Citation Nr: 21027056 Decision Date: 05/04/21 Archive Date: 05/04/21 DOCKET NO. 18-11 107A DATE: May 4, 2021 ORDER Entitlement to a disability rating higher than 20 percent for chondromalacia patella of the right knee with traumatic arthritis (painful flexion) is denied. Entitlement to a disability rating higher than 20 percent for chondromalacia patella of the right knee with instability is denied. A separate 20 percent disability rating for a meniscus condition of the right knee is granted. REMANDED Entitlement to service connection for a left knee disability, claimed as secondary to the service-connected right knee disability, is remanded. Entitlement to service connection for a stomach disability, to include gastroesophageal reflux disease (GERD), claimed as secondary to the service-connected right knee disability, is remanded. Entitlement to service connection for a lumbar spine disability, claimed as secondary to the service-connected right knee disability, is remanded. FINDINGS OF FACT 1. During the appeal period, the Veteran's chondromalacia patella of the right knee with traumatic arthritis (painful flexion) has been manifested by pain, stiffness, occasional swelling with limitation of flexion to 30 degrees when considering functional impairment on use and during flare ups. 2. During the appeal period, the Veteran's chondromalacia patella of the right knee with instability is manifested moderate instability. 3. During the appeal period, the Veteran's right knee disability was manifested by a meniscal condition resulting in pain, effusion, and instability. CONCLUSIONS OF LAW 1. The criteria for a rating higher than 20 percent for chondromalacia patella of the right knee with traumatic arthritis (painful flexion) is not warranted. 38 U.S.C. §§ 5260. 2. The criteria for a rating higher than 20 percent for chondromalacia patella of the right knee with instability is not warranted. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5257. 3. The criteria for a separate 20 percent rating, but no higher, for right knee meniscal condition is warranted. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5258. REASONS AND BASES FOR FINDING AND CONCLUSIONS The Veteran served on active duty in the United States Army from September 1984 to May 1985. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a September 2014 rating decision of the Department of Veterans' Affairs (VA) Regional Office (RO). In a June 2019 decision, the Board, in pertinent part, denied the Veteran's claims of entitlement to increase disability ratings for chondromalacia patella of the right knee with instability and chondromalacia patella of the right knee with traumatic arthritis-painful flexion. Thereafter, the Veteran appealed to the United States Court of Appeals for Veterans Claims (Court). In an April 2020 Joint Motion for Partial Remand (JMPR), the Secretary of VA and the Veteran (the parties) moved the Court to vacate the June 2019 decision as to the issues involving the Veteran's right knee instability and painful flexion. The Court granted the JMPR in an April 2020 order. In October 2020, the Board remanded the issues for evidentiary development consistent with the JMPR, and these matters are now back before the Board for adjudication. The Board finds that the RO substantially complied with the October 2020 remand instructions, and appellate adjudication may proceed without prejudice to the Veteran. Stegall v. West, 11 Vet. App. 268 (1998). Similarly, in an April 2020 Board decision, the Board denied the Veteran's claim for entitlement to service connection for degenerative arthritis of the lumbar spine, to include secondary to service-connected right knee disability. The Veteran timely appealed to the Court. In a January 2021 Joint Motion for Remand (JMR), the parties moved the Court to vacate the April 2020 Board decision as to the issue involving the Veteran's lumbar spine. The Court granted the JMR in a January 2021 Order. The issue of entitlement to service connection for degenerative arthritis of the lumbar spine is now before the Board for adjudication. As discussed in further detail below, remand is required for additional evidentiary development consistent with the JMR. Throughout the appeal period, the Veteran has described the impact his right knee disability has on his ability to work. However, at no point during the appeal period has the Veteran asserted he is unemployable and most recent treatment records and examination reports imply that the Veteran is currently gainfully employed. Thus, the Board concludes that a claim for TDIU is not raised by the rating issue on appeal. Rice v. Shinseki, 22 Vet. App. 447 (2009) Increased Rating Disability evaluations are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing his symptomatology with the criteria set forth in the Schedule for Rating Disabilities (Rating Schedule). 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10. If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation; otherwise, the lower evaluation will be assigned. 38 C.F.R. § 4.7. Staged ratings are appropriate for any rating claim when the factual findings show distinct time periods during the appeal period where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). In determining the appropriate evaluation for musculoskeletal disabilities, particular attention is focused on functional loss of use of the affected part. Under 38C.F.R. §4.40, functional loss may be due to pain, supported by adequate pathology and evidenced by visible behavior on motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. Under 38C.F.R. §4.45, factors of joint disability include increased or limited motion, weakness, fatigability, or painful movement, swelling, deformity or disuse atrophy. Under 38 C.F.R. § 4.59, painful motion is an important factor of joint disability and actually painful joints are entitled to at least the minimum compensable rating for the joint. This regulation also requires that, whenever possible, the joints involved are tested for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with the range of the opposite undamaged joint. See Correia v. McDonald, 28 Vet. App. 158, 168 (2016). Where functional loss is alleged due to pain upon motion, the provisions of 38 C.F.R. § 4.40 and §4.45 must be considered. DeLuca v. Brown, 8 Vet. App. 202, 207-08 (1995). Within this context, a finding of functional loss due to pain must be supported by adequate pathology and evidenced by the visible behavior of the claimant. Johnston v. Brown, 10 Vet. App. 80, 85 (1997). Pain itself does not rise to the level of functional loss as contemplated by §4.40 and §4.45 but may result in functional loss only if it limits the ability to perform the normal working movements of the body with normal excursion, strength, coordination or endurance. Mitchell v. Shinseki, 25 Vet. App. 32, 43 (2011). The Court recently addressed what constitutes an adequate explanation for an examiner's inability to estimate motion loss in terms of degrees during periods of flare-ups. Sharp v. Shulkin, 29 Vet. App. 26 (2017). Additionally, the Court held that a VA examiner must attempt to elicit information from the record and the Veteran regarding the severity, frequency, duration, or functional loss manifestations during flare-ups before determining that an estimate of motion loss in terms of degrees could not be given. It also held that any inability to furnish such an estimate must be predicated on a lack of medical knowledge among the medical community at large, rather than insufficient knowledge by the individual examiner. Id. During the pendency of the appeal, the Veteran's right knee disability has been assigned a 20 percent disability rating for painful flexion pursuant to 38 C.F.R. § 4.71a, Diagnostic Code 5010-5260 and a separate 20 percent disability rating for instability pursuant to 38 C.F.R. § 4.71a, Diagnostic Code 5010-5257. Under Diagnostic Code 5260, a 20 percent rating is assigned when flexion is limited to 30 degrees; and a 30 percent rating is assigned when flexion is limited to 15 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5260. Alternatively, Diagnostic Code 5261, which assigns disability ratings based on limitation of extension, may also be applicable in this case. Under Diagnostic Code 5261, a 20 percent rating is assigned when extension is limited to 15 degrees; a 30 percent rating is assigned when extension is limited to 20 degrees; a 40 percent rating is warranted for extension limited to 30 degrees; and a 50 percent rating is assigned when extension is limited to 45 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5261. Under Diagnostic Code 5257, which evaluates recurrent subluxation or lateral instability of a knee, and assigns a 10 percent disabling for a slight impairment, 20 percent disabling for a moderate impairment, and 30 percent disabling for a severe impairment. 38 C.F.R. § 4.71a, Diagnostic Code 5257. Under Diagnostic Code 5258, a maximum 20 percent rating is warranted for semilunar cartilage, dislocated, with frequent episodes of "locking", pain, and effusion into the joint. Lastly, under Diagnostic Code 5259, a maximum 10 percent rating is warranted for removal of semilunar cartilage that is symptomatic. 38 C.F.R. § 4.71a, Diagnostic Codes 5258 and 5259. Separate ratings under Diagnostic Codes 5260 and 5261 may be assigned for disability of the same knee joint. See VAOPGCPREC 9-2004. Additionally, for a knee disability already rated under Diagnostic Codes 5260 and/or 5261, a claimant would have additional disability justifying a separate rating if there is instability and/or subluxation of the knee joint under Diagnostic Code 5257. See generally VAOPGCPREC 23-97. Furthermore, the rating criteria do not preclude separate ratings for meniscal injury under Diagnostic Codes 5258 and 5259 where there are separate ratings for limitation of motion under Diagnostic Codes 5260 and/or 5261, or instability under Diagnostic Code 5257. Lyles v. Shulkin, 29 Vet. App. 107 (2017). The terms "slight," "moderate," "severe" are not defined in the Rating Schedule. Rather than applying a mechanical formula, the Board must evaluate all the evidence to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6. The use of terminology such as "slight" or "moderate" by VA examiners and others, although an element of evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. The normal range of knee motion is 140 degrees of flexion and zero degrees of extension. 38 C.F.R. § 4.71, Plate II. During the pendency of the appeal, the rating criteria for evaluating musculoskeletal disabilities under 38 C.F.R. § 4.71a were amended, effective February 7, 2021. 85 Fed. Reg, 230 (Nov. 30, 2020). These amendments revised select diagnostic codes "to ensure that this portion of the rating schedule uses current medical terminology and provides detailed and updated criteria for the evaluation of musculoskeletal disabilities." Id. If a law or regulation changes during the course of a claim or an appeal, the version more favorable to the Veteran will apply, to the extent permitted by any stated effective date in the amendment in question. 38 U.S.C. § 5110(g). If the revised version of the regulation is more favorable, the implementation of that regulation under 38 U.S.C. § 5110(g) can be no earlier than the effective date of that change. If the former version is more favorable, VA can apply the earlier version of the regulation for the period prior to, and from, the effective date of the change. 38 U.S.C. § 5110. In this regard, Diagnostic Codes 5258 to 5261 did not change. However, under the new Diagnostic Code 5257, recurrent subluxation or instability that is manifested by unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribes both an assistive device (e.g., cane(s), crutch(es), walker) and bracing for ambulation warrants a 30 percent rating. For a 20 percent rating, one of the following must be present: a) sprain, incomplete ligament tear, or repaired complete ligament tear causing persistent instability, and a medical provider prescribes a brace and/or assistive device (e.g., cane(s), crutch(es), walker) for ambulation, or b) unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribes either an assistive device (e.g., cane(s), crutch(es), or a walker) or bracing for ambulation. A 10 percent rating is warranted for sprain, incomplete ligament tear, or complete ligament tear (repaired, unrepaired, or failed repair) causing persistent instability, without a prescription from a medical provider for an assistive device (e.g., cane(s), crutch(es), walker) or bracing for ambulation. With respect to patellar instability, a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for a brace and either a cane or walker warrants a 30 percent rating. A diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for one of the following: a brace, cane, or walker warrants a 20 percent rating. Lastly, a diagnosed condition involving the patellofemoral complex with recurrent instability (with or without history of surgical repair) that does not require a prescription from a medical provider for a brace, cane, or walker warrants a 10 percent rating. Note (1): For patellar instability, the patellofemoral complex consists of the quadriceps tendon, the patella, and the patellar tendon. Note (2): A surgical procedure that does not involve repair of one or more patellofemoral components that contribute to the underlying instability shall not qualify as surgical repair for patellar instability (including, but not limited to, arthroscopy to remove loose bodies and joint aspiration). Therefore, with respect to the Veteran's right knee instability, the Board will consider the Veteran's claim under the old criteria prior to February 7, 2021 and both the old and new rating criteria from February 7, 2021. The criteria that is more favorable to the Veteran will be applied. Turning to the facts of the case, the Veteran filed an increased rating claim for his service-connected right knee disability in December 2011. In a December 2012 physical therapy note, the Veteran reported constant right knee pain, which he rated 6/10 in severity. Active range of motion testing revealed flexion to 123 degrees and full extension. Subsequent private treatment records reflect the Veteran's constant knee pain, which he rated 5/10 at rest and 9/10 with certain activities. He denied having any clicking, locking, or instability of the joint. Upon examination, the Veteran's right knee had mild effusion along with moderate, medial and lateral joint line tenderness. Diagnostic testing revealed marked degenerative changes of the patellofemoral joint with moderate degenerative change of the medial compartment. At the March 2014 VA examination, the Veteran reported right knee unsteadiness and pain, which he rated 8-9/10. He stated that his right knee pain flared up every day during work. Range of motion testing revealed flexion to 125 degrees and full extension. While there was evidence of pain upon flexion, there was no objective evidence of painful motion on extension. The Veteran was able to perform repetitive-use testing with three repetitions; however, the examiner noted additional functional impairment and additional limitation in motion with repetitive use. There was evidence of tenderness and pain to palpation of the joint. The examiner found that the Veteran demonstrated normal muscle strength upon right knee flexion; however, muscle strength was 4/5 upon right knee extension. While there was no evidence of a history of recurrent patellar subluxation or dislocation, there was evidence of posterior instability in the right knee. The examiner also noted that the Veteran had a meniscus condition, which resulted in frequent episodes of joint locking, pain, and effusion. The examiner noted that the Veteran walked with a mild right antalgic limp. There was also evidence of severe crepitus of the right knee. The Veteran occasionally used a cane to ambulate. In September 2014, a different VA examiner reviewed the claims file (including the March 2014 VA examination report) and indicated he could not, without speculation, opine to what degree flare ups or prolonged use would impact the Veteran's right knee function. At the January 2018 VA examination, the Veteran described having progressively increasing pain in the right knee, along with laxity, swelling, and decreased range of motion. He stated that at times, his right knee "just gives out." In terms of flare ups, the Veteran described having pain and swelling when standing more than 15 minutes, ambulating more than 20-30 minutes, and upon extension more than 15-20 inches. Range of motion testing revealed flexion to 100 degrees and full extension. The examiner noted pain upon range of motion that caused functional loss. There was also evidence of crepitus and pain with weight bearing and non-weight bearing, along with tenderness/pain on palpation along the medial and lateral joint line in addition to subpatellar and patellofemoral pain with range of motion and palpation. While the Veteran was able to perform repetitive use testing with at least three repetitions, the examiner found that pain, weakness, and lack of endurance additionally limited flexion of the right knee to 50 degrees. With repeated use over time, the examiner estimated that flexion of the Veteran's right knee was limited to 90 degrees. However, during flare ups, the examiner estimated that pain, weakness, lack of endurance, and incoordination limited flexion of the right knee to 30 degrees. There was no evidence of any limitation of extension with repetitive use over time or during flare ups. There was also swelling and disturbance of locomotion contributing to the disability. The Veteran demonstrated normal strength of the right knee and there was no evidence of muscle atrophy or ankylosis of the knee. The examiner noted a history of lateral instability of the right knee along with a history of recurrent effusion. The Veteran occasionally used a knee brace to ambulate. Subsequent private treatment records document the Veteran's continued complaints of right knee pain, swelling, and limitation of motion. Upon examination, the Veteran endorsed tenderness and mild swelling. Range of motion testing revealed flexion to 120 degrees and full extension. The Veteran demonstrated normal strength, normal reflexes and an antalgic gait. Treatment included pain medication and steroid injections. At the December 2019 VA examination, the Veteran reported pain, instability, and swelling of the right knee. His treatment included pain medication and physical therapy. He denied flare ups, but in terms of functional impairment, he described having worse knee pain with kneeling and squatting. Range of motion testing revealed flexion to 110 degrees with full extension. The examiner noted pain on examination, which caused functional loss. There was no evidence of pain with weight bearing nor was there objective evidence of crepitus; the examiner noted objective evidence of pain when non-weight bearing. The examiner also noted moderate tenderness to palpation on the patella. The Veteran was able to perform repetitive use with no additional loss of function or range of motion. The examiner found that neither pain, weakness, fatiguability, or incoordination significantly limited the Veteran's functional ability of the right knee with either repeated use over time or during flare ups, as the Veteran denied having flare ups. The Veteran endorsed normal strength in the right knee and there was no evidence of muscle atrophy or ankylosis. While the examiner found there was evidence of recurrent effusion, as evidenced by intermittent right knee swelling, there was no history of recurrent subluxation nor was there evidence of instability. The joint stability tests yielded normal results. There was also evidence of a meniscus tear, as evidenced by frequent episodes of joint pain. The Veteran did not use any assistive devices and he endorsed normal gait and stance at the time of the examination. The examiner found no knee weakness or laxity upon examination. Most recently, at the November 2020 VA examination, the Veteran reported daily pain in the right knee, which he rated 8-10/10. His treatment included medication, physical therapy, and injections. The Veteran described his flare ups as having worsened pain when having to work quickly along with worsened pain when ambulating stairs or with long periods of standing or kneeling. Range of motion testing revealed full range of motion upon flexion and extension of the right knee; while there was pain noted on the exam, such pain did not result in or cause functional loss. There was no objective evidence of localized tenderness or pain on palpation of the joint, nor was there evidence of pain with weight bearing or evidence of crepitus. The Veteran was able to perform repetitive use testing with at least three repetitions with no additional loss of function or range of motion. The examiner found that neither pain, weakness, fatigability, or incoordination significantly limited functional ability with either repeated use over time or during flare ups. The Veteran demonstrated normal muscle strength testing in the right knee and there was no evidence of muscle atrophy or ankylosis. There was no objective evidence of instability and joint stability tests yielded normal results. Upon consideration, the Board finds that higher ratings based on limitation of motion and instability of the right knee are not warranted. As it pertains to the limitation of flexion of the right knee, in order to warrant a higher 30 percent rating, flexion must be limited to 15 degrees or less. Here, the Veteran was afforded several examinations during the appeal period. At worse, the Veteran's right knee flexion was limited to 50 degrees after three repetitions at the January 2018 examination. Even when considering the examiners' estimates as to limitation of motion with repeated use over time or during flare ups, the Veteran's flexion of the right knee was not limited to 15 degrees or less. Again, the most restrictive range of motion during flare-ups was still to 30 degrees. As there is no lay or medical evidence demonstrating flexion being limited to 15 degrees or the functional equivalent thereto, the Board finds that a rating higher than 20 percent pursuant to Diagnostic Code 5260 is not warranted. In this regard, the Board has also considered the criteria under Diagnostic 5261 but finds that a separate rating is not warranted for limitation of extension. On this record, the Veteran demonstrated full extension of the right knee, and even after three repetitions, he did not demonstrate any additional functional loss or limitation in motion that is functionally equivalent to limitation to 5 degrees extension. The Board recognizes that the JMR directed the Board to consider the Veteran's loss of extension as noted in the January 2018 VA examination. However, review of this report clearly shows that there was no additional loss of extension following repetitive use, repeated use over time or during flare-ups. When taking his lay statements into consideration, the examiners estimated that the Veteran was able to fully extend his knee even after repeated use over time and during flare ups. As there is no lay or medical evidence demonstrating extension being limited to 5 degrees, a separate compensable rating for limitation of extension of the right knee is not warranted. As it pertains to instability, the Board finds that a rating higher than 20 percent is not warranted under either the old or new Diagnostic Code 5257. During the early portion of the appeal period, the Veteran consistently described right knee instability/giving way. During the appeal period, VA examiners performed the requisite instability tests; the results of which are documented in the examination reports. At worst, VA examination reports indicate that the Veteran's instability was 2+, ranging from 5 to 10 millimeters. Most recent examination reports, which include the Veteran's lay statements, demonstrate that the Veteran's right knee was stable; his joint stability tests yielded normal results. Thus, under the old criteria, the evidence shows moderate instability at worst; severe instability of the right knee is not shown. Therefore, a rating higher than 20 percent is not warranted for instability of the right knee. While a higher rating is not warranted based on limitation of motion or instability, the Board finds that a separate 20 percent disability rating is warranted for the Veteran's right knee disability pursuant to 38 C.F.R. § 4.71a, Diagnostic Code 5258. The March 2014 and December 2019 VA examination reports indicate that the Veteran had a history of a meniscus tear of the right knee with frequent episodes of locking, pain, and effusion to the joint. This finding, coupled with the Veteran's subjective reports of joint effusion, warrants a separate 20 percent rating for the right knee disability under Diagnostic Code 5258. However, the Board finds no basis for additional compensation under any potentially applicable criteria as all aspects of the disability are properly considered in the currently assigned separate ratings. There is no evidence of ankylosis of the knee (Diagnostic Code 5256), symptomatic removal of semilunar cartilage (Diagnostic Code 5259), impairment of the tibia and fibula (Diagnostic Code 5262) or genu recurvatum (Diagnostic Code 5263). The Board has considered the Veteran's lay statements regarding the severity of his right knee disability which is consistent with the medical evaluations. However, as it pertains to the specific findings regarding the extent of range of motion, instability, and/or meniscal injury, the Board finds that the findings by trained clinicians have significantly greater probative value than the lay descriptions. Therefore, separate individual ratings higher than 20 percent are not warranted for right limitation of flexion or instability. That said, a separate 20 percent rating is warranted for the meniscal impairment of the right knee, and the claim for an increased rating is granted to that extent only. REASONS FOR REMAND While further delay is regrettable, the Board finds that another remand is required to obtain adequate nexus opinions for the benefits sought on appeal. Left Knee Disability The Veteran contends that his current left knee disability is due to or aggravated by his service-connected right knee disability. Specifically, he asserts that his current left knee arthritis developed as a result of overcompensation due to right knee arthritis. In support of this theory of entitlement, the Veteran's representative has submitted medical literature purporting to show how arthritis can develop after repetitive use and, in this case, after the Veteran started to "favor using his left knee" following development of arthritis in the right knee. See March 2018 letter from the Veteran's attorney. Most recently, this claim was before the Board in June 2020, at which time, the Board acknowledged the Veteran's contentions and remanded for an addendum opinion based on his theory of entitlement. The October 2020 addendum opinion purports to be responsive to the June 2020 remand instructions. The October 2020 examiner found that the Veteran's left knee disability was less likely than not caused or aggravated by his service-connected right knee. In so finding, the examiner noted that arthritis is caused by aging and chronic overuse of the joint and reasoned that the Veteran's left knee arthritis was independent of his right knee arthritis. The Board finds that another addendum opinion is required. Here, while the October 2020 VA examiner noted that arthritis of the knee was caused by overuse, the examiner did not address the Veteran's contentions that overuse of his left knee was caused by his right knee disability. In addition, the examiner did not address the medical literature provided by the Veteran discussing development of arthritis. Stomach Disability Similarly, the Veteran asserts that he has a stomach disability, to include GERD, that is proximately due to or aggravated by his service-connected right knee. In this regard, he contends that medications taken to treat pain from the right knee disability, which include Motrin, Tylenol, Ibuprofen, and Asprin, caused or aggravated his stomach disability. Regarding the Ibuprofen, the Veteran has reported that he no longer can take ibuprofen because he has gastric erosions. See March 2014 VA Examination. In the June 2020 remand, the Board sought an additional addendum opinion addressing the Veteran's contentions. The October 2020 VA examiner, in response to the June 2020 remand instructions, opined that the Veteran's stomach disability was less likely than not caused or aggravated by his right knee disability. In so finding, the examiner acknowledged the Veteran's various pain medications for his right knee disability and opined that usage of these pain medications for the right knee disability "can be associated" with GERD. However, the examiner ultimately found that the medical record did not reveal consistent clinical usage of such medications that could negatively impact and proximately cause GERD. The Board finds that the October 2020 negative nexus is problematic as it is conclusory at best and appears to contradict the objective evidence of record. The examiner acknowledges that the medications the Veteran takes could cause GERD yet fails to explain why his level of usage is not sufficient to cause or aggravate GERD. In that regard, the objective medical evidence, to include the VA examinations, reflect that the Veteran used pain medication daily to alleviate his right knee pain. Given these reasons, remand is required to obtain an adequate nexus opinion. Lumbar Spine As previously noted, in a January 2021 JMR, the parties agreed that the December 2019 VA examination and opinion, upon which the Board based its April 2020 denial, was inadequate. Specifically, the parties found that the examiner's opinion did not discuss relevant medical history that could contribute to aggravation and development of degenerative lumbar spine arthritis, nor did the opinion answer whether the Veteran's right knee arthritis could have impacted his lumbar spine arthritis. As such, the Board finds that remand is required to afford the Veteran a new examination and to obtain an adequate nexus opinion. The matters are REMANDED for the following action: 1. Obtain addendum opinions from an appropriate clinician regarding the etiology of the Veteran's left knee arthritis. Following a review of the record, the clinician should provide the following opinions: (a) Determine whether it is at least as likely as not (50 percent probability or higher) that the Veteran's left knee arthritis is caused by his service-connected right knee disabilities, to include due to overcompensating using his left knee. Why or why not? (b) Determine whether it is at least as likely as not (50 percent probability or higher) that the Veteran's left knee arthritis is aggravated by his service-connected right knee disabilities, to include due to overcompensating using his left knee. Why or why not? In rendering the opinions, the clinician must discuss the following: The Veteran's lay statements that his right knee arthritis has caused him to overcompensate using his left knee; and An article cited in the September 2018 correspondence from the Veteran's attorney ("Osteoarthritis" Mayo Clinic). The clinician must provide a rationale for each opinion rendered. If the clinician cannot provide an opinion without resorting to speculation, he or she should explain why this is so. 2. Obtain addendum opinions from an appropriate clinician regarding the etiology of the Veteran's stomach condition, to include esophagitis, acid reflux, hiatal hernia, and gastric erosion. Following a review of the record, the clinician should provide the following information: (a) Identify all diagnosed stomach conditions. (b) With respect to each diagnosis in (a), determine whether it is at least as likely as not (50 percent probability or higher) that the stomach condition is caused by the medication the Veteran takes for his service-connected right knee disability. Why or why not? (c) With respect to each diagnosis in (a), determine whether it is at least as likely as not (50 percent probability or higher) that the condition is aggravated by the medication the Veteran takes for his service-connected right knee disability. Why or why not? The clinician must provide a rationale for each opinion rendered. If the clinician cannot provide an opinion without resorting to speculation, he or she should explain why this is so. 3. Obtain addendum opinions from an appropriate clinician regarding the etiology of the Veteran's degenerative arthritis of the spine. (a) Determine whether it is at least as likely as not (50 percent probability or higher) that the Veteran's degenerative arthritis of the spine is caused by his service-connected right knee disability. Why or why not? (b) Determine whether it is at least as likely as not (50 percent probability or higher) that the Veteran's degenerative arthritis of the spine is aggravated by his service-connected right knee disability. Why or why not? In rendering these opinions, the examiner must accept as true the Veteran's reports of walking with a limp and/or antalgic gait. The clinician must provide a rationale for each opinion rendered. If the clinician cannot provide an opinion without resorting to speculation, he or she should explain why this is so. (CONTINUED ON NEXT PAGE) 4. The AOJ must review the opinions to ensure they are adequate and comply with the Board's specific remand directives herein. If deficient in any manner, corrective action must be taken at once. J. O'CONNELL Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board C. Orie, 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.