still in controversy and on appeal. AB v. Brown, 6 Vet. App. 35 (1993). Thus, the Board will evaluate each staged ratings period on appeal. See Fenderson v. West, 12 Vet. App. 119, 126 (1999). a) The Period Prior to February 15, 2012 For the period prior to February 15, 2012, the Board has noted that the Veteran’s claims file includes years of VAMC and CAPRI records. The Veteran’s claims file also includes private treatment records, which have also been reviewed. In no instance prior to February 15, 2012 has the Veteran been noted to have anemia. Furthermore, during several VAMC consultations the Veteran specifically denied experiencing diarrhea and/or an inability to gain weight. See further January 2009 and April 2009 Martin Army Community Hospital consultation note. In fact, during regular consultations between 2009 through 2010 the Veteran “denied abdominal pain.” See January 2009 Martin ACH consultation note. During a primary care consultation in August 2011 the Veteran “denie[d] chronic diarrhea or constipation.” That denial has been consistently repeated through nursing notes and VAMC consultations back through at least August 2007. There is no evidence that either the VA or private examiners were not competent or credible, and as the reports were based on accurate facts and objective examinations, the Board finds they are entitled to significant probative weight as to the severity of the Veteran’s disability. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). In consideration of the above, the Board finds that the severity of the Veteran’s service-connected abdominal disability most nearly approximates the noncompensable rating for the period prior to February 15, 2012. As noted above, at no point has the Veteran during this time period demonstrated that he his symptoms are characterized by diarrhea, anemia, and/or an inability to gain weight. These represent the minimum threshold requirements for a compensable disability rating of 20 percent under DC 7328. Again, the Board is reminded that in every instance where the schedule does not provide a zero percent evaluation for a diagnostic code, a zero percent evaluation shall be assigned when the requirements for a compensable evaluation are not met. 38 C.F.R. § 4.31. As a result, the Board finds that the symptomatology of the Veteran’s service-connected abdominal disability more nearly approximates the zero percent evaluation for the period prior to February 15, 2012, as the requirements for a compensable evaluation are not met. 38 C.F.R. § 4.31. The Board has also considered other ratings criteria and found that there is no basis to assign an alternative evaluation for the Veteran’s abdominal disability other than that discussed above. See Schafrath v. Derwinski, 1 Vet. App. 589, 593 (1991) In reaching these conclusions, the Board finds that the preponderance of the evidence is against the claim. Neither the Veteran nor his Representative have raised any other issues, nor have any other issues been reasonably raised by the record. See 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). As such, the benefit of the doubt rule is not for application, and the claim must be denied. 38 U.S.C. § 5107 (b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). b) The period from February 15, 2012 To begin, the Board notes that in a rating decision from May 2012, the RO increased the Veteran’s disability rating for the service-connected abdominal disability to 20 percent, effective February 15, 2012. Turning to the available evidence, the Veteran was given a VA examination in May 2012. The Veteran was seen in person, and his claims file was reviewed. The examiner confirmed the Veteran’s diagnosis and noted the Veteran’s lay statements that he “takes stool softener daily.” During the exam, the only symptom noted attributable to the Veteran’s diagnosis was constipation. Other symptoms, such as diarrhea, anemia and nausea were not mentioned. The Veteran did not have weight loss, nor an inability to gain weight that was attributable to the intestinal surgery. There was also no interference with the Veteran’s absorption and nutrition attributable to the resection of the small intestine. No further medical abnormalities were noted, including any impairment of health objectively. In accordance with the Board’s remand directives from May 2019, the Veteran was given a VA examination. That examination occurred in August 2019, and the Veteran was seen in person. The Veteran’s claims file was reviewed by the examiner. During the exam, the Veteran reported that he “has stomach cramps and has constant pain in stomach and is constipated.” The examiner noted that medication was not required, and that the Veteran did not have additional symptoms such as diarrhea, nausea, vomiting, or anemia. The VA examiner did however note that the Veteran had an inability to gain weight which was attributable to the intestinal surgery, such that the Veteran’s baseline weight was 180 lbs., and his current weight was 180 lbs. There was no interference with absorption or nutrition attributable to the diagnosis, nor other manifested impairments of health objectively supported by the examination findings. The Board notes that further VAMC, CAPRI and private treatment records are consistent with the findings of the May 2012 and August 2019 VA examiners. The Veteran has consistently denied diarrhea, anemia and/or sudden weight loss or an inability to gain weight. The recurring symptom noted in the Veteran’s nursing consultation notes is that he regularly takes stool softeners for constipation and has reported abdominal pain. There is no evidence that either the VA or private examiners were not competent or credible, and as the reports were based on accurate facts and objective examinations, the Board finds they are entitled to significant probative weight as to the severity of the Veteran’s disability. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). In consideration of the above, the Board finds that the severity of the Veteran’s service-connected abdominal disability most nearly approximates the current 20 percent rating for the period on appeal from February 15, 2012. Importantly, May 2012 was the first time that the Veteran was found to have symptoms related to his abdominal disability. As noted by the RO, that single symptom was constipation, despite that symptom not being listed in the diagnostic criteria of DC 7328. The most recent VA examination from August 2019 did note that the Veteran had an inability to gain weight which was attributable to the intestinal surgery, since the Veteran’s baseline weight was 180 lbs., and his current weight was 180 lbs. That symptom still however matches the criteria of the 20 percent disability rating. At no point has the Veteran’s service-connected abdominal disability been manifested by symptoms required for the higher 40 percent rating. His symptoms have not been characterized as showing a definite interference with absorption and nutrition, manifested by an impairment of health which is objectively supported by examination findings including definite weight loss. As a result, the Board finds that the symptomatology of the Veteran’s service-connected abdominal disability more nearly approximates the current 20 percent disability rating for the period from February 15, 2012, and the preponderance of the evidence is against a finding that he is entitled to the higher 40 percent disability rating. The Board has also considered other ratings criteria and found that there is no basis to assign an alternative evaluation for the Veteran’s abdominal disability other than that discussed above. See Schafrath v. Derwinski, 1 Vet. App. 589, 593 (1991) Neither the Veteran nor his Representative have raised any other issues, nor have any other issues been reasonably raised by the record. See 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). As such, the benefit of the doubt rule is not for application, and the claim must be denied. 38 U.S.C. § 5107 (b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 2. Entitlement to a disability rating in excess of 20 percent for the period from December 7, 2020, for service-connected right knee anterior cruciate ligament reconstruction with degenerative joint disease (a right knee disability). The Veteran has claimed that his right knee disability is worse than currently rated. A disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. It is essential that the examination upon which ratings are based adequately portray the anatomical damage, and the functional loss, with respect to all these elements. 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 it may be due to pain, supported by adequate pathology and evidenced by the visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. A little used part of the musculoskeletal system may be expected to show evidence of disuse, either through atrophy, the condition of the skin, absence of normal callosity or the like. 38 C.F.R. § 4.40. Evidence of pain, weakened movement, excess fatigability, or incoordination must be considered in determining the level of associated functional loss in light of 38 C.F.R. § 4.40, taking into account any part of the musculoskeletal system that becomes painful on use. DeLuca v. Brown, 8 Vet. App. 202 (1995). The provisions regarding the avoidance of pyramiding do not forbid consideration of a higher rating based on greater limitation of motion due to pain on use, including flare-ups. 38 C.F.R. § 4.14. The provisions of 38 C.F.R. § 4.40 and 38 C.F.R. § 4.45, however, should only be considered in conjunction with the diagnostic codes predicated on limitation of motion. Johnson v. Brown, 9 Vet. App. 7 (1996). The intent of the rating schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. It is the intention 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. With respect to the joints, the factors of disability reside in reductions of their normal excursion of movements in different planes. Inquiry will be directed to these considerations: (a) less movement than normal (due to ankylosis, limitation or blocking, adhesions, tendon-tie-up, contracted scars, etc.); (b) more movement than normal (from flail joint, resections, nonunion of fracture, relaxation of ligaments, etc.); (c) weakened movement (due to muscle injury, disease or injury of peripheral nerves, divided or lengthened tendons, etc.); (d) excess fatigability; (e) incoordination, impaired ability to execute skilled movements smoothly; and (f) pain on movement, swelling, deformity or atrophy of disuse. Instability of station, disturbance of locomotion, interference with sitting, standing, and weight bearing are related considerations. 38 C.F.R. § 4.45. The final sentence of 38 C.F.R. § 4.59 requires that VA examinations include joint testing for pain on 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. Correia v. McDonald, 28 Vet. App. 158 (2016). A recent Court decision also addressed what constitutes an adequate explanation for an examiner’s inability to estimate motion loss in terms of degrees during periods of flare-ups. Sharp v. Shulkin, 29 Vet. App. 26 (2017). In Sharp, the Court held that a VA examiner must attempt to elicit information from the record and the Veteran regarding the severity, frequency, duration, or functional loss manifestations during flare-ups before determining that an estimate of motion loss in terms of degrees could not be given. It also held that any inability to furnish such an estimate must be predicated on a lack of medical knowledge among the medical community at large, rather than insufficient knowledge by the individual examiner. The Veteran’s right knee disability is rated under Diagnostic Code 5260-5003. Included within 38 C.F.R. § 4.71a are multiple Diagnostic Codes that evaluate impairment resulting from service-connected knee disorders, including Diagnostic Code 5257 (other impairment, including recurrent subluxation or lateral instability), Diagnostic Code 5261 (limitation of extension), Diagnostic Code 5262 (impairment of the tibia and fibula), and Diagnostic Code 5260 (limitation of flexion). Diagnostic Code 5257 provides that an evaluation of 10 percent is assigned for slight recurrent subluxation or lateral instability, an evaluation of 20 percent is assigned when the impairment is moderate, and an evaluation of 30 percent is assigned when the impairment is severe. Diagnostic Code 5260 pertains to limited flexion of the knee. Flexion limited to 60 degrees is noncompensable. A 10 percent rating applies when flexion is limited to 45 degrees. A 20 percent rating applies when flexion is limited to 30 degrees. A 30 percent rating applies when flexion is limited to 15 degrees. Diagnostic Code 5261 pertains to limited extension. Extension limited to 5 degrees warrants a 0 percent rating, extension limited to 10 degrees warrants a 10 percent rating, extension limited to 15 degrees warrants a 20 percent rating, extension limited to 20 degrees warrants a 30 percent rating, extension limited to 30 degrees warrants a 40 percent rating, and extension limited to 45 degrees warrants a 50 percent rating. Under Diagnostic Code 5262, a 10 percent rating is warranted for malunion of the tibia and fibula with slight knee or ankle disability; a 20 percent rating when there is malunion of the tibia and fibula with moderate knee or ankle disability; a 30 percent rating for malunion of the tibia and fibula with marked knee or ankle disability; and a maximum rating of 40 percent for nonunion of the tibia and fibula with loose motion, requiring brace. 38 C.F.R. § 4.71a. The VA General Counsel held that a Veteran who has arthritis and instability of the knee may be rated separately under Diagnostic Codes 5003 (which provides for a 10 percent rating for a noncompensable limitation of motion or painful motion of an affected joint) and 5257, provided that a separate rating must be based upon additional disability. VAOPGCPREC 23-97, 62 Fed. Reg. 63,604 (1997); VAOPGCPREC 9-98, 63 Fed. Reg. 56,704 (1998). Also, separate ratings may be assigned for limitation of flexion, limitation of extension, and subluxation of the same knee. Specifically, where a Veteran has both a compensable limitation of flexion, compensable subluxation, and a compensable limitation of extension of the same knee, the limitations must be rated separately to adequately compensate for functional loss associated with the disability. VAOPGCPREC 9-04 (Sept. 17, 2004), 69 Fed. Reg. 59990 (2005). The Board notes that the Veteran’s right knee disability was previously rated at 10 percent, but in a decision from December 2020, the RO increased the Veteran’s disability rating to 20 percent, effective December 7, 2020. As a result, as the maximum benefit has not yet been awarded, the Board will address each of the staged ratings periods of the Veteran’s claim. See AB, Id. See further, Fenderson, Id. Importantly, the period on appeal prior to December 7, 2020 is addressed in the Remand portion of this Decision. a) The Period from December 7, 2020 The Veteran was given a VA examination in December 2020. The Veteran was seen in person, his claims file was reviewed, and the Veteran’s diagnosis was confirmed. During the exam, the Veteran stated that his right knee had worsened, and that it was an “achy, constant pain … with swelling.” The Veteran did not report any flare ups of the right knee, but he did state that he cannot “walk for a long time.” On range of motion (ROM) testing, the Veteran exhibited extension and flexion from 0 to 30 degrees. There was objective evidence of localized tenderness and pain, that the examiner classed as “mild.” There was no evidence of pain with weight bearing, nor evidence of crepitus. The Veteran was able to perform repetitive use testing with no additional loss of range of motion. The examiner noted no additional factors contributing to the disability, with no reduction of muscle strength. Ankylosis was not shown, and there was no history of recurrent subluxation or instability. There were also no shin splints, meniscal conditions, nor any other tibial or fibular impairment. The examiner noted that the Veteran uses a cane. There was no objective evidence of pain in the right knee when used in non-weight bearing situations. The examiner noted that this all represented a “worsening of the Veteran’s symptoms,” yet there was “no change to the … diagnosis and no additional diagnoses have been rendered.” There is no evidence that the VA examiner was not competent or credible, and as the report was based on accurate facts and objective examinations, the Board finds they are entitled to significant probative weight as to the severity of the Veteran’s disability. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). In consideration of the above, the Board finds that the severity of the Veteran’s left knee disability more nearly approximates the current 20 percent disability rating. The most recent exam is from December 2020, which the Board has afforded significant probative weight. The December 2020 examiner found that the Veteran can fully extend his right knee, however his right knee flexion is limited to 20 degrees. There was no additional loss of range of motion after repetitive use, and the Veteran has not claimed that flare ups occur to his right knee. As such, based on the ROM measurements described above, under DC 5260, the Veteran’s right knee disability more nearly approximates the current 20 percent disability rating. At no point have the symptoms of the Veteran’s right knee disability matched that for the next higher 30 percent disability rating, in that his right knee has not shown to have flexion limited to only 15 degrees. The Board has also considered additional diagnostic codes related to the knee. The Veteran has at no point demonstrated ankylosis, so DC 5256 is inapplicable. The December 2020 examiner denied that the Veteran had joint stability issues such as recurrent subluxation, so DC 5257 is also inapplicable. The Veteran demonstrated full right knee extension, so therefore DC 5261, which details limitations to the extension of the knee, is inapplicable. Tibial and/or fibular impairments were each denied by the examiner under DC 5262, and the remaining diagnostic codes (5259 and 5263) only allow for disability ratings of 10 percent, which would be lower than the Veteran’s current disability rating of 20 percent. Thus, the Board finds that the Veteran is currently appropriately rated under DC 5260-5003 for his right knee disability, and the severity of that right knee disability more nearly approximates the current 20 percent disability rating. Neither the Veteran nor his Representative have raised any other issues, nor have any other issues been reasonably raised by the record. See 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). As such, the Board finds that the preponderance of the evidence is against a disability rating in excess of 20 percent for the period from December 7, 2020 for the Veteran’s service-connected right knee disability. As such, the benefit of the doubt rule is not for application, and the claim must be denied. 38 U.S.C. § 5107 (b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). REASONS FOR REMAND The Board finds that additional evidentiary development is required before the claims on appeal are adjudicated. 1. Entitlement to service connection for aortic atherosclerosis, and entitlement to service connection for bladder cysts, both to include as due to service-connected disabilities is remanded. The Veteran has claimed that he has a diagnosed aortic atherosclerosis, and bladder cysts, and that each are due to his service-connected disabilities. To establish an entitlement to service connection, the Veteran must establish (1) the existence of a present disability, (2) an in-service occurrence or aggravation of a disease or injury, and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. 38 C.F.R. § § 3.303(a). Service connection may also be granted as secondary to a currently service-connected disability. To meet the criteria for secondary service connection, a Veteran must prove that there is (1) a current disability that is not already service-connected; and (2) at least one service-connected disability; and (3) evidence that the non-service connected disability is either proximately due to or the result of a service-connected disability, or aggravated (increased in severity) beyond its natural progress by a service connected disability. 38 C.F.R. § 3.310; Allen v. Brown, 7 Vet. App. 439 (1995). In Stegall v. West, 11 Vet. App. 268, 271 (1998), the United States Court of Appeals for Veterans Claims (Court) held that a remand by the Board confers upon the Veteran or other claimant, as a matter of law, the right to compliance with the Board’s remand order. Moreover, the Court further held that the Board itself errs when it fails to ensure compliance with the terms of its remand. Id. As noted above, this matter was remanded in May 2019. Among other directives, the RO was to schedule the Veteran for a VA examination to determine the nature and etiology of the Veteran’s claimed aortic atherosclerosis, as well as his bladder cysts. Those examinations have not taken place, nor have the etiological opinions been rendered. Again, a Board remand confers upon the Veteran, as a matter of law, the right to compliance with the remand order. Stegall, 11 Vet. App. at 270-71. Thus, in accordance with Stegall, violation for full compliance with the Board’s prior remand is warranted. On remand, the Veteran should be given VA examinations for both claimed disabilities. The Veteran’s current diagnoses should be confirmed, and etiological opinions should be provided on both a direct and a secondary basis. See McLendon v. Nicholson, 20 Vet. App. 79 (2006) (discussing circumstances under which a VA examination is required). 2. Entitlement to service connection for a kidney disorder (claimed as kidney cyst), to include as due to service-connected disabilities is remanded. The Veteran has claimed that he has a kidney disorder (also claimed as kidney cyst) that is due to his active duty service. He has also claimed that his kidney disorder may be secondary to his service-connected disabilities. As discussed above, the Veteran’s claim was previously remanded in May 2019 for a VA examination to determine the nature and etiology of the Veteran’s claimed kidney disorder. The Veteran was given a VA examination in August 2019. The Veteran was seen in person, and his claims file was reviewed. The examiner noted that the Veteran did not have a current kidney disorder. The following rationale was provided: Symptoms are subjective only. Objective exam is normal. There is no objective evidence of a chronic condition. A nexus has not been established. As such, the examiner denied that the Veteran had a current kidney disability. The examiner also however provided a disability benefits questionnaire (DBQ) along with that etiological opinion. On the DBQ, the examiner wrote that the Veteran did have a diagnosis of a “cyst on kidney.” The Veteran stated that this cyst was caused by his service, because he “had a lot of anthrax shots,” and that the “cysts on kidneys has gotten worse,” because he is “going to the restroom a lot.” No etiological opinion was provided for the kidney cysts. Importantly, when VA undertakes to provide a Veteran with an examination, that examination must be adequate for VA purposes. Barr v. Nicholson, 21 Vet. App. 303 (2007). In consideration of the above, the Board finds that the August 2019 VA examination is inadequate. While the examiner confirmed a diagnosis of a kidney cyst, they then denied a current diagnosis of any kidney disorder when providing an etiological opinion. Thus, an etiological opinion was not provided for the cyst itself, which is the primary claim of the Veteran. There is further evidence that only the lay statements of the Veteran are considered, as opposed to evidence from the claims file, since no records are cited, and then the examiner wrote that the “symptoms are subjective only.” Finally, even if the diagnosis had been confirmed, an opinion on secondary service connection was not rendered, despite the Veteran’s past claims that his service-connected disabilities have caused the cysts. Because the Veteran's entire history is reviewed when making disability evaluations, the record must be complete for such service connection determinations to be made. See Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Therefore, a remand is necessary to ensure that there is a complete record upon which to decide the Veteran's claim for an entitlement to service connection so that he is afforded every possible consideration. 38 U.S.C. § 5103 (A); 38 C.F.R. § 3.159. The Veteran must be afforded a VA examination to confirm whether or not the Veteran has a current diagnosis of a kidney disorder, to include kidneys cysts, and then to provide etiological opinions on both a direct and secondary basis. 3. Entitlement to a disability rating in excess of 10 percent for the period prior to December 7, 2020, for service-connected right knee anterior cruciate ligament reconstruction with degenerative joint disease (a right knee disability) is remanded. The Veteran has claimed that his service-connected right knee disability was worse than rated during the period prior to December 7, 2020. As an initial matter, the Board notes that in the May 2019 remand directives, the Board requested that, following a VA examination, the VA examiner provide estimations that were not part of the previous VA examinations, pursuant to Correia v. McDonald, 28 Vet. App. 158 (2016) (VA examinations include joint testing for pain on 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). The examiner was to base these estimations on VA examinations from January 2007, March 2011, May 2012, and January 2015. If those estimations were not possible without resorting to speculation, the examiner was to 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). Jones v Shinseki, 23 Vet. App. 382 (2010). The Veteran was then afforded a VA examination in August 2019. Following that examination, in August 2020, the RO noted that the examiner had not made those estimations pursuant to Correia, and they requested a follow up exam. The follow up exam in December 2020 did not provide estimations for each previous examination. Instead, the examiner noted that “specifically noting the [January 2015] examination and comparing to today’s examination, the Veteran’s ROM bilaterally has decreased.” Prior to noting the adequacy of the August 2019 VA examination, the Board notes that the requested opinion has not been given. Because the Veteran’s entire history is reviewed when making disability evaluations, the record must be complete for such service connection determinations to be made. See Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Since this opinion is necessary for determining the severity of the Veteran’s disability rating prior to December 7, 2020, the Board finds it appropriate to remand this issue so that the VA examiner can offer the requested opinion. See Barr v. Nicholson, 21 Vet. App. 303 (2007). 38 U.S.C. § 5103 (A); 38 C.F.R. § 3.159. 4. Entitlement to a disability rating in excess of 10 percent for the period prior to December 7, 2020, and in excess of 20 percent thereafter, for service-connected complete rupture of the medial head of the left triceps (left triceps disability) is remanded. The Veteran has claimed that his service-connected complete rupture of the medial head of the left triceps (left triceps disability) is worse than currently rated. As an initial matter, the Board notes that the Veteran is currently service connected for a left triceps disability, fibromyalgia, cervical radiculopathy involving left upper extremity, left elbow strain with limited flexion, and left elbow strain with impaired supination and pronation. Each are classed as different disabilities through various diagnostic codes, however each encompasses the area of the left arm. Importantly, the critical element in permitting the assignment of several ratings under various Diagnostic Codes is that none of the symptomatology for any one of the disabilities is duplicative or overlapping with the symptomatology of the other disability. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). It is for this reason that in the prior May 2019 remand, the Board directed the VA examiner to distinguish the symptomatology of the Veteran’s service-connected left triceps disability, with his other service-connected disabilities. While that examination occurred, and the Board has no reason to doubt the competence or credibility of the examiner, the distinguishing of possible overlapping symptomatology did not take place. That information is necessary before the Board can adjudicate either period on appeal, given the multiple – possibly overlapping – service-connected disabilities of the Veteran’s left arm. Thus, the Board finds that a remand is necessary so that an advisory opinion can be provided which distinguishes between the symptomatology of the Veteran’s service-connected left triceps disability and his other service-connected disabilities of the left arm. See Esteban, Id. 5. Entitlement to an initial compensable disability rating for service-connected left leg length discrepancy is remanded. The Veteran has claimed that his service-connected left leg length discrepancy is worse than currently rated. See March 2018 Statement in Support of Claim. Despite that claim, the Veteran has not been issued a VA examination to confirm the current discrepancy of the Veteran’s leg length. The Veteran was initially service connected for this disability based on an examination that occurred while he was still on active duty. Since the grant of service connection in September 2007, and since the Veteran’s subsequent Notice of Disagreement (NOD) in October 2007, he has not been afforded a recent VA examination. A new examination is appropriate when there is an assertion (and indication) of an increase in severity since the last examination. Palczewski v. Nicholson, 21 Vet. App. 174, 181 (2007). Also, where the Veteran claims that a disability is worse than when originally rated, VA must provide a new examination. See Olsen v. Principi, 3 Vet. App. 480, 482 (1992). Therefore, the Board finds that the Veteran should be afforded a new VA examination to determine the current nature and severity of his service-connected left leg length discrepancy. See, Weggenmann v. Brown, 5 Vet. App. 281 (1993); see also, Snuffer v. Gober, 10 Vet. App. 400 (1997) (a Veteran is entitled to a new examination where there is evidence that the condition may have worsened since the last examination). The matters are REMANDED for the following action: 1. Obtain all outstanding VA and/or private treatment records. For any private treatment records, obtain the appropriate signed releases from the Veteran, and associate any additional records with the claim. Should such records exist, associate them with the electronic claims file. 2. Schedule the Veteran for VA examination(s) (or telehealth interview(s), review(s) of the record, etc., if an in-person examination(s) is not feasible) to assess the nature and etiology of the Veteran’s claimed kidney disability (kidney cysts), bladder cysts and aortic atherosclerosis disorders, as well as his service-connected left leg length discrepancy. Different examinations should be scheduled with appropriate professionals as deemed necessary. The entire record must be reviewed by the examiner(s). All necessary tests should be conducted. Based on the examination results and the review of the entire claims folder, the examiner(s) are asked to opine as to the following: As it relates to the Veteran’s claimed aortic atherosclerosis: (a.) Confirm the current diagnosis for the Veteran’s aortic atherosclerosis disability. For any currently diagnosed disability, provide an opinion as to whether it is at least as likely as not (50 percent or greater) that the Veteran’s diagnosed disability is causally related to, or aggravated by, his military service. Any opinion should include a complete rationale. (b.) If not, opine as to whether it is at least as likely as not (50 percent or greater) that the Veteran’s aortic atherosclerosis disability is causally related to, or aggravated by, his service-connected disabilities. Again, any opinion should include a complete rationale. As it relates to the Veteran’s claimed bladder cysts: (a.) Confirm the current diagnosis for the Veteran’s bladder cysts. For any currently diagnosed disability, provide an opinion as to whether it is at least as likely as not (50 percent or greater) that the Veteran’s diagnosed disability is causally related to, or aggravated by, his military service. Any opinion should include a complete rationale. (b.) If not, opine as to whether it is at least as likely as not (50 percent or greater) that the Veteran’s bladder cysts are causally related to, or aggravated by, his service-connected disabilities. Again, any opinion should include a complete rationale. As it relates to the Veteran’s claimed kidney disorder (kidney cysts): (c.) Confirm the current diagnosis of the Veteran’s kidney disability (to include kidney cysts). For any currently diagnosed disability, provide an opinion as to whether it is at least as likely as not (50 percent or greater) that the Veteran’s diagnosed disability is causally related to, or aggravated by, his military service. Any opinion should include a complete rationale. (d.) If not, opine as to whether it is at least as likely as not (50 percent or greater) that the Veteran’s kidney disability (kidney cysts) is causally related to, or aggravated by, his service-connected disabilities. Again, any opinion should include a complete rationale. As it relates to the Veteran’s service-connected left leg length discrepancy: (e.) Provide an assessment as to the current nature and severity of the Veteran’s service-connected left leg length discrepancy, in accordance with Diagnostic Code 5275. Any indicated tests and studies for the Veteran’s service-connected left leg length discrepancy must be accomplished. All clinical findings must be reported in detail and correlated to the specific diagnosis. A detailed rationale for the opinions must be provided. The examiner(s) are reminded that the term “as likely as not” does not mean “within the realm of medical possibility,” but rather that the evidence of record is so evenly divided that, in the examiner’s expert opinion, it is as medically sound to find in favor of the proposition as against it. If the examiner(s) feels that the requested opinions cannot be rendered without resorting to speculation, the examiner(s) must 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). Jones v Shinseki, 23 Vet. App. 382 (2010). 3. Send the Veteran’s claims file to the same VA examiner who conducted the August 2019 examination for the Veteran’s service-connected complete rupture of the medial head of the left triceps (left triceps disability) for an addendum opinion. The examiner is asked to review the entire record as it relates to the Veteran’s service-connected left triceps disability, versus his other service-connected disabilities. An additional examination should be scheduled if deemed necessary. Following review of the record, the examiner is asked to provide an opinion which distinguishes the symptomatology related to the Veteran’s left triceps disability from his other service-connected disabilities of the left arm. The examiner is reminded that the Veteran is currently service connected for a left triceps disability, fibromyalgia, cervical radiculopathy involving left upper extremity, left elbow strain with limited flexion, and left elbow strain with impaired supination and pronation. The examiner is also reminded that the critical element in permitting the assignment of several ratings under various Diagnostic Codes is that none of the symptomatology for any one of the disabilities is duplicative or overlapping with the symptomatology of the other disability. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). 4. Send the Veteran’s claims file to the same VA examiner who conducted the August 2019 examination, and provided the December 2020 addendum opinion, for an additional opinion related to the Veteran’s service-connected right knee anterior cruciate ligament reconstruction with degenerative joint disease (a right knee disability). The examiner is asked to review the entire record as it relates to the Veteran’s service-connected right knee disability, with specific attention drawn to the January 2007, March 2011, May 2012 and January 2015 VA examinations. Following that review, the examiner is asked to provide an opinion which addresses joint testing for pain on 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. Correia v. McDonald, 28 Vet. App. 158 (2016). Estimations should be provided based on each of the previous VA examinations listed. If those estimations are not possible without resorting to speculation, the examiner is to 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). Jones v Shinseki, 23 Vet. App. 382 (2010). (Continued on next page.) 5. Thereafter, readjudicate the issues on appeal as noted above. If the determination remains unfavorable to the Veteran, he and his Representative should be furnished a supplemental statement of the case (SSOC) which addresses all evidence associated with the claims file since the last statement of the case. The Veteran and his Representative should be afforded the applicable time period to respond. Michael A. Pappas Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board G. Mulrain, 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.