Citation Nr: 21011679 Decision Date: 03/02/21 Archive Date: 03/02/21 DOCKET NO. 14-16 880 DATE: March 2, 2021 ORDER From April 5, 2012, to December 3, 2020, entitlement to a separate rating of 20 percent for the service-connected right knee meniscectomy with residual patellofemoral dysfunction, sprain at the medial and lateral collateral ligaments, and right knee degenerative joint disease (herein right knee disability) under Diagnostic Code (DC) 5258 is granted. From December 3, 2020, entitlement to a rating in excess of 20 percent for the service-connected right knee disability under DCs 5010-5258 is denied. Entitlement to a rating in excess of 10 percent for the service-connected right knee disability based upon limitation of extension under DCs 5010-5261 is denied. REMANDED Entitlement to service connection for a left knee disability, to include as secondary to the service-connected right knee disability and low back disability, is remanded. Entitlement to service connection for an upper back disability, to include as secondary to the service-connected low back disability, is remanded. Entitlement to a total disability rating based upon individual unemployability (TDIU) due to service-connected disabilities is remanded. FINDINGS OF FACT 1. Throughout the appeal period, the Veteran’s right knee disability has been manifested by dislocation of the semilunar cartilage with frequent episodes of locking, pain, and effusion into the joint. 2. Throughout the appeal period the Veteran’s right knee disability based upon limitation of extension has been manifested by painful limitation of motion, without additional functional loss due to pain, weakness, incoordination, fatigue, or other symptoms so as to limit flexion to 60 degrees or less or limit extension to 5 degrees or more. CONCLUSIONS OF LAW 1. From April 5, 2012, to December 3, 2020, the criteria for a separate 20 percent rating for the service-connected right knee disability have been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.40, 4.45, 4.49, 4.71a, DC 5258. 2. From December 3, 2020, the criteria for a rating in excess of 20 percent for the right knee disability have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.40, 4.45, 4.49, 4.71a, DCs 5010-5258. 3. The criteria for a rating in excess of 10 percent for the service-connected right knee disability based upon limitation of extension have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.40, 4.45, 4.49, 4.71a, DCs 5010-5261. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served in the United States Army Reserve, with an initial period of active duty for training (ACDUTRA) from May 1979 to August 1979, with additional Reserve service thereafter. These matters come before the Board of Veterans’ Appeals (Board) on appeal from an October 2012 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). In December 2016 and November 2018, the Board remanded these matters to the RO for further development. As an initial matter, the Board notes that in a December 2020 rating decision, the Agency of Original Jurisdiction (AOJ) granted service connection for a right knee disability under DCs 5010-5258, in association with the Veteran’s increased rating claim for his right knee disability based upon limitation of extension, and assigned a 20 percent rating from December 3, 2020. Because this separate 20 percent award is part and parcel of the Veteran’s right knee disability increased rating claim, the matter remains at issue before the Board. See AB v. Brown, 6 Vet. App. 35, 39 (1993). The Board also notes that in January 2014, VA received the Veteran’s claim for service connection for a skin condition. See January 2014 VA Form 21-526EZ, Application for Disability Compensation and Related Compensation Benefits. As the AOJ has not yet adjudicated this claim, the Board does not have jurisdiction over this matter. Accordingly, entitlement to service connection for a skin condition is again REFERRED to the AOJ for appropriate action. 1. From April 5, 2012, to December 3, 2020, entitlement to a separate 20 percent rating for the service-connected right knee disability, and a rating in excess of 20 percent thereafter; and entitlement to a rating in excess of 10 percent for the service-connected right knee disability based upon limitation of extension The Veteran seeks increased ratings for his service-connected right knee disability. He is currently in receipt of a 10 percent rating for his right knee disability based upon limitation of extension under DCs 5010-5261, and a separate 20 percent rating for his right knee disability, under DCs 5010-5258, from December 3, 2020. Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Staged ratings are appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505, 509 (2007). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise the lower rating will be assigned. 38 C.F.R. § 4.7. All benefit of the doubt will be resolved in the Veteran’s favor. 38 C.F.R. § 4.3. Disability of the musculoskeletal system is primarily the inability, due to damage or infection in the parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. For disabilities evaluated on the basis of limitation of motion, VA is required to apply the provisions of 38 C.F.R. §§ 4.40, 4.45, pertaining to functional impairment. The United States Court of Appeals for Veterans Claims (Court) has instructed that in applying these regulations VA should obtain examinations in which the examiner determined whether the disability was manifested by weakened movement, excess fatigability, incoordination, or pain. Such inquiry is not to be limited to muscles or nerves. These determinations are, if feasible, be expressed in terms of the degree of additional range-of-motion loss due to any weakened movement, excess fatigability, incoordination, flare-ups, or pain. DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Johnston v. Brown, 10 Vet. App. 80, 84-5 (1997); 38 C.F.R. § 4.59. In Mitchell v. Shinseki, 25 Vet. App. 32 (2011), the Court held that, although pain may cause a functional loss, “pain itself does not rise to the level of functional loss as contemplated by VA regulations applicable to the musculoskeletal system.” Rather, pain may result in functional loss, but only if it limits the ability “to perform the normal working movements of the body with normal excursion, strength, speed, coordination, or endurance.” Id., quoting 38 C.F.R. § 4.40. The Board notes that during the pendency of the appeal, the rating criteria for evaluating musculoskeletal disabilities under 38 C.F.R. § 4.71a were amended effective February 7, 2021. Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 76453-76463 (Nov. 30, 2020). These amendments revised select DCs “to ensure that this portion of the rating schedule uses current medical terminology and provides detailed and updated criteria for the evaluation of musculoskeletal disabilities.” Id. If a law or regulation changes during the course of a claim or an appeal, the version more favorable to the Veteran will apply, to the extent permitted by any stated effective date in the amendment in question. 38 U.S.C. § 5110(g). If the revised version of the regulation is more favorable, the implementation of that regulation under 38 U.S.C. § 5110(g) can be no earlier than the effective date of that change. If the former version is more favorable, VA can apply the earlier version of the regulation for the period prior to, and from, the effective date of the change. 38 U.S.C. § 5110. Therefore, the Board will consider the Veteran's claim under the old criteria prior to February 7, 2021 and both the old and new rating criteria from February 7, 2021. The criteria that is more favorable to the Veteran will be applied. Prior to the regulatory change, DC 5010 contemplated traumatic arthritis, which was to be rated as for degenerative arthritis. 38 C.F.R. § 4.71a. DC 5003 address degenerative arthritis, which states degenerative arthritis established by X-ray findings is rated on the basis of limitation of motion under the appropriate DCs for the specific joint or joints involved. 38 C.F.R. § 4.71a, DC 5003 (2020). DC 5003 further provides that when limitation of motion due to arthritis is noncompensable under the appropriate DC, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under DC 5003. As of February 7, 2021, under the amended criteria, DC 5003 concerns degenerative arthritis, other than post-traumatic arthritis, while DC 5010 provides that post-traumatic arthritis should be rated as limitation of motion, dislocation, or other specified instability under the affected joint. 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, DCs 5003, 5010). Limitation of extension of the knee is rated under DC 5261 and limitation of flexion of the knee is rated under DC 5260. 38 C.F.R. § 4.71a. The Board notes that the recent amendments to the rating criteria for evaluating musculoskeletal disabilities did not revise these DCs, and, as such, they were not changed. Under these codes, a 10 percent rating is warranted when flexion of the knee is limited to 45 degrees or when extension is limited to 10 degrees. A 20 percent rating is warranted when flexion is limited to 30 degrees or when extension is limited to 15 degrees. A 30 percent rating is warranted when flexion is limited to 15 degrees or when extension is limited to 20 degrees. A 40 percent rating is warranted when extension is limited to 30 degrees and a 50 percent rating is warranted when extension is limited to 45 degrees. Id. Normal range of motion of a knee is from zero degrees of extension to 140 degrees of flexion. 38 C.F.R. § 4.71, Plate II. Additionally, DC 5258 provides that a 20 percent rating may be assigned for dislocated semilunar cartilage with frequent episodes of “locking,” pain, and effusion into the joint while DC 5259 provides that a 10 percent rating may be assigned for symptomatic removal of the semilunar cartilage. 38 C.F.R. § 4.71a. The Board also notes that the recent amendments to the rating criteria for evaluating musculoskeletal disabilities did not revise these DCs, and, as such, they are not changed. Separate ratings for knee disabilities may also be assigned for a disability of the same joint, if none of the symptomatology on which each rating is based is duplicative or overlapping. See VAOPGCPREC 9-04 (2004); 69 Fed. Reg. 59,990 (2004); 38 C.F.R. § 4.14. As an initial matter, the Board notes that VA received the Veteran’s non-initial right knee increased rating claim on April 5, 2012. As such, the Board will consider the evidence of record from April 5, 2011 (one year prior to the date of the Veteran’s claim). Turning to the evidence of record, in October 2012, the Veteran underwent a VA knee examination. At the time of the examination, he reported flare-ups and pain in his right knee that were exacerbated by prolonged standing, walking, and sitting, as well as cold, rainy weather. The Veteran also referred giving away of the right knee and sporadic swelling. At that time, he constantly used a cane. Range of motion testing showed flexion to 115 degrees, with painful motion beginning at 115 degrees, and extension to zero degrees with no objective evidence of painful motion. The examiner found that the Veteran did not have additional limitation in range of motion of the knee following repetitive use testing but noted weakened movement and pain on movement that contributed to his functional impairment. Physical examination showed 4/5 muscle strength testing for both right knee flexion and extension. There was also normal anterior instability and posterior instability testing and no evidence of a history of recurrent patellar subluxation/dislocation. The examiner noted that the Veteran underwent prior right knee meniscectomies in 1993 and 2005 and had residual signs and symptoms of pain and weakness from these surgeries. The examiner also found that the Veteran’s condition did not impact his ability to work. Thereafter, VA treatment records continued to reflect complaints of right knee pain. For example, a November 2012 VA physical therapy note reflects that the Veteran’s chronic right knee pain had worsened since April 2012. Physical examination revealed normal muscle strength as well as right knee flexion to 137 degrees on a supine position and extension to zero degrees on a sitting position. Another November 2012 VA treatment record reflects that the Veteran had full active and passive range of motion. He had mild pain at the medial right knee but there was no evidence of laxity. In March 2014, the Veteran reported peristent right knee pain with walking and that his pain had not improved with pain medication. See March 2014 VA treatment record. That month, an MRI showed bilateral joint effusions that were more conspicuous on the right side. See March 2014 VA MRI findings. Another right knee MRI, in May 2014, showed thinning of the patellofemoral cartilage and a moderate size joint effusion. There was also a loss of substance at the body and anterior horn of the medial meniscus but no signs of a ligamentous injury. Subsequent July 2014, March 2015, and November 2016 VA treatment records reflect the Veteran had full range of motion of his extremities. A November 2016 VA orthopedic treatment record indicated that the Veteran had some atrophy in his quads. In July 2016, he also underwent another right knee MRI with VA which showed a large knee effusion as well as patellofemoral and medial femorotibial chondromalacia changes. See July 2016 MRI and treatment records. The July 2016 MRI also showed irregular contour of the medial meniscus posterior horn remnant central root insertion and a complex tear of the lateral meniscus anterior horn extending to the body. In June 2017, the Veteran reported intermittent right knee pain, which was severe with exertion. See June 2017 VA treatment record. Specifically, he reported that his pain worsened with walking and reported a history of approximately four falls due to his leg giving out. On examination, he had mild bilateral knee effusions and clicking sounds with flexion/extension. He also had full active and passive range of motion. His treating physician noted that his MRI studies indicated chondromalacia and meniscal degeneration/tear as the etiology of his knee pain. In July 2017, the Veteran underwent another VA knee examination. He reported constant bilateral knee pain that worsened when he assumed a standing position from a sitting position. He also reported severe flare-ups of pain that resulted in limited standing and limited long distance ambulation. At the time of the examination, he regularly used a cane for his knee and low back pain. Range of motion testing revealed flexion to 140 degrees and extension to zero degrees. The examiner noted there was evidence on pain with flexion but that his pain did not result in or cause functional loss and there was evidence of pain with passive range of motion without functional loss. There was also no evidence of pain with weight-bearing or with non-weight-bearing. The examiner was unable to say without mere speculation whether pain, weakness, fatigability, or incoordination could significantly limit functional ability with repeated use over a period of time or during flare-ups. The examiner noted, however, that pain could significantly limit functional ability during flare-ups or when the joint is used repeatedly over a period of time but that at the time of the physical examination there was no evidence of fatigability, incoordination, muscle weakness, or pain. On physical examination, there was also no evidence of ankylosis nor muscle atrophy. The Veteran’s muscle strength testing was normal. The examiner also found that the Veteran did not have a history of recurrent subluxation, lateral instability, nor recurrent effusion. Joint stability testing was normal and there was otherwise no evidence of joint instability. The examiner further noted that the Veteran had a meniscal condition, which resulted in a meniscal tear, frequent episodes of joint locking, joint pain, and joint effusion while the Veteran’s prior meniscectomies resulted in residuals of pain. The examiner additionally found that the Veteran’s disability impacted his ability to work in that his condition limited his ambulation and ability to remain in a standing position. After his July 2017 VA examination, the Veteran continued to report knee pain that worsened with prolonged walking and standing. See September 2017 VA treatment record. A September 2017 VA physical treatment examination showed that he had full active and passive range of motion with mild bilateral knee effusions. He was assessed with bilateral knee pain secondary to his degenerative joint disease/osteoarthritis and right meniscal tear. Another September 2017 VA treatment record reflects that the Veteran’s knee pain had been unresponsive to conservative measures. Moreover, a December 2017 VA treatment record reflects that the Veteran was receiving bilateral knee injections for his knee pain. On examination, he had full active and passive range of motion with normal muscle strength. There was no evidence of laxity and anterior drawer, posterior drawer, varus stress, and valgus stress testing were all negative. He had minimal crepitus. Thereafter, a March 2019 VA treatment record reflects that the Veteran had full active and passive range of motion of his lower extremities. On the other hand, a November 2019 VA treatment record reflects that the Veteran’s right knee had limited range of motion and that MRI results of the right knee showed moderate to severe degenerative changes, chondrocalcinosis, and a large suprapatellar effusion. In December 2020, the Veteran last underwent a knee VA examination. He reported that he continued to experience functional loss and right knee pain that worsened with prolonged standing and ambulation activities. He also explained that he experienced flare-ups approximately once per month, which lasted less than 30 minutes. At the time of the examination, he regularly used a cane due to his service-connected knee and back conditions. On physical examination, range of motion testing showed flexion to 130 degrees and extension to zero degrees. The examiner noted that his passive range of motion was the same as his active range of motion and that while flexion exhibited pain, the Veteran’s range of motion itself did not contribute to functional loss. There was also no evidence of pain with weight-bearing and with non-weightbearing. The examiner further found that the Veteran’s pain limited his functional ability with repeated use over a period of time and during flare-ups. She estimated that his range of motion after repeated use over time would be zero to 130 degrees and during flare-ups would be zero to 100 degrees. There was no evidence of ankylosis, and the Veteran endorsed normal muscle strength testing. The examiner found that the Veteran did not have a history of recurrent subluxation, lateral instability, nor recurrent effusion. Stability testing was also normal without evidence of joint instability. The December 2020 VA examiner further found that the Veteran had a right knee meniscal condition, which resulted in frequent episodes of joint locking, pain, and effusion. His disability impacted his ability to work because the Veteran would have to avoid prolonged standing and ambulation activities. The December 2020 VA examiner also provided the Veteran’s range of motion testing, as noted on the prior VA examinations of record, for the appeal period and found that the Veteran’s condition had progressed/worsened since onset. As such, the Board finds that the VA examiner sufficiently complied with the November 2018 Board directives for a retrospective opinion on the Veteran’s range of motion throughout the appeal period and the historical severity of his disability. Applying the facts in this case, to the criteria set forth above, the Board first finds that the preponderance of the evidence is against the assignment of a rating in excess of 10 percent for the Veteran’s right knee disability based upon limitation of extension, under DCs 5010-5261, at any point doing the appeal period. In this regard, the evidence shows that throughout the appeal period, the Veteran had full extension of his right knee and that his flexion was at, worse, to 100 degrees when considering range of motion during flare-ups. Critically, several treatment records throughout the appeal period indicate that the Veteran had full active and passive range of motion. To reiterate, the criteria for the next-higher 20 percent rating under either DC 5260 or DC 5261 contemplates flexion limited to 30 degrees and extension limited to 15 degrees respectively, which has not been shown during the appeal period. Accordingly, the Board finds that the Veteran is not entitled to a higher rating for his right knee disability based upon limitation of extension at any point in the appeal period. In reaching this conclusion, the Board is cognizant that the evidence shows the Veteran had functional loss causing limitation of motion due to pain, which was exacerbated during flares and repetitive use. However, the Veteran’s range of motion limitations, particularly the range of motion testing, as documented in the medical records, as well as the estimates provided after repeated use and during flare-ups, do not meet or more closely approximate the limitations that would be associated with a higher rating. Indeed, the evidence of record does not show range of motion measurements that approximate the limitations contemplated for noncompensable ratings under either DCs 5260 and/or 5261. To the extent that any of the VA examinations do not document range of motion during flares or after repetitive use, the Board notes that the examination reports of record detail the Veteran’s reported pain during flares and his reported functional loss. The Board finds such information pertinent and useful when evaluating his disability picture. Thus, the Board finds that the VA examination reports, together with the other evidence, are adequate to decide the Veteran’s increased rating claim. The Board has also considered the implications of the decision in Correia v McDonald, 28 Vet. App. 158, 168 (2017), in which the Court held that 38 C.F.R. § 4.59 creates range of motion testing requirements with which VA must comply. 28 Vet. App. 158 (2016). The Board finds that the December 2020 VA examiner specifically addressed Correia considerations in rendering findings that there was no pain with weight bearing or non-weightbearing range of motion testing and that passive range of motion was the same as active range of motion. The Board notes that where no pain was noted, as with this examination, the additional range of motion testing would not result in additional loss of range of motion. Additionally, although the examiner noted that the Veteran’s right knee flexion exhibited pain, the examiner found that the Veteran’s noted pain did not result in or cause functional loss. As such, in this case, the examiner did not have to offer an opinion as to the degree of additional functional loss due to pain. Accordingly, the Board finds that even when specifically considering the Veteran’s pain, and functional loss during flare-ups and repeated use, a rating in excess of 10 percent for the Veteran’s right knee disability based upon limitation of extension is not warranted. However, the Board finds that a separate 20 percent rating for the Veteran’s right knee disability is warranted under DC 5258 from April 5, 2012, the date of the Veteran’s increased rating claim, to December 3, 2020. In this regard, the evidence since the Veteran’s increased rating claim shows that his right knee disability also involves dislocated semilunar cartilage with frequent episodes of locking, pain, and effusion into the joint. Specifically, the October 2012 VA examiner noted that the Veteran experienced residual signs and symptoms of pain and weakness from his prior right knee meniscectomies while the July 2017 VA examiner found that the Veteran had frequent episodes of locking, pain, and effusion into the joint. Significantly, the March 2014, May 2014, July 2016, and November 2019 MRI results reflect joint effusion. The evidence also shows the Veteran complained of medial knee pain. As such, the Board finds that an additional rating of 20 percent under DC 5258 is warranted from April 5, 2012, to December 3, 2020, the date the AOJ assigned an additional/separate 20 percent rating to account for the Veteran’s meniscal symptoms. Moreover, the Board finds that the assignment of a separate rating under DC 5258 does not violate the prohibition against pyramiding. In this regard, other disability ratings may be assigned only if the symptomatology for a disability is not duplicative or overlapping with the symptomatology of any other disability. See 38 C.F.R. § 4.14; Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). The symptoms manifested by the Veteran's right knee cartilage and meniscal issues, as contemplated by DC 5258, do not overlap with the symptoms contemplated by the 10 percent disability rating assigned by the AOJ under DCs 5010-5261 for limitation of range of motion. Separate ratings are supported by the evidence of record in this case, and an award under DC 5261 does not preclude the award of a separate rating under DC 5258 for the separate and distinct meniscal symptoms for the Veteran's right knee. See 38 C.F.R. § 4.14; VAOPGCPREC 23-97; Lyles v. Shulkin, 29 Vet. App. 107,109 (2017). Specifically, although DC 5258 contemplates pain as a symptom, DC 5261 contemplates the Veteran’s painful motion, including during flare-ups, and functional loss which limit his ability to engage in ambulation activities or remain in a prolonged standing position. The Board also notes that a 20 percent rating under DC 5258 is the maximum allowable rating under this DC. Finally, the Board finds that the Veteran is not entitled to additional or higher ratings throughout the appeal period (for any of the ratings associated with his right knee disability) under DCs 5256, 5257, 5262, and 5263, even with consideration of the amended criteria for evaluating musculoskeletal disabilities, effective February 7, 2021. These DCs concern disabilities that involve ankylosis of the knee, instability, patellar instability, recurrent subluxation or lateral instability, nonunion or malunion of the tibia and fibula, shin splints, and/or genu recurvation. The evidence does not show that the Veteran has any of these additional conditions that would warrant a separate rating under these DCs. The Board acknowledges that the October 2012 VA examination notes the Veteran referred to giving way of the right knee and that a June 2017 VA treatment record reflects the Veteran reported a history of approximately four falls due to his leg giving out. However, besides these two instances, the Veteran has not reported any right knee instability and the evidence does not show any objective findings of instability in the VA examinations or treatment records. Significantly, the Veteran did not report any instability or fall issues during his last two VA examinations in July 2017 and December 2020 while stability testing throughout the appeal period has been normal. Based upon the objective clinical findings as well as the Veteran’s reports to physicians throughout the appeal period, which overwhelmingly do not contain complaints concerning instability, the Board finds that the evidence does not show instability, let alone recurrent instability or peristent instability, so as to warrant a separate or higher rating in this case. In sum, from April 5, 2012, to December 3, 2020, entitlement to a separate 20 percent rating for the Veteran’s right knee disability under DC 5258 is granted. However, the preponderance of the evidence is against entitlement to a rating in excess of 20 percent for his right knee disability under DCs 5010-5258 from December 3, 2020, and is against entitlement to a rating in excess of 10 percent for his right knee disability based upon limitation of extension under DCs 5010-5261. REASONS FOR REMAND Although the Board sincerely regrets the additional delay, a remand is necessary to ensure that due process is followed and that there is a complete record upon which to decide the Veteran’s claims so that he is afforded every possible consideration. 38 U.S.C. § 5103A; 38 C.F.R. § 3.159. 1. Entitlement to service connection for a left knee disability, to include as secondary to the service-connected right knee disability and low back disability Unfortunately, the Board finds that a remand is again warranted as there has not been substantial compliance with the prior November 2018 Board decision. See Stegall v. West, 11 Vet. App. 268, 270-71 (1998). In this regard, in the November 2018 decision, the Board remanded the Veteran’s claim because the July 2017 VA examiner did not adequately address the Veteran’s contention that his left knee disability was secondary to his other service-connected disabilities, to include that his altered gait, caused from his service-connected right knee and/or low back disability, is related to his left knee disability. Specifically, the Board noted that the July 2017 VA examiner did not address the Veteran’s reports and other evidence in the claims file showing he had an antalgic gait due to his right knee pain. As such, the Board instructed the VA examiner, on remand, to consider the Veteran’s reports that he walked with a cane due to pain as well as the other evidence of record noting the Veteran had an abnormal/antalgic gait, and that if the VA examiner discounted this evidence to provide a rationale for doing so. Thereafter, the December 2020 VA examiner opined that the Veteran’s left knee disability was not proximately due to or aggravated by his service-connected right knee or low back disabilities. The examiner explained that the Veteran’s left knee disability and service-connected disabilities were different disease entities with different pathophysiological processes unrelated to each other and that there was no objective evidence of aggravation. The examiner also noted, without any further discussion, that there was no evidence of chronicity of antalgic gait pattern or weight shifting during the physical examination the VA examiner had conducted in relation to his claim. The VA examiner did not otherwise address the evidence of record showing the Veteran had an antalgic gait or his assertions that his left knee disability is related to his altered gait as instructed to do so in prior Board remand directives. As such, the Board finds that this opinion is inadequate and that a remand is warranted for an addendum opinion that reflects consideration of all the evidence of record, including the Veteran’s lay statements and medical documentation showing an antalgic gait. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). 2. Entitlement to service connection for an upper back disability, including as secondary to the service-connected low back disability Unfortunately, the Board finds that a remand is also warranted for the Veteran’s service connection claim for an upper back disability because the last VA opinion, in December 2020, is inadequate. In this regard, the December 2020 VA examiner opined that the Veteran’s upper back disability, diagnosed as a cervical strain, degenerative arthritis of the spine, degenerative disc disease, and spinal stenosis, was not proximately due to or aggravated by his service-connected low back disability. As rationale, the examiner noted that the Veteran’s cervical spine and low back disabilities were different disease entities with different pathophysiological processes unrelated to each other and that there was no objective evidence of aggravation. The Board finds that the VA examiner’s rationale for her negative nexus opinions are inadequate because she did not explain her reasoning. Specifically, she did not explain how the Veteran’s upper back and lower back disabilities had different pathophysiological processes or were otherwise unrelated to each other and merely noted, without further discussion, a lack of evidence for finding there was no aggravation. The Board notes that a medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008). Here, the VA examiner failed to provide a reasoned medical explanation or supporting data. The VA examiner also failed to account for the evidence indicating the Veteran experienced radiating back pain. As such, a remand is warranted for an addendum opinion that includes adequate rationale. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007).   3. Entitlement to a TDIU due to service-connected disabilities The Board finds that because a decision on the remanded issues associated with the Veteran’s service connection claims for a left knee disability and upper back disability could significantly impact a decision on the issue of an award of TDIU, the issues are inextricably intertwined. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (two issues are “inextricably intertwined” when they are so closely tied together that a final Board decision on one issue cannot be rendered until the other issue has been considered). As such, a remand of the claim for TDIU is also required. The matters are REMANDED for the following action: 1. Obtain and associate with the claims file any outstanding VA treatment records. The last VA treatment record is dated November 2020. 2. Then, obtain an addendum opinion from an appropriate VA medical professional to determine the nature and origin of the Veteran’s left knee disability. The need to examine or speak with the Veteran is left to the discretion of the examiner. The Veteran’s claims file, to include a copy of this Remand, should be made available to and be reviewed by the examiner. The following opinions are requested: (a) It is at least as likely as not (50 percent probability or greater) that his left knee disability is (1) caused by OR (2) aggravated by his service-connected right knee disability? (b) Is it at least as likely as not (50 percent probability or greater) that his left knee disability is (1) caused by OR (2) aggravated by his service-connected low back disability? In rendering his or her opinion, the examiner should address BOTH the causation and aggravation questions in his or her rationale. In other words, even if the Veteran’s service-connected right knee and low back disabilities, did not cause his left knee disability, the examiner should still address whether these service-connected disabilities could have worsened his left knee disability. If aggravation is found, the examiner should quantify the degree of aggravation, if possible and state whether there was an increase in disability regardless of permanence, but medically ascertainable. In providing the above opinions, the examiner is asked to specifically ADDRESS the Veteran’s contentions and other evidence of record indicating that his service-connected right knee disability and/or low back disability alter his gait, which, in turn, impacts his left knee disability. The examiner should DISCUSS how this contention/evidence relates to his claim. The VA examiner should also consider and address as appropriate: (1) the February and May 1998 treatment records reflecting that the Veteran’s pain in his low back radiated to his left leg; (2) the February 2007 VA examination report noting the Veteran had an antalgic gait due to limping from his right knee disability; (3) the August 2008 VA treatment record reflecting the Veteran had an antalgic gait because he put weight on his left side to protect his right knee; (4) the July 2009 SSA gait description form indicating the Veteran limped favoring his right leg and that his gait was protecting his right leg; (5) the October 2012 VA examination report reflecting the Veteran complained of sporadic left knee pain due to increased effort as related to his lower back pain and right knee; and (6) the recent February 2020 VA treatment record reflecting that the Veteran had an antalgic limp and walked, assisted, with a cane. The examiner should provide a complete rationale for all opinions. A discussion of the relevant facts and medical principles would be of considerable assistance to the Board. 3. Then, obtain an addendum opinion from an appropriate VA medical professional to determine the nature and origin of the Veteran’s diagnosed upper back disability. The need to examine or speak with the Veteran is left to the discretion of the examiner. The Veteran’s claims file, to include a copy of this Remand, should be made available to and be reviewed by the examiner. The following opinion is requested: Is it at least as likely as not (50 percent probability or greater) that the Veteran’s diagnosed upper back disability (diagnosed as a cervical strain, degenerative arthritis of the spine, degenerative disc disease, and spinal stenosis during the December 2020 VA examination) is (1) caused by OR (2) aggravated by his service-connected low back disability? In rendering his or her opinion, the examiner should address BOTH the causation and aggravation questions in his or her rationale. In other words, even if the Veteran’s service-connected low back disability, did not cause his upper back disability, the examiner should still address whether his service-connected disability could have worsened his upper back disability. If aggravation is found, the examiner should quantify the degree of aggravation, if possible and state whether there was an increase in disability regardless of permanence, but medically ascertainable The examiner should ADDRESS the evidence of record indicating radiating back pain and DISCUSS how it relates to the Veteran’s claims. In this regard, an October 2007 VA treatment record reflects the Veteran had low back pain with irradiation to his upper back and neck areas, that he had spasms of the paravertebral muscles in the lumbar area, and that his back and neck pain was secondary to his muscle spasm while the July 2017 VA examiner noted that the Veteran reported radiating pain in the back and that his July 2009 diagnosis of myositis at the cervical and lumbar spine is a common condition developed as part of his underlying degenerative changes of the spine. The examiner should provide a complete rationale for all opinions. A discussion of the relevant facts and medical principles would be of considerable assistance to the Board. MARJORIE A. AUER Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Amanda Purcell, 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.