Citation Nr: 21015354 Decision Date: 03/17/21 Archive Date: 03/17/21 DOCKET NO. 17-41 996 DATE: March 17, 2021 ORDER From March 1, 2016, through June 26, 2019, a 60 percent rating for status post left total knee arthroscopy is granted. From December 28, 2015, through June 26, 2019, a 60 percent rating for status post right total knee arthroscopy is granted. An initial rating in excess of 20 percent for right shoulder full thickness tear of the supraspinatus tendon and tendinopathy with impingement syndrome of the infraspinatus tendon from December 28, 2015, through June 26, 2019, is denied. REMANDED The issue of service connection for a lumbar spine disability, to include as secondary to service-connected bilateral knee disabilities, is remanded. The issue of service connection for right hip degenerative joint disease, to include as secondary to the service-connected right knee disability, is remanded. The issue of service connection for left hip trochanteric pain syndrome, to include as secondary to the service-connected left knee disability, is remanded. The issue of service connection for left ankle degenerative joint disease with tendinopathy, to include as secondary to the service-connected left knee disability, is remanded. FINDINGS OF FACT 1. From March 1, 2016, through June 26, 2019, status post left total knee arthroscopy was manifested by chronic residuals consisting of severely painful motion or weakness. 2. From December 28, 2015, through June 26, 2019, status post right total knee arthroscopy was manifested by chronic residuals consisting of severely painful motion or weakness. 3. Since service connection was established December 28, 2015, through June 26, 2019, right shoulder full thickness tear of the supraspinatus tendon and tendinopathy with impingement syndrome of the infraspinatus tendon was manifested at worst by forward flexion from 0 to 90 degrees and abduction from to 100 degrees with severe pain on motion. CONCLUSIONS OF LAW 1. Resolving all reasonable doubt in favor of the Veteran, from December 28, 2015, through June 26, 2019, the criteria for a rating of 60 percent for status post left total knee arthroscopy have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5055. 2. Resolving all reasonable doubt in favor of the Veteran, from March 1, 2016, through June 26, 2019, the criteria for a rating of 60 percent for status post right total knee arthroscopy have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5055-5261. 3. Since service connection was established December 28, 2015, through June 26, 2019, the criteria for an initial rating in excess of 20 percent for right shoulder full thickness tear of the supraspinatus tendon and tendinopathy with impingement syndrome of the infraspinatus tendon have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5003-5201. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from January 1978 to December 1978. This matter comes before the Board of Veterans’ Appeals (Board) from July 2015, November 2015, and May 2016 rating decisions. In September 2019, the Veteran testified at a Board hearing; a transcript of the hearing is associated with the claims file. In February 2020, the Board remanded the appeal to the agency of original jurisdiction (AOJ) for additional development. At that time, the Board had inadvertently omitted the issue of service connection for a left ankle disability. The Veteran has not withdrawn his appeal of that issue and it is addressed in the Remand section of this decision. Increased Ratings 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; 38 C.F.R. § 4.1. 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. Where there is a question as to which of two ratings should be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. 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; Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). Generally, when an increase in the disability rating is at issue, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). When the appeal arises from an initial assigned rating, consideration must be given to whether staged ratings should be assigned to reflect entitlement to a higher rating at any point during the pendency of the claim. Fenderson v. West, 12 Vet. App. 119 (1999). Staged ratings are also for consideration in any increased rating claim in which distinct time periods with different ratable symptoms can be identified. Hart v. Mansfield, 21 Vet. App. 505, 510 (2007). Analysis in this decision has been undertaken with consideration of the possibility that different ratings may be warranted for different time periods as to the pending claims. 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. 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 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.” 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. 1. A rating in excess of 30 percent for status post left total knee arthroscopy from March 1, 2016, through June 26, 2019 2. A rating in excess of 50 percent for status post right total knee arthroscopy from December 28, 2015, through June 26, 2019 The Veteran contends that a 60 percent rating is warranted for each knee disability for the period following the one-year, 100 percent rating assigned after each total knee arthroscopy until an August 2020 rating decision increased the rating to 60 percent for each knee effective June 27, 2019. He is also seeking an initial 30 percent rating for his right shoulder disability from the date service connection was granted until the August 2020 rating decision increased the rating to 30 percent effective June 27, 2019. Regarding the left knee, a February 2015 rating decision had assigned a 100 percent rating effective January 5, 2015, followed by a 30 percent rating effective March 1, 2016. In August 2015, the Veteran filed a claim for an increased rating for his left knee disability, indicating he believed the 30 percent rating should be increased to 60 percent. A November 2015 rating decision continued the 30 percent rating to be assigned for his status post left total knee arthroscopy effective March 1, 2016. In his December 2015 notice of disagreement (NOD), he indicated he believed a 60 percent disability rating was warranted for his left knee effective March 1, 2016. On December 28, 2015, VA received the Veteran’s claim for service connection for a right shoulder disability claimed as secondary to his right and left knee disabilities. The May 2016 rating decision granted service connection for a right shoulder disability and assigned a 20 percent rating effective December 28, 2015. That rating decision also decreased the assigned rating for status post right total knee arthroscopy from 60 percent to 50 percent, also effective December 28, 2015. In his July 2016 NOD regarding those ratings, he asserted that an initial 30 percent rating was warranted for his right shoulder disability and that a 60 percent rating was warranted for his right knee disability. He reiterated his belief that a 60 percent rating was also warranted for his left knee disability. Later in July 2016, the AOJ issued another rating decision that continued the 30 percent rating assigned for the left knee disability. In July 2019 correspondence, the Veteran’s attorney argued on his behalf that he was seeking a 60 percent rating for each knee disability and a 30 percent rating for his right shoulder disability. An August 2020 rating decision increased the assigned ratings for status post left and right total knee arthroscopies to 60 percent each and increased the rating for the right shoulder disability to 30 percent; the effective date of each increased rating was June 27, 2019. In summary, the Veteran clearly and specifically communicated his belief that a 60 percent rating was warranted for each knee disability and a 30 percent rating was warranted for his right shoulder disability. As the benefit sought for each increased rating claim on appeal was granted effective June 27, 2019, the remaining issues on appeal are entitlement to (1) a rating in excess of 30 percent for left total knee arthroscopy from March 1, 2016, through June 26, 2019; (2) a rating in excess of 50 percent for right total knee arthroscopy from December 28, 2015, through June 26, 2019; and (3) an initial rating in excess of 20 percent for a right shoulder disability from December 28, 2015, through June 26, 2019. In addition to those benefits being granted, the Veteran had sought a total disability rating based on individual unemployability (TDIU) due to service-connected disabilities, particularly, his knees and right shoulder. Regarding the effects of his right and left knee disabilities on his usual occupation as a lead medical support assistant at a VA facility, he reported he had medically retired following his knee replacements surgeries. A September 2020 rating decision granted a TDIU effective January 1, 2015. Also, service connection had previously been granted for surgical scars associated with each total knee arthroscopy. During the applicable time periods on appeal, the Veteran’s left knee disability has been rating 30 percent disabling pursuant to 38 C.F.R. § 4.71a, Diagnostic Code 5055 (2020), and his right knee disability has been rated 50 percent disabling pursuant to Diagnostic Code 5055-5261. 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 rating assigned. The additional code is shown after a hyphen. 38 C.F.R. § 4.27. In this case, Diagnostic Code 5055 pertains to knee replacement (prosthesis), and 5261 refers to limitation of extension of the leg. 38 C.F.R. § 4.71a, Diagnostic Codes 5055, 5261. Under Diagnostic Code 5055, a 100 percent rating is assigned for one year following implantation of a knee prosthesis. After that period, a minimum rating of 30 percent is assigned. When there are chronic residuals consisting of severe painful motion or weakness in the affected extremity, a 60 percent rating is assigned. With intermediate degrees of residual weakness, pain, or limitation of motion, the knee is rated by analogy to diagnostic codes 5256, 5261, or 5262. 38 C.F.R. § 4.71a, Diagnostic Code 5055 (2020). Diagnostic Code 5256 pertains to ankylosis of the knee and Diagnostic Code 5262 pertains to impairment of the tibia and fibula manifested by malunion or nonunion. Neither the right nor left knee has been manifested by favorable or unfavorable ankylosis or impairment of the tibia and fibula at any time during the applicable appeal periods. For VA compensation purposes, normal range of motion for the knee is flexion to 140 degrees and extension to 0 degrees. 38 C.F.R. § 4.71, Plate II. Diagnostic Codes 5260 and 5261 provide for rating based on limitation of motion. Ratings for limitation of flexion of a knee are assigned as follows: flexion limited to 60 degrees is 0 percent; flexion limited to 45 degrees is 10 percent; flexion limited to 30 degrees is 20 percent; and flexion limited to 15 degrees is 30 percent. 38 C.F.R. § 4.71a, Diagnostic Code 5260. Ratings for limitation of extension of the knee are assigned as follows: extension limited to 5 degrees is 0 percent; extension limited to 10 degrees is 10 percent; extension limited to 15 degrees is 20 percent; extension limited to 20 degrees is 30 percent; extension limited to 30 degrees is 40 percent; and extension limited to 45 degrees is 50 percent. Id., Diagnostic Code 5261. VA General Counsel has held that separate ratings may be assigned under Diagnostic Code 5260 and Diagnostic Code 5261, where a Veteran has both a limitation of flexion and limitation of extension of the same leg; limitations must be rated separately to adequately compensate for functional loss associated with injury to the leg. VAOPGCPREC 9-2004 (Sept. 17, 2004). Because ratings may be separately assigned for limitation of flexion and limitation of extension, the Board will consider both Diagnostic Codes. Turning to the evidence of record, in March 2016, the Veteran was afforded a VA examination to evaluate his right knee disability. He reported that since his November 2015 right total knee replacement, he had worsened pain and swelling and he had difficulty standing because his knee “collapses under” him. He did not report experiencing flare-ups of right knee symptoms. He stated he regularly used a wheelchair for this right and left knee disabilities. Right knee range-of-motion testing revealed flexion to 95 degrees and normal extension to 0 degrees with pain on motion and with weight-bearing. Following repetitive-motion testing, there was no additional functional loss or range of motion. The examiner indicated that pain and lack of endurance limited functional ability with repeated use over time, resulting in the limitation of flexion demonstrated on examination. Other right knee examination findings included moderate edema and tenderness around the entire knee; no crepitus; normal (5/5) muscle strength with no muscle atrophy; no ankylosis; normal stability on anterior (Lachman test), posterior (posterior drawer test), medial (valgus pressure applied), and lateral (varus pressure applied) stability testing; and no shin splints or meniscus (semilunar cartilage) conditions. The examiner concluded that the right knee demonstrated intermediate degrees of residual weakness, pain, or limitation of motion following the November 2015 joint replacement surgery. The examiner identified the functional impact of the right knee disability as moderate pain with standing or walking. In June 2016, the Veteran was afforded a VA examination to evaluate his left knee disability. He described having severe pain around both sides of his knee and down the calf since the January 2015 knee replacement surgery and reported that he continued to use several medications for pain. He stated that his left knee gets weak sometimes and will not hold him up. He reported getting spasms in his knee, pain with walking, having to walk up stairs sideways if he is even able to ascend stairs, and being barely able to get out of bed somedays. He reported difficulty standing due to pain and needing to take showers because he was unable to raise his leg over the bathtub. He did not report experiencing flare-ups of left knee symptoms. He indicated he regularly used a wheelchair or cane and occasionally used a walker that he received after his surgery. Left knee range-of-motion testing revealed flexion to 70 degrees with full extension to 0 degrees with pain noted on flexion and extension. The examiner observed the Veteran had difficulty getting out of the chair because his leg would not bend underneath him. Following repetitive-use testing, there was no additional functional loss or range of motion of the left knee. Other left knee examination findings included the following: a reduction in muscle strength (4/5) on flexion and extension entirely due to the status post left total knee arthroscopy disability; no muscle atrophy; no ankylosis; normal stability on anterior, posterior, medial, and lateral stability testing; and no shin splints or meniscal conditions. The examiner concluded that the left knee demonstrated intermediate degrees of residual weakness, pain, or limitation of motion following the January 2015 joint replacement surgery. The examiner identified the functional impact of the left knee disability as causing pain with prolonged standing and walking, inability to climb ladders, and difficulty with stairs. In June 2016 and October 2017, the Veteran presented for a VA pain clinic evaluation. His complaints included bilateral knee pain and he reported using a motorized scooter since approximately March 2014 due to a combination of pain factors, including bilateral knee pain status post bilateral total knee arthroplasties. On examination, his weight was recorded as 370 pounds with a BMI of 54.75. His ability to transfer from sit to stand and stand to sit was described as “modified independent” and with some difficulty, using the arms of his motorized scooter, the arms of chairs, and the clinic room desk as an improvised walking bar. The examiner observed the Veteran was a short-distance ambulator only, with a short stride length, antalgic gait, wide-based and unsteady gait with mild balance deficits. The impression included morbid obesity. The examiner explained that the Veteran’s body habitus and poorly controlled diabetes presented relative contraindications to interventional pain procedures. An April 2019 VA emergency department note reflects the Veteran’s complaint of pain in the bottom of his right foot and his belief that he might have a laceration or an infection. The examining physician noted the Veteran was morbidly obese and unable to bend his leg to look at the bottom of his foot. He had extreme difficulty with mobility due to knee replacements with poor range of motion and impaired mobility due to obesity. The physician removed the foreign body superficially imbedded in the right foot and ordered a social work consultation, noting that the Veteran would likely need a home health aid due to worsening mobility issues. During an April 2019 visit with his private primary care provider, A. Albert, M.D., the Veteran stated that his right knee was tremendously painful and weak and it was “ruining” his life. He reported he was unable to stand up without assistance and instead must drag his leg up into bed with his cane. On examination, he had “no pain with knee motion.” X-rays of both knees showed total knee arthroplasties, which were stable and without any evidence of loosening or hardware failure. The physician recommended weight loss. In September 2019, the Veteran testified that due to his right and left knee pain, he was able to stand for only a matter of minutes. He described needing to use a stool in the bathroom to shave or brush his teeth and having to sit in the shower. He stated that his right knee was particularly painful and stiff and that he needed to use his cane to elevate his foot because he was not strong enough to lift his leg independently. He reported he had been sleeping in a recliner for the last several months because he could not get into bed. Having considered the medical and lay evidence of record, the evidence appears to be evenly balanced as to whether higher ratings are warranted for the left and right knee disabilities during the applicable time periods. Although the March 2016 and June 2016 VA examination reports indicated the Veteran’s status post right and left total knee arthroscopy disabilities were manifested by intermediate degrees of residual weakness, pain, or limitation of motion, other medical and lay evidence of records suggests each knee is manifested by chronic residuals consisting of severely painful motion or weakness. For example, the evidence shows that the Veteran is able to stand or walk for only a limited time period such as a shorter duration than it takes to brush his teeth, he generally uses an electric scooter to get around, he is unable to bend his knee to see the bottom of his foot, he has difficulty rising from a chair, and he is unable to lift his legs to get into bed. The evidence of record tends to support a finding that the Veteran experiences severely painful motion and weakness in each knee. As the reasonable doubt created by the relative equipoise in the evidence must be resolved in favor of the Veteran, a higher 60 percent rating is warranted for the left knee disability from March 1, 2016, through June 26, 2019, and a higher 60 percent rating is warranted for the right knee disability from December 28, 2015, through June 26, 2019. 38 U.S.C. § 5107; 38 C.F.R. § 4.3. 3. An initial rating in excess of 20 percent for right shoulder full thickness tear of the supraspinatus tendon and tendinopathy with impingement syndrome of the infraspinatus tendon from December 28, 2015, through June 26, 2019 Since service connection was established and prior to June 27, 2019, the Veteran’s right shoulder disability was rated 20 percent disabling pursuant to 38 C.F.R. § 5003-5201. Diagnostic Code 5003 refers to degenerative arthritis. Diagnostic Code 5201 refers to limitation of motion of the arm. Diagnostic Code 5003 provides that 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 diagnostic code 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. 38 C.F.R. § 4.71a, Diagnostic Code 5003. In the absence of limitation of motion, a 10 percent rating is warranted for x-ray evidence of arthritis with evidence of involvement of 2 or more major joints or 2 or more minor joint groups, and a 20 percent rating is warranted for x-ray evidence of arthritis with evidence of involvement of 2 or more major joints or 2 or more minor joint groups, with occasional incapacitating exacerbations. Id. The 20 percent and 10 percent ratings based on x-ray findings will not be combined with ratings based on limitation of motion. Id., Note 1. In addition, the 20 percent and 10 percent ratings based on x-ray findings will not be utilized in rating conditions listed under diagnostic codes 5013 to 5024. Id., Note 2. Under Diagnostic Code 5201, limitation of motion of the arm at shoulder level (90 degrees) warrants a 20 percent rating for both the major and minor extremity. Limitation of motion of the arm midway between side and shoulder (45 degrees) warrants a 20 percent rating for the minor extremity and a 30 percent rating for the major extremity. Limitation of motion of the arm to 25 degrees from side warrants a maximum 30 percent rating for the minor joint and a maximum 40 percent rating for the major joint. 38 C.F.R. § 4.71a, Diagnostic Code 5201. Normal range of motion of the shoulder joint includes forward elevation (flexion) from 0 degrees to 180 degrees and shoulder abduction (side elevation) from 0 degrees to 180 degrees. 38 C.F.R. § 4.71, Plate I. Diagnostic Code 5201 “does not provide separate ratings for limitation of motion in the flexion and abduction planes, but rather is addressed generically to limitation of motion of the arm.” Yonek v. Shinseki, 722 F.3d 1355, 1358 (Fed. Cir. 2013). Handedness for the purpose of a dominant rating will be determined by the evidence of record, or by testing on VA examination. Only one hand shall be considered dominant. 38 C.F.R. § 4.69. The evidence of record indicates the Veteran is right hand dominant. Therefore, his right shoulder disability is rated as the major or dominant shoulder joint. In February 2016, the Veteran was afforded a VA examination to evaluate his right shoulder disability. He reported that he started having right shoulder pain in 2013 after his knees buckled and he caught himself falling. He described having right shoulder pain most of the time, difficulty sleeping on his side, and difficulty extending out his arm due to shoulder pain. He did not report having flare-ups of right shoulder symptoms. Right shoulder range-of-motion testing revealed forward flexion from 0 to 90 degrees and abduction from to 100 degrees with pain noted in all planes of motion. The Veteran was unable to perform repetitive-use testing with at least three repetitions because he was in severe pain with single range-of-motion testing. As a result, the examiner was unable to determine whether pain, weakness, fatigability, or incoordination significantly limited the Veteran’s right shoulder functional ability with repeated use over a period of time. Other right shoulder examination findings included no evidence of pain with weight-bearing; objective evidence of localized tenderness and edema over the acromioclavicular joint; no evidence of crepitus; difficulty raising his arm above his head due to pain and swelling; reduced muscle strength manifested by active movement against gravity (3/5) with no muscle atrophy; no ankylosis; clinical testing positive for rotator cuff impairment; no instability, dislocation, or labral pathology; and no impairment of the humerus. The examiner reviewed a February 2013 right shoulder MRI study, which confirmed mild degenerative hypertrophy of the acromioclavicular joint among other findings. The examiner summarized the functional impact of the veteran’s right shoulder disability as “moderate to severe-significant pain with [range of motion] and inability to raise arm above head.” VA treatment records during the time period from December 2015 to June 2019 reflect complaints and evaluation related to left shoulder pain. During a June 2017 psychology visit, the Veteran spoke at length about chronic pain affecting several joints, including his right shoulder. In September 2019, the Veteran testified that he avoids lifting due to stabbing pain in his right shoulder. He indicated he could carry a gallon of milk if he used both hands. Having considered the medical and lay evidence of record, an initial rating in excess of 20 percent for the Veteran’s right shoulder disability is not warranted at any time from November 28, 2015, through June 26, 2019. Throughout this time period, the right shoulder disability was manifested at worst by forward flexion from 0 to 90 degrees and abduction from to 100 degrees with severe pain on motion. These findings are consistent with the 20 percent rating assigned during this time period for the right (major) shoulder joint. A higher, 30 percent rating is not warranted during this time period because at no time was right shoulder flexion or abduction limited to 45 degrees or midway between the side and shoulder level. The Board considered whether any other Diagnostic Codes related to disabilities of the shoulder would provide for a higher disability rating. The evidence of record, however, shows the Veteran does not have ankylosis of the scapulohumeral articulation or impairment of the humerus. See 38 C.F.R. § 4.71a, Diagnostic Codes 5200, 5202. As the preponderance of the evidence is against the Veteran’s claim for a higher rating than that assigned for his right shoulder disability from December 28, 2015, through June 26, 2019, the benefit-of-the-doubt doctrine is not applicable. See 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. REASONS FOR REMAND 1. The issue of service connection for a lumbar spine disability, to include as secondary to service-connected bilateral knee disabilities, is remanded. 2. The issue of service connection for right hip degenerative joint disease, to include as secondary to the right knee disability, is remanded. 3. The issue of service connection for left hip trochanteric pain syndrome, to include as secondary to the left knee disability, is remanded. 4. The issue of service connection for left ankle degenerative joint disease with tendinopathy, to include as secondary to the left knee disability, is remanded. The Veteran contends that his lumbar spine, right and left hip, and left ankle disabilities were caused or aggravated by his service-connected knee disabilities. More specifically, he describes significant weight gain over time as his right and left knee disabilities increased in severity, resulting in morbid obesity and decreased mobility. He believes that the additional strain on his joints due to intermediate weight gain associated with his knee disabilities caused or aggravated his back, bilateral hip, and left ankle disabilities. Although prior VA examinations included medical opinions addressing whether the Veteran’s service-connected knee disabilities proximately caused his lumbar spine, right and left hip, and left ankle disabilities, none of the opinions addressed whether his knee disabilities aggravated these claimed disabilities. Similarly, medical opinions are required to address whether the Veteran’s obesity was an intermediate step in causing or aggravating his lumbar spine, right and left hip, and left ankle disabilities. The AOJ should request an addendum medical opinion. In September 2019, the Veteran testified that he had received ongoing treatment at the Bay Pines VA Medical Center but had been receiving his orthopedic treatment from private doctors. The most recent record associated with the claims file from Orthopaedic Associates of West Florida is dated in April 2015. After the hearing, the Veteran submitted an April 2019 treatment record from A. Albert, MD. The AOJ should request outstanding private treatment records pertinent to the Veteran’s claims as well as ongoing treatment records from the Bay Pines VA Medical Center dating since September 2020. Finally, because the prior Remand omitted the issue of service connection for the left ankle disability, the AOJ has not reviewed additional evidence received related to that claim since the August 2017 statement of the case (SOC). Neither the Veteran nor his attorney has waived consideration of this evidence by the AOJ. To afford due process to the Veteran, this claim must be remanded to allow the AOJ to consider the evidence in the first instance. See 38 C.F.R. §§ 19.31, 19.37, 20.901. The matters are REMANDED for the following action: 1. With any necessary assistance from the Veteran, obtain the following records: a) Any ongoing treatment records from Orthopaedic Associates of West Florida dating since April 2015. b) Any treatment records from A. Albert, M.D., or from other orthopedic treatment providers at Pinellas Medical Associates, dated since January 2015, including the reports of imaging studies. c) Any other private treatment records the Veteran identifies pertinent to his claims for service connection for lumbar spine, right and left hip, and left ankle disabilities. 2. Obtain any ongoing treatment records from the Bay Pines VA Medical Center dating since September 2020. 3. Provide the Veteran’s electronic claims file to an appropriate clinician to obtain addendum medical opinions regarding his claimed back, right and left hip, and left ankle disabilities. Following a review of the claims file, the reviewing examiner should provide opinions as to whether it is at least as likely as not (a 50 percent or greater probability) that: a) the Veteran’s lumbar spine, right and left hip, and left ankle disabilities are, or have been, aggravated by his service-connected right and/or left knee disabilities. b) the Veteran’s obesity represents an intermediate step between his service-connected right and left knee disabilities in either (1) causing his lumbar spine, right and left hip, and left ankle disabilities; or (2) in aggravating his lumbar spine, right and left hip, and left ankle disabilities. A detailed medical rationale must be provided for all opinions expressed. 4. Readjudicate the issues on appeal. With respect to the issue of service connection for a left ankle disability, consider all evidence added to the claims file since the August 2017 SOC. Regarding the claims for service connection for a lumbar spine and right and left hip disabilities, consider all evidence added to the claims file since the September 2020 supplemental statement of the case (SSOC). If any benefit sought on appeal is not (Continued on next page) granted in full, issue the Veteran and his attorney an SSOC and provide the Veteran an opportunity to respond. JAMES L. MARCH Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Laura Kirscher Strauss 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.