Citation Nr: 21014125 Decision Date: 03/11/21 Archive Date: 03/11/21 DOCKET NO. 05-28 200 DATE: March 11, 2021 ORDER Entitlement to an evaluation in excess of 20 percent for lumbar spine degenerative disc disease prior to June 3, 2011, is denied. Entitlement to an evaluation in excess of 20 percent for lumbar spine degenerative disc disease since August 1, 2011, is denied. REMANDED Entitlement to evaluation in excess of 10 percent for left knee arthritis is remanded. FINDINGS OF FACT 1. Prior to June 3, 2011, the Veteran’s lumbar spine degenerative disc disease manifested by no worse than forward flexion of the thoracolumbar spine to 75 degrees. 2. Since August 1, 2011, the Veteran’s lumbar spine degenerative disc disease has manifested by no worse than forward flexion of the thoracolumbar spine to 40 degrees. CONCLUSIONS OF LAW 1. The criteria for an increased rating in excess of 20 percent for lumbar spine degenerative disc disease, prior to June 3, 2011 are not met. 38 U.S.C. §§ 1155, 5107, 38 C.F.R. §§ 4.1 – 4.7, 4.21, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5242. 2. The criteria for an increased rating in excess of 20 percent for lumbar spine degenerative disc disease, from August 1, 2011 are not met. 38 U.S.C. §§ 1155, 5107, 38 C.F.R. §§ 4.1 – 4.7, 4.21, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5242. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from June 1979 to January 1988. These matters come before the Board of Veterans’ Appeals (Board) on appeal from an April 2005 rating decision by the Denver, Colorado, Regional Office (RO) of the United States Department of Veterans Affairs. These issues were previously before the Board, most recently in May 2018, at which time they were remanded for additional development. The Veteran was granted a temporary total disability evaluation based on the need for convalescence due to his back surgery for the period from June 3, 2011, to August 1, 2011. As the Veteran is in receipt of the maximum rating available for this period, the Board will not address entitlement to increased disability ratings for the lumbar spine for the period from June 3, 2011 to August 1, 2011. Duty to Notify and Assist VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C. §§ 5100, 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.159, 3.326(a). These duties have been satisfied in this case. Appropriate notice was provided in July 2004. The RO associated the Veteran’s service and VA private outpatient treatment records with the claims file. All released or submitted private treatment records have been associated with the claims file. No other relevant records have been identified and are outstanding. Appropriate and necessary examinations were afforded the Veteran, and are adequate for evaluation, as they include needed findings to permit application of the rating schedule and identification of current disability. As such, VA has satisfied its duty to assist with the procurement of relevant records. 38 U.S.C. § 5103A; 38 C.F.R. § 3.159(c). Neither the Veteran nor his representative have raised any issues with the duty to notify or duty to assist. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016). Increased Rating Disability evaluations are determined by the application of the facts presented to VA’s Schedule for Rating Disabilities (Rating Schedule) at 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and the residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.321(a), 4.1. In evaluating the severity of a particular disability, it is essential to consider its history. 38 C.F.R. § 4.1; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary importance. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Separate ratings may be assigned for separate periods of time based on the facts found, however. This practice is known as “staged” ratings. Fenderson v. West, 12 Vet. App. 119, 126 - 127 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). If the evidence for and against a claim is in equipoise, the claim will be granted. A claim will be denied only if the preponderance of the evidence is against the claim. See 38 U.S.C. § 5107 (West 2002); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 56 (1990). Any reasonable doubt regarding the degree of disability should be resolved in favor of the claimant. 38 C.F.R. § 4.3. Where there is a question as to which of two evaluations shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that evaluation. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Competent medical evidence is evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may also include statements conveying sound medical principles found in medical treatises. It also includes statements contained in authoritative writings, such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159(a)(1). Competent lay evidence is any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159(a)(2). This may include some medical matters, such as describing symptoms or relating a contemporaneous medical diagnosis. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011). It should also be noted that, when evaluating disabilities of the musculoskeletal system, 38 C.F.R. § 4.40 allows for consideration of functional loss due to pain and weakness causing additional disability beyond that reflected on range of motion measurements. DeLuca v. Brown, 8 Vet. App. 202 (1995). Further, 38 C.F.R. § 4.45 provides that consideration also be given to decreased movement, weakened movement, excess fatigability, incoordination, and pain on movement, swelling, and deformity or atrophy of disuse. The intent of the rating schedule is 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. Painful motion is considered limited motion at the point that pain actually sets in. See VAOPGCPREC 9-98. Lumbar Spine The Veteran’s lumbar spine disability is evaluated under 38 C.F.R. § 4.71a, Diagnostic Code 5243. Code 5243 pertains to intervertebral disc syndrome and direct that evaluations of the lumbar spine are to be rated under the General Rating Formula for Diseases and injuries of the Spine or under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, whichever results in a higher rating. The Board notes that the rating criteria for musculoskeletal disorders were revised on February 7, 2021. The amended regulations became effective on February 7, 2021 and claims that were pending on this date must be considered under the former and revised criteria with the most favorable version applied to the claim. See Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 76453, 76463 (Nov. 30, 2020) (to be codified at 38 C.F.R. § 4.71a, Diagnostic Codes 5003, 5010, 5242, 5243). However, the general rating criteria for diseases and injuries of the spine and the formula for rating intervertebral disc syndrome based on incapacitating episodes remains unchanged under the new rating criteria. Pursuant to the general rating criteria for diseases and injuries of the spine, a 20 percent evaluation is warranted for forward flexion of the thoracolumbar spine greater than 60 degrees; or, the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal, kyphosis. A 40 percent evaluation is warranted for forward flexion of the thoracolumbar spine 30 degrees or less; or favorable ankylosis of the entire thoracolumbar spine. A higher evaluation of 50 percent is warranted for unfavorable ankylosis of the entire thoracolumbar spine. The highest evaluation of 100 percent is warranted for unfavorable ankylosis of the entire spine. Pursuant to the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, a 20 percent evaluation is assigned for incapacitating episodes having a total duration of at least 2 weeks but less than 4 weeks during the past 12 months. A 40 percent evaluation is assigned for incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months. A 60 percent evaluation is assigned for incapacitating episodes having a total duration of at least 6 weeks during the past 12 months. 38 C.F.R. § 4.71a, Diagnostic Code 5243. An “incapacitating episode” is a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician. 38 C.F.R. § 4.71a, Diagnostic Code 5243, Note 1. VA regulations define normal range of motion of the lumbar spine as flexion to 90 degrees, extension to 30 degrees, lateral flexion to 30 degrees, and rotation to 30 degrees. 38 C.F.R. § 4.71a, Plate V. Under the former rating criteria, Diagnostic Code 5242 evaluated Degenerative arthritis of the Spine (see also diagnostic code 5003). 38 C.F.R. § 4.71a, Code 5242 (2020). Under the new criteria, Code 5242 applies to Degenerative arthritis, degenerative disc disease other than intervertebral disc syndrome (also, see either diagnostic code 5003 or 5010). See Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 76453, 76463 (Nov. 30, 2020) (to be codified at 38 C.F.R. § 4.71a, Diagnostic Code 5242). Under the former rating criteria, Diagnostic Code 5243 evaluated Intervertebral disc syndrome (IVDS). 38 C.F.R. § 4.71a, Code 5243 (2020). Under the new criteria, Code 5243 still applies to Intervertebral disc syndrome; but more specifically as this code is only to be assigned when there is disc herniation with compression and/or irritation of the adjacent nerve root; assign diagnostic code 5242 for all other disc diagnoses. See Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 76453, 76463 (Nov. 30, 2020) (to be codified at 38 C.F.R. § 4.71a, Diagnostic Code 5243). The Board finds that the appropriate Diagnostic Code for the evaluating the Veteran’s lumbar spine disability, based on the new regulations, Diagnostic Code 5242, Degenerative arthritis, degenerative disc disease other than intervertebral disc syndrome. The Veteran underwent a VA medical examination in October 2004. The Veteran reported that he gets intermittent lower backache when he is carrying something around; very minimal pain and is not a bother to him. He had no lower extremity radicular symptoms, no weakness, or numbness into the legs, or incontinence of bowel or bladder and he described no flares, just an occasional mid lower backache when he is carrying something; perhaps twice a month he will notice any discomfort. The VA examiner noted there was no need for additional therapy or increase in medication due to the back. Physical examination revealed lumbar range of motion as follows: flexion 0 to 90 degrees, extension 0 to 30 degrees, right side bending 0 t0 30 degrees, and bilateral rotation 0 to 60 degrees, respectively. The VA examiner noted a loss of lumbar lordosis and a bit of muscle spasm, but no tenderness or significant point tenderness. The VA examiner diagnosed lumbar degenerative disc disease, with minor intermittent discomfort without radicular symptoms and no significant findings. Based on these findings, the Veteran was assigned a 20 percent disability evaluation for lumbar degenerative disc disease. The Veteran underwent a VA spine examination in July 2008. The Veteran reported no surgery to his back, and that he has a brace but did not bring it to the examination. Subjective complaints included back hurts 5 days a week “at least,” discomfort averaging a 5 out of 10, flare-ups occurring 3 days a week without apparent cause, and pain going down the right lower extremity with numbness approximately 3 times a week. The Veteran reported no current treatment and no incapacitating episodes. Physical examination revealed spine was tender to palpation right and left paralumbar muscles without muscle spasm, tender right posterior superior iliac spine region and slight tenderness in right mid-buttock; complains of pain midline percussion lumbar spine, pelvis was level. Deep tendon reflexes were 2 out of 4, seated straight-leg raising was negative, manual muscle strength testing was 5 out of 5. Sensory, light touch and scratch, on thighs, legs and ankles were decreased on right side as compared to left. Range of motion testing was performed twice only due to pain; the examiner noted that the Veteran held onto his cane with the left hand and occasionally for some of these motions to the chair with his right hand. Flexion was to 75 degrees, extension was to 25 degrees, right lateral flexion was to 30 degrees, left lateral flexion was 25 – 30 degrees, right lateral rotation was to 35 degrees and left lateral rotation was to 30 degrees. The VA examiner noted the Veteran’s diagnosis of lumbosacral spine degenerative disc disease/degenerative joint disease. Functional impairment was noted to be between slight and moderate. No weakness, fatigability, or incoordination was noted. VA treatment notes dated December 2008 indicate normal contour of back, no tenderness, and mildly limited range of motion and reflect complaint of back pain. A mental health treatment note dated December 13, 2008 reflects full range of motion of the back and no pain. VA treatment records note the Veteran’s complaints of back pain in July and August 2010. VA treatment records reflect the Veteran’s June 2011 lumbar discectomy. In July 2011 and October 2011, the Veteran was treated for post-op residual back pain. The Veteran underwent a VA spine examination in September 2012. The VA examiner noted the Veteran’s diagnosis of lumbar strain, herniated disc L5-S1 and mild degenerative joint disease lumbar spine. The Veteran reported he underwent surgery in June 2011 after injuring his back while lifting boxes and herniating his L5-S1 on right. He continued to have radicular signs. The Veteran did not report experiencing flare-ups that impacted function of his thoracolumbar spine. Physical examination revealed range of motion as follows: forward flexion to 85 degrees, with painful motion at 85 degrees; extension ends at 15 degrees with no objective evidence of painful motion; right lateral flexion ends at 30 degrees with no objective evidence of painful motion; left lateral flexion ends at 20 degrees with no objective evidence of painful motion; right lateral rotation to 30 degrees with no objective evidence of painful motion; and left lateral rotation ends at 30 degrees with no objective evidence of painful motion. The Veteran was not able to perform repetitive-use testing. Contributing factors disability include pain on movement. The Veteran did not have localized tenderness or pain to palpation for joints and/or soft tissue of the thoracolumbar spine, nor guarding and/or muscle spasm. Muscle strength test results were normal with the exception of right ankle plantar flexion and right great to extension, both of which were 4 out of 5. No muscle atrophy was present. The examiner noted the Veteran’s radiculopathy of the right lower extremity with involvement of the right sciatic nerve. The VA examiner noted that the Veteran did not have IVDS. Arthritis was documented by X-rays. A July 2011 MRI of the lumbar spine revealed minimal edema central L5-S1 disc without clear evidence for discitis, likely postsurgical in nature; multi-level disc bulge including L5-S1, as before; central annular tear L2-L3 as before; possible contact exiting left L4-L5 nerve root from adjacent facet and ligamentum flavum hypertrophy as before. VA treatment records from January and February 2013 reflect continued complaints of chronic low back pain. A May 2013 physical therapy report reflected the Veteran reported low back pain which has been bothering him since his 2011 back surgery. Lumbar spine MRI showed grade 1/4 anterolisthesis of L5 on S1; mild-moderate bilateral neural foraminal stenosis at L5-S1 level to two spondylolisthesis. Range of motion was as follows: flexion to 40 degrees with pain, extension to 10 degrees with pain, right and left side bending to 10 degrees with pain. The Veteran’s core and back muscles were noted to be weak and were not working to support the lumbar spine. October 2013 physical therapy notes reflect the Veteran’s history of lumbar fusion L4-L5 in 2011 and his continuing complaints of back pain. Physical therapy notes reflect treatment through December 2017. The Veteran underwent a VA contract back examination in August 2017. The VA examiner noted the Veteran’s diagnosis of lumbar spine degenerative disc disease. The Veteran did not report experiencing flare-ups. Functional loss was described as “putting rap at house, too many stairs.” The contract examiner noted that the Veteran was unable to safely get on the examination table and follow directions to perform range of motion testing as he has Parkinson’s. No guarding or muscle spasm of the thoracolumbar spine was noted, and no additional contributing factors of disability were noted. Muscle strength test results were normal. Reflex and sensory test results were normal. The examiner noted that the Veteran did not have IVDS of the thoracolumbar spine. This examination was found to be inadequate for adjudication purposes by the Board in its May 2018 remand. VA treatment records from November and December 2018 reflect the Veteran’s continued complaints of chronic low back pain. The Veteran underwent a VA contract back examination in March 2019. The VA contract examiner noted the Veteran’s diagnosis of lumbar degenerative disc disease, s/p lumbar stimulator implant, s/p multiple lumbar infusions. The Veteran reported that his condition has continued to get worse over the years requiring several surgeries and the implant of a lumbar spinal stimulator. Flare-ups were described as shooting pains in the legs and back “to where my legs and feet go numb.” He did not report any functional loss or functional impairment of the thoracolumbar spine. Physical examination revealed range of motion as follows: forward flexion from 0 to 25 degrees; extension from 0 to 10 degrees; right lateral flexion from 0 to 15 degrees; left lateral flexion from 0 to 10 degrees, and bilateral lateral rotation from 0 to 30 degrees. The VA contract examiner noted that although the range of motion was outside of “normal” range, it was normal for Veteran due to “poor effort vs. body habitus vs. Parkinson’s vs pain.” The VA contract examiner noted that pain was noted on examination, in all ranges of motion, but did not result in or cause functional loss. There was no evidence of pain with weightbearing. The Veteran was able to perform three repetitions, which did not result in additional loss of function or range of motion. Pain, weakness, fatigability, or incoordination did not significantly limit functional ability with repeated use over time. No muscle spasm or guarding of the back was present. Muscle strength test results were all normal. The Veteran did not have muscle atrophy. Sensory exam revealed decreased sensation to light touch in all aspects; reflexes were normal. The VA contract examiner determined that the Veteran did not have IVDS. VA treatment records through August 2019 show continued complaints of chronic low back pain. The Veteran underwent a VA contract back examination in November 2020. The VA contract examiner noted the Veteran’s diagnoses of degenerative disc disease, lumbar spine and degenerative joint disease, lumbar spine. The Veteran reported that he underwent a L5-S1 discectomy in June 2011 and continued to have low back pain and radicular symptoms. In January 2012 he had a right L5-S1 transforaminal epidural steroid injection and was treated with spinal cord stimulator placement in 2018. He continues to have chronic back pain. The Veteran reported his condition has worsened. Subjective complaints include constant low back pain every day; 6 out of 10 in severity at rest; movement helps the pain. He stated that if he sits for too long, he has intermittent shooting pain down his legs. Functional loss or functional impairment was described as “physical stuff. I can sit a ½ hour at the most depending on the chair. I cannot walk very far, pretty much just walk around the house. I live in a mobile home so it’s not that big.” Physical examination revealed range of motion as follows: forward flexion from 0 to 65 degrees; extension from 0 to 25 degrees; bilateral lateral flexion from 0 to 25 degrees; bilateral lateral rotation from 0 to 20 degrees. Range of motion contributed to a functional loss in that the Veteran was unable to bend over fully and requires assistance to put on shoes and socks. Pain was noted on examination in all ranges and caused functional loss. No objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue of the thoracolumbar spine was present. There was evidence of pain on weight bearing. The Veteran was not able to perform repetitive-use testing with at least three repetitions; he became very dizzy and had to sit down. He was able to complete three repetitions of the other movements and there was no additional loss of function or range of motion after three repetitions with these movements. Pain, weakness, fatigability, and lack of endurance significantly limited functional ability with repeated use over a period of time. The VA contract examiner described it in terms of range of motion as forward flexion from 0 to 55 degrees, extension from 0 to 20 degrees, bilateral lateral rotation from 0 to 20 degrees and bilateral lateral rotation from 0 to15 degrees. No flare-ups were reported, and no muscle spasm or guarding was present. Additional contributing factors of disability were identified as interference with sitting, interference with standing, and inability to perform any strenuous activities or heavy lifting; he is unable to stand, sit or walk for prolonged periods. Muscle strength test results were normal for bilateral hip and knee extension and were 4 out of 5 for bilateral ankle plantar flexion, ankle dorsiflexion and great toe extension. No muscle atrophy was present. Reflexes were normal for the knees and hypoactive for the ankles. Sensory examination revealed sensation to light touch was normal in the bilateral upper anterior thighs and thighs/knees and decreased in bilateral lower legs/ankles and feet/toes. Straight leg raising test was positive bilaterally. No ankylosis of the spine was present. The Veteran did not have IVDS. The Veteran reported using a cane for the last two years due to his knees, back and Parkinson’s disease. The VA contract examiner noted a December 2016 MRI which revealed grade one anterolisthesis of L5 on S1 with severe degenerative disc disease at L5-S1 and severe left foraminal narrowing, and moderate narrowing of the right intervertebral foramina at L5-S1 and L4-5, annular tears at L1-2 and L2-3. Objective evidence of pain when back used in non-weight bearing was noted. Passive range of motion testing could not be performed. The accompanying medical opinion indicated that the Veteran’s back condition was worsened by the herniated disc requiring surgery in 2011, however, this is considered a progression of his degenerative disc disease. The VA contract examiner determined that the Veteran’s “Parkinson’s Disease (PD) is likely worsening his lumbar spine condition in the fact that his mobility, gait, and balance are affected by PD. He has a significant fall risk due to PD and lumbar spine conditions. The Parkinson’s Disease is likely worsening his lumbar spine condition as his gait, posture and mobility are affected. However, veteran has significant lumbar spine disease evident by findings on MRIs. Therefore, his lumbar spine conditions including radiculopathy would likely result in significant signs and symptoms even without the PD, which compounds the issues.” Prior to June 3, 2011 The Board has carefully considered all the evidence and potentially applicable diagnostic codes, including the DeLuca factors, and finds that the disability picture of the Veteran’s lumbar spine disability does not more nearly approximate the rating criteria of a higher disability level. Motion was, at worst, limited to forward flexion to 75 degrees, warranting the currently assigned 20 percent rating, even upon consideration of the functional impact of pain with use and on flare-ups. Flexion is not reduced to less than 30 degrees, nor did the Veteran experience incapacitating episodes to warrant assignment of a yet higher rating. The Board finds that the overall disability picture prior to June 3, 2011 is not severe enough to warrant assignment of an evaluation in excess of 20 percent. Therefore, the Board finds that a rating in excess of 20 percent for the Veteran’s service-connected lumbar spine degenerative disc disease, prior to June 3, 2011, is not warranted. In addition, the Board has considered the doctrine of reasonable doubt but has determined that it is not applicable because the preponderance of the evidence is against the claim for a higher rating. 38 C.F.R. §§ 4.7, 4.21. From August 1, 2011 The Board has carefully considered all the evidence and potentially applicable diagnostic codes, including the DeLuca factors, and finds that the disability picture of the Veteran’s lumbar spine disability does not more nearly approximate the rating criteria of a higher disability level. Motion was, at worst, limited to forward flexion to 40 degrees, in May 2013, warranting the currently assigned 20 percent rating, even upon consideration of the functional impact of pain with use and on flare-ups. The Board notes that at the VA examinations in September 2012 and in November 2020, forward flexion was limited to 85 degrees and 65 degrees, respectively. The Board notes that at the March 2019 VA contract examination flexion was limited to 25 degrees, however, this examination was found to be incomplete as it failed to address the impact of the Veteran’s 2011 disc herniation injury and his Parkinson’s Disease on his service-connected back disability. Additionally, the results of this examination were determined to be unreliable due to the Veteran’s behavior and poor effort. The evidence shows that flexion is not reduced to less than 30 degrees, nor has the Veteran experienced incapacitating episodes to warrant assignment of a yet higher rating. The Board finds that the overall disability picture from August 1, 2011 is not severe enough to warrant assignment of an evaluation in excess of 20 percent. Therefore, the Board finds that a rating in excess of 20 percent for the Veteran’s service-connected lumbar spine degenerative disc disease, from August 1, 2011, is not warranted. In addition, the Board has considered the doctrine of reasonable doubt but has determined that it is not applicable because the preponderance of the evidence is against the claim for a higher rating. 38 C.F.R. §§ 4.7, 4.21. REASONS FOR REMAND The Board finds that additional development is required to adjudicate the Veteran’s claim for an evaluation in excess of 10 percent for his left knee arthritis. At a June 2020 mental health visit, the Veteran reported he had a left total knee replacement 2 weeks earlier. A review of the file reveals these records have not been associated with the file. On remand, an attempt to obtain these records and associate them with the file should be made. Additionally, the Veteran should be scheduled for a knee examination to ascertain the current nature and severity of his service-connected left knee disability. The matters are REMANDED for the following action: 1. Take appropriate action to obtain and associate all relevant VA treatment records and private treatment records, including any records relating to treatment for his left knee disability, including records from his May or June 2020 left knee replacement. 2. Schedule the Veteran for a knee examination to ascertain the current level and severity of his left knee arthritis, status post left knee replacement. 3. Then, readjudicate the remanded issue. If the benefit sought remains denied, the Veteran should be provided with a supplemental statement of the case. The case should then be returned to the Board for appellate review if otherwise in order. WILLIAM H. DONNELLY Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. M. Lunger, Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.