Citation Nr: 21013626 Decision Date: 03/10/21 Archive Date: 03/10/21 DOCKET NO. 17-44 633 DATE: March 10, 2021 ORDER A rating in excess of 10 percent for residuals of left knee injury is denied. A 60 percent rating from September 1, 2015, through January 28, 2018, for status post right knee replacement is granted, subject to the rules and regulations governing the award of monetary benefits. A rating in excess of 60 percent from July 1, 2019, for status post right knee replacement is denied. REMANDED Entitlement to service connection for a right hip disability, to include on a secondary basis, is remanded. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) prior to July 1, 2019, is remanded. FINDINGS OF FACT 1. For the entire appeal period, the Veteran’s service-connected left knee disability has been manifested by limitation of flexion in excess of 45 degrees, even when considering additional functional loss; but without history of surgery or limitation of extension, subluxation or instability, ankylosis, or impairment of the tibia or fibula. 2. For the period from September 1, 2015, through January 28, 2018, the Veteran’s service-connected right knee disability was manifested by chronic residuals of surgery consisting of severe painful motion and weakness; the Veteran did not undergo any additional right knee surgery during this period. 3. For the period beginning July 1, 2019, the Veteran’s service-connected right knee disability has been manifested by chronic residuals of surgery consisting of severe painful motion and weakness; the Veteran has not undergone any additional right knee surgery. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 10 percent for residuals of left knee injury have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5010, 5260. 2. The criteria for a 60 percent rating, but no higher, from September 1, 2015, through January 28, 2018, for status post right knee replacement have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5055 (2020). 3. The criteria for a rating excess of 60 percent from July 1, 2019, for status post right knee replacement have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.7, 4.14, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5055 (2020); 85 Fed. Reg. 76453, 76461 (Nov. 30, 2020) (to be codified at 38 C.F.R. § 4.71a, Diagnostic Code 5055. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from September 1977 to December 1978. His private attorney formally withdrew representation in May 2019. The Veteran has not elected alternate representation and is proceeding with his appeal pro se. These matters were previously before the Board in July 2019 and March 2020 when they were remanded for additional development. Increased Ratings Disability evaluations are determined by application of the VA Schedule for Rating Disabilities, which is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Each disability must be viewed in relation to its history and there must be emphasis upon the limitation of activity imposed by the disabling condition. 38 C.F.R. § 4.1. Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. 38 C.F.R. § 4.7. It is not expected that all cases will show all the findings specified; however, findings sufficiently characteristic to identify the disease and the disability therefrom and coordination of rating with impairment of function will be expected in all instances. 38 C.F.R. § 4.21. All benefit of the doubt will be resolved in the Veteran’s favor. 38 C.F.R. § 4.3. Veteran’s entire history is to be considered when assigning disability ratings. 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). The Board will consider entitlement to staged ratings to compensate for times since filing the claim when the disability may have been more severe than at other times during the course of the claim on appeal. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). When evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use and, therefore, not be reflected on range-of-motion testing. Additionally, 38 C.F.R. § 4.45 requires consideration also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Nonetheless, even when the background factors listed in § 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a; a separate or higher rating under § 4.40 or 4.45 itself is not appropriate. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016) (“[I]t is clear that the guidance of § 4.40 is intended to be used in understanding the nature of the veteran’s disability, after which a rating is determined based on the § 4.71a criteria.”). Under 38 C.F.R. § 4.59, painful motion is a factor to be considered with any form of arthritis; however, 38 C.F.R. § 4.59 is not limited to disabilities involving arthritis. See Burton v. Shinseki, 25 Vet. App. 1 (2011). In Correia v. McDonald, 28 Vet. App. 158 (2016), the United States Court of Appeals for Veterans Claims (Court) held that the final sentence of 38 C.F.R. § 4.59 requires that the examiner record the results of range of motion testing “for pain on both active and passive motion [and] in weight-bearing and non-weight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint.” The spine has no opposite joint. In Sharp v. Shulkin, 29 Vet. App. 26 (2017), the Court held that VA examiners must obtain information about the severity, frequency, duration, precipitating and alleviating factors, and extent of functional impairment of flares from the veterans themselves, when a flare-up is not observable at the time of examination. Normal range of motion of the knee is from 0 degrees of extension (leg in straight line from hip to heel) to 140 degrees of flexion (leg bent with heel near posterior thigh). See 38 C.F.R. § 4.71a, Plate II. Under 38 C.F.R. § 4.71a, Diagnostic Code 5010, ratings for traumatic arthritis are assigned under Diagnostic Code 5003, consistent with the criteria for degenerative arthritis. The criteria under Diagnostic Code 5003 allow for a 10 percent rating for arthritis with X-ray evidence of 2 or more major joints or 2 or more minor joint groups; or a 20 percent rating for arthritis with X-ray evidence of 2 or more major joints or 2 or more minor joint groups with occasional incapacitating episodes. Id. Under 38 C.F.R. § 4.71a, Diagnostic Code 5256, a 30 percent rating (and even higher ratings) is warranted for ankyloses of a knee in a favorable angle in full extension, or in slight flexion between 0 degrees and 10 degrees. Ankylosis is immobility and consolidation of a joint due to disease, injury, surgical procedure. Nix v. Brown, 4 Vet. App. 462, 465 (1993); and Shipwash v. Brown, 8 Vet. App. 218, 221 (1995). Diagnostic Code 5257 rates impairment resulting from other impairment of the knee, to include recurrent subluxation or lateral instability. A 10 percent rating is assigned with evidence of slight recurrent subluxation or lateral instability of a knee; 20 percent rating is assigned with evidence of moderate recurrent subluxation or lateral instability; and 30 percent rating is assigned with evidence of severe recurrent subluxation or lateral instability. Pursuant to 38 C.F.R. §§ 4.40 and 4.45, pain is inapplicable to ratings under Diagnostic Code 5257 because it is not predicated on loss of range of motion. See Johnson v. Brown, 9 Vet. App. 7, 11 (1996). Under 38 C.F.R. § 4.71a, Diagnostic Code 5260, a noncompensable rating is warranted where knee flexion is limited to 60 degrees, a 10 percent rating is warranted where knee flexion is limited to 45 degrees, a 20 percent rating is warranted where knee flexion is limited to 30 degrees, and a 30 percent rating is warranted where knee flexion is limited to 15 degrees. Under 38 C.F.R. § 4.71a, Diagnostic Code 5261 a noncompensable rating is warranted where knee extension is limited to 5 degrees. A 10 percent rating is warranted where knee extension is limited to 10 degrees. A 20 percent rating is warranted where knee extension is limited to 15 degrees. A 30 percent rating is warranted where knee extension is limited to 20 degrees. A 40 percent rating is warranted where knee extension is limited to 30 degrees, and a 50 percent rating is warranted where knee extension is limited to 45 degrees. Finally, pursuant to Diagnostic Code 5055, prosthetic replacement of a knee joint is rated 100 percent for one year following implantation of the prosthesis. The one-year total rating commences after a one-month convalescent rating under 38 C.F.R. § 4.30. Thereafter, chronic residuals consisting of severe painful motion or weakness in the affected extremity warrant a 60 percent rating. Intermediate degrees of residual weakness, pain, or limitation of motion are rated by analogy to Diagnostic Codes 5256, 5261, or 5262. The minimum rating following replacement of a knee joint is 30 percent. 38 C.F.R. § 4.71a, Diagnostic Code 5055. The Board notes that effective February 7, 2021, during the pendency of this appeal, VA’s Schedule, 38 C.F.R. Part 4, was amended with regard to rating musculoskeletal disabilities. 85 Fed. Reg. 76453 (Nov. 30, 2020). VA’s General Counsel, in a precedent opinion, has held that when a new regulation is issued while a claim is pending before VA, unless clearly specified otherwise, VA must apply the new provision to the claim from the effective date of the change as long as the application would not produce retroactive effects. VAOPGCPREC 7-03; 69 Fed. Reg. 25179 (2003). The amended versions may only be applied as of their effective date. Before that time, only the former version of the regulation may be applied. VAOPGCPREC 3-00; 65 Fed. Reg. 33422 (2000). Importantly, the former version remains for consideration throughout the rating period on appeal, both prior to and after the effective date of the change. See Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). The periods relevant to this decision are prior to and after the February 7, 2021, amendments. Effective February 7, 2021, Diagnostic Code 5003 was revised only insofar as it was renamed to make clear that this diagnostic code only applies to degenerative arthritis. Additionally, Diagnostic Code 5010 was revised rate post-traumatic arthritis as limitation of motion, dislocation, or other specified instability under the affected joint. If there are 2 or more joints affected, each rating shall be combined in accordance with § 4.25. See 85 Fed. Reg. 76453, 76460 (Nov. 30, 2020) (to be codified at 38 C.F.R. § 4.71a, Diagnostic Codes 5003, 5010). Under the revised version of Diagnostic Code 5055, effective February 7, 2021, a minimum 30 percent rating is warranted for total knee replacement only. A 60 percent rating is warranted for prosthetic replacement of the knee joint with chronic residuals consisting of severe painful motion or weakness in the affected extremity. Intermediate degrees of residual weakness, pain or limitation of motion are rated by analogy to diagnostic codes 5256, 5261, or 5262. A 100 percent rating is warranted for 4 months following knee resurfacing or replacement. See 85 Fed. Reg. 76453, 76461 (Nov. 30, 2020) (to be codified at 38 C.F.R. § 4.71a, Diagnostic Code 5055). Diagnostic Codes 5256, 5260, and 5261 were not changed by the February 7, 2021, amendments. While Diagnostic Codes 5257 (subluxation or instability) and 5262 (impairment of tibia and fibula) were revised, these diagnostic codes are not for application based on the findings in this case, as described below. 1. Left Knee The Veteran has appealed a June 2015 rating decision that denied a rating in excess of 10 percent for his service-connected left knee disability. For the entire period of the appeal, the Veteran has been in receipt of a 10 percent rating for his left knee disability under Diagnostic Codes 5010-5260. See 38 C.F.R. § 4.71a. (Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned.) A May 2014 VA Knee and Lower Leg Conditions Disability Benefits Questionnaire (DBQ) notes the Veteran’s history of arthritis. At the examination, the Veteran complained of daily left knee pain that was aggravated by prolonged sitting and standing, and walking more than 100 yards. He also reported flare-ups of pain several times a week with additional loss of 30 degrees of flexion. He reported wearing a knee brace and using a walker as needed; he denied any surgery. On examination, range of motion of the left knee was from 0 degrees of extension to 130 degrees of flexion, with pain beginning at 130 degrees of flexion. The Veteran was able to complete repetitive use testing; range of motion was unchanged with no additional functional impairment. The examiner stated that it would be speculative to provide range of motion during a flare-up or after repetitive use over time because the Veteran was not examined during a flare-up. Muscle strength was 5/5 and stability testing was normal. There was no evidence or history of patellar subluxation/dislocation. Private medical records were received in June 2016. The treating physician noted that an October 2015 MRI study of the left knee showed diffuse tearing of the lateral meniscus and diffuse high-grade articular cartilage loss throughout the lateral compartment. The ACL was not well defined on the images, which was most likely related to at least a partial tear. On examination of the left knee, the Veteran’s range of motion was from -10 degrees extension to 110 degrees flexion; AMA range of motion was from 0 degrees extension to 135 degrees flexion. There was no effusion; twist test was negative. The impression was complex lateral meniscus tear. A May 2019 VA Knee and Lower Leg DBQ notes the Veteran’s history of left knee injury with traumatic arthritic changes. The Veteran complained of knee pain that was worse with bending, and prolonged standing and walking. On examination, range of motion of the left knee was from 0 degrees extension to 100 degrees flexion with pain on both flexion and extension. There was also pain on weight bearing, non-weight bearing and passive range of motion. The Veteran was able to complete repetitive use testing; no additional functional loss was shown. The examiner opined that pain and flare-ups would limit functional ability with repeated use over time; range of motion in such circumstances was estimated to be from 0 degrees extension to 95 degrees flexion. There was no crepitus on examination. Muscle strength was 5/5 and there was no muscle atrophy. There was no ankylosis. There was no instability or effusion on examination. There was no history of subluxation or dislocation. The Veteran reported using a knee brace and walker constantly. X-ray studies revealed mild to moderate osteoarthritis of the left knee. A January 2021 VA Knee and Lower Leg DBQ notes the Veteran’s history of left knee arthritis. The Veteran complained of knee pain but did not report any flare-ups. On examination, range of motion of the left knee was from 0 degrees extension to 120 degrees flexion with pain on both flexion and extension. There was pain on weight bearing. There was no pain on non-weight bearing testing. The Veteran was able to complete repetitive use testing; no additional functional loss was shown. The examiner opined that pain, weakness, fatigability, and incoordination would not limit functional ability with repeated use over time. There was no crepitus or swelling on examination. Muscle strength was 5/5 and there was no muscle atrophy. There was no ankylosis. There was no instability or effusion on examination. There was no history of subluxation or dislocation. The Veteran had no history of left knee surgery. He reported using a knee brace and walker occasionally for balance and ambulating distances. In light of the probative evidence above, the Board finds that a rating in excess of 10 percent is not warranted at any point during the appeal period. A rating in excess of 10 percent is not warranted under Diagnostic Code 5260 because while the Veteran has repeatedly complained of chronic knee pain, the limitation of motion findings for flexion recorded in the VA examinations (130 degrees, 95 degrees and 120 degrees) and private treatment records (110 degrees) do not meet the requirements for the next higher rating under Diagnostic Code 5260 (limitation to 30 degrees), even considering related functional impairment. In addition, the Board has considered whether a separate rating is warranted for limitation of extension under Diagnostic Codes 5261 and 5257. As noted above, however, there are no findings that would warrant a separate rating for limitation of extension or instability/subluxation, as these were not found on examination. Finally, for the period beginning February 7, 2021, the Board again notes that no changes were made to Diagnostic Code 5260. The Board has considered whether separate/higher ratings are available under other applicable diagnostic codes for knee disabilities. However, the required pathology was not shown in this case, i.e., limitation of extension, subluxation or instability, ankylosis, impairment of tibia and fibula, or replacement/resurfacing of knee joint. 38 C.F.R. § 4.71a. For the above reasons, for the period of the appeal, a rating higher than 10 percent for service-connected left knee is not warranted. A preponderance of the evidence is against the assignment of any further higher or separate ratings; hence, the benefit of the doubt doctrine is not for application. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3, 4.7. 2. Right Knee The Veteran has appealed a June 2015 rating decision that awarded a 100 percent rating for service-connected right knee disability effective July 17, 2014, and a 30 percent rating effective September 1, 2015. The Veteran’s service-connected right knee disability is currently assigned the following disability ratings under Diagnostic Code 5055: 100 percent, effective July 17, 2014; 30 percent from September 1, 2015, through January 28, 2018; 100 percent from January 29, 2018, through June 30, 2019; and 60 percent beginning July 1, 2019. As 100 percent is the maximum rating available, these periods will not be considered below. The Veteran underwent right knee surgery (incision and drainage of acute septic arthritis after a total knee replacement) in July 2014. VA treatment records dated from September 2015 through January 2018 show the Veteran’s ongoing complaints of right knee pain. In May 2016, he was seen with complaints of aching, stabbing pain and occasional knee buckling. Examination revealed poor quadriceps tone. Although the Veteran was able to extend his right knee fully, he had shaking associated with weakness. He used a cane to ambulate. Private medical records were received in June 2016. The treating physician noted that an October 2015 MRI study of the right knee showed evidence of past arthroplasty. Large joint effusion and diffuse full thickness articular cartilage loss was shown. On examination of the right knee, the Veteran’s range of motion was from 0 degrees extension to 125 degrees flexion; AMA range of motion was from 0 degrees extension to 135 degrees flexion. There was no effusion; twist test was negative. The physician also reviewed August 2015 X-ray studies and concluded that the arthroplasty was in a satisfactory position with no evidence of loosening. VA treatment records show that in in March 2017, the Veteran complained of significant right knee pain. Examination revealed no external signs of infection. There was residual joint swelling and mild instability medially and laterally. Range of motion was from 0 degrees extension to 100 degrees flexion. In May 2017 the Veteran reported that his right knee pain was 6/10. On examination, right knee instability consistent with apparent loose prosthesis was noted. The Veteran underwent additional right knee surgery, to include infection treatment and another knee replacement, in January 2018, April 2018, and May 2018. A May 2019 VA Knee and Lower Leg Conditions DBQ the Veteran’s history of total knee replacement in 2014, with surgical revision and antibiotic spacer in January 2018, new right knee prosthesis in April 2018, and surgery for infection in May 2018. The Veteran complained of knee pain that was worse with bending, and prolonged standing and walking. He also complained of buckling of the knee with falling. He used a brace and walker to ambulate, and took antibiotics due to prior chronic knee infection. On examination, range of motion of the right knee was from 15 degrees extension to 70 degrees flexion with pain on both flexion and extension. There was also pain on weight bearing, non-weight bearing and passive range of motion. The Veteran was able to complete repetitive use testing; no additional functional loss was shown. The examiner opined that pain would limit functional ability with repeated use over time and during flare-ups; range of motion in such circumstances was estimated to be from 10 degrees extension to 65 degrees flexion. There was no crepitus on examination. Muscle strength was 3/5 and there was no muscle atrophy. There was no ankylosis. Joint stability testing showed no instability; there was no effusion on examination. X-ray studies in April 2019 revealed status post arthroplasty in place with findings which could be related to loosening of the tibial component versus a non-healed fracture. Associated osteomyelitis could not be ruled out. VA treatment records dated from July 2019 to December 2020 note the Veteran’s ongoing right knee complaints. On July 3, 2019, the Veteran was seen for a follow-up visit. He was taking iv antibiotics through a home infusion program. He reported that he was able to be physically active and do housework without pain or swelling. On July 6, 2019, he was discharged from infection treatment. In February 2020, right knee swelling was noted. The treating physician indicated that the right knee infection was stable. The Veteran reported he was independent with activities of daily living. In March 2020, the Veteran reported right knee pain at 8/10. Examination revealed muscle strength of 3/5. A January 2021 VA Knee and Lower Leg DBQ notes the Veteran’s history of right knee replacement in 2018. The Veteran complained of knee pain but did not report any flare-ups. On examination, range of motion of the right knee was from 0 degrees extension to 110 degrees flexion with pain on both flexion and extension. There was pain on weight bearing. There was no pain on non-weight bearing testing. The Veteran was able to complete repetitive use testing; no additional functional loss was shown. The examiner opined that pain, weakness, fatigability, and incoordination would not limit functional ability with repeated use over time. There was no crepitus on examination. Some swelling was noted. Muscle strength was 5/5 and there was no muscle atrophy. There was no ankylosis. There was no instability or effusion on examination. He reported using a knee brace and walker occasionally for balance and ambulating distances. For the period from September 1, 2015, through January 28, 2018, the Veteran’s right knee disability is rated 30 percent disabling under Diagnostic Code 5055. However, review of the record shows that for this time period, the evidence is at least in equipoise as to whether the criteria for higher 60 percent rating for service-connected right knee disability are met. As noted above, for this period, the evidence shows that the Veteran’s right knee manifested by weakness and limitation of motion with severe pain. Such evidence equates to the criteria for establishing a 60 percent rating. Accordingly, for this period, 60 percent rating for service-connected right knee disability is granted. However, an even higher 100 percent rating is not warranted for this period because the Veteran did not undergo any additional right knee replacement surgery during this period. See 38 C.F.R. § 4.71a, Diagnostic Code 5055 (2020). For the period beginning July 1, 2019, the Veteran’s right knee disability is rated 60 percent disabling under Diagnostic Code 5055. Under the rating criteria in effect prior to February 7, 2021, a higher rating of 100 percent is only warranted for the 1-year period following the implantation of the prosthesis. 38 C.F.R. § 4.71a, Diagnostic Code 5055 (2020). The Board notes that a rating under Diagnostic Code 5055 encompasses all identifiable residuals of total knee replacement, including limitation of motion, instability, and functional impairment. The rule against pyramiding prohibits compensating twice for the same manifestations. See 38 C.F.R. § 4.14. Therefore, separate ratings under any other knee diagnostic codes is not warranted. Moreover, the Veteran did not undergo any additional right knee replacement surgery during this period. Thus, separate ratings and a higher rating under Diagnostic Code 5055 are not warranted for this period. No other diagnostic code regarding knee disabilities would allow the Veteran a rating higher than 60 percent. Pursuant to 38 C.F.R. § 4.68, the combined rating for disabilities of an extremity shall not exceed the rating for the amputation of the elective level, where amputation to be performed. DCs 5162 through 5164, regarding amputation approximately at the knee, only allow for a maximum 60 percent disability rating. Therefore, the Board finds that from July 1, 2019, the Veteran is not entitled to a rating in excess of 60 percent for his service-connected right knee disability. Finally, the Board notes that the revised rating criteria is effective for the period beginning February 7, 2021. Under this code, a 100 percent rating is warranted for 4 months following knee resurfacing or replacement. See 85 Fed. Reg. 76453, 76461 (Nov. 30, 2020) (to be codified at 38 C.F.R. § 4.71a, Diagnostic Code 5055). The Veteran has not undergone knee resurfacing or replacement during the period at issue. Therefore, the Veteran would not benefit from the application of the revised criteria beginning February 7, 2021. REASONS FOR REMAND Service Connection for a Right Hip Disability This issue was remanded in March 2020 to obtain nexus opinions (direct and secondary); the examiner was directed to specifically address the Veteran’s June 2015 statement that his hip is worse because of poor posture due to favoring his service-connected left knee for so long. While medical opinions were obtained in January 2021, the etiology opinions provided are not adequate for adjudication purposes. In part, the opinions do not address the Veteran’s June 2015 statement about posture. Additionally, no direct service connection opinion was provided. 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). The Board regrets any further delay; however, compliance with the Board’s remand instructions is neither optional nor discretionary. Because there has not been substantial compliance with the Board’s previous remand directives, and another remand is required. See Stegall v. West, 11 Vet. App. 268, 271 (1998). TDIU Prior to July 1, 2019 Consideration of entitlement to a TDIU prior to July 1, 2019, is dependent upon the impact of the Veteran’s service-connected disabilities on his ability to obtain or retain substantially gainful employment. Accordingly, the matter of a TDIU is inextricably intertwined with the Veteran’s service connection claim remanded herein. Harris v. Derwinski, 1 Vet. App. 180 (1991). Remand of the inextricably intertwined TDIU claim is, thus, also required. The matters are REMANDED for the following action: Forward the Veteran’s claims file to an appropriate VA examiner who must review the claims file (to include this remand) and provide an addendum opinion as to: a) whether it is at least as likely as not (a 50 percent or greater probability) that the Veteran’s right hip disability is related to any incident from his period of active military service (as distinguished from any post-service incident); and b) whether it is at least as likely as not (a 50 percent or greater probability) that the Veteran’s service-connected disabilities, including current right and left knee disabilities, caused or aggravated his right hip disability. In responding to this question, the examiner should specifically address the Veteran’s June 2015 statement that his hip is worse because of poor posture due to favoring his service-connected left knee for so long. For the purposes of secondary service connection, the examiner is advised that aggravation is defined as “any increase in disability.” See Allen v. Brown, 7 Vet. App. 439, 448 (1995). If the examiner determines that the requested opinion may not be provided without a physical examination of the Veteran, then such should be scheduled. (Continued on the next page)   A complete rationale must be provided for all opinions presented. If the examiner cannot provide the requested opinion without resorting to speculation, he or she should provide an explanation stating why this is so. In so doing, the examiner should explain whether the inability to provide a more definitive opinion is the result of a need for additional information or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question. A. ISHIZAWAR Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Fletcher, Kathleen 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.