Citation Nr: 21012988 Decision Date: 03/08/21 Archive Date: 03/08/21 DOCKET NO. 15-04 144A DATE: March 8, 2021 ORDER Service connection for a low back disability is granted. Entitlement to an initial rating in excess of 10 percent for left knee and lower extremity stress fractures (claimed as knee pain and shin splints) is denied. Entitlement to an initial rating in excess of 10 percent for right knee and lower extremity stress fractures (claimed as knee pain and shin splints) is denied. Entitlement to an initial rating in excess of 10 percent for a right ankle sprain is denied. REMANDED Entitlement to service connection for a left ankle disorder is remanded. Entitlement to an initial compensable rating for tension headaches is remanded. Entitlement to an initial compensable rating for an unspecified insomnia disorder is remanded. FINDINGS OF FACT 1. The evidence is at least in equipoise as to whether the Veteran’s current back disability is etiologically related to active duty service. 2. Throughout the pendency of the appeal, the Veteran’s left knee and lower extremity disability was symptomatic of painful motion but was not manifested by ankylosis, recurrent subluxation or instability, a meniscal condition, flexion limited to 60 degrees or less, extension limited to 5 degrees or less, impairment of the tibia and fibula or genu recurvatum; a knee sprain, a knee ligament tear or knee or shin surgery have not been shown. 3. Throughout the pendency of the appeal, the Veteran’s right knee and lower extremity disability was symptomatic of painful motion but was not manifested by ankylosis, recurrent subluxation or instability, a meniscal condition, flexion limited to 60 degrees or less, extension limited to 5 degrees or less, impairment of the tibia and fibula or genu recurvatum, a knee sprain, a knee ligament tear or knee or shin surgery have not been shown. 4. Throughout the pendency of the appeal Veteran’s right ankle disability did not result in marked symptomatology; limitation of motion of less than 5 degrees of dorsiflexion or less than 10 degree of plantar flexion has not been shown. CONCLUSIONS OF LAW 1. The criteria for service connection for a low back disability have been met. 38 U.S.C. §§ 1110, 1112, 1113, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 2. The criteria for an initial rating in excess of 10 percent for a left knee and lower extremity disability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.7, 4.40, 4.45, 4.71a, Diagnostic Codes (DCs) 5257, 5260, 5261, 85 Fed. Reg. 76453, 76463 (Nov. 30, 2020) (to be codified at 38 C.F.R. § 4.71a, Diagnostic Code 5257). 3. The criteria for an initial rating in excess of 10 percent for a right knee and lower extremity disability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.7, 4.40, 4.45, 4.71a, Diagnostic Codes (DCs) 5257, 5260, 5261, 85 Fed. Reg. 76453, 76463 (Nov. 30, 2020) (to be codified at 38 C.F.R. § 4.71a, Diagnostic Code 5257). 4. The criteria for a rating in excess of 10 percent for a right ankle sprain are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code (DC) 5271, 85 Fed. Reg. 76453, 76463 (Nov. 30, 2020) (to be codified at 38 C.F.R. § 4.71a, Diagnostic Code 5271). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active duty service from November 2006 to April 2007, October 2009 to October 2013, and from June 2017 to September 2017. These matters come before the Board of Veterans’ Appeals (Board) on appeal from a March 2014 rating decision from the Department of Veterans Affairs (VA) Regional office (RO). An August 2020 rating decision granted a rating of 10 percent each for left knee and lower extremity stress fractures, right knee and lower extremity stress fractures, and right ankle sprain effective October 21, 2013. Since the Veteran has not expressed satisfaction with that decision these claim remains on appeal and have been recharacterized to reflect the increase granted by the RO. These matters were remanded for further development in August 2018 and August 2019. The Board finds that there has been substantial compliance with those remand directives regarding the low back, bilateral knees and right ankle appeals. See Stegall v. West, 11 Vet. App. 268, 271 (1998); see also D’Aries v. Peake, 22 Vet. App. 97, 105 (2008). Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110; 38 C.F.R. § 3.303 (a). To establish service connection, a Veteran must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service, the so-called “nexus” requirement. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Service connection may be granted for any disease initially diagnosed after discharge when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303 (d). In addition, service connection for certain chronic diseases, including arthritis, may be established on a presumptive basis by showing that the condition manifested to a degree of 10 percent or more within one year from the date of separation from service. 38 U.S.C. §§ 1101, 1112, 1113, 1131, 1137; 38 C.F.R. §§ 3.307, 3.309(a). Although the disease need not be diagnosed within the presumption period, it must be shown, by acceptable lay or medical evidence, that there were characteristic manifestations of the disease to the required degree during that time. 38 U.S.C. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309(a). For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. If chronicity in service is not established, a showing of continuity of symptoms after discharge may support the claim. 38 C.F.R. §§ 3.303 (b), 3.309; Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. When all of the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event, or whether a fair preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). The Board notes that it has reviewed all of the evidence in the Veteran’s claims file, with an emphasis on the evidence relevant to this appeal. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Hence, the Board will summarize the relevant evidence as appropriate and the Board’s analysis will focus specifically on what the evidence shows, or fails to show, as to the claim. 1. Entitlement to service connection for a low back disorder. The Veteran contends in his February 2015 VA Form 9 that his low back was injured as a result of carrying heavy weighted packs during ruck marches. A March 2019 VA Back and Thoracolumbar Spine Conditions assigned a diagnosis of lumbosacral strain, consistent with findings in VA post service treatment records. Such is sufficient to meet the first element for establishing service connection, i.e., a current disability. Moreover, the Veteran’s June 2013 separation examination and physical notes that he has intermittent lower back pain and tightening. Therefore, the second element for establishing service connection, in-service incurrence, is established. The question before the Board in this case is whether the evidence suggests that a relationship exists between the Veteran’s current diagnosis for his low back disorder and his active duty service. To that end, the Board finds that it does. A July 2020 VA examiner reviewed the Veteran’s entire claims file and opined that it is more likely than not that the Veteran’s lumbosacral strain is related to active duty service. The rationale for the opinion was that the Veteran had evidence of mild lumbar spine strain noted on his separation examination. He then filed a claim for a back disability and was examined by VA in March 2014. The examiner concluded that the Veteran had a back condition at separation for which he continued to have complaints. Significantly, the Veteran’s VA examinations and VA treatment records reflect that he has reported persistent low back pain since separation from service. An April 2014 VA Primary Care note indicated that the Veteran complained of and sought treatment at VA for chronic low back pain within six months of separation. The Board finds the Veteran’s report of the continuation of low back pain to be competent. Layno v. Brown, 6 Vet. App. 465, 470 (1994). This evidence tends to show that the Veteran’s low back disorder, which initially manifested during active duty service, has continued since. See 38 U.S.C. § 1110; 38 C.F.R. § 3.303 (a), (d). The Board acknowledges the negative nexus opinions provided by the March 2019 January 2020 and August 2020 VA examiners. However, these VA examiners’ opinions are inadequate because they do not consider the Veteran’s competent and credible statements regarding continuity of symptomatology as well as evidence of such. Consequently, the Board finds that these VA examinations cannot serve as a basis for a denial of service connection. In sum, in resolving reasonable doubt in the Veteran’s favor, the Board finds that competent and credible evidence establishes the criteria for service connection for a low back disability has been met. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. Accordingly, service connection for a low back disability is granted. Increased Rating Disability ratings are determined by applying the criteria set forth in VA’s Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C. § 1155 (2012); 38 C.F.R. § 4.1 (2017). The basis of disability evaluations is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. In determining the severity of a disability, the Board is required to consider the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the veteran, as well as the entire history of the veteran’s disability. 38 C.F.R. §§ 4.1, 4.2 (2017); Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). In deciding this appeal, the Board has considered whether separate ratings for different periods of time, based on the facts found, are warranted, a practice of assigning ratings referred to as “staging the ratings.” See Hart v. Mansfield, 21 Vet. App. 505 (2007). 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. 38 C.F.R. § 4.40. It is important that when evaluating disabilities of the musculoskeletal system, functional loss due to pain and weakness causing additional disability beyond that reflected on range of motion measurements must be considered. See 38 C.F.R. § 4.40; DeLuca v. Brown, 8 Vet. App. 202 (1995). Consideration must also be given to weakened movement, excess fatigability and incoordination. 38 C.F.R. § 4.45. It is the intent of the schedule to recognize painful motion with joint or periarticular pathology as productive of disability. It is also 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. The Board notes that it has reviewed all of the evidence in the Veteran’s claims file, with an emphasis on the evidence relevant to these appeals. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (holding that VA must review the entire record but does not have to discuss each piece of evidence). Hence, the Board will summarize the relevant evidence where appropriate and the Board’s analysis below will focus specifically on what the evidence shows, or fails to show, as to the claim. When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit-of-the doubt in resolving each such issue shall be given to the veteran. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 2. Entitlement to an initial rating in excess of 10 percent for left knee and lower extremity stress fractures (claimed as knee pain and shin splints). 3. Entitlement to an initial rating in excess of 10 percent for right knee and lower extremity stress fractures (claimed as knee pain and shin splints). As an initial matter the Board notes that the agency of original jurisdiction (AOJ) requested the Veteran submit any relevant private treatment records or submit information with which VA can assist the Veteran in obtaining private treatment records. The Veteran indicated in an October 2013 phone call documented in VA Form 21-0820 Report of General Information, that he had not received any medical treatment since leaving the military. Subsequently, the Veteran only identified VA and service treatment records relevant to his claims on appeal. The duty to assist is not a one - way street. Wood v. Derwinski, 1 Vet. App. 190 (1991). Here, the Board finds that VA has satisfied the duty to assist. No further notice or assistance to the Veteran is required to fulfill VA’s duty to assist in development of appeals pertaining to the Veteran’s knees or ankles. Smith v. Gober, 14 Vet. App. 227 (2000); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Knee disabilities are rated under 38 C.F.R. § 4.71a, Diagnostic Codes (DCs) 5256 to 5263. The multiple DCs that evaluate impairment resulting from service-connected knee disorders, include DC 5256 (ankylosis), DC 5257 (other impairment, including recurrent subluxation or lateral instability), DC 5258 (dislocated semilunar cartilage), DC 5259 (symptomatic removal of semilunar cartilage), DC 5260 (limitation of flexion), DC 5261 (limitation of extension), DC 5262 (impairment of the tibia and fibula), and DC 5263 (genu recurvatum). Additionally, if the knee condition involves arthritis, the knee disability may be rated under provisions for evaluating arthritis. Arthritis due to trauma is rated as degenerative arthritis according to DC 5003. Under Diagnostic Code 5003, degenerative arthritis established by x-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. When, however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, 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. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. In the absence of limitation of motion, the disability is to be rated as follows: with X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups, with occasional incapacitating exacerbations, 20 percent; with X- ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups, 10 percent. 38 C.F.R. § 4.71a, DC 5003. The Veteran’s left and right knee disabilities have each been assigned the minimum compensable (10 percent) rating for painful motion of the knee pursuant to 38 C.F.R. § 4.59 and are rated under DC 5727 for knee impairment with recurrent subluxation or lateral instability. VA amended the criteria for rating musculoskeletal disabilities effective February 7, 2021. These new regulations apply to all applications for benefits received by VA or that are pending before the agency of original jurisdiction on or after February 7, 2021. Claims pending prior to the effective date will be considered under both old and new rating criteria, and whatever criteria is more favorable to the veteran will be applied. The Board cannot apply a current regulation prior to its effective date, unless the regulation explicitly provides otherwise. Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). However, the Board is not precluded from applying prior versions of the applicable regulation to the period on or after the effective dates of the new regulation if the prior version was in effect during the pendency of the appeal. For claims filed prior to February 7, 2021, DC 5257, knee impairment with recurrent subluxation or lateral instability is rated 10 percent when slight, 20 percent when moderate, and 30 percent when severe. 38 C.F.R. § 4.71 (a), DC 5257. For claims filed on or after February 7, 2021, DC 5257 provides that a knee impairment with recurrent subluxation or lateral instability is rated 10 percent for a sprain, incomplete ligament tear, or complete ligament tear (repaired, unrepaired or failed repair) causing persistent instability without a prescription from a medical provider for an assistive device or bracing for ambulation, 20 percent for either a sprain, incomplete ligament tear, or repaired complete ligament tear causing persistent instability and a medical provider prescribes a brace and/or an assistive device for ambulation or an unrepaired or failed repair of a complete ligament tear causing persistent instability and a medical provider prescribes either an assistive device or brace for ambulation, and 30 percent for an unrepaired or failed repair of a complete ligament tear causing persistent instability, and a medical provider prescribes both an assistive device and a brace for ambulation. 85 Fed. Reg. 76453, 76463 (Nov. 30, 2020) (to be codified at 38 C.F.R. § 4.71a, DC 5257). For claims filed on or after February 7, 2021, DC 5257 also provides that a knee impairment with patellar instability is rated 10 percent for a diagnosed condition involving the patellofemoral complex with recurring instability (with or without history of surgical repair) that does not require a prescription from a medical provider for a brace, cane or walker, 20 percent for a diagnosed condition involving the patellofemoral complex with recurring instability after surgical repair that requires a prescription from a medical provider for a brace, cane or walker and 30 percent for a diagnosed condition involving the patellofemoral complex with recurring instability after surgical repair that requires a prescription from a medical provider for a brace, and either a cane or a walker. Id. Lastly, for claims filed on or after February 7, 2021, DC 5257 provides that a knee impairment resulting in medial tibial stress syndrome (MTSS), or shin splints is rated 0 percent for treatment less than 12 consecutive months, one or both lower extremities, 10 percent for treatment lasting at least 12 consecutive months, and unresponsive to either shoe orthotics or other conservative treatment for one or both lower extremities, 20 percent for treatment lasting at least 12 consecutive months, and unresponsive to surgery and either shoe orthotics or other conservative treatment, one lower extremity, and 30 percent for treatment lasting at least 12 consecutive months and unresponsive to surgery and either shoe orthotics or other conservative treatment for both lower extremities. Id. The Board has closely reviewed the medical evidence of record. VA treatment records documented the Veteran’s complaint of ongoing bilateral knee pain and treatment with NSAIDS and naproxen as necessary. The Veteran had bilateral knee X-rays and MRIs performed at the El Paso VA in August 2015 and September 2015 respectively to assess his knee pain. The Veteran’s bilateral knee X-rays were normal as was his right knee MRI. The Veteran’s left knee MRI identified a linear tear of the posterior horn of the meniscus. At a March 2018 orthopedic consult, the Veteran complained of increased knee pain with walking, standing from a seated position, kneeling and stairs. While the Veteran experienced occasional catching and swelling after activities he denied locking or giving away episodes. The diagnosis was bilateral retropatellar pain syndrome. In April 2018 the Veteran underwent PT for his knee pain, which noted that despite his bilateral knee condition he was full weight bearing and employed full time as a firefighter. A May 2018 VA treatment note indicated that slip on knee brace sleeves were requested for the Veteran. Significantly, a January 2019 VA primary care follow up note indicated that the Veteran’s bilateral knee disability was stable. The Veteran was examined by VA in July 2013 and October 2017. The Board acknowledges that VA examinations must include joint testing for pain on both active and passive motion, in weight-bearing and non-weightbearing and, if possible, with range of motion measurements of the opposite undamaged joint. 38 C.F.R. § 4.59; Correia v. McDonald, 28 Vet. App. 158 (2016). The Board has also considered the United States Court of Appeals for Veterans’ Claims (Court’s) holding in Sharp v. Shulkin, 29 Vet. App. 26, 33 (2017), addressing 38 C.F.R. § 4.40, which states that a VA examiner must “express an opinion on whether pain could significantly limit functional ability” and the examiner’s determination in such regard “should, if feasible, be portrayed in terms of the degree of additional range-of-motion loss due to pain on use or during flare-ups.” In light of these requirements, the Board has carefully considered the VA examinations of record and whether they complied with Correia and Sharp and notes that while the July 2013 examination did not substantially conform to those requirements, the October 2017 examination did. Significantly, however, to the extent that the examination findings of record relative to the Veteran’s knees are not completely in compliance with Correia and/or Sharp, the Board finds that remand for additional examination would serve no useful purpose. Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991). The July 2013 VA examiner conducted an in – person examination of the Veteran and reviewed his claims file. The examiner diagnosed the Veteran’s disability as bilateral chronic knee pain. The Veteran reported that he had constant aching of both knees. His disorder began as bilateral leg pain in his shins when carrying heavy weights and running. A bone scan in January 2013 was consisted with bilateral stress related changes. The Veteran denied flareups of his knee condition. Initial range of motion testing of the right knee showed flexion at 140 degrees or greater with no objective evidence of painful motion and extension at 0 degrees with no objective evidence of painful motion. Testing of the left knee showed flexion at 135 degrees and extension at 0 degrees with no objective evidence of painful motion. There was no evidence of pain on palpation and with weight bearing. There was no additional loss of range of motion on repetitive use testing, joint stability testing was normal and there was no patellar subluxation or dislocation or arthritis on X-ray. The examiner noted the Veteran had stress fractures of both lower extremities. Additionally, the Veteran had protruding muscles that was non-tender on the anterior tibia of both legs. There was no ankylosis and no muscle atrophy. Functionally, the Veteran’s bilateral knee disorder did not impact his ability to work. An assistive device was not required. The October 2017 VA examiner also conducted an in – person examination of the Veteran and reviewed his claims file. The examiner assigned diagnoses of bilateral lower extremity stress fractures which were asymptomatic and bilateral knee strain. The Veteran reported flareups of his knee condition when performing strenuous activities for a prolonged period of time. The Veteran stated that his bilateral knee disability resulted in functional difficulty with squatting and performing strenuous activities for a prolonged period of time. Initial range of motion testing of the right knee showed flexion at 100 degrees and extension at 0 degrees. Testing of the left knee showed flexion at 105 degrees and extension at 0 degrees. The abnormal range of motion was caused by pain which limited the Veteran’s ability to bend on flexion. There was objective evidence of pain on palpation and with weight bearing on the anterior portions of both knees described as moderate. There was evidence of crepitus. There was evidence of pain on passive range of motion testing although there was no additional loss of range of motion on repetitive use testing. The examiner opined that pain would limit the Veteran’s functional ability with repeated use over time but opined there would be no change in the Veteran’s range of motion measurements. Joint stability testing was normal and there was no patellar subluxation or dislocation or arthritis on X-ray. There was no ankylosis and no muscle atrophy. An assistive device was not required. The examiner opined that the diagnosis of bilateral knee strain was a progression of the Veteran’s service – connected bilateral knee and lower extremity disabilities. After careful consideration, the Board concludes that the preponderance of the evidence is against finding that the Veteran’s bilateral knee and lower extremity disabilities warrant an evaluation in excess of 10 percent at any point during the appeal period. Specifically, each of the Veteran’s knees is currently rated at 10 percent under DC 5257, which evaluates instability of the knees. Under DC 5257 prior to February 7, 2021, a higher rating of 20 percent is assigned only if moderate instability is found. The Board notes that words such as mild, moderate, and severe are not defined in the Rating Schedule. Rather than applying a mechanical formula, VA must evaluate all evidence, to the end that decisions will be equitable and just. 38 C.F.R. § 4.6. While the Board acknowledges that the October 2017 VA examiner noted the Veteran had moderate pain with weight bearing on the anterior portion of his knees bilaterally, no joint instability was noted. Without any clinical evidence of moderate instability in the left knee, the evidence does not support the assignment of a higher 20 percent rating under DC 5257 prior to February 7, 2021. Significantly, while the Veteran indicated that pain from his bilateral knee disability resulted in functional difficulty with squatting and performing strenuous activities for a prolonged period of time, the competent medical evidence documented that he remained fully weight bearing and functionally able to perform full time duties as a firefighter. After February 7, 2021, DC 5257 provides a 20 percent rating for a knee impairment with recurrent subluxation or lateral instability that is either a sprain, incomplete ligament tear, or repaired complete ligament tear causing persistent instability and or an unrepaired or failed repair of a complete ligament tear causing persistent instability requiring a prescribed assistive device or brace for ambulation. There is no evidence that the Veteran has or had either a knee sprain or a ligament tear of either knee so a 20 percent rating for recurrent subluxation or lateral instability under this provision is not warranted. For claims filed on or after February 7, 2021, DC 5257 also provides a 20 percent rating for a diagnosed condition involving the patellofemoral complex with recurring instability after surgical repair that requires a prescription from a medical provider for a brace, cane or walker. The Board acknowledges that the Veteran’s VA medical records indicated a diagnosis of bilateral retropatellar pain syndrome and also documented that knee sleeve braces were prescribed. However, there is not medical evidence which suggested that the Veteran, underwent or required surgery for the condition and as discussed above, there is no evidence of joint instability. Therefore, a 20 percent rating for a knee condition involving patellofemoral complex pursuant to this provision of the diagnostic code is not warranted. Lastly for claims filed on or after February 7, 2021, DC 5257 also provides a 20 percent rating for a knee impairment resulting in medial tibial stress syndrome (MTSS), or shin splints for treatment lasting at least 12 consecutive months, and are unresponsive to surgery and either shoe orthotics or other conservative treatment of one lower extremity. While the medical record documented that the Veteran experienced bilateral shin pain during the appeals period, the condition did not require surgery. Therefore, a 20 percent rating for a knee impairment resulting in medial tibial stress syndrome (MTSS), or shin splints is not warranted under this provision. The Board’s inquiry does not end here. The Board must also consider increased evaluations under other potentially applicable DCs. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991); cf. 38 C.F.R. § 4.14; Esteban v. Brown, 6 Vet. App. 259, 262 (1994). After careful evaluation of the Veteran’s claims file, the Board finds that DC 5256 is not applicable because the evidence does not show ankylosis of either knee. There is no allegation to the contrary. Diagnostic Code 5262 is not applicable for either knee because it did not involve the impairment of the tibia or the fibula. There is no allegation to the contrary. There is no evidence of nonunion or malunion of the knee or ankle. There is no allegation to the contrary. Furthermore, without the showing of genu recurvatum (acquired, traumatic, with weakness and insecurity in weight-bearing), a disability rating under Diagnostic Code 5263 is not warranted. There is no allegation to the contrary. Under DC 5259, a disability rating of 10 percent is assigned for manifestations symptomatic of the removal of semilunar cartilage, and under DC 5258, a disability rating of 20 percent is assigned for dislocated semilunar cartilage with frequent episodes of “locking,” pain, and effusion into the joint. 38 C.F.R. § 4.71a, DC 5258, 5259. While the Board acknowledges that a September 2015 left knee MRI identified a linear tear of the posterior horn of the Veteran’s left knee meniscus, there is no evidence of a removal of the cartilage. Furthermore, although the Veteran has endorsed symptoms of pain of a dislocated semilunar cartilage of the left knee, he has specifically denied episodes of “locking,” as required pursuant to the regulation. Accordingly, DCs 5258 and 5259 are not applicable, respectively. Limitation of motion of the knee is contemplated in 38 C.F.R. § 4.71a, DCs 5260 and 5261. Under Diagnostic Code 5260, a noncompensable rating is warranted when flexion of the leg is only limited to 60 degrees. A 10 percent rating is assigned when flexion is limited to 45 degrees. A 20 percent evaluation is warranted when flexion is limited to 30 degrees. A 30 percent rating is assigned when flexion is limited to 15 degrees. Id. The Veteran’s flexion was limited to 105 degrees in the left knee and to 100 degrees in the right knee. Accordingly, a compensable rating under DC 5260 is not warranted. Under DC 5261, a noncompensable rating is warranted when extension of the leg is limited to 5 degrees. A 10 percent disability rating is assigned when extension is limited to 10 degrees. A 20 percent disability rating is warranted when extension is limited to 15 degrees. A 30 percent disability rating is assigned when the evidence shows extension limited to 20 degrees. A 40 percent disability rating is warranted when extension is limited to 30 degrees. A 50 percent disability rating is assigned when extension is limited to 45 degrees. Id. The Veteran had extension to 0 degrees in both knees consistently throughout the appeals period. Accordingly, a rating under DC 5261 is not warranted. Here, given the reported pain in the Veteran’s bilateral knees and lower extremities which causes a noncompensable rating of knee impairment with recurrent subluxation or lateral instability, the Veteran has already been compensated with a 10 percent rating in each knee due to painful limited motion. In reaching this conclusion, the Board has considered whether a higher disability evaluation is warranted on the basis of functional loss due to pain or due to weakness, fatigability, incoordination, or pain on movement of a joint under 38 C.F.R. §§ 4.40 and 4.45. See also DeLuca v. Brown, 8 Vet. App. 202 (1995). Functional loss contemplates the inability of the body to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance, and must be manifested by adequate evidence of disabling pathology, especially when it is due to pain. 38 C.F.R. § 4.40. Additionally, painful motion is an important factor of disability; and joints that are actually painful, unstable, or malaligned, due to healed injury, should be entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. As noted previously herein, the Veteran’s range of left knee motion was most limited at his October 2017 VA examination when flexion was limited to 105 degrees in the left knee and to 100 degrees in the right knee. However, even then, the Veteran was able to complete repetitive motion testing without experiencing additional pain or additional functional loss or loss of range of motion of either knee. Thus, the Board finds that a higher disability evaluation is not warranted on the basis of functional loss due to pain or due to weakness, fatigability, incoordination, or pain on movement of a joint under 38 C.F.R. §§ 4.40 and 4.45. See also DeLuca v. Brown, 8 Vet. App. 202 (1995). In light of the foregoing the Board finds that an initial rating in excess of 10 percent each for the Veteran’s service – connected bilateral knee disabilities is not warranted and the Veteran’s bilateral knee and lower extremity claims on appeal are denied. 4. Entitlement to an initial rating in excess of 10 percent for a right ankle sprain. The Veteran’s right ankle sprain is currently rated 10 percent under DC 5271 for ankle limitation of motion. Prior to February 7, 2021 under DC 5271, a 10 percent rating is warranted for moderate limitation of motion and a 20 percent rating is warranted for marked limitation of motion. Normal range of motion of the ankle is from 0 to 20 degrees of dorsiflexion and 0 to 45 degrees of plantar flexion. 38 C.F.R. § 4.71a, Plate II. Notably, the terms “moderate” and “marked” are not defined in the Rating Schedule. Additionally, the Board observes that the Veterans Benefits Administration (VBA) has determined that these terms as they pertain to the ankle, as used in DCs 5271 and 5262, involve broad language that does not explicitly include consideration of any particular symptomatology. On or after February 7, 2021, under DC 5271, a 10 percent rating is warranted for moderate limitation of motion defined as less than 15 degrees dorsiflexion or less than 30 degrees plantar flexion and a 20 percent rating is warranted for marked limitation of motion defined as less than 5 degrees dorsiflexion or less than 10 degrees plantar flexion. 85 Fed. Reg. 76453, 76463 (Nov. 30, 2020) (to be codified at 38 C.F.R. § 4.71a, DC 5271). In July 2013, the Veteran underwent a VA examination to evaluate his right ankle disability. Range of motion testing showed normal left ankle range of motion, with no objective evidence of pain on movement. Right ankle plantar flexion was at 45 degrees or greater and dorsiflexion was at 20 degrees or greater. There was no additional loss in range of motion following repetitive use testing. There was no joint instability and no ankylosis. The Veteran denied ankle flare-ups in both ankles. In October 2017, the Veteran’s right ankle was again evaluated by VA. The Veteran reported flareups of his right ankle if he walked for a long period of time which caused pain and swelling. The Veteran described functional loss from flareups as difficulty performing strenuous activities for a prolonged period of time. Range of motion testing showed right ankle plantar flexion at 25 degrees and right ankle dorsiflexion at 15 degrees with pain noted on both movements during examination. There was evidence of right ankle pain with weight bearing. However, there was no additional loss of range of motion on repetitive use testing, no joint instability, and no ankylosis. The examiner indicated that the examination was neither medically consistent or inconsistent with the Veteran’s statements describing functional loss with repetitive use over time or during flare-ups. The examiner also indicated that pain limited functional ability with repeated use over a period of time and during flare-ups but opined that the range of motion measurement would not change. The Veteran’s right ankle was most recently evaluated by VA on January 2020. The Veteran denied flare-ups. Range of motion testing showed normal right ankle range of motion with dorsiflexion to 20 degrees and plantar flexion to 45 degrees with no pain noted on examination. There was no evidence of pain with weight bearing/non-weight bearing, no additional loss of range of motion on passive testing, no additional loss of range of motion on repetitive use testing, no muscle atrophy, and no ankylosis. VA treatment records document the Veteran’s complaints of chronic right ankle pain. Significantly, they do not reflect any significant changes or worsening of the Veteran’s right ankle disability. In light of the probative evidence above, the Board finds that an initial rating higher than 10 percent is not warranted. In pertinent part at worst the Veteran demonstrated range of motion of right ankle plantar flexion at 25 degrees and right ankle dorsiflexion at 15 degrees during the October 2017 VA examination. The remaining range of motion measurements were normal thorough out the appeals period. Moreover, although there was evidence of some functional limitation, and pain on range of motion, these symptoms and their severity are more closely approximated as moderate (i.e., 10 percent rating criteria). Prior to February 7, 2021, a higher rating requires at least marked symptomatology/limitation of motion. See 38 C.F.R. § 4.71a, DC 5271 (as previously indicated, the broad language in the criteria contemplates the symptoms indicated above, even though they are not specifically listed). Such marked symptomatology is not demonstrated here. The Veteran’s right ankle has not demonstrated less than 5 degrees dorsiflexion or less than 10 degrees plantar flexion at any time during the appeals period. Thus DC 5271 in effect since February 7, 2021 does not apply. The Board acknowledges that VA examinations must include joint testing for pain on both active and passive motion, in weight-bearing and non-weight bearing and, if possible, with range of motion measurements of the opposite undamaged joint. 38 C.F.R. § 4.59; Correia v. McDonald, 28 Vet. App. 158 (2016). The Board has also considered the United States Court of Appeals for Veterans’ Claims (Court’s) holding in Sharp v. Shulkin, 29 Vet. App. 26, 33 (2017), addressing 38 C.F.R. § 4.40, which states that a VA examiner must “express an opinion on whether pain could significantly limit functional ability” and the examiner’s determination in such regard “should, if feasible, be portrayed in terms of the degree of additional range-of-motion loss due to pain on use or during flare-ups.” In light of these requirements, the Board has carefully considered the VA examinations of record and whether they complied with Correia and Sharp. The Board notes that while the July 2013 examination did not substantially conform to those requirements, the October 2017 and January 2020 examination did. Significantly, however, to the extent that the examination findings of record relative to the right ankle are not completely in compliance with Correia and/or Sharp, the Board finds that remand for additional examination would serve no useful purpose. Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991). The Board has considered whether separate/higher ratings are available under other applicable DCs for ankle disabilities (DCs 5262, 5272, 5273, and 5274). However, the required pathology was not shown in this case, i.e., nonunion/malunion of the tibia/fibula; ankylosis, of the subastragalar or tarsal joint, malunion of the os calcis or astragalus; or astragalectomy. 38 C.F.R. § 4.71a. Therefore, an initial rating in excess of 10 percent for the Veteran’s service – connected right ankle sprain is denied. REASONS FOR REMAND 1. Entitlement to service connection for a left ankle disorder is remanded. The Veteran stated in his February 2015 VA Form 9 that he experienced and sought treatment for left ankle pain during active duty. He contends that he has had ongoing pain and weakness in his left ankle since active duty. The Veteran’s May 2006 enlistment examination noted that the Veteran had a grade 4 left ankle sprain. A September 2010 STR entitled Screening Note of Acute Medical Care documented that the Veteran has a history of a broken left ankle “2-3 times”. A February 2013 STR physical therapy note indicated that the Veteran had a long history of bilateral ankle pain and recurrent inversion injuries. An April 2013 service treatment record note (STR) indicated that the Veteran has musculoskeletal symptoms which include bilateral ankle pain. A March 2018 post – service VA orthopedic surgery consultation stated that the Veteran had a history of bilateral ankle sprains in the military. The Veteran’s VA treatment records documented ongoing complaints of bilateral ankle pain. The Veteran’s claim for service connection for his left ankle was remanded in August 2018 and August 2019. Regrettably, it must once again be remanded. An October 2017 VA examiner indicated that the Veteran’s left ankle had reduced range of motion but did not offer a medical opinion regarding nexus with active duty. A January 2020 VA examiner did not identify any left ankle diagnosis but indicated that the Veteran had functional complaints. The examiner proffered a negative nexus opinion. The rationale for the opinion was that the Veteran’s left ankle was normal, and he worked for the fire department without any problems. The RO obtained another medical opinion based on a medical records review in July 2020. The July 2020 examiner also offered a negative nexus opinion. The rationale was that there was no competent medical evidence of a left ankle sprain while on active duty. The Board finds that the October 2017, January 2020 and July 2020 VA medical opinions are inadequate for adjudication purposes. The Board is obligated by law to ensure that the RO complies with its directives. Stegall v. West, 11 Vet. App. 268 (1998). Moreover, where VA provides the Veteran with an examination in a service connection claim, the examination must be adequate. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). As noted above, in April 2018, the Federal Circuit issued a precedential decision, holding that pain alone, even without an underlying pathology or diagnosis, can constitute a disability under VA law where such pain results in functional impairment. Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018). Here, the January 2020 specifically noted functional complaints and the Veteran’s post service treatment records document ongoing complaints of bilateral ankle pain. Accordingly, remand is warranted to assess whether the Veteran’s left ankle condition rises to the level of disability as determined in Saunders. In addition, no examiner has offered an opinion regarding whether the Veteran’s left ankle disability was a pre – existing condition and if so whether it was aggravated by active duty service. 2. Entitlement to an initial compensable rating for tension headaches is remanded. The Veteran is service – connected for tension headaches rated at 0 percent. A March 2020 VA treatment note indicated that the Veteran sought care for a migraine headache which lasted 2 days. Further he stated that his migraine headaches were becoming more frequent. The Veteran was last examined by VA in October 2017. At that time the diagnosis was tension headaches and the Veteran experienced less frequent attacks defined as less than once every two months. In light of the March 2020 VA treatment note which indicates a possible worsening of the Veteran’s headache disability, the Board finds that the medical evidence of record is not sufficient to adjudicate of the Veteran’s tension headache disability, and a new VA examination is required. McLendon v. Nicholson, 20 Vet. App. 79 (2006). 3. Entitlement to an initial compensable rating for an unspecified insomnia disorder is remanded. The Veteran is service- connected for an unspecified insomnia disorder rated at zero percent under DC 9440 chronic adjustment disorder. In February 2018 the Veteran reported that he was having difficulty staying asleep and reported tossing and turning all night in spite of over the counter sleeping aides. VA prescribed trazadone. It appears that the Veteran’s sleep disability has worsened since his VA examination. Thus, the Board finds that VA’s duty to assist is triggered and an additional VA examination to determine the nature and severity of the Veteran’s insomnia is warranted. The matters are REMANDED for the following action: 1. Obtain updated VA treatment records. 2. Schedule the Veteran for a VA examination with an appropriate examiner to determine the nature and etiology of his claimed left ankle disability. The evidence of record, to include a copy of this Remand, must be made available to the examiner and the examiner must indicate that the pertinent medical records and lay statements have been reviewed and considered in all opinions. The examiner is asked to provide responses to the following: (a.) Provide diagnoses for all left ankle disabilities, to include those noted during the appeal period. (b.) In addition to any diagnoses of record, the examiner is asked to elicit from the Veteran the history of his symptoms and statements as to how his left ankle pain impacts his activities and identify any and all functional limitations caused by left ankle pain. The examiner should note that pain alone, even without an underlying pathology or diagnosis, can constitute a disability under VA law where such pain results in functional impairment. Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018) (holding that a “disability” under 38 U.S.C. § 1110 refers to functional impairment of earning capacity; pain need not be diagnosed as connected to a current underlying condition to function as an impairment). (c.) Is it clear and unmistakable (undebatable) that the Veteran entered active duty with pre-existing left ankle condition? In responding to this question, the examiner is asked to address the May 2006 enlistment examination which noted that the Veteran had a grade 4 left ankle sprain prior to entering active duty. (d.) If YES, is it clear and unmistakable that the Veteran’s pre-existing left ankle condition WAS NOT aggravated beyond the natural progress of the disorder during his service? (e.) For all identified left ankle disabilities, is it at least as likely as not (50 percent or greater probability) it had its onset during or is otherwise related to the Veteran’s active service? In responding to this question, the examiner is asked to address a September 2010 STR entitled Screening Note of Acute Medical Care that documented that the Veteran has a history of a broken left ankle “2-3 times”, a February 2013 STR physical therapy note that indicated that the Veteran had a long history of bilateral ankle pain and recurrent inversion injuries and an April 2013 service treatment record note (STR) that indicated that the Veteran has musculoskeletal symptoms which included bilateral ankle pain. 3. Schedule the Veteran for an appropriate examination to assess the nature and severity of his service - connected tension headache disability. 4. Schedule the Veteran for an appropriate examination to assess the nature and severity of his service - connected insomnia disability. Jennifer White Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Alexander 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.