Citation Nr: 21011545 Decision Date: 03/02/21 Archive Date: 03/02/21 DOCKET NO. 15-10 435A DATE: March 2, 2021 ORDER Entitlement to service connection for bilateral hearing loss is denied. Entitlement to service connection for tinnitus is denied. Entitlement to service connection for a respiratory disorder, to include asthma is denied. Entitlement to a separate 20 percent rating, but no higher, for right knee medial meniscectomy residuals with traumatic arthritis based on dislocated semilunar cartilage since January 14, 2011 is granted. Entitlement to a rating in excess of 20 percent for right knee medial meniscectomy residuals with traumatic arthritis based on recurrent subluxation/lateral instability from prior to February 7, 2021 is denied. Entitlement to a rating in excess of 10 percent for right knee medial meniscectomy residuals with traumatic arthritis based on limitation of extension prior to October 13, 2015 is denied. Entitlement to a 40 percent rating, but no higher, for right knee medial meniscectomy residuals with traumatic arthritis based on limitation of extension, since October 13, 2015 is granted subject to the laws and regulations governing the award of monetary benefits. Entitlement to a separate 10 percent rating, but no higher, for left knee medial meniscectomy residuals with traumatic arthritis based on symptomatic removal of semilunar cartilage since January 14, 2011 is granted, subject to the laws and regulations governing the award of monetary benefits. Entitlement to a 10 percent rating, but no higher, for left knee medial meniscectomy residuals with traumatic arthritis based on recurrent subluxation/instability on December 17, 2019 is granted, subject to the laws and regulations governing the award of monetary benefits. Entitlement to a rating in excess of 10 percent for left knee medial meniscectomy residuals with traumatic arthritis based on recurrent subluxation/lateral instability from December 18, 2019 to February 6, 2021 is denied. Entitlement to a rating in excess of 10 percent for left knee medial meniscectomy residuals with traumatic arthritis based on impairment of the tibia and fibula is denied. Entitlement to a 50 percent rating for migraine headaches from January 14, 2011 to December 16, 2019 is granted, subject to the laws and regulations governing the award of monetary benefits. Entitlement to a rating in excess of 30 percent for migraine headaches since December 17, 2019 is denied. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) from January 14, 2011 to October 12, 2015 and since December 17, 2019 is granted, subject to the laws and regulations governing the award of monetary benefits. REMANDED Entitlement to service connection for a spine disorder is remanded. Entitlement to service connection for a left shoulder disorder is remanded. Entitlement to service connection for an eye disorder is remanded. Entitlement to a rating in excess of 20 percent for right knee medial meniscectomy residuals with traumatic arthritis based on recurrent subluxation/lateral instability since February 7, 2021 is remanded. Entitlement to a rating in excess of 10 percent for left knee medial meniscectomy residuals with traumatic arthritis based on recurrent subluxation/lateral instability since February 7, 2021 is remanded. FINDINGS OF FACT 1. The preponderance of the evidence is against finding that bilateral hearing loss is related to an in-service injury or disease, manifested during service, or was compensably disabling within a year of separation from active duty. 2. The preponderance of the evidence is against finding that tinnitus is related to an in-service injury or disease, manifested during service, or was compensably disabling within a year of separation from active duty. 3. The preponderance of the evidence is against finding that a respiratory disorder, to include asthma is related to an in-service injury or disease. 4. Since January 14, 2011, right knee medial meniscectomy residuals with traumatic arthritis were manifested by dislocated semilunar cartilage with frequent episodes of locking, pain and effusion into the joint. 5. Prior to February 7, 2021, right knee medial meniscectomy residuals with traumatic arthritis are not manifested by severe recurrent subluxation or lateral instability. 6. Prior to October 13, 2015, right knee medial meniscectomy residuals with traumatic arthritis were not manifested by extension limited to 15 degrees or more or flexion limited to 60 degrees or less. 7. Since October 13, 2015, right knee medial meniscectomy residuals with traumatic arthritis were manifested by extension limited to 30 degrees, but no by extension limited to 45 degrees or flexion limited to 60 degrees or less. 8. Since January 14, 2011, left knee medial meniscectomy residuals with traumatic arthritis were manifested by symptomatic removal of semilunar cartilage, but not by dislocated semilunar cartilage with frequent episodes of locking and effusion into the joint. 9. Since December 17, 2019, left knee medial meniscectomy residuals with traumatic arthritis were manifested by slight recurrent subluxation or lateral instability, but not by moderate recurrent subluxation or lateral instability. 10. Left knee medial meniscectomy residuals with traumatic arthritis are not manifested by malunion or nonunion of the tibia and fibula. 11. From January 14, 2011 to December 16, 2019, the Veteran’s migraine headaches were manifested by very frequent, completely prostrating and prolonged attacks productive of severe economic inadaptability. 12. Since December 17, 2019, the Veteran’s migraine headaches were not manifested by very frequent, completely prostrating and prolonged attacks productive of severe economic inadaptability. 13. From January 14, 2011 to October 12, 2015 and since December 17, 2019, the Veteran’s service-connected disabilities precluded him from securing or following substantially gainful employment. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for bilateral hearing loss are not met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1137, 5107; 38 C.F.R. §§ 3.303, 3.307, 3.309. 2. The criteria for entitlement to service connection for tinnitus are not met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1137, 5107; 38 C.F.R. §§ 3.303, 3.307, 3.309. 3. The criteria for entitlement to service connection for a respiratory disorder are not met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.303, 3.307, 3.309. 4. The criteria for entitlement to a separate 20 percent rating for right knee medial meniscectomy residuals with traumatic arthritis based on dislocated semilunar cartilage since January 14, 2011 are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.7, 4.40, 4.59, 4.71a, Diagnostic Codes (DC) 5258. 5. The criteria for entitlement to a rating in excess of 20 percent for right knee medial meniscectomy residuals with traumatic arthritis based on recurrent subluxation/lateral instability from January 14, 2011 to February 6, 2021 are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.7, 4.40, 4.59, 4.71a, DC 5257. 6. The criteria for entitlement to a rating in excess of 10 percent for right knee medial meniscectomy residuals with traumatic arthritis based on limitation of extension prior to October 13, 2015 are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.7, 4.40, 4.59, 4.71a, DCs 5260, 5261. 7. The criteria for entitlement to a 40 percent rating, but no higher, for right knee medial meniscectomy residuals with traumatic arthritis based on limitation of extension, since October 13, 2015 are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 438 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.7, 4.40, 4.59, 4.71a, DC 5260, 5261. 8. The criteria for entitlement to a separate 10 percent rating, but no higher, for left knee medial meniscectomy residuals with traumatic arthritis based on symptomatic removal of semilunar cartilage since January 14, 2011 are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.7, 4.40, 4.59, 4.71a, DC 5259. 9. The criteria for entitlement to a 10 percent rating, but no higher, for left knee medial meniscectomy residuals with traumatic arthritis based on recurrent subluxation/lateral instability on December 17, 2019 are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.7, 4.40, 4.59, 4.71a, DC 5257. 10. The criteria for entitlement to a rating in excess of 10 percent for left knee medial meniscectomy residuals with traumatic arthritis based on recurrent subluxation/instability from December 18, 2019 to February 6, 2021 are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.7, 4.40, 4.59, 4.71a, DC 5257. 11. The criteria for entitlement to a rating in excess of 10 percent for left knee medial meniscectomy residuals with traumatic arthritis based on impairment of the tibia and fibula are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.7, 4.40, 4.59, 4.71a, DC 5262; Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 76453, 76463 (Nov. 30, 2020) (to be codified at 38 C.F.R. § 4.71a, DC 5262). 12. For the period from January 14, 2011 to December 16, 2019, the criteria for entitlement to a 50 percent rating for migraine headaches are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.124a, DC 8100. 13. For the period since December 17, 2019, the criteria for entitlement to a rating in excess of 30 percent for migraine headaches are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.124a, DC 8100. 14. The criteria for assignment of a TDIU from January 14, 2011 to October 12, 2015 and since December 17, 2019 are met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.15, 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from February 1973 to April 1976. These matters are before the Board of Veterans’ Appeals (Board) on appeal of May 2013, April 2015, and November 2015 rating decisions of a Department of Veterans Affairs (VA) Regional Office (RO). In July 2018 the Board remanded the appeals for further development. The issues have now been returned to the Board. Service Connection Bilateral hearing loss and tinnitus The Veteran contends that he has bilateral hearing loss and tinnitus which are related to in-service noise exposure. Service connection is established on a direct basis when there is competent, credible evidence of (1) a current disability, (2) in-service incurrence or aggravation of an injury or disease, and (3) a nexus, or link, between the current disability and the in-service disease or injury. 38 U.S.C. § 1110; Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303 (a), (d). Where a veteran served continuously for ninety days or more during a period of war, or during peacetime service after December 31, 1946, and sensorineural hearing loss or tinnitus becomes manifest to a degree of 10 percent within one year from the date of termination of active duty, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. For the purposes of applying the laws administered by VA, impaired hearing will be considered to be a disability when the auditory threshold in any of the frequencies at 500, 1000, 2000, 3000, or 4000 Hertz is 40 decibels or greater; or when the auditory thresholds for at least three of the frequencies at 500, 1000, 2000, 3000, or 4000 Hertz are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385. Even though disabling hearing loss is not demonstrated at separation, a veteran may, nevertheless, establish service connection for a current hearing disability by submitting evidence that a current disability is related to service. Hensley v. Brown, 5 Vet. App. 155 (1993). The Veteran’s DD-214 show a military occupational specialty (MOS) of fabrics and rubber products specialist. The Veteran’s service treatment records reveal no complaints or diagnosis of hearing loss or tinnitus. A June 1974 service treatment record noted the Veteran’s left ear contained fluid behind the eardrum, and his right ear was “cloudy.” In May 2012 correspondence, the Veteran stated that his hearing loss and tinnitus “happened when I was in the Air Force when I worked on the flight ramp.” At a November 2012 VA examination, the Veteran reported that his tinnitus began “within 5 years of discharge.” The Veteran was diagnosed with bilateral hearing loss and tinnitus. In February 2013, the examiner opined that hearing loss and tinnitus were less likely than not related to active-duty service, to include in-service noise exposure. The examiner reasoned that the Veteran’s hearing was normal on separation from active-duty service and that medical evidence did not support the development of hearing loss many years after noise exposure. The examiner further reasoned that if the Veteran had experienced tinnitus during service, he would have reported it, and that the normal hearing sensitivity thresholds on separation indicated no acoustic damage. At a December 2019 VA examination, the Veteran reported that his tinnitus began during service. The examiner diagnosed bilateral hearing loss and tinnitus but opined that the disorders were less likely than not related to active-duty service. The examiner reasoned that the Veteran’s hearing was normal on separation and that medical evidence did not support the development of hearing loss many years after noise exposure. With regard to tinnitus, the examiner reasoned that the Veteran denied any history of ear trouble on military separation and there was no evidence of acoustic damage upon military separation. In a May 2020 addendum opinion, the examiner discussed the June 1974 service treatment record noting left ear fluid build-up and a “cloudy” right ear. However, the examiner noted that fluid and ear infections could be transient in nature and the Veteran left service without evidence of permanent ear damage. On this basis, the examiner opined that it was less likely than not that hearing loss was related to the Veteran’s active-duty service. The Board acknowledges that as organic diseases of the nervous system, sensorineural hearing loss and tinnitus are disorders which, if manifest to a degree of 10 percent within one year after separation from active duty, may be presumed to have been incurred in service. 38 C.F.R. §§ 3.307, 3.309. Moreover, because tinnitus is “subjective,” its existence is generally determined by whether a person claims to experience it. Tinnitus has been specifically found to be a disorder with symptoms that can be identified through lay observation alone. Charles v. Principi, 16 Vet. App. 370 (2002). However, to the extent that the Veteran has asserted his tinnitus began during active-duty service or within one year thereafter, the Board finds that assertion lacks credibility. Such assertion is directly contradicted by his reported history at the November 2012 VA examination that his tinnitus began within five years of separation. Moreover, the first documented allegation that tinnitus began during service was made decades after separation, in the course of a claim for benefits. See Buchanan v. Nicholson, 451 F.3d 1331 (2006) (the Board can consider bias in lay evidence, the lack of contemporaneous medical records, and significant time delay between the observations and the date on which the statements were written in weighing credibility.) Additionally, to the extent that the Veteran has asserted that his hearing loss began during active-duty service, or within one year thereafter, the Veteran is not competent to provide a diagnosis of hearing loss or determine that any symptoms were manifestations of a sensorineural hearing loss, or of hearing loss for VA compensation purposes generally. The diagnosis of the appellant’s hearing loss is medically complex, as diagnosis of hearing loss requires knowledge of interpretation of complicated diagnostic medical testing. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). The Board thus gives more probative weight to the competent medical evidence of record, that being the audiological test results contained within the service-treatment records, and the December 2019 VA audiologist’s opinion and May 2020 addendum against an onset of hearing loss or tinnitus during active-duty service. The available evidence preponderates against finding manifestations sufficient to identify a chronic hearing loss or tinnitus disorder in active-duty service, or within one year thereafter. Thus, service connection is not warranted on a presumptive basis. 38 C.F.R. §§ 3.307, 3.309. The evidence preponderates against finding that hearing loss and tinnitus are directly related to active-duty noise exposure. While the Veteran has stated that he believes his hearing loss and tinnitus are related to in-service noise exposure, the Veteran is not competent to provide an opinion in this regard. The etiologies of hearing loss and tinnitus are medically complex as they have multiple possible etiologies. Jandreau, 492 F.3d at 1377 n.4. The Board again acknowledges the Veteran’s reports that tinnitus began in service. To the extent that the Veteran has reported continuous symptoms of tinnitus since active-duty service, those statements lack credibility as they are contradicted by his report of history at the November 2012 VA examination that tinnitus began within five years of separation. See Buchanan, 451 F.3d at 1331. The Board thus gives more probative weight to the December 2019 VA audiologist’s opinion and May 2020 addendum against an in-service etiology of hearing loss and tinnitus than to the Veteran’s assertions in that regard. The preponderance of the evidence is against finding that bilateral hearing loss or tinnitus are related to an in-service injury or disease, manifested during service, or were compensably disabling within a year of separation from active duty service. The claims are denied. Respiratory disorder The Veteran contends that he has a respiratory disorder which is related to his active duty service, to include exposure to toluene. The Veteran’s service treatment records note complaints of a cough with chest pain in April 1973 with a diagnosis of bronchitis. In September 1975 he was treated for persistent cough and congestion and assessed with a persistent upper respiratory infection. In May 2012 correspondence, the Veteran stated that he inhaled toluene vapors during his active-duty service, resulting in unconsciousness, and acute bronchitis with bronchospasm soon after, requiring hospitalization. At a November 2012 VA examination, the Veteran was diagnosed with asthma. The examiner declined to provide any etiological opinion due to the lack of availability of the Veteran’s claims file. In November 2012 correspondence, a fellow service-member stated that he and another airman found the Veteran unconscious during service and noted the smell of toluene. He reported that thereafter the Veteran developed a bad cough requiring hospitalization. At a December 2019 VA examination, the Veteran was again diagnosed with asthma. The examiner opined that asthma was less likely than not related to the Veteran’s active-duty service, to include toluene exposure. The examiner reasoned that the service treatment records did not reveal symptoms or diagnosis of asthma or chronic bronchitis, and the Veteran’s separation examination was negative for a respiratory condition. While there were isolated respiratory symptoms in service, the first documentation of asthma was in 2010. The examiner stated that it was “highly unlikely that chemical exposures in the mid-1970s would remain asymptomatic for over 30 years and then result in asthma.” To the extent that the Veteran has asserts that his asthma is related to his active-duty service to include toluene exposure, the Veteran is not competent to provide a medical opinion in this regard. The etiology of asthma is medically complex, as it has multiple possible etiologies. Jandreau, 492 F.3d at 1377, 1377 n.4. The Board thus gives more probative weight to the competent medical evidence of record, that being the December 2019 VA examiner’s opinion against an in-service etiology of a respiratory disorder. The preponderance of the evidence is against finding that a respiratory disorder is related to an in-service injury or disease, to include toluene exposure. The claim is denied. Increased Rating Knees The Veteran contends that his right and left knee disorders are more severely disabling than represented by the currently assigned 20 percent rating based on right knee recurrent subluxation/lateral instability, 10 percent rating based on right knee limitation of extension, 10 percent rating based on left knee impairment of the tibia and fibula, and 10 percent rating based on left knee instability since December 18, 2019. Disability evaluations are determined by the application of the VA’s Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4. The percentage ratings 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 their residual conditions in civil occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Where an increase in the level of a service-connected disability is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet. App. 55 (1999). Nevertheless, separate ratings can be assigned for separate periods of time based on the facts found, a practice known as “staged” ratings. See Fenderson v. West, 12 Vet. App. 119, 126 (1999). The analysis is therefore undertaken with consideration of the possibility that different ratings may be warranted for different time periods within the period on appeal. Where there is a question as to which of the two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. 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 on which ratings are based adequately portrays the anatomical damage, and the functional loss, with respect to these elements. In addition, functional loss may be due to pain, supported by adequate pathology and evidenced by the visible behavior of the veteran undertaking the motion. Weakness is as important as limitation of motion, and a part which becomes painful on use must be regarded as seriously disabled. 38 C.F.R. § 4.40. The intent of the 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. Certain rating criteria for evaluating musculoskeletal disabilities were revised during the period on appeal, effective February 7, 2021. Below, the relevant substantive changes to the rating criteria are discussed in further detail. There is no indication that the revised criteria are intended to have retroactive effect, and accordingly, the claims will be evaluated according to the revised criteria beginning only on the effective date of those new criteria. See VAOPGCPREC 3-2000 (2000) and 7-2003 (2003). The Veteran’s right and left knee disabilities are currently rated under 38 C.F.R. § 4.71a DC 5257, based on recurrent subluxation or lateral instability, DC 5261 based on limitation of extension, and DC 5262 based on an impairment of the tibia and fibula. DC 5257 provides ratings for recurrent subluxation or lateral instability. Prior to February 7, 2021, recurrent subluxation or lateral instability warranted a 10 percent rating if it was “slight,” 20 percent rating if it was “moderate,” and 30 percent rating if it was “severe.” 38 C.F.R. § 4.71a. Revised rating criteria under DC 5257 are available starting February 7, 2021. Those rating criteria are discussed further in the Reasons for Remand section below. Throughout the period on appeal, DC 5258 provides that a 10 percent rating may be assigned for symptomatic removal of semi-lunar cartilage and a 20 percent rating may be assigned for dislocated semilunar cartilage with frequent episodes of “locking,” pain, and effusion into the joint. 38 C.F.R. § 4.71a. DCs 5260 and 5261 are unchanged by the revised rating criteria. Throughout the period on appeal, under DC 5260, a 10 percent rating is assigned when flexion of the knee is limited to 45 degrees. 38 C.F.R. § 4.71a. Under DC 5261, a 10 percent rating is assigned when extension of the knee is limited to 10 degrees, a 20 percent rating is assigned when extension is limited to 15 degrees, a 30 percent rating is assigned when extension is limited to 20 degrees, a 40 percent rating is assigned when extension is limited to 30 degrees, and a 50 percent rating is assigned when extension is limited to 45 degrees. 38 C.F.R. § 4.71a. DC 5262 provides ratings for impairment of the tibia and fibula. Prior to February 7, 2021, a 10 percent rating was assigned where knee or ankle disability was “slight,” and a 20 percent rating was assigned where it was “moderate.” Effective February 7, 2021, DC 5262 provides that impairment of the tibia and fibula will be assigned a 40 percent rating where there is nonunion with loose motion, requiring brace. Malunion of the tibia and fibula will be evaluated under DCs 5256, 5257, 5260, or 5261 for the knee. The revised criteria also provide for ratings where there is malunion of the tibia and fibula with medial tibial stress syndrome (MTSS) or shin splints. Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 76453, 76463 (Nov. 30, 2020) (to be codified at 38 C.F.R. § 4.71a, DC 5262). Additionally, relevant to the present appeal, DC 7801 provides ratings for burn or other scars (not on the head, face, or neck) that are deep and nonlinear. Deep and nonlinear scars involving an area or areas of at least 6 square inches (39 square cm) but less than 12 square inches (77 square cm) are rated 10 percent. 38 C.F.R. § 4.118. Note (1) specifies that a deep scar is one associated with underlying soft tissue damage. 38 C.F.R. § 4.118. Under DC 7802, burn scars or scars due to other causes, not of the head, face, or neck, that are superficial and nonlinear warrant a rating of 10 percent for area or areas of 144 square inches (929 square cm) or greater. Note (1) provides that a superficial scar is one not associated with underlying soft tissue damage. 38 C.F.R. § 4.118. Under DC 7804, unstable or painful scars warrant a rating of 10 percent for one or two scars that are unstable or painful. Note (1) provides that an unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. Note (2) provides that if one or more scars are both unstable and painful, add 10 percent to the evaluation that is based on the total number of unstable or painful scars. Note (3) provides that scars evaluated under DC 7800, 7801, 7802, or 7805 may also receive an evaluation under this DC, when applicable. 38 C.F.R. § 4.118. DC 7805, for other scars (including linear scars) and other effects of scars evaluated under DC 7800, 7801, 7802, and 7804, provides for evaluation of disabling effects not considered in a rating provided under DC 7800-04 under an appropriate diagnostic code. 38 C.F.R. § 4.118. A July 2012 VA examiner noted a history of bilateral surgically repaired meniscal tears, as well as anterior cruciate ligament repair in the right knee. Right knee range of motion was from 0 degrees of extension to 110 degrees of flexion and left knee range of motion was from 0 degrees of extension to 130 degrees of flexion. The Veteran did not report flare-ups, but there was pain on movement in the right knee. Joint stability testing was normal, but there was a history of moderate right knee recurrent patellar subluxation/dislocation. There were bilateral shin splints which were asymptomatic at the time of examination. The examiner noted a history of bilateral meniscal tears with frequent episodes of joint locking and effusion in the right knee only, but frequent episodes of joint pain bilaterally. The Veteran was noted to regularly use a right knee brace, and occasionally use a cane. The examiner noted knee scars which were not painful, unstable, and did not comprise an area larger than 39 square centimeters. On October 13, 2015 a VA examiner reported right knee range of motion from 10 degrees of extension to 105 degrees of flexion, and left knee range of motion from 0 degrees of extension to 120 degrees of flexion. The Veteran reported flare-ups manifested by swelling, Baker’s cysts, redness and heat. There was sharp pain below the kneecap, popping, and weakness. The examiner opined that repetitive use and flare-ups would produce additional functional loss but declined to estimate any such additional functional loss because the Veteran was not examined immediately following repetitive use or during a flare-up. The examiner noted a history of moderate recurrent subluxation and slight lateral instability in the right knee, as well as recurrent effusion. There was no history of recurrent subluxation or lateral instability of the left knee. No joint instability was noted on examination in either knee. There was no tibial and fibular impairment. The Veteran was noted to have a history of bilateral meniscal tears, with frequent episodes of locking, pain and effusion in the right knee only, and frequent episodes of joint pain bilaterally. The Veteran was noted to occasionally use a wheelchair, constantly use a brace, regularly use a cane and occasionally use motorized carts in stores due to his right knee disability. The examiner noted knee scars which were not painful, unstable, and did not comprise an area larger than 39 square centimeters. On VA examination on December 17, 2019, the examiner reported right knee range of motion from 5 degrees of extension to 95 degrees of flexion, and left knee range of motion from 0 degrees of extension to 130 degrees of flexion. On repetitive use, right knee range of motion was reduced to 10 degrees of extension to 95 degrees of flexion and left knee range of motion was reduced to 0 degrees of extension to 125 degrees of flexion. The Veteran reported flare-ups described as increased pain in the right knee going down into his shin, several times per week, “8-9/10 severity,” and left knee pain “like a screwdriver in there, twisting” every 1-2 weeks for 1 day, “8/10 severity.” The examiner opined that following repeated use over a period of time, right knee range of motion would be further reduced to 15 degrees of extension to 90 degrees of flexion, but left knee range of motion would not be further reduced. On flare-up, the examiner opined that right knee range of motion would be reduced to 30 degrees of extension to 80 degrees of flexion and left knee range of motion would not be further reduced. The examiner noted a history of moderate recurrent right knee subluxation, and instability, with recurrent effusion, and slight left knee recurrent subluxation and lateral instability, also with recurrent effusion. Joint stability testing was normal in the right knee on examination, but in the left knee there was 0-5 millimeters of medial instability. There was no tibial and/or fibular impairment. Right knee meniscal tear was noted with frequent episodes of locking, pain and effusion, and left knee meniscal tear was associated with frequent episodes of joint pain. The Veteran was noted to make regular use of a brace, occasional use of crutches, occasional use of a cane, and occasional use of motorized carts in store, due to his bilateral knee instability and pain. The examiner noted pain on passive range of motion, weight-bearing and non-weight bearing bilaterally. The examiner noted knee scars which were not painful, unstable, and did not comprise an area larger than 39 square centimeters. The Board turns first to the issue of increased ratings based on recurrent subluxation/lateral instability under DC 5257. Prior to February 7, 2021, a rating in excess of 20 percent for right knee moderate recurrent subluxation or lateral instability is not warranted. In this regard, the evidence prior to February 7, 2021 preponderates against finding “severe” recurrent subluxation or lateral instability. The medical evidence of record has characterized the right knee recurrent subluxation or lateral instability as no more than moderate. With regard to the left knee, the Board finds that the 10 percent rating for slight recurrent subluxation or lateral instability should be assigned starting December 17, 2019, the date of the examination where such symptom was first shown. However, a rating in excess of 10 percent for left knee recurrent subluxation or lateral instability is not warranted prior to February 7, 2021. In this regard, the medical evidence of record reveals no more than a slight left knee recurrent subluxation or lateral instability. Ratings warranted under DC 5257 for the period since February 7, 2021 are discussed further in the Reasons for Remand section below. The Board turns next to DC 5258 and 5259, and finds that a separate 20 percent rating is warranted for right knee dislocated semilunar cartilage with frequent episodes of locking, pain and effusion into the joint, and 10 percent rating for left knee symptomatic removal of semilunar cartilage since January 14, 2011. In this regard, the July 2012, October 2015, and December 2019 VA examinations explicitly note bilateral meniscectomies, with frequent right knee episodes of locking, pain and effusion, and left knee pain. The currently assigned knee ratings do not contemplate this symptomatology. Notably, the evidence preponderates against finding that the criteria for a 20 percent rating for left knee removal of semilunar cartilage are met, as the evidence does not demonstrate frequent episodes of locking, or effusion into the joint with regard to the left knee. Turning next to DCs 5260 and 5261, based on limitation of motion, for the entirety of the period on appeal, the evidence preponderates against finding any separate rating is warranted based on right or left knee flexion under DC 5260. There is no evidence that right or left knee flexion has been limited to 60 degrees or less at any time during this period. On the contrary, the VA examinations report greater than 60 degrees of flexion at all times, to include after repetitive use and on flare-up. For the period prior to October 13, 2015, the evidence preponderates against finding entitlement to a rating in excess of 10 percent for right knee limitation of extension. In this regard, prior to October 13, 2015, there is no evidence of limitation of right knee extension to 15 degrees or less. At the October 13, 2015 VA examination, the examiner opined that the Veteran would have additional limitation of function after repetitive use and during flare-ups but declined to provide an estimate of such functional loss in terms of degrees of limitation of motion. On examination in December 2019, the examiner opined that the Veteran’s right knee extension would be limited to 30 degrees during flare-ups. Limitation of right knee extension to 30 degrees supports a 40 percent rating. Given that the October 13, 2015 examiner identified increased functional loss during flare-ups, the award of a 40 percent rating based on limitation of right knee extension is effective as of the October 13, 2015 examination. For the period since October 13, 2015, however, there is no evidence of right knee extension limited to 45 degrees, to support a higher rating. With regard to left knee extension, the evidence preponderates against finding entitlement to a compensable rating at any time during the period on appeal. In this regard, there is no evidence of left knee extension limited to 10 degrees or more, to include after repetitive use or on flare-up. The Board has also considered entitlement to a separate or higher rating based on DC 5262, relating to an impairment of the tibia and fibula, but no higher rating is warranted based on the criteria in effect prior to February 7, 2021, or the criteria in effect thereafter. In this regard, the rating criteria in effect prior to February 7, 2021 and thereafter require evidence a malunion or nonunion of the tibia and fibula. While the July 2012 examiner noted bilateral shin splints, they were described as asymptomatic, and the examiner did not specifically note any malunion or nonunion of the tibia and fibula. The October 2015 and December 2019 examiners explicitly denied any impairment of the tibia and fibula. This evidence preponderates against finding malunion or nonunion of the tibia and fibula such as to support a higher or separate rating during the period on appeal. Finally, the Board notes that the June and July 2020 Supplemental Statements of the Case (SSOCs) addressed the issue of whether higher ratings were warranted for the Veteran’s knee scars and appear to erroneously state that the Veteran has been assigned separate compensable ratings for his knee scars. However, in this case, the evidence preponderates against finding that a separate compensable rating is warranted for knee scars. There is no evidence of record to indicate that the Veteran’s knee scars themselves were painful, unstable, or comprised an area larger than 39 square centimeters, or were productive of any other functional impairment at any time during the period on appeal. Accordingly, a separate or higher rating on this basis is not warranted. Based on the foregoing, entitlement to a separate 20 percent rating, but no higher, for right knee medial meniscectomy residuals with traumatic arthritis based on dislocated semilunar cartilage since January 14, 2011 is granted; a rating in excess of 20 percent based on right knee recurrent subluxation/lateral instability prior to February 7, 2021 is denied; a rating in excess of 10 percent for right knee limitation of extension, prior to October 13, 2015 is denied; a 40 percent rating, but no higher, for right knee limitation of extension since October 13, 2015 is granted; a separate 10 percent rating, but no higher, for left knee symptomatic removal of semilunar cartilage since January 14, 2011 is granted; a 10 percent rating, but no higher, for left knee recurrent subluxation/lateral instability on December 17, 2019 is granted; a rating in excess of 10 percent for left knee recurrent subluxation/lateral instability from December 18, 2019 to February 6, 2021 is denied; and a rating in excess of 10 percent for left knee impairment of the tibia and fibula is denied. Entitlement to a 50 percent rating for migraine headaches from January 14, 2011 to December 16, 2019 is granted; a rating in excess of 30 percent since December 17, 2019 is denied. The Veteran contends that his migraine headaches are more severely disabling than represented by the currently assigned 30 percent rating. The Veteran’s migraine headaches are rated under Diagnostic Code 8100. 38 C.F.R. § 4.124a. Under this code, migraine headaches with characteristic prostrating attacks occurring on an average of once a month over the last several months are rated as 30 percent disabling. Migraine headaches with very frequent, completely prostrating and prolonged attacks productive of severe economic inadaptability warrant a 50 percent evaluation, which is the maximum evaluation available under this DC. 38 C.F.R. § 4.124a, DC 8100. In July 2012 the Veteran was provided a VA examination regarding his migraine headaches. He reported pulsating and throbbing head pain on both sides of his head with nausea, sensitivity to light and vision changes. The examiner noted characteristic prostrating attacks of migraine headache pain more than once per month and noted very frequent prostrating and prolonged attacks of migraine headache pain. The examiner noted the functional impact of the Veteran’s headache condition was that the Veteran was retired on Social Security disability due to the headaches and arthritis in his right knee and back. On December 17, 2019 the Veteran was provided a second VA examination. At that time, the Veteran reported constant head pain on both sides of his head and behind his eyes, with nausea, vomiting, light and sound sensitivity, and changes in vision. The examiner noted characteristic prostrating attacks of migraine headache pain once per month, but no very frequent prostrating and prolonged attacks productive of severe economic inadaptability. The examiner noted no impact of migraine headaches on the Veteran’s ability to work. Based on the foregoing evidence, a 50 percent rating is warranted from January 14, 2011 to December 16, 2019. During this period, the available evidence indicates that the Veteran had “very frequent prostrating and prolonged attacks of migraine headache pain.” While the examiner did not explicitly indicate that those attacks were productive of severe economic inadaptability, the examiner did indicate that the migraine headaches contributed to unemployability, suggesting that they were productive of severe economic inadaptability. On balance, the Board finds this evidence to be at least in equipoise, and a 50 percent rating is granted. From December 17, 2019, however, the evidence preponderates against finding that a rating higher than 30 percent is warranted. In this regard, the December 17, 2019 examiner explicitly found that prostrating headaches attacks of migraine headaches pain occurred only once per month, and that such attacks were not “very frequent prostrating and prolonged attacks productive of severe economic inadaptability.” The preponderance of the evidence is thus against finding that the criteria for a rating in excess of 30 percent since December 17, 2019 were met. Thus, entitlement to a 50 percent rating for migraine headaches from January 14, 2011 to December 16, 2019 is granted. A rating in excess of 30 percent since December 17, 2019 is denied. Entitlement to a TDIU from January 14, 2011 to October 12, 2015, and since December 17, 2019 is granted. The Veteran contends that he is unable to sustain gainful employment due to his service-connected disabilities. A TDIU is authorized for any disability or combination of disabilities where the schedular rating is less than total, and the claimant is unable to secure and maintain substantially gainful employment because of the severity of service-connected disabilities. If there is only one such disability, it must be rated as at least 60 percent disabling. If two or more disabilities, at least one must be rated as at least 40 percent disabling, with sufficient additional service-connected disability to bring the combined rating to 70 percent. 38 C.F.R. §§ 4.15, 4.16(a). For the above purpose, VA will consider disabilities resulting from common etiology, a single accident, or affecting a single body system as one disability. 38 C.F.R. § 4.16(a). For a TDIU, the critical question is whether the veteran’s service-connected disabilities alone are sufficient to cause unemployability, absent consideration of any nonservice-connected condition. See Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). Other factors that may receive consideration include his employment history, level of education and vocational attainment. See 38 C.F.R. § 4.16; see also Ferraro v. Derwinski, 1 Vet. App. 326, 331-32 (1991). From January 14, 2011 to November 11, 2013, the Veteran was service connected for migraine headaches rated 50 percent disabling; a right knee medial meniscectomy with traumatic arthritis rated 20 percent disabling based on recurrent subluxation or lateral instability, 20 percent disabling based on dislocated of semilunar cartilage, and 10 percent disabling based on limitation of extension; and a left knee arthroscopic meniscectomy with traumatic arthritis rated 10 percent disabling based on removal of semilunar cartilage, and 10 percent disabling based on impairment of the tibia and fibula. From November 12, 2013, to October 12, 2015 the Veteran was service connected for migraine headaches rated 50 percent disabling; persistent depressive disorder rated 50 percent disabling; a right knee medial meniscectomy with traumatic arthritis rated 20 percent disabling based on recurrent subluxation or lateral instability, 20 percent disabling based on dislocated semilunar cartilage, and 10 percent disabling based on limitation of extension; and a left knee arthroscopic meniscectomy with traumatic arthritis rated 10 percent disabling based on removal of semilunar cartilage, and 10 percent disabling based on impairment of the tibia and fibula. From October 13, 2015 to December 16, 2019 the Veteran was service connected for migraine headaches rated 50 percent disabling; a persistent depressive disorder rated 50 percent disabling; right knee medial meniscectomy residuals with traumatic arthritis rated 40 percent disabling based on limitation of extension, 20 percent disabling based on recurrent subluxation or lateral instability, and 20 percent disabling based on dislocated semilunar cartilage; and left knee medial meniscectomy residuals rated 10 percent disabling based on symptomatic removal of semilunar cartilage, and 10 percent disabling based on impairment of the tibia and fibula. Since December 17, 2019 the Veteran was service connected for peristent depressive disorder rated 50 percent disabling; migraine headaches rated 30 percent disabling; a right knee medial meniscectomy residuals with traumatic arthritis rated 40 percent disabling based on limitation of extension, 20 percent disabling based on recurrent subluxation/lateral instability, and 20 percent disabling based on dislocated semilunar cartilage; and left knee medial meniscectomy residuals with traumatic arthritis rated 10 percent disabling based on impairment of the tibia and fibula, 10 percent disabling based on removal of semilunar cartilage and 10 percent disabling based on recurrent subluxation/lateral instability. After application of the relevant bilateral factors, the Veteran’s combined rating was 80 percent from January 14, 2011 to November 11, 2013, 90 percent from November 12, 2013 to October 12, 2015, 100 percent from October 13, 2015 to December 16, 2019, and 90 percent since December 17, 2019. Thus, the appellant meets the schedular requirements for a TDIU from January 14, 2011 to October 12, 2015, and since December 17, 2019. 38 C.F.R. § 4.16. In his January 14, 2011 claim, the Veteran reported being unable to work, and that he last worked on September 29, 2010. A February 2011 decision of the Social Security Administration noted that the Veteran was found entitled to Social Security disability benefits based on a primary diagnosis of disorders of the back, with a secondary diagnosis of disorders of muscle, ligament and fascia. In April 2011, the Veteran reported that he was claiming TDIU due to his knee and back disabilities. In a May 2011 TDIU application, the Veteran reported working in logistics from October 1977 through November 2011, although he indicated last working full time in September 2010, and noted 14 months of time lost due to illness. He reported being unemployable due to knee, spine, asthma, hearing, tinnitus, left shoulder and migraines disabilities. He noted one year of college education. On VA examination in July 2012, the functional impairment due to bilateral knee disabilities was described as needing to keep his right knee elevated as much as possible, which his previous employment would not allow. At a July 2012 migraines examination, the examiner noted the Veteran was retired and receiving Social Security disability benefits due to the combined effects of his migraines, low back and knee disabilities. On VA examination in October 2015, the functional impairment due to the Veteran’s knee disabilities was that he was unable to do prolonged sitting or get up quickly/walk quickly after prolonged sitting, unable to do prolonged standing, walking, climbing stairs or ladders, kneeling, squatting, crawling, heavy lifting, jumping or running. In a March 2016 opinion, a private psychologist, Dr. H.H., opined that the Veteran’s migraine headaches, knee disabilities, and depressive disorder prevented him from maintaining substantially gainful employment. She noted that the depressive disorder prevented the Veteran from sustaining the stress of a competitive work environment. On VA examination in December 2019, the functional impairment due to the Veteran’s knee disabilities was that he was unable to sit for long periods with knees bent, and unable to do prolonged walking or standing, unable to climb or descend stairs, unable to run and unable to walk “very far.” On VA examination in December 2019, the Veteran’s migraine headaches were reported to produce no functional impact. On VA examination in January 2020, the Veteran’s persistent depressive disorder was reported to cause occupational and social impairment with reduced reliability and productivity. In an October 2020 opinion, a private physician, Dr. M.B., opined that the Veteran was unable to maintain substantially gainful employment since at least January 14, 2011, due to his service-connected disabilities. Dr. M.B. provided an extensive discussion of the relevant evidence and reasoned that limited mobility, severe pain, need for leg elevation, severely interrupted sleep, frequent prostrating headaches and side effect of medication and physical and mental limitations combined to render the Veteran unemployable. This evidence is at least in equipoise as to whether the Veteran’s service-connected disabilities precluded all forms of substantially gainful employment consistent with his education and occupational experience from January 14, 2011 to October 12, 2015, and since December 17, 2019. Significantly, the only competent evidence of record addressing the combined effects of the Veteran’s service-connected disabilities on his employability is the March 2016 opinion of Dr. H.H. and October 2020 opinion of Dr. M.B. The opinion of Dr. M.B., in particular, is afforded great probative value as it reflects a thorough review of the record and complete rationale. While the Veteran reported being “employed” through November 2011, he also indicated that he stopped working full time in September 2010 and reported 14 months lost due to illness. In affording the benefit of the doubt, the Board finds that the Veteran was precluded from maintaining substantially gainful employment from January 14, 2011. His TDIU application is presumed to indicate that although he maintained formal employment status through November 2011, he was unable to work from January 14, 2011 due to disability. The Board acknowledges that the award of a combined 100 percent rating does not categorically render an individual unemployability claim moot. See Bradley v. Peake, 22 Vet. App. 280 (2008) (holding that there could be a situation where a veteran has a schedular total rating for a particular service-connected disability, and could establish a rating based on individual unemployability for another service-connected disability in order to qualify for special monthly compensation under 38 U.S.C. § 1114 (s) by having an “additional” disability of 60 percent or more (“housebound” rate)). In this case, however, for the period from October 13, 2015 to December 16, 2019, neither the Veteran nor the record reasonably raise the contention that the Veteran was totally disabled due to any single disability. Rather, in this case, the functional impacts of the Veteran’s service-connected disabilities combine to support the total combined rating and there is no evidence or argument that any individual disability would support a TDIU on its own, to include the claimed disabilities remanded below. Accordingly, in this case, the issue of entitlement to a TDIU for purposes of entitlement to SMC from October 13, 2015 to December 16, 2019 is moot. Thus, entitlement to a TDIU from January 14, 2011 to October 12, 2015, and since December 17, 2019 is granted. REASONS FOR REMAND Entitlement to service connection for left shoulder and spine disorders is remanded. In December 2019 the Veteran was provided VA examinations regarding his claimed left shoulder and spine disorders. The examiners opined that it was less likely than not that left shoulder and spine disorders were caused or aggravated by his service-connected left knee disorder. However, the examiner did not provide separate findings and rationales addressing the separate questions of causation and aggravation. See Atencio v. O’Rourke, 30 Vet. App. 74 (2018) (holding that causation and aggravation are independent concepts and should have separate findings and rationales). Remand is required to obtain an adequate opinion which separately considers causation and aggravation. Entitlement to service connection for an eye disorder is remanded. In its July 2018 remand, the Board directed that the Veteran be afforded a VA examination to consider the nature and etiology of any current eye disorder. The examiner was to specifically provide an opinion whether each diagnosed eye disorder was related to the Veteran’s active-duty service or caused or aggravated by his migraine headaches. However, the examiner did not address whether any eye disorder was caused or aggravated by migraine headaches. Remand is required to obtain an adequate medical opinion in compliance with the Board’s July 2018 remand directives. Additionally, the examiner found that diplopia preexisted the Veteran’s active-duty service, based on the Veteran’s own report. However, exophoria/diplopia was not noted on entrance to active-duty service, and the presumption of soundness therefore applies. The examiner did not address whether diplopia was clearly and unmistakably not aggravated by active-duty service. On remand, the clinician must also address this question. Entitlement to ratings in excess of 20 percent for right, and 10 percent for left knee medial meniscectomy residuals with traumatic arthritis based on recurrent subluxation/lateral instability since February 7, 2021 is remanded. As discussed above, during the claims period the rating criteria pertaining to musculoskeletal disabilities were revised. The Veteran is in receipt of a 20 percent ratings for his right, and 10 percent for left knee medial meniscectomy residuals with traumatic arthritis based on recurrent subluxation/lateral instability under DC 5257. Effective February 7, 2021, DC 5257 provides, in relevant part, for a 20 percent rating where there is patellar instability with a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for one of the following: a brace, cane or walker. A 30 percent rating is assigned where there is patellar instability with a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for a brace and either a cane or walker. Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 76453, 76463 (Nov. 30, 2020) (to be codified at 38 C.F.R. § 4.71a, Diagnostic Code 5257). The revised criteria also provide for a 20 percent rating where there is recurrent subluxation or instability with one of the following: a) sprain, incomplete ligament tear, or repaired complete ligament tear causing persistent instability, and a medical provider prescribes a brace and/or assistive device (e.g., cane(s), crutch(es), walker) for ambulation; or b) unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribes either an assistive device (e.g., cane(s), crutch(es), or a walker) or bracing for ambulation. A 30 percent rating is warranted where there is recurrent subluxation or instability with unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribes both an assistive device (e.g., cane(s), crutch(es), walker) and bracing for ambulation. Id. Based on the evidence of record, it is not clear whether the Veteran meets the criteria for a higher rating based on the revised criteria, and none of the VA examinations of record have directly spoken to those criteria. Accordingly, remand is required to obtain a medical opinion to ascertain whether a higher rating is warranted under the revised criteria. The matters are REMANDED for the following action: 1. Obtain an addendum opinion from an appropriate clinician to determine the etiology of current left shoulder and spine disorders. The reviewer should state: (a.) What diagnosed left shoulder and spine disorders have been present at any time since January 14, 2011? (b.) For any such left shoulder and spine disorder: is it at least as likely as not proximately caused by right and left knee meniscotomy residuals with traumatic arthritis? (c.) For any such left shoulder and spine disorder: is it at least as likely as not aggravated beyond its natural progression by right and left knee meniscotomy residuals with traumatic arthritis? 2. Obtain an addendum opinion from an appropriate clinician to determine the etiology of current eye disorders other than a refractive error. The reviewer should state: (a.) What diagnosed eye disorders, other than a refractive error, have been present at any time since January 14, 2011? (b.) For any such eye disorder: is it at least as likely as not related to an in-service injury, event or disease? i. The examiner must state whether there is clear and unmistakable evidence (such that reasonable minds could not differ) that exophoria/diplopia was not aggravated by active-duty service. ii. If the examiner finds that there is not clear and unmistakable evidence that exophoria/diplopia was not aggravated by active-duty service, the examiner must take as conclusive fact that such disorder did not exist prior to any period of qualifying service. (c.) For any such eye disorder: is it at least as likely as not proximately caused by migraine headaches? (d.) For any such eye disorder: is it at least as likely as not aggravated beyond its natural progression by migraine headaches? 3. Obtain an addendum opinion from the examiner who conducted the December 2019 knee examination, or another appropriate clinician if that examiner is not available. The reviewer should state whether the Veteran’s right and left knee medial meniscotomy residuals with traumatic arthritis are manifested by: (a.) Patellar instability with a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for one of the following: a brace, cane or walker; (b.) Patellar instability with a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for a brace and either a cane or walker; (c.) Recurrent subluxation or instability with one of the following: a) sprain, incomplete ligament tear, or repaired complete ligament tear causing persistent instability, and a medical provider prescribes a brace and/or assistive device (e.g., cane(s), crutch(es), walker) for ambulation; or b) unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribes either an assistive device (e.g., cane(s), crutch(es), or a walker) or bracing for ambulation; or, (d.) Recurrent subluxation or instability with unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribes both an assistive device (e.g., cane(s), crutch(es), walker) and bracing for ambulation. LAURA E. COLLINS Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Paul J. Bametzreider 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.