Citation Nr: 21025836 Decision Date: 04/29/21 Archive Date: 04/29/21 DOCKET NO. 16-53 681 DATE: April 29, 2021 ORDER Service connection for left hand 3rd digit crush injury plus residuals is granted. Service connection for left hand 4th digit crush injury residuals is granted. Service connection for low back pain/strain with spasm is granted. A 30 percent rating for irritable bowel syndrome is granted. A 10 percent evaluation for left patellofemoral pain syndrome with meniscal tear with painful motion is granted. A 20 percent rating for left knee locking from May 1, 2015 to December 20, 2016 is granted. An increased rating for left knee locking since December 20, 2016 is denied. A separate 10 percent rating for left knee instability is granted. REMANDED Entitlement to a rating higher than 30 percent for irritable bowel syndrome since April 28, 2016 is remanded. Entitlement to an evaluation higher than 10 percent for left patellofemoral pain syndrome with meniscal tear with painful motion is remanded. Entitlement to a rating higher than 10 percent for left knee instability is remanded. FINDINGS OF FACT 1. The Veteran’s left-hand 3rd digit crush injury plus symptoms injury is related to injury that occurred while on active duty. 2. The Veteran’s left-hand 4th digit crush injury plus symptoms injury is related to injury that occurred while on active duty. 3. The evidence is at least evenly balanced as to whether the Veteran’s low back pain disability is related to his active duty service. 4. Throughout the appeal period, the Veteran’s irritable bowel syndrome manifested in symptoms of alternating diarrhea and constipation with more or less constant abdominal distress. 5. The Veteran’s left patellofemoral pain syndrome with meniscal tear was characterized by painful motion. 6. Throughout the period on appeal, the Veteran’s left knee disability has been productive of locking, pain, and effusion. 7. Throughout the period on appeal, the evidence is at least evenly balanced as to whether symptoms of the Veteran’s left knee disability have more nearly approximated slight lateral instability, but the preponderance of the evidence on file reflects that they have not more nearly approximated moderate lateral instability. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for left hand 3rd digit crush injury plus symptoms have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for entitlement to service connection for left hand 4th digit crush injury plus symptoms have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. 3. The criteria for entitlement to service connection for low back pain/strain with spasm have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. 4. Throughout the period on appeal, the criteria for entitlement to a 30 percent rating for irritable bowel syndrome have been met. 38 U.S.C. §§ 1155, 5103(a), 5103A, 5107; 38 C.F.R. §§ 4.3, 4.7, 4.114, Diagnostic Code 7319. 5. The criteria for a 10 percent evaluation for left patellofemoral pain syndrome with meniscal tear with painful motion have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.27, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5003-5260. 6. The criteria for a rating of 20 percent, but no higher, from May 1, 2015 to December 20, 2016 for left knee locking symptoms have been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.40, 4.45, 4.49, 4.71a, Diagnostic Code 5258. 7. The criteria for a rating higher than 20 percent since December 20, 2016 for left knee locking symptoms have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.40, 4.45, 4.49, 4.71a, Diagnostic Code 5258. 8. The criteria for a separate 10 percent rating for left knee lateral instability are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.303(a), 3.321, 4.1 - 4.7, 4.40, 4.45, 4.59, 4.71a, DC 5257. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran has active duty service from January 1999 to April 2015, including service in Iraq nd Afghanistan. The Veteran appeared at a videoconference hearing before the undersigned VLJ in March 2020. Service Connection As a preliminary matter, the Veteran asserts that each of the disabilities had its onset and has been recurrent since service. In addition, the Veteran reports having served in combat and that the “combat presumption” set forth in 38 U.S.C. § 1154(b) is applicable. Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). 1. Entitlement to service connection for left hand 3rd digit crush injury plus symptoms. 2. Entitlement to service connection for left hand 4th digit crush injury plus symptoms. The Veteran reports that his left-hand 3rd digit crush injury plus symptoms and left-hand 4th digit crush injury plus symptoms are related to injury that incurred during active duty service. See October 2015 Statement in Support of Claim. He explains that his 3rd and 4th fingers were injured during a mishap that occurred while on deployment to Kuwait. The Veteran also explains that his service treatment records documenting his injury have been misplaced. He states that following his injury, he underwent “micro-surgery” at an Air Force field hospital, that his 3rd and 4th fingers were put in a splint and he was given pain medication to alleviate symptoms. He also endorses that he has experienced numbness and immobility in his left-hand 3rd digit and left-hand 4th digit since injury. In October 2015, VA received a statement from Gunnery Sergeant M.P. who served with the Veteran during his deployment to Kuwait. Gunnery Sergeant M.P. witnessed injury to the Veteran’s left-hand 3rd and 4th digits during the deployment and confirms that the Veteran’s fingers were crushed while building runways. He explains that the Veteran’s left-hand 3rd digit and left-hand 4th digit injury required surgery, followed by splints. He also corroborates the Veteran’s complaint that he has had pain, numbness, and tingling of his left-hand 3rd digit and left-hand 4th digit consistently following this injury. See M.P.’s October 2015 statement. The Board concludes that the Veteran has a current disability that began during active duty service. 38 U.S.C. §§ 1110, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a). A May 2015 Disability Benefits Questionnaire demonstrates that the Veteran has symptoms of left-hand digit tingling and numbness. The Board acknowledges that while the examiner did not diagnose peripheral neuropathy, he documented that the Veteran experiences left-hand mild paresthesias and/or dysesthesias and numbness. The Veteran notes that while he informed the examiner that he also has symptoms of pain that impacts function of his 3rd and 4th digits, the examiner failed to document all of the Veteran’s symptoms. See October 2015 Notice of Disagreement. The Board finds that the May 2015 examination and the Veteran’s statements are enough to establish the existence of a current disability. The Veteran presented sworn testimony at his March 2020 Board hearing detailing injury to his left-hand 3rd and 4th digits while in Kuwait. He explained that his medical records were not kept by his unit’s medical personnel, thus documentation regarding his treatment while in Kuwait has been misplaced. He also testified that he has continually experienced numbness and tingling due to injury to his left-hand 3rd and 4th digits that he incurred on active duty. Based on the Veteran’s competent and credible testimony during the Board hearing as well as the lay witness statement, the Board finds that the such symptoms have continued since service. Thus, the question becomes whether the current disabilities are related to service. The Board finds that the Veteran’s left-hand 3rd digit crush injury plus symptoms and left-hand 4th digit crush injury plus symptoms are etiologically related to military service as his symptoms began during service and have continued since. The Veteran explained in detail how the disability began during service and has continued since. See March 2020 Board hearing. The Board finds this testimony to be probative. Accordingly, after resolving all doubt in favor of the Veteran, the Board finds that service connection for left-hand 3rd digit crush injury plus symptoms and left-hand 4th digit crush injury plus symptoms is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 3. Entitlement to service connection for low back pain/strain with spasm. The Veteran states that he has a low back pain/strain with spasm condition that was incurred during his deployment in Iraq in 2004. See October 2015 Statement in Support of Claim. He explains that the injury occurred after being knocked off a truck by a forklift that he was guiding. The Veteran describes landing on his back and being unable to stand due to the severity of the injury. He states that he was placed on bedrest for a minimum of 48 hours following the injury but was assigned to external security patrol the next day. The Veteran states that he has had back pain that impacts his mobility since this incident. Id. A July 2009 service treatment record documents the Veteran’s complain of lower back pain, and diagnosis of degenerative joint disease. A May 2015 Disability Benefits Questionnaire documents the Veteran’s complaint of lower back pain. The examiner, however, opined that the Veteran does not have a diagnosed low back disability with symptoms of pain, pain on motion, localized tenderness, spasm, or limitation of motion. The Veteran notes that while he informed the examiner that he has symptoms of chronic back pain, spasms, and pain that causes loss of motion, the examiner failed to properly document his symptoms. See October 2015 Notice of Disagreement. The Board finds that the examiner’s notation which indicates the Veteran does not experience back pain is inconsistent with both the Veteran’s credible testimony of having back pain as well as claim’s record, and finds that evidence of record is enough to establish the existence of a current back disability manifested by pain and spasms. For example, the October 2015 statement from Gunnery Sergeant M.P. describes his witness of injury to the Veteran’s back while they were deployed to Iraq. See M.P.’s October 2015 statement. Gunnery Sergeant M.P. also observed that the Veteran continues to experience back pain that impacts his functional ability. Id. Additionally, an August 2016 radiological report confirms that the Veteran has partial sacralization L5 with sclerosis of pseudoarticulation on the right, manifested by low back pain. The Veteran also testified during his March 2020 Board hearing that he has low back pain that has persisted since active duty service. See March 2020 Board transcript. Thus, the Board concludes that the Veteran has a current back disability that began during active service and is related to that service. 38 U.S.C. §§ 1110, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a). Therefore, service connection for low back pain/strain is granted. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Increased Ratings Disability evaluations are determined by the application of a schedule of ratings which is based, as far as can practically be determined, on the average impairment of earning capacity. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Each service-connected disability is rated on the basis of specific criteria identified by Diagnostic Codes. 38 C.F.R. § 4.27. When rating the Veteran’s service-connected disability, the entire medical history must be borne in mind. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where there is a question as to which of two evaluations is to be applied, the higher evaluation 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. Where a claimant appeals the initial rating assigned following an award of service connection, evidence contemporaneous with the claim for service connection and with the rating decision granting service connection would be most probative of the degree of disability existing at the time that the initial rating was assigned and should be the evidence “used to decide whether an [initial] rating on appeal was erroneous....” Fenderson v. West, 12 Vet. App. 119, 126 (1999). If later evidence obtained during the appeal period indicates that the degree of disability increased or decreased following the assignment of the initial rating, “staged” ratings may be assigned for separate periods of time based on facts found. Id. 4. Entitlement to a 30 percent rating for irritable bowel syndrome. The Veteran seeks a higher rating for service-connected irritable bowel syndrome, which is currently evaluated as noncompensable from May 1, 2015 to April 28, 2016 and rated as 10 percent disabling from April 28, 2016. The Veteran’s irritable bowel syndrome is rated under Diagnostic Code (DC) 7319. Under DC 7319, mild symptoms characterized by disturbances of the bowel function with occasional episodes of abdominal distress warrant a noncompensable initial rating. A 10 percent rating is warranted for moderate symptoms including frequent episodes of bowel disturbance with abdominal distress. Severe symptoms, such as diarrhea, or alternating diarrhea and constipation, with more or less constant abdominal distress warrant the highest rating of 30 percent. After considering the totality of the record, the evidence more nearly approximates the criteria for a disability rating of 30 percent throughout the appeal period, since the Veteran has displayed symptoms of alternating diarrhea and constipation with more or less constant abdominal distress as would warrant such a rating. The Veteran explains that his frequent symptoms of irritable bowel syndrome impacts both his work and personal life daily. Specifically, he explains that his ability to work is impacted because he has frequent and urgent episodes of bowel disturbance. See October 2015 Statement in Support of Claim. The condition also makes eating difficult. Id. The October 2015 statement from Gunnery Sergeant M.P. indicates that he has witnessed the impact of the Veteran’s symptoms of irritable bowel syndrome. Specifically, he has witnessed the Veteran’s frequent and urgent symptoms of gastrointestinal distress. See M.P.’s October 2015 statement. According to the May 2015 VA examination report, the Veteran’s irritable bowel syndrome does not result in constant abdominal distress and indicated that the Veteran experiences diarrhea three times a day three times a week. The Veteran disagrees and explains that the examiner failed to properly document his symptoms. See October 2015 statement. May and June 2016 VA treatment records document the Veteran’s symptoms of recurrent abdominal pain. The February 2017 VA Intestinal Conditions examination documents the Veteran’s reports of abdominal bloating, cramping excess gas, and frequent bowel movements. The examiner opined that the functional impact of the Veteran’s condition is that it causes him to lose work due to frequent loose stools and causes abdominal cramping and pain. The Veteran testified at the March 2020 Board hearing that he experiences symptoms of pain on a daily basis without relief. He also explained that his symptoms of irritable bowel syndrome impact his ability to work due to constant abdominal distress. The Veteran explains that the February 2017 VA examiner did not properly document all of the symptoms he experiences. See March 2020 Board Hearing Transcript. Overall, severe symptoms characterized by alternating diarrhea and constipation with more or less constant abdominal distress has been approximated. The Veteran has described abdominal pain and frequent constipation during the period on appeal. Based on these findings, the Board finds a rating of 30 percent is warranted for the Veteran’s irritable bowel syndrome. The Board has also considered entitlement to an increased rating under other criteria for gastrointestinal disabilities. 38 C.F.R. § 4.114 sets forth that ratings under Diagnostic Codes 7301 to 7329, inclusive, 7331, 7342, and 7345 to 7348 will not be combined with each other. A single rating will be assigned under the Diagnostic Code which represents the predominant disability picture, with elevation to the next higher rating where the severity of the overall disability warrants such rating. The Board finds that the evidence of record does not currently support a rating in excess of 10 percent based upon another Diagnostic Code pertaining to abdominal disabilities. As discussed above, the predominant manifestations of the irritable bowel syndrome are frequent constipation and diarrhea with abdominal distress. The evidence of record does not currently reflect a hernia or hernia-like symptoms such as pain, vomiting, material weight loss, and hematemesis or melena. There also is no showing of ulcerative colitis as is rated under Diagnostic Code 7323. Diagnostic Code 7332 provides for higher ratings for loss of anal sphincter control or occasional involuntary bowel movements requiring the wearing of a pad; this is neither alleged nor shown in this instance. Therefore, the other Diagnostic Codes regarding abdominal conditions do not afford a basis for the assignment of an initial rating higher than 10 percent in the absence of a showing of the symptoms or findings discussed. See 38 C.F.R. § 4.114, Diagnostic Codes 7301, 7304, 7305, 7306, 7307, 7332. In short, the Board has considered rating the service-connected disability under other possibly applicable diagnostic codes found at 38 C.F.R. § 4.114 (containing the schedule for rating disorders of the digestive system), but finds none applicable that would grant the Veteran a higher disability rating. See Butts v. Brown, 5 Vet. App. 532, 538 (1993); see also Pernorio v. Derwinski, 2 Vet. App. 625, 629 (1992). In conclusion, the preponderance of the evidence supports an increased initial rating to 30 percent for the Veteran’s irritable bowel syndrome. 5. Evaluation to a 10 percent evaluation for left patellofemoral pain syndrome with meniscal tear with painful motion. 6. Entitlement to a 20 percent rating for left knee locking from May 1, 2015 to December 20, 2016. 7. Entitlement to a rating higher than 20 percent rating for left knee locking since December 20, 2016. 8. Entitlement to a 10 percent rating for left knee instability. The Veteran states that the current rating for his service-connected left knee disability does not reflect the severity of his left knee symptoms and seeks a higher rating. The Veteran’s left knee disability is evaluated as noncompensable from May 1, 2015, and as 20 percent disabling from December 21, 2016. Specifically, the Veteran states that his left patellofemoral pain syndrome with meniscal tear causes pain that impacts functional mobility. See October 2015 Statement in Support of Claim. He endorses left knee pain, instability and locking that impacts functional mobility. Id. Diagnostic Code 5003 directs that the disability should be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. 38 C.F.R. § 4.71a. If limitation of motion is noncompensable, a 10 percent rating should be assigned if objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. Id. Separate ratings can be assigned for knee disabilities when none of the symptomatology overlaps and the separate rating is based on additional disabling symptomatology; this includes separate ratings based on limitation of flexion (Diagnostic Code 5260), limitation of extension (Diagnostic Code 5261), lateral instability or recurrent subluxation (Diagnostic Code 5257), and meniscal conditions (Diagnostic Codes 5258, 5259). See Lyles v. Shulkin, 29 Vet. App. 107 (2017). The normal range of motion of the knee is from 0 degrees extension to 140 degrees flexion. 38 C.F.R. § 4.71, Plate II. Limitation of flexion warrants 10, 20, and 30 percent ratings when limitation is to 45 degrees, 30 degrees, and 15 degrees, respectively. 38 C.F.R. § 4.71a, Diagnostic Code 5260. Limitation of extension warrants 10, 20, 30, 40, and 50 percent ratings when limitation is to 10 degrees, 15 degrees, 20 degrees, 30 degrees, and 45 degrees, respectively. 38 C.F.R. § 4.71a, Diagnostic Code 5261. A 10 percent rating can also be assigned for the knee joint if there is painful motion without compensable limitation of motion. 38 C.F.R. §§ 4.59, 4.71a, Diagnostic Code 5003; see also Burton v. Shinseki, 25 Vet. App. 1 (2011) (holding that the applicability of 38 C.F.R. § 4.59 is not limited to arthritis claims). Recurrent subluxation and lateral instability of the knee warrants a 10, 20, or 30 percent rating if slight, moderate, or severe, respectively. 38 C.F.R. § 4.71a, Diagnostic Code 5257. The words “slight,” “moderate,” and “severe” used in the various diagnostic codes are not defined in the VA Rating Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence for “equitable and just” decisions. 38 C.F.R. § 4.6. Ratings can also be assigned when the knee disability affects the meniscus, with a 20 percent rating for dislocated semilunar cartilage with frequent episodes of “locking,” pain, and effusion into the joint and a 10 percent rating for removal of semilunar cartilage (e.g., meniscectomy) and current residual symptoms. 38 C.F.R. § 4.71a. Diagnostic Codes 5258, 5259. Ratings can also be assigned for impairment of the tibia or fibula, genu recurvatum, or ankylosis of the knee. 38 C.F.R. § 4.71a, Diagnostic Codes 5256, 5262, 5263. Ankylosis is stiffening or fixation of a joint as the result of a disease process, with fibrous or bony union across the joint. Dinsay v. Brown, 9 Vet. App. 79, 81 (1996). Ankylosis is also defined as “immobility and consolidation of a joint due to disease, injury, or surgical procedure.” DORLAND'S ILLUSTRATED MEDICAL DICTIONARY 93 (30th ed. 2003). In this case the evidence does not reflect, and the Veteran does not allege that he has tibia or fibula impairment, genu recurvatum, or ankylosis of the knee. As such, those diagnostic codes are not for application. 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.”). Accordingly, when evaluating the Veteran’s left knee disability, the Board may assign separate ratings for: (1) recurrent subluxation or lateral instability; (2) limitation of flexion; (3) limitation of extension; and (4) symptoms associated with the dislocation or removal of semilunar cartilage. The evidence, most recently the December 2016 VA examination report, shows that the Veteran has had a meniscal condition in his left knee, which currently manifests in frequent episodes of joint pain and swelling, however, full range of motion of the left knee was indicated. In the Veteran’s hearing, he endorsed knee pain that causes functional limitation. The evidence of record does not reflect such reduced flexion and extension to warrant a compensable rating within the criteria. However, there is objective evidence of pain with movement. Thus, the Veteran is entitled a 10 percent rating based on pain with movement. 38 C.F.R. §§ 4.59, 4.71a, Diagnostic Codes 5003-5260. Instability In the Veteran’s March 2020 Board hearing, he endorsed lateral instability of the knee that causes him to lose his balance. The Veteran was afforded a VA knee examination in December 2016. While the Veteran has consistently reported flare-ups in his left knee, the examiner documented that the Veteran does not report flare-ups of the knee. See December 2016 Knee and Lower Leg Conditions Examination. The examiner did, however, document the Veteran’s reports of locking and knee instability. Id. The examiner documented that the Veteran does not have subluxation, lateral instability, or locking. However, the examiner did note that the Veteran requires the occasional use of braces for left knee pain and buckling. The Board again notes that while the December 2016 stability tests found normal stability, the Veteran has provided lay evidence that he experiences instability of the knees. Significantly, the Veteran reports left knee instability that occurs several times a month. See October 2015 Statement in Support of Claim. During the March 2020 Board hearing, the Veteran reported the use of a knee brace as an assistive device for his left knee due to instability but notes that he does not currently use it because of discomfort. The Veteran also explains that his left knee instability has caused him to fall. The October 2015 statement from Gunnery Sergeant M.P. corroborates that the Veteran has complained of left knee instability continually since active duty service. See M.P.’s October 2015 statement. Given the Veteran’s testimony as to instability, the evidence is at least evenly balanced as to whether he has experienced lateral instability warranting separate compensable ratings under DC 5257. As the reasonable doubt created by this relative equipoise in the evidence must be resolved in favor of the Veteran, entitlement to separate 10 percent initial ratings for left knee instability under DC 5257 is granted. Locking The Board further finds that a 20 percent rating is warranted during the period from May 1, 2015 to December 20, 2016 under Diagnostic Code 5258 for the Veteran’s left knee to account for the locking the Veteran experiences. According to the rating schedule, a claimant is entitled to a 20 percent rating for dislocated semilunar cartilage with frequent episodes of “locking,” pain, and effusion into the joint. As stated above, the evidence shows that the Veteran has had a meniscal condition in his left knee, which currently manifests in frequent episodes of joint pain and swelling. The Veteran indicates that the symptoms also cause left knee locking. Thus, the Board finds that a separate 20 percent rating is warranted from May 1, 2015 to December 20, 2016 under Diagnostic Code 5258 to compensate him for these symptoms. See 38 C.F.R. § 4.20; see also Lyles v. Shulkin, 29 Vet. App. 107 (2017) (holding that the evaluation of a knee disability under Diagnostic Code 5257 and Diagnostic Code 5260 or 5261 do not preclude, as a matter of law, a separate evaluation under Diagnostic Code 5258). However, a 20 percent rating is the maximum rating allowable under Diagnostic Code 5258; thus, a higher rating since December 20, 2016 is not warranted. REASONS FOR REMAND 10. Entitlement to a rating higher than 30 percent for irritable bowel syndrome is remanded. 11. Entitlement to an evaluation higher than 10 percent for left patellofemoral pain syndrome with meniscal tear with painful motion is remanded. 12. Entitlement to a rating higher than 10 percent for left knee instability is remanded. The Board observes that the Veteran has not been afforded VA examinations as to his service-connected irritable bowel syndrome disability and left knee disability, in approximately four and five years, respectively and the Veteran has indicated in statements and testimony on appeal that his symptoms worsened since his last VA examinations. Further, the record clearly raises a question as to the severity of those service-connected disabilities. In his March 2020 hearing, the Veteran endorsed severe abdominal distress, including frequent bowel disturbances that have impacted his ability to work during the period on appeal. Additionally, the Veteran has also endorsed symptoms of left knee flare-ups that cause limitation of motion and instability, as well as pain, swelling, and dislocation. The U.S. Court of Appeals for Veteran’s Claims (the Court) has issued the decisions in Sharp v. Shulkin, 29 Vet. App. 26 (2017) concerning the adequacy of VA orthopedic examinations. The Board emphasizes that in Sharp the Court held that the examiner must “elicit relevant information as to the veteran’s flares or ask him to describe the additional functional loss, if any, he suffered during flares and then estimate the veteran's functional loss due to flares based on all the evidence of record, including the veteran's lay information, or explain why she could not do so.” Thus, the Veteran’s left knee limitation of motion during flare-ups and on repeated use must be assessed for the period on appeal. As such, the Board finds it necessary to remand this matter to afford the Veteran an opportunity to undergo VA examinations to assess the severity of his irritable bowel syndrome and left knee conditions during the periods on appeal. See Snuffer v. Gober, 10 Vet. App. 400, 403 (1997); VAOPGCPREC 11-95 (1995), 60 Fed. Reg. 43186 (1995). The matters are REMANDED for the following actions: 1. Notify the Veteran that he may submit lay statements from himself and from other individuals who have first-hand knowledge, and/or were contemporaneously informed of the nature, extent, and severity of his service-connected irritable bowel syndrome condition and left knee condition, and the impact of those conditions on his ability to work. He should be afforded an appropriate amount of time to submit this lay evidence. 2. Schedule the Veteran for VA examinations (or telehealth interview, review of the record, etc., if an in-person examination is not feasible) to determine the extent and severity of his service-connected irritable bowel syndrome condition and left knee condition. The claims file must be reviewed by the examiner. All indicated tests should be conducted and all signs and symptoms of the service-connected irritable bowel syndrome condition and left knee condition should be reported in detail. STEVEN D. REISS Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board T. Booker 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.