Citation Nr: 21012814 Decision Date: 03/05/21 Archive Date: 03/05/21 DOCKET NO. 13-13 855 DATE: March 5, 2021 ORDER Entitlement to a separate rating of 10 percent for left foot tenosynovitis prior to April 21, 2015 is granted. Entitlement to a rating in excess of 30 percent for postoperative residuals of a left ankle sprain with fibular lesion, recurrent ganglion cysts and degenerative changes is denied. Entitlement to a rating in excess of 20 percent since for postoperative residuals of an osteochondral defect and osteoarthritis of the left knee from April 21, 2015 is denied. Entitlement to a rating in excess of 10 percent since for instability of the left knee from April 21, 2015 is denied. REMANDED Entitlement to a rating in excess of 10 percent prior to April 21, 2015 for postoperative residuals of an osteochondral defect and osteoarthritis of the left knee is remanded. Entitlement to a compensable rating prior to April 21, 2015 for instability of the left knee is remanded. Entitlement to service connection for a right knee disorder is remanded. Entitlement to service connection for a left hip disorder is remanded. Entitlement to service connection for obstructive sleep apnea is remanded. FINDINGS OF FACT 1. From the date of claim on November 17, 2009, the Veteran has manifested a moderate impairment of dorsal movements of the forefoot and toes, propulsion thrust in walking, and pain as a result of excision of recurrent ganglion cysts, resection of a herniated extensor digitorum brevis, and tenosynovitis. 2. As of November 17, 2009, the Veteran’s left lower extremities below the knee have received the maximum allowed that is equivalent to amputation below the knee. 3. As of April 21, 2015, the Veteran’s left lower extremities above the knee have received the maximum allowed that is equivalent to amputation above the knee. CONCLUSIONS OF LAW 1. For the period prior to April 21, 2015, the criteria for entitlement to separate a disability rating of 10 percent for left foot tenosynovitis are met. 38 U.S.C. §§ 1151, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 4.1, 4.2, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.56, 4.73, Diagnostic Code 5310. 2. A rating in excess of 30 percent for postoperative residuals of a left ankle sprain with fibular lesion, recurrent ganglion cysts and degenerative changes is denied as a matter of law. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.68, 4.71a, DC 5270. 3. From April 21, 2015, a rating in excess of 10 percent for postoperative residuals of an osteochondral defect and osteoarthritis of the left knee is denied as a matter of law. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.68, 4.71a, DC 5261. 4. From April 21, 2015, a rating in excess of 10 percent since for instability of the left knee is denied as a matter of law. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.68, 4.71a, DC 5257. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active duty from February 1987 to September 1988. This matter comes to the Board of Veterans’ Appeals (Board) on appeal from June 2010 and March 2015 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Roanoke, Virginia. In December 2015, the Board denied higher ratings for the left knee and left ankle. The Veteran appealed to the Veterans Claims Court. In July 2017, the Court affirmed the Board decision with regard to the left knee prior to April 15, 2015 and remanded the remaining issues. Subsequently, the Court withdrew its July 2017 decision and entered a new decision that vacated the entirety of the Board’s December 2015 decision in December 2017. See December 2017 Decision. The appeal was most recently remanded for VA examinations in March 2019. These examinations were performed in August 2019 by a physician’s assistant. In a December 2019 statement, the Veteran challenged the credentials of this examiner, noting that he had requested that the examinations be performed by a specialist, indicating that he had searched for information regarding the examiner’s qualifications in orthopedics and found none. The Board remanded the appeal in February 2020 for the VA examiner to provide a resume or C.V. In the March 2019 decision, the Board denied service connection for OSA. The Veteran appealed to the Veterans Claims Court. The parties agreed the Board erred in failing to obtain private medical records that had been adequately identified by the Veteran. See January 2020 JMR. 1. Entitlement to a separate rating of 10 percent for left foot tenosynovitis is granted. Initially, the Veteran filed a November 2009 claim for torn ligaments secondary to his left ankle disability. See November 2009 Claim. The Court also found in the December 2017 JMR that the Board erred in not considering a separate evaluation under Diagnostic Code (DC) 5310 for the Veteran’s history of excision of the herniated extensor digitorum brevis. The Veteran is service connected for left ankle postoperative residuals of a left ankle sprain with fibular lesion, recurrent ganglion cysts and degenerative changes with mid-foot arthritis and is assigned a single 30 percent evaluation for this disability under DC’s 5271-5284. The Board finds a 10 percent evaluation is warranted based evidence of moderate impairment of dorsal of the movements of the forefoot and toes, propulsion thrust in walking, and pain as a result of recurrent ganglion cysts of the extensor tendon tenosynovium, resection of a herniated extensor digitorum brevis, and tenosynovitis. See January 2020 VA Examination. Criteria for Muscle Injury Under 38 C.F.R. § 4.73, Diagnostic Code 5310, injury of Muscle Group X (10), the Foot and Leg, governing movements of the forefoot and toes, and propulsion thrust in walking, as to the dorsal muscles, a slight injury warrants a noncompensable rating; when moderate, a 10 percent rating is warranted; and a 10 percent rating is also warranted when moderately severe; and when severe, a 20 percent rating is warranted. The criteria for a slight injury, a moderate injury and for a moderately severe injury are set forth at 38 C.F.R. §§ 4.56(d)(1), 4.56(d)(2) and 4.56(d)(4). Under 38 C.F.R. § 4.56(d) muscle injuries shall be classified as slight, moderate, moderately severe or severe. In determining the classification of the injury, the type of injury, history and complaints, and objective findings are considered. The word used to describe the overall severity of a service-connected disorder, e.g., “moderate”, “severe” and “pronounced”, are not defined in the VA Schedule for Rating Disabilities. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are “equitable and just.” 38 C.F.R. § 4.6. 38 C.F.R. § 4.56(d)(1)(i) indicates that, as to the type of injury, slight disability of muscles will stem from a simple wound of a muscle without debridement or infection. As to history and complaints, 38 C.F.R. § 4.56(d)(1)(ii) indicates that service department record of superficial wound with brief treatment and return to duty is to be expected. Healing with good functional results and no cardinal signs or symptoms of muscle disability, as defined in 38 C.F.R. § 4.56(c). As to objective findings, 38 C.F.R. § 4.56(d)(1)(iii) requires minimal scarring, no evidence of fascial defect, atrophy or impaired tonus and no impairment of function or metallic fragments retained in muscle tissue. A moderate muscle disability will be demonstrated by through and through or deep penetrating wound of short track from a single bullet, small shell or shrapnel fragment, without explosive effect of high velocity missile, residuals of debridement, or prolonged infection. 38 C.F.R. § 4.56(d)(2)(i). As to history and complaints, 38 C.F.R. § 4.56(d)(2)(ii) requires service department record or other evidence of in-service treatment for the wound. Record of consistent complaint of one or more of the cardinal signs and symptoms of muscle disability as defined in paragraph (c) of this section, particularly lowered threshold of fatigue after average use, affecting the particular functions controlled by the injured muscles. As to objective findings requires 38 C.F.R. § 4.56(d)(2)(ii) entrance and (if present) exit scars, small or linear, indicating short track of missile through muscle tissue. Some loss of deep fascia or muscle substance or impairment of muscle tonus and loss of power or lowered threshold of fatigue when compared to the sound side. 38 C.F.R. § 4.56(a) provides that an open comminuted fracture with muscle or tendon damage will be rated as a severe injury of the muscle group involved unless, for locations such as in the wrist or over the tibia, evidence establishes that the muscle damage is minimal. 38 C.F.R. § 4.56(d)(4)(i) provides that as to the type of injury, severe disability of muscles will stem from a through-and-through or deep penetrating wound due to high-velocity missile, or large or multiple low velocity missiles, or with shattering bone fracture or open comminuted fracture with extensive debridement, prolonged infection, or sloughing of soft parts, intermuscular binding and scarring. As to history and complaints, 38 C.F.R. § 4.56(d)(4)(ii) provides that there is to be service department record or other evidence showing hospitalization for a prolonged period for treatment of the wound. Also considered is whether there have been consistent complaints of cardinal signs and symptoms of muscle disability, as defined in 38 C.F.R. § 4.56(c), worse than those shown for moderately severe muscle injuries, and, if present, evidence of inability to keep up with work requirements. As to objective findings, 38 C.F.R. § 4.56(d)(4)(iii) provides that for severe disability there is to be ragged, depressed and adherent scars indicating wide damage to muscle groups in missile track. Palpation shows loss of deep fascia or muscle substance, or soft flabby muscles in wound area. Muscles swell and harden abnormally in contraction. Tests of strength, endurance, or coordinated movements compared with the corresponding muscles of the uninjured side indicate severe impairment of function. If present, the following are also signs of severe muscle disability: (a) X-ray evidence of minute multiple scattered foreign bodies indicating intermuscular trauma and explosive effect of the missile; (b) adhesion of scar to one of the long bones, scapula, pelvic bones, sacrum or vertebrae, with epithelial sealing over the bone rather than true skin covering in an area where bone is normally protected by muscle; (c) diminished muscle excitability to pulsed electrical current in electrodiagnostic tests; (d) visible or measurable atrophy; (e) adaptive contraction of an opposing group of muscles; (f) atrophy of muscle groups not in the track of the missile, particularly of the trapezius and serratus in wounds of the shoulder girdle; (g) induration or atrophy of an entire muscle following simple piercing by a projectile. Analysis The 10 percent rating encompasses a moderate injury of the dorsal muscles of the foot. A moderately severe injury is envisioned when, in pertinent part, there is intermuscular scarring, with such factors as not only hospitalization but, also, prolonged treatment. The record indicates multiple surgeries to remove recurrent ganglion cysts and in June 2002, the Veteran underwent resection of a herniated extensor digitorum brevis. See June 1999 Operative Report; June 2002 Operative Report; see also January 2020 VA Examination. Ultimately, the Veteran appears to have had surgery for recurrent ganglion cysts in approximately 1992, February 1996, June 1999, and June 2002. See December 2004 Examination. In October 2009, the MRI of the Veteran’s left foot showed increased fluid surrounding the tendon sheaths of the peroneus brevis and longus, flexor digitorum and flexor longus tendons compatible with tenosynovitis. Tenosynovitis was also present on MRI in October 2016. See January 2020 VA Examination. The January 2020 examination includes a summary of the Veteran’s left ankle, mid-foot arthritis, and tenosynovitis and the Board finds that this examination clearly indicates the presence of tenosynovitis and attributes it to the Veteran’s service-connected left ankle and mid-foot disabilities. The Veteran is also service connected for bilateral pes planus however, his tenosynovitis affects the dorsal area of the foot. He reported to the January 2020 examiner that he experienced severe pain on the top of his foot, stiffness, weakness, fatigue, and swelling. The Veteran also reported when he experienced a flare-up he had to sit down. As noted above, the June 2002 operative report indicates resection of the extensor digitorum brevis, which is associated with the dorsal section of the foot. 38 C.F.R. § 4.73, Diagnostic Code 5310. While his left foot tenosynovitis and accompanying operative scars involve the muscles of the foot, there is no evidence of ragged, depressed and adherent scars indicating wide damage to muscle groups. Similarly, the January 2020 examination shows no loss of deep fascia or muscle substance, or soft flabby muscles in wound area. Based the evidence of record and the January 2020 VA examination, the Board finds there are no indications of a severe muscle disability such as listed under 38 C.F.R. § 4.56(d)(4)(iii). Accordingly, tenosynovitis of the left foot, is not productive of a level of functional impairment such as to warrant a rating in excess of a 10 percent. In reaching this determination the Board has considered the doctrine of resolving doubt in favor of the Veteran, and a separate 10 percent evaluation for tenosynovitis is granted. Amputation Rule Here, the Veteran filed a claim for a separate evaluation for left foot soft tissue disability received on November 17, 2009. By function of this decision, from November 17, 2009, the Veteran is in receipt of separate ratings for left ankle disability degenerative changes, left knee arthritis, and tenosynovitis. The amputation rule provides, in pertinent part, that the combined rating for disabilities of an extremity shall not exceed the rating for the amputation at the elective level, were an amputation to be performed. 38 C.F.R. § 4.68. A 40 percent rating is the maximum rating provided for an amputation below the knee. See 38 C.F.R. § 4.71, Diagnostic Codes 5165, 5166. An above the knee amputation, not to include a thigh amputation, is rated 60 percent disabling. See 38 C.F.R. § 4.71a, Diagnostic Codes 5162, 5163. Accordingly, the Veteran may not receive a combined rating greater than 40 and 60 percent for left lower extremity disability below and above the knee, respectively. After April 21, 2015, the Veteran has a combined disability evaluation of 60 percent for the left lower extremity above the knee for the period. A schedular rating greater than 60 percent is barred. The separate 10 percent rating for tenosynovitis is not proper as of April 21, 2015. Assigning the separate rating for left foot tenosynovitis disability past April 21, 2015, would violate the amputation rule, and is denied as a matter of law. 2. Entitlement to a rating in excess of 30 percent for postoperative residuals of a left ankle sprain with fibular lesion, recurrent ganglion cysts and degenerative changes is denied. In regard to an evaluation in excess of 30 percent for left ankle disability, the Veteran is in receipt of an evaluation of 10 percent for tenosynovitis until April 21, 2015 and an evaluation of 30 percent for left ankle disability. Prior to April 21, 2015, the Veteran has combined disability evaluation of 40 percent for the left lower extremity below the knee. Because the Veteran’s disability is in the ankle, the amputation rule precludes a schedular rating in excess of 40 percent. After April 21, 2015, the Veteran has a combined disability evaluation of 60 percent for the left lower extremity above the knee for the period. A schedular rating greater than 60 percent is barred. Therefore, since the Veteran’s claim for increased rating for left ankle disability, received November 17, 2009, any separate or increased evaluation for the Veteran’s left ankle disability is denied as a matter of law. 38 C.F.R. § 4.68. 3. Entitlement to a rating in excess of 20 percent since for postoperative residuals of an osteochondral defect and osteoarthritis of the left knee from April 21, 2015 is denied. 4. Entitlement to a rating in excess of 10 percent since for instability of the left knee from April 21, 2015 is denied. In regard to an evaluation in excess of 20 percent for left knee limitation of extension or an evaluation in excess of 10 percent for left knee instability, from April 21, 2015, the Veteran has a combined evaluation of 60 percent for disabilities above the knee. The Veteran is in receipt of an evaluation of 10 percent for tenosynovitis prior to August 25, 2015, an evaluation of 30 percent for left ankle disability, a 10 percent evaluation for arthritis with painful motion of the left knee, and limitation of extension of the left knee evaluated at 20 percent. Accordingly, the Veteran has a combined disability evaluation of 60 percent for the left lower extremity below the knee for the period after April 21, 2015. A schedular rating greater than 60 percent is barred. That is, the combined rating for disabilities of an extremity shall not exceed the rating for the amputation at the elective level, were amputation to be performed. See 38 C.F.R. § 4.68, Amputation Rule. An above the knee amputation, not to include a thigh amputation, is rated 60 percent disabling. See 38 C.F.R. § 4.71a, Diagnostic Codes 5162, 5163. Accordingly, the Veteran may not receive a combined rating greater than 60 percent. Therefore, any separate or increased evaluation for the Veteran’s left lower extremity above the knee from April 21, 2015 for his left knee disabilities is denied as a matter of law. 38 C.F.R. § 4.68. REASONS FOR REMAND 1. Entitlement to a rating in excess of 10 percent prior to April 21, 2015 for postoperative residuals of an osteochondral defect and osteoarthritis of the left knee is remanded. The Board previously remanded this appeal in December 2017 and June 2018 for compliance with the Court’s holding in Correia v. McDonald, 28 Vet. App. 158 (2016). The Board directed VA obtain an examination to address the severity of a disability affecting functioning of a joint that included range of motion testing expressed in degrees for active motion, passive motion, weight-bearing, and non-weight-bearing, and for the opposing joint. The Veteran was afforded VA knee examinations in July 2018 and August 2019. However, the examiners failed to follow the Board’s specific directives to address Correia instructions to “test and record the range of motion of each knee in active motion, passive motion, weight-bearing, and non-weight bearing.” If the examiner was unable to provide the required testing or if the testing was unnecessary, the examiner was to “explain why this is so.” The July 2018 and August 2019 examiners failed to provide the required testing and failed to provide an explanation for not doing so. Instead, they merely recorded range of motion without specifying the conditions of the test (whether active, passive, weight-bearing, or non-weight bearing) and noted pain resulting in functional loss with. The Board also directed that a retrospective opinion regarding impairment during the appeal, to include prior to the VA examinations in this claim and address Correia criteria prior to April 2015. See June 2018 Remand. The July 2018 and August 2019 examiners did not address this question or provide any indication of why they did not provide this information. Where the remand orders of the Board are not complied with, the Board errs as a matter of law when it fails to ensure compliance. Stegall v. West, 11 Vet. App. 268 (1998). Here, the Board finds prior remand directives to obtain adequate opinions on functional impairment throughout the appellate period and Correia criteria are not met and additional examination and opinion is necessary. 2. Entitlement to a compensable rating prior to April 21, 2015 for instability of the left knee is remanded. As to the claim for an increased evaluation for left knee instability, the Board finds the July 2018 and August 2019 examinations are inadequate. The record shows the examiners found normal joint stability and no history of joint instability. However, the Board finds that the opinions provided are inadequate because they were based on an inaccurate factual history-the Veteran has a significant history of instability and demonstrated lateral instability in April 2015. See December 2017 JMR; see also April 2015 VA Examination. The December 2017 JMR found the Board erred in not considering a separate evaluation under DC 5258 for evidence of cartilage, semilunar, dislocated with frequent episodes of locking, pain, and effusion into the joint. The Court identified findings from the April 2015 VA examination that indicate a semilunar cartilage disability. Importantly, this examiner also found that imaging results were required to confirm this diagnosis. Imaging and surgery that followed ultimately determined the Veteran has an intact semilunar cartilage and meniscus in August 2017. The Veteran has reported over the course of the appeal that he sustained a meniscal tear however, operative reports indicate an intact meniscus upon surgical examination. See June 2006 Operative Report; see also August 2017 Operative Report. Unfortunately, the August 2019 VA examiner appears to have not considered this evidence and reported the Veteran underwent meniscectomy in 2009, which is not consistent with the treatment record. The August 2019 examiner has not considered an accurate history when evaluating the Veteran’s left knee instability or an accurate history of meniscal or semilunar disability of the left knee. See Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (a medical opinion based on an inaccurate factual premise is not probative). Here, the Board finds prior remand directives to obtain adequate opinions on functional impairment throughout the appellate period are not met and additional opinion is necessary. Therefore, the Board finds that a remand to obtain an adequate examination and opinion is required. See 38 U.S.C. § 5103A(d); Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (holding that when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate). 3. Entitlement to service connection for a right knee disorder is remanded. 4. Entitlement to service connection for a left hip disorder is remanded. As noted above, the Board remanded the appeal in February 2020 for the VA examiner to provide a resume or C.V. The examiner responded to a request from the RO for her credentials on April 1, 2020 but did not provide a resume or C.V. See April 2020 Correspondence. While the Board acknowledges the difficulty experienced by heath care workers over the last year, the Veteran’s representative has challenged the competency of the medical examiner and the Board is unable to discern whether the examiner possesses the necessary qualifications. Francway v. Wilkie, 940 F.3d 1304 (Fed. Cir. 2019) (holding that once a challenge is raised, the presumption of competency is rebutted, and VA must satisfy its burden of persuasion as to the examiner’s qualifications and respond to the challenge by providing information about the qualifications of a medical examiner to the veteran). Given these circumstances, remand is warranted for an additional attempt to obtain the VA examiner’s credentials, either the resume or curriculum vitae. The Veteran also contends he is entitled to an examination from a specialist. VA satisfies its duty to assist when it provides a medical examination performed by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions, whether that is a doctor or other medical specialist. See Cox v. Nicholson, 20 Vet. App. 563, 569 (2007). Therefore, the August 2019 VA examination and opinions are not necessarily inadequate on this basis. However, based on the evidence of record, the Board also finds that secondary service connection (with obesity as an intermediate step) has been raised by the record. The Board must consider whether a service-connected disability aggravated a Veteran’s obesity when the theory is explicitly raised by the veteran or reasonably raised by the record. 38 C.F.R. § 3.310. Although obesity (of itself) is not a compensable disability, it may act as an “intermediate step” between an already service-connected disability and the disability for which secondary service-connection is sought under 38 C.F.R. § 3.310(a). See Walsh v. Wilkie, 32 Vet. App. 300, 305-307 (2020). The Veteran is service connected for bilateral pes planus, bilateral ankle disabilities, right hip, left knee, lumbar and left lower extremity radiculopathy disabilities and VA examiners have indicated the Veteran has mobility limitations due to these disabilities. The record also contains evidence that the Veteran is considered obese. See August 2019 Examination. The August 2019 VA examiner opined that that obesity is a risk factor for the development of the Veteran’s’ left hip and right knee disabilities. The August 2019 VA opinion did not address whether the Veteran’s’ left hip and right knee disabilities are secondary to his service-connected disabilities (with obesity as an intermediate step). The Board finds an additional opinion is necessary. Accordingly, development for a medical opinion is necessary. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). 5. Entitlement to service connection for obstructive sleep apnea is remanded. This issue of service connection for OSA was previously before the Board and was denied in March 2019. Since this denial, United States Court of Appeals for Veterans Claims in a Joint Motion for Remand (JMR) found the Board erred in failing to obtain records from Tidewater Neurologist Sleep Disorder Specialist Inc. and from Hampton Roads-ENT. See January 2020 JMR. Specifically, records from December 4, 2007, December 31, 2007 from Tidewater and records from January 1, 2015 from Hampton were identified by the Veteran prior to the Board’s denial. The JMR further noted that the Board must ensure that the Veteran is asked to provide any outstanding private treatment record or a release for those records. Accordingly, this issue is remanded for VA to request the Veteran authorize release of these records. The Board also finds that secondary service connection (with obesity as an intermediate step) has been raised by the record. The Veteran is service connected for bilateral pes planus, bilateral ankle disabilities, right hip, left knee, lumbar and left lower extremity radiculopathy disabilities and VA examiners have indicated the Veteran has mobility limitations due to these disabilities. The also record contains evidence that the Veteran is considered obese. See July 2018 Examination. The July 2018 VA examiner opined that that obesity is a risk factor for the development of the Veteran’s’ OSA disability, but they did not address whether the Veteran’s’ OSA is secondary to his service-connected disabilities (with obesity as an intermediate step). Accordingly, development for an additional medical opinion is necessary. See McLendon, 20 Vet. App. at 79. The matters are REMANDED for the following action: 1. Contact the VA examiner who performed the August 2019 VA examinations related to the knees, and left hip, and request that she provide a copy of her resume/CV and any other available information regarding her qualifications, in particular as they relate to orthopedic disabilities. Upon receipt, associate the documents with the record and provide the Veteran and his representative with a copy. If the requested resume/CV is not obtainable, the Veteran and his representative should be notified and the reasons for such should be documented in the record. 2. Request the Veteran authorize release of his medical records from December 4, 2007, December 31, 2007 from Tidewater Neurologist Sleep Disorder Specialist Inc. and records from January 1, 2015 from Hampton Roads-ENT and conduct any necessary development in order to obtain these records. 3. After all available records have been associated with the claims file, obtain an additional examination with opinions regarding the Veteran’s left knee disability and the resultant impairment. The entire record must be made available to and reviewed by the examiner in conjunction with the examination. a. To the extent possible, the examiner is asked to provide retrospective commentary on the Veteran’s level of the left knee disabilities during the appeal period (since November 2009), to include the prior VA examinations performed in conjunction with this claim, and to comment on the range of motion movements that would be painful on passive use, in weight-bearing and non-weight-bearing. b. The examiner must offer an opinion on whether the Veteran has manifested a meniscal tear or dislocated semilunar cartilage of the left knee at any time since November 2009. The examiner should address November 2013 medical records showing a meniscal tear and June 2006 and August 2017 operative reports showing an intact meniscus. The examiner must TEST and RECORD the range of motion for BOTH knees and ankles in active motion, passive motion, weight-bearing, and non-weight-bearing. If the examiner is unable to conduct the required testing or concludes that the required testing is not necessary in this case, he or she should clearly explain why that is so. In reporting the results of range of motion testing, the examiner should identify any objective evidence of pain, and the degree at which pain begins. The extent of any weakened movement, excess fatigability, and incoordination on use should also be described by the examiner. The examiner should assess the additional functional impairment due to weakened movement, excess fatigability, or incoordination in terms of the degree of additional range of motion loss. The examiner is reminded that he/she should specify the degree of additional functional loss/motion due to pain, to include during flare-ups, or state why it was not feasible to provide such information, as required for an adequate examination. The examiner should determine whether the Veteran has ankylosis of the knee; instability or subluxation of the knee; nonunion of the tibia and fibula with loose motion and requiring knee braces; dislocated semilunar cartilages with frequent episodes of locking, pain, and effusion; or severe painful motion or weakness in either knee. As it relates to the instability/subluxation, the examiner is requested indicate whether the impairment is slight, moderate or severe in nature. The examiner must provide a comprehensive report including complete rationales for all opinions and conclusions reached, citing the objective medical findings leading to the conclusions. 4. Arrange for the Veteran’s claims file to be forwarded to an appropriate examiner for review and a medical opinion that addresses whether his right knee, left hip, and OSA disabilities are secondary to (was caused or aggravated by) his service-connected bilateral pes planus, bilateral ankle disabilities, right hip, left knee, lumbar and left lower extremity radiculopathy disabilities, specifically whether inactivity due to service-connected disability caused him to become obese, and the obesity, in turn, was a substantial factor in his development of his right knee, left hip, and OSA disabilities. If further examination of the Veteran is deemed necessary for an opinion sought, such should be arranged. The consulting provider should respond to the following: a. Is it at least as likely as not (a 50% or greater probability) that the Veteran’s service-connected bilateral pes planus, bilateral ankle disabilities, right hip, left knee, lumbar and left lower extremity radiculopathy disabilities caused him to become obese (by negatively impacting on ability to exercise)? b. If so, was the obesity caused by his service-connected bilateral pes planus, bilateral ankle disabilities, right hip, left knee, lumbar and left lower extremity radiculopathy disabilities at least as likely as not a substantial factor in causing his right knee, left hip, and OSA disabilities? c. Would the Veteran’s right knee, left hip, and OSA disabilities not have occurred but for the obesity caused by the service-connected bilateral pes planus, bilateral ankle disabilities, right hip, left knee, lumbar and left lower extremity radiculopathy disabilities?   Include rationale with all opinions. J. B. FREEMAN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Trickey 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.