Citation Nr: 21016232 Decision Date: 03/22/21 Archive Date: 03/22/21 DOCKET NO. 20-23 275 DATE: March 22, 2021 ORDER Entitlement to service connection for a low back disability is granted. Entitlement to an initial rating of 20 percent, but not more, prior to May 8, 2018, for left knee disability is granted. Entitlement to a 100 percent rating for total left knee arthroplasty, from May 8, 2018 to May 8, 2019, is granted. Entitlement to a 30 percent rating for status post total left knee arthroplasty, from May 8, 2019 to April 2, 2020, is granted. Entitlement to an initial rating of 20 percent, but not more, February 26, 2018, for right knee disability is granted. Entitlement to a 100 percent rating for total right knee arthroplasty, from February 26, 2018 to February 26, 2019, is granted. Entitlement to a 30 percent rating for status post total right knee arthroplasty, from February 26, 2019 to April 2, 2020, is granted. Entitlement to an initial rating of 50 percent for posttraumatic stress disorder (PTSD) is granted. Entitlement to a total rating based on individual unemployability due to service-connected disability (TDIU) is granted. Entitlement to special monthly compensation (SMC) from February 26, 2018 to March 8, 2019, pursuant to 38 U.S.C. § 1114(s), is granted. REMANDED ISSUES Entitlement to service connection for sleep apnea is remanded. Entitlement to a rating in excess of 30 percent on and after May 8, 2019, for left knee disability is remanded. Entitlement to a rating in excess of 30 percent on and after February 26, 2019, for right knee disability is remanded. Entitlement to a rating in excess of 50 percent for PTSD is remanded. INTRODCUTION The Veteran served on active duty from September 1987 to June 1993, including service in Iraq during Desert Storm. The Veteran received two Bronze Stars. These matters come before the Board of Veterans’ Appeals (Board) on appeal from rating decisions by a Department of Veterans’ Affairs (VA) Regional Office (RO). In January 2021, the Veteran testified at a hearing before the undersigned Veterans Law Judge. A transcript of this hearing has been associated with the claims file.   FINDINGS OF FACT 1. The Veteran’s low back disability had its onset in service. 2. Prior to March 8, 2018, the Veteran’s left knee disability more nearly approximated limitation of flexion to 30 degrees, but no limitation of extension or instability. 3. The Veteran underwent total left knee arthroplasty on March 8, 2018. 4. The minimum rating following the one-year period of 100 percent for total left knee arthroplasty is 30 percent. 5. Prior to February 26, 2018, the Veteran’s right knee disability more nearly approximates limitation of flexion to 30 degrees, but no limitation of extension or instability. 6. The Veteran underwent total right knee arthroplasty on February 26, 2018. 7. The minimum rating following the one-year period of 100 percent for total right knee arthroplasty is 30 percent. 8. The Veteran’s PTSD has been productive of at least occupational and social impairment with reduced reliability and productivity. 9. The Veteran’s service-connected disabilities have precluded him from obtaining and maintaining substantial and gainful employment consistent with his education and occupational experience. 10. From February 26, 2018 to March 8, 2019, the Veteran’s total left or right knee arthroplasty is rated at 100 percent, while the Veteran’s additional service-connected disabilities are independently ratable at 60 percent, separate and distinct from the 100 percent ratings for his knees. CONCLUSIONS OF LAW 1. The criteria for service connection for a low back disability have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.102, 3.303. 2. Prior to March 8, 2018, the criteria for an initial 20 percent rating, but not more, for left knee disability have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.71A, Diagnostic Code 5260. 3. The criteria for a 100 percent rating for total left knee arthroplasty have been met from March 8, 2018 to March 8, 2019. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.71a, Diagnostic Code 5055. 4. The criteria for a 30 percent rating for total left knee arthroplasty have been met from March 8, 2019 to April 2, 2020. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.71a, Diagnostic Code 5055. 5. Prior to February 26, 2018, the criteria for an initial 20 percent rating, but not more, for right knee disability have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.71A, Diagnostic Code 5260. 6. The criteria for a 100 percent rating for total right knee arthroplasty have been met from February 26, 2018 to February 26, 2019. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.71a, Diagnostic Code 5055. 7. The criteria for a 30 percent rating for total right knee arthroplasty have been met from February 26, 2019 to April 2, 2020. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.71a, Diagnostic Code 5055. 8. The criteria for a 50 percent rating for PTSD have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.130, Diagnostic Code 9411. 9. The criteria for a TDIU have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.326, 3.340, 4.16 10. From February 26, 2018 to March 8, 2019, the criteria for entitlement to SMC pursuant to 38 U.S.C. § 1114 (s) have been met. 38 U.S.C. §§ 1114, 1154, 5107; 38 C.F.R. §§ 3.102, 3.350, 3.351. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Low Back The Veteran seeks service connection for his low back disability. He reports that his back problems originated while he was on active duty, and symptoms thereof have been recurrent since his service separation. Generally, service connection will be granted if the evidence demonstrates that a current disability resulted from a disease or injury incurred in active military service. See 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Establishing service connection requires evidence of a current disability, an in-service incurrence, disease or injury and a causal relationship between the current disability and the in-service incurrence, disease or injury. See Saunders v. Wilkie, 886 F.3d 1356, 1361 (Fed. Cir. 2018). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall resolve reasonable doubt in favor of the claimant. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). To deny a claim on its merits, the evidence must preponderate against the claim. See Alemany v. Brown, 9 Vet. App. 518 (1996). The Veteran’s service treatment records are replete with complaints of and treatment for low back pain, including an undated report of recurrent low back pain for one year. Significantly, on his April 1993 separation report of medical history, the Veteran endorsed recurrent back pain. The examiner reviewing this report indicated that the Veteran marked an onset while stationed in Germany when a transmission slipped off a truck. According to the Veteran’s separation examination report, the examiner determined that the Veteran experienced “intermittent mechanical low back pain.” The Veteran was scheduled for a VA general medical evaluation pursuant to this claim, but he failed to appear and has not provided good cause for doing so. As such, the Board will adjudicate claim based on the evidence of record. The evidence of record includes a current diagnosis of lumbar spine degenerative disc disease at L4-L5-S1. During the January 2021 hearing, the Veteran testified that he was treated during his active duty for a low back injury, that he was unable to perform physical therapy during active duty, and that he low back symptoms worsened since his service separation. In light of the foregoing, and resolving doubt in the Veteran’s favor, the Board finds service connection is warranted because there is clear evidence of in-service onset and his competent and credible assertions that he continued to experience lay observable symptoms since his service separation. See 38 C.F.R. § 3.303(a); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Increased Ratings Disability evaluations are determined by the application of a schedule of ratings, 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. The percentage ratings in VA’s Schedule for Rating Disabilities (Rating Schedule) represent as far as can practicably be determined the average impairment in earning capacity resulting from such disabilities and their residual conditions in civil occupations. 38 C.F.R. § 4.1. Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability more closely approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3. Where entitlement to compensation has already been established and increase in disability is at issue, the present level of disability is of primary concern. See Francisco v. Brown, 7 Vet. App. 55 (1994). However, “staged” ratings are appropriate where the factual findings show distinct time periods when the service-connected disability exhibits symptoms that would warrant different ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007); see also Fenderson v. West, 12 Vet. App. 119 (1999). When evaluating joint disabilities rated on the basis of limitation of motion, VA must consider granting a higher rating in cases in which functional loss due to pain, weakness, excess fatigability, or incoordination is demonstrated, and those factors are not contemplated in the relevant rating criteria. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202 (1995). The Court has clarified that although pain may be a cause or manifestation of functional loss, limitation of motion due to pain is not necessarily rated at the same level as functional loss where motion is impeded. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011); cf. Powell v. West, 13 Vet. App. 31, 34 (1999); Hicks v. Brown, 8 Vet. App. 417, 421 (1995); Schafrath v. Derwinski, 1 Vet. App. 589, 592 (1991). Instead, the Court in Mitchell explained that pursuant to 38 C.F.R. §§ 4.40 and 4.45, the possible manifestations of functional loss include decreased or abnormal excursion, strength, speed, coordination, or endurance, as well as less or more movement than is normal, weakened movement, excess fatigability, and pain on movement (as well as swelling, deformity, and atrophy) that affects stability, standing, and weight-bearing. See 38 C.F.R. §§ 4.40, 4.45. Thus, functional loss caused by pain must be rated at the same level as if the functional loss were caused by any of the other factors cited above. In evaluating the severity of a joint disability, VA must determine the overall functional impairment due to these factors. Knees In a November 2017 rating decision, service connection was granted for left and right knee disability; separate 10 percent ratings were assigned thereto under Diagnostic Codes 5003 and 5260, indicating a limitation of flexion due to osteoarthritis. The Veteran appealed seeking increased initial ratings. During the pendency of this appeal, the RO issued an April 2020 rating decision wherein it increased the 10 percent ratings to 30 percent, effective April 2, 2020. Preliminarily, the Board observes that the Veteran underwent total left and right knee arthroplasty in 2018. Specifically, the Veteran underwent total right knee arthroplasty on February 26, 2018, and total left knee arthroplasty on March 8, 2018. Under Diagnostic Code 5055, a 100 percent rating is assigned for one year following knee replacement. Further, following this one-year period, the minimum rating assignable is 30 percent. 38 C.F.R. § 4.71A, Diagnostic Code 5055. As the evidence of record demonstrates that the Veteran underwent total right knee arthroplasty, the criteria for a 100 percent rating is warranted from February 26, 2018 to February 26, 2019. Likewise, the evidence of record demonstrates that the Veteran underwent total left knee arthroplasty, a 100 percent rating is warranted from March 8, 2018 to March 8, 2019. Additionally, the currently assigned 10 percent rating for left knee disability from May 8, 2019 to April 2, 2020, is increased to 30 percent, which is the minimum rating assignable subsequent to the prescribed 100 percent period. For the same reasons, the 10 percent rating assigned to the Veteran’s right knee disability from February 26, 2019 to April 2, 2020, is increased to 30 percent. Id. Herein, the Board is remanding the issue of entitlement to a rating in excess of 30 percent on and after May 8, 2019, for left knee disability and the issue of entitlement to a rating in excess of 30 percent on and after February 26, 2019 for right knee disability. As such, the merits of these issues will not be considered herein. The remaining issues pending before the Board are, thus, entitlement to an initial rating in excess of 10 percent for left knee disability prior to March 8, 2019, and entitlement to an initial rating in excess of 10 percent for right knee disability prior to February 26, 2018. Left and Right Knee Prior to Replacement As noted above, separate 10 percent ratings have already been assigned for left and right knee disabilities during this period (i.e., prior to March 8, 2018 for left knee and prior to February 26, 2018 for right knee). Normal range of motion of the knee is from 0 degrees extension to 140 degrees flexion. 38 C.F.R. § 4.71a, Plate II. Under Diagnostic Code 5260, flexion limited to 45 degrees is assigned a 10 percent rating, flexion limited to 30 degrees is assigned a 20 percent rating, and flexion limited to 15 degrees is assigned a 30 percent rating. In November 2017, the Veteran underwent a VA examination to assess the severity of his left and right knee disabilities. The examiner rendered diagnoses of left and right knee osteoarthritis. The Veteran described knee pain as “a dull tooth ache,” but also endorsed instances of “sharp pain with a lot of grinding.” He stated that his pain was increased by with prolong standing or walking and ached more during cold weather. He reported worse pain going down versus going up stairs. With respect to functional loss or functional impairment of his knees with repeated use over time, the Veteran stated that it was either difficult or impossible for to standing for prolonged periods, running, walking, sitting, and carry anything heavy. The Veteran’s bilateral range of knee motion was zero degrees of extension to 140 degrees of flexion, both in active and passive testing. However, the Veteran reported pain of 8/10 across his patella and knee joint, bilaterally, in extension and flexion, as well as pain with weight bearing and objective evidence of crepitus. Based on the results of the November 2017 VA examination, and with consideration of the Veteran’s statements, his service treatment records, and subsequent need to undergo bilateral total knee arthroplasty, the Board finds that the Veteran’s service-connected left knee disability meets or more nearly approximates limitation of flexion to 30 degrees prior to March 8, 2018. For the same reasons, the Board finds that the Veteran’s right knee disability meets or more nearly approximates limitation of flexion to 30 degrees prior to February 26, 2018. 38 C.F.R. §§ 4.7, 4.71A, Diagnostic Code 5260. Consequently, the Board finds that a 20 percent rating, but not more, for left knee disability is warranted prior to March 8, 2018. Further, the Board finds that a 20 percent rating, but not more, for right knee disability is warranted prior to February 26, 2018. Although separate ratings for knee disabilities are assignable for limitation of extension and instability, the preponderance of the evidence is against such ratings prior to March 8, 2018 for the left knee and prior to February 26, 2018 for the right knee. 38 C.F.R. § 4.71A, Diagnostic Codes 5257, 5261. The November 2017 VA examination determined that the Veteran’s bilateral range of motion included extension to zero degrees. Further, no subluxation or lateral instability was observed on any administered clinical test. Consequently, separate ratings are not warranted for either the Veteran’s left or right knee prior to the respective replacement surgeries. PTSD Throughout the pendency of this appeal, the Veteran’s service-connected PTSD has already been assigned a 30 percent rating. PTSD is rated under the General Rating Formula for Mental Disorders. 38 C.F.R. § 4.130, Diagnostic Code 9411. Under the General Rating Formula for Mental Disorders, a 30 percent rating is warranted for occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). A 50 percent rating is warranted for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. A 70 percent rating is warranted for occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals that interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); inability to establish and maintain effective relationships. A 100 percent rating is warranted for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. 38 C.F.R. § 4.130, Diagnostic Code 9411. The symptoms listed in General Rating Formula for Mental Disorders are not intended to constitute an exhaustive list, but rather serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436, 443 (2002). In November 2017, the Veteran underwent a VA examination to assess the severity of his PTSD. The examiner observed that the Veteran’s discharge documentation included the Veteran’s report of depression or excessive worry and frequent trouble sleeping. After reviewing the evidence of record, administering clinical testing, and interviewing the Veteran, the examiner determined that the Veteran’s PTSD was manifested by anxiety/nervous tension, suspiciousness, chronic sleep impairment, mild memory loss (including remembering names), and difficulty concentrating. The Veteran reported nightmares, hyper-alertness, a need to scan and patrol rooms, mood swings, excessive startle responses, and racing thoughts with difficulty shutting them down. The Veteran denied occupational difficulties; but stated that he switched employers because people did not “tell him the truth.” He endorsed marital and familial difficulties. At the time of the examination, he had been married to his third spouse for eight years. In light of the foregoing, the Board finds that the criteria of at least 50 percent for the entire appeal period have been met. The Board finds that further development is warranted in order to address the Veteran’s claim of entitlement to a rating in excess of 50 percent for PTSD, which will be discussed in the remand portion of the decision below. TDIU It is the established policy of the VA that all veterans who are unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities shall be rated totally disabled. A total disability will be considered to exist when there is present any impairment of mind or body which is sufficient to render it impossible for the average person to follow a substantially gainful occupation. Entitlement to a TDIU is based on an individual’s particular circumstances. 38 C.F.R. § 4.16; Todd v. McDonald, 27 Vet. App. 79, 85-86 (2014). Thus, in adjudicating a TDIU claim, VA must take into account the individual veteran’s education, training, and work history, but not his or her age or the impairment caused by nonservice-connected disabilities. See 38 C.F.R. §§ 3.341, 4.16, 4.19; see also Todd, 27 Vet. App. at 85-86. The ultimate question of whether a Veteran is capable of substantial gainful employment is an adjudicatory determination, not a medical one. See Geib v. Shinseki, 733 F.3d 1350, 1354 (Fed. Cir. 2013). A TDIU may be assigned where the schedular rating is less than total, when it is found that the disabled person is unable to secure or follow a substantially gainful occupation as a result of a single service-connected disability ratable at 60 percent or more, or as a result of two or more service-connected disabilities, provided that one of those disabilities is ratable at 40 percent or more, and there is sufficient additional service-connected disabilities to bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16(a). In determining whether a veteran can secure and follow a substantially gainful occupation, attention must be given to: The veteran’s history, education, skill, and training; Whether the veteran has the physical ability (both exertional and non-exertional) to perform the type of activities (e.g., sedentary, light, medium, heavy, or very heavy) required by the occupation at issue. Factors that may be relevant include, but are not limited to, the veteran’s limitations, if any, concerning lifting, bending, sitting, standing, walking, climbing, grasping, typing, and reaching, as well as auditory and visual limitations; and Whether the veteran has the mental ability to perform the activities required by the occupation at issue. Factors that may be relevant include, but are not limited to, the veteran’s limitations, if any, concerning memory, concentration, ability to adapt to change, handle workplace stress, get along with coworkers, and demonstrate reliability and productivity. Ray v. Wilkie, 31 Vet. App. 58, 73 (2019). Service connection has been granted and ratings have been assigned as follows: PTSD at 50 percent (but potentially higher after remand development); status post total left knee arthropathy at 30 percent (but potentially higher after remand development); status post total right knee arthroplasty at 30 percent (but potentially higher after remand development); hypertension at 10 percent; right knee surgical scars at noncompensable; and left knee surgical scars at noncompensable. Moreover, herein, the Board has granted service connection for the Veteran’s low back disability (diagnosed as lumbar degenerative disc disease at L4-L5-S1) for which a rating will be assigned by the RO in the first instance. The Veteran asserts that the impact of his service-connected disabilities cause him to be unable to secure or follow a substantially gainful occupation. The Board notes that the Veteran’s service-connected disabilities meet the schedular criteria for an award of TDIU. As such, the issue before the Board is whether the Veteran is capable of gainful employment. 38C.F.R. § 4.16. During his November 2017 PTSD VA examination, the Veteran denied undergoing additional eduction or training subsequent to his period of active duty. During the January 2021 hearing, the Veteran testified that he was unable to work due to his disability associated with his service-connected knee disabilities and his now service-connected back disability. Specifically, the Veteran stated that he last worked in December 2017, but ceased working because he could not stand for very long, walk very far, or sit for prolonged periods. Further, he experienced difficulties sleeping due to pain and PTSD symptoms. In a February 2021 submission, the Veteran indicated that he ceased working December 2017 as a truck driver because his service-connected knee disability prevented him from completing occupational tasks. After a review of the evidence of record, the Board finds, resolving any reasonable doubt as mandated by law (38 U.S.C. § 5107; 38 C.F.R. § 3.102), that the evidence supports the conclusion that the Veteran’s service-connected disabilities prevent him from securing and following substantially gainful employment. In reaching this determination, the Board notes that the United States Court of Appeals for the Federal Circuit (Federal Circuit) held that determination of whether a veteran is unable to secure or follow a substantially gainful occupation due to service-connected disabilities is a factual rather than a medical question and that it is an adjudicative determination properly made by the Board or the RO. See Geib, 733 F.3d 1350. Given the evidence regarding the severity of the Veteran’s service-connected disabilities, and evidence indicating the Veteran’s functional limitations due to his disabilities, and in light of his individual work experience, training and education, the Board finds that the evidence shows he is entitled to an award of a TDIU rating. See Geib, 733 F.3d 1350. SMC In light of the above grants of 100 percent for the Veteran’s service-connected total left and right knee arthroplasties and pursuant to VA’s “well-established” duty to maximize a claimant’s benefits, the Board finds that the Veteran is entitled to an award of SMC. See Buie v. Shinseki, 24 Vet. App. 242, 250 (2010); AB v. Brown, 6 Vet. App. 35, 38 (1993); Bradley v. Peake, 22 Vet. App. 280, 294 (2008) (finding that SMC “benefits are to be accorded when a Veteran becomes eligible without need for a separate claim”). Special monthly compensation is payable where the Veteran has a single service-connected disability rated as 100 percent and (1) has additional service-connected disability or disabilities independently ratable at 60 percent, separate and distinct from the 100 percent service-connected disability and involving different anatomical segments or bodily systems, or (2) is permanently housebound by reason of service-connected disability or disabilities. 38 U.S.C. § 1114(s); 38 C.F.R. § 3.350(i). Subsection 1114(s) requires that a disabled Veteran whose disability level is determined by the ratings schedule must have at least one disability that is rated at 100 percent in order to qualify for the special monthly compensation provided by that statute. Under the law, subsection 1114(s) benefits are not available to a Veteran whose 100 percent disability rating is based on multiple disabilities, none of which is rated at 100 percent disabling. In this case, the Veteran is in receipt of a 100 percent disability rating for his service-connected total left or right knee arthroplasty from February 26, 2018 to March 8, 2019. Additionally, the Veteran has other service-connected disabilities that combine to be independently rated at more than 60 percent during this period. Thus, the criteria for SMC at the housebound rate are met. Considering the Court’s decisions in Bradley and Buie, entitlement to SMC at the housebound rate under 38 U.S.C. § 1114(s) is granted from February 26, 2018 to March 8, 2019. REASONS FOR REMAND Sleep Apnea The Board finds that a remand is warranted in order to provide the Veteran another VA examination and to obtain etiological opinions on both direct and secondary service-connected for sleep apnea. Left and Right Knee and PTSD The most recent VA examinations of record for these disabilities occurred in November 2017. The Board finds that these examinations are too remote, and the evidence of record is otherwise insufficient, to adequately evaluate the current severity of these disabilities. As such, a remand to provide the Veteran with additional VA examinations is warranted. The matters are REMANDED for the following action: 1. Request that the Veteran submit or identify relevant evidence not already associated with the claims file pertaining to sleep apnea, left knee disability, right knee disability, and PTSD. Attempt to obtain all identified evidence. 2. Schedule the Veteran for an appropriate VA examination (or telehealth interview, review of the record, etc., if an in-person examination is not feasible) to determine the onset and/or etiology of his sleep apnea. The claims file must be reviewed by the examiner. The examiner must provide an opinion as to whether it is at least as likely as not the Veteran’s sleep apnea is related to and/or had its onset during the Veteran’s period of service. The examiner must also state whether it is at least as likely as not that the Veteran’s sleep apnea was caused or aggravated by the Veteran’s service-connected disabilities, to include medication prescribed to treat those disabilities. 3. Schedule a VA examination (or telehealth interview, review of the record, etc. if an in-person examination is not feasible) to assess the severity of the Veteran’s left and right knee disabilities. The examiner should identify all left and right knee pathology found to be present. The examiner should conduct all indicated tests and studies, to include range of motion studies. The joints involved should be tested in both active and passive motion, in weight-bearing and non-weight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint. If the examiner is unable to conduct the required testing or concludes that the required testing is not necessary in this case, he or she should clearly explain why that is so. The examiner should describe any pain, weakened movement, excess fatigability, instability of station and incoordination present. The examiner should also state whether the examination is taking place during a period of flare-up. If not, the examiner should ask the Veteran to describe the flare-ups he experiences, including: frequency, duration, characteristics, precipitating and alleviating factors, severity and/or extent of functional impairment he experiences during a flare-up of symptoms and/or after repeated use over time. Based on the Veteran’s lay statements and the other evidence of record, the examiner should provide an opinion estimating any additional degrees of limited motion caused by functional loss during a flare-up or after repeated use over time. If the examiner cannot estimate the degrees of additional range of motion loss during flare-ups or after repetitive use without resorting to speculation, the examiner should state whether the need to speculate is caused by a deficiency in the state of general medical knowledge (i.e. no one could respond given medical science and the known facts) or by a deficiency in the record or the examiner (i.e. additional facts are required, or the examiner does not have the needed knowledge or training). 4. Schedule a VA examination (or telehealth interview, review of the record, etc. if an in-person examination is not feasible) to assess the current, extent and nature and severity of his PTSD. STEVEN D. REISS Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Sean G. Pflugner, 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.