Citation Nr: 21027182 Decision Date: 05/04/21 Archive Date: 05/04/21 DOCKET NO. 16-29 937 DATE: May 4, 2021 ORDER A disability rating of 40 percent, but no higher, for the service-connected lumbar DDD with IVDS for the period on appeal from June 1, 2016 is granted. An initial disability rating of 30 percent for the service-connected right knee degenerative joint disease (DJD) status post arthroscopy is granted. A separate disability rating of 10 percent, but no higher, for right knee removal of semilunar cartilage for the period on appeal from March 3, 2010 to January 11, 2013 is granted. REMANDED An initial disability rating in excess of 20 percent for the service-connected lumbar degenerative disk disease (DDD) with intervertebral disc disease (IVDS) for the period on appeal prior to June 1, 2016, and a rating in excess of 40 percent thereafter, is remanded. An initial disability rating in excess of 30 percent for the service-connected right knee degenerative joint disease (DJD) status post arthroscopy is remanded. An initial disability rating in excess of 10 percent for the service-connected right knee instability for the period on appeal from January 11, 2013 to January 28, 2020 is remanded. A disability rating in excess of 20 percent for the service-connected right knee instability for the period on appeal from January 28, 2020 is remanded. An initial disability rating in excess of 20 percent for the service-connected right shoulder rotator cuff tear with impingement for the period on appeal prior to January 28, 2020 is remanded. A disability rating in excess of 40 percent for the service-connected right shoulder rotator cuff tear with impingement for the period on appeal from January 28, 2020 is remanded. An initial disability rating in excess of 20 percent for the service-connected left shoulder rotator cuff tear with impingement for the period on appeal prior to January 28, 2020 is remanded. A disability rating in excess of 40 percent for the service-connected left shoulder rotator cuff tear with impingement for the period on appeal from January 28, 2020 is remanded. A total disability rating based on unemployability (TDIU) due to service-connected disabilities for the period on appeal prior to April 5, 2010 is remanded. FINDINGS OF FACT 1. For the period on appeal from June 1, 2016, the Veteran's lumbar DDD with IVDS was manifested by symptoms approximating forward flexion of the thoracolumbar spine of 30 degrees or less, to include consideration of additional functional loss following repeated use and during flare-ups. 2. For the entire period on appeal, the Veteran's right knee DJD was manifested by symptoms most closely approximating limitation of flexion of the right knee to 30 degrees or less, to include consideration of additional functional loss following repeated use over time and during flare-ups. 3. For the period on appeal prior to January 11, 2013, the Veteran's right knee disability was manifested by removal of semilunar cartilage; however, for the period on appeal from January 11, 2013, assignment of a disability rating for removal of semilunar cartilage would result in impermissible pyramiding. CONCLUSIONS OF LAW 1. For the period on appeal from June 1, 2016, the criteria for a disability rating of 40 percent for the service-connected DDD with IVDS have been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.3, 4.40, 4.45, 4.71a, Diagnostic Code 5243. 2. For the entire period on appeal, the criteria for an initial disability rating of 30 percent for the service-connected right knee DJD have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5260. 3. For the period on appeal from March 3, 2010 to January 11, 2013, the criteria for a separate 10 percent disability rating for removal of semilunar cartilage have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5259. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from August to December 1977 and October 2004 to August 2007 according to the DD Form 214's of record with extensive periods of reserve and National Guard service. However, the Veteran's Veterans Affairs/Department of Defense Identity Repository (VADIR) profile (accessed on May 23, 2019) reveals the following periods of Guard/Reserve Active Service (GRAS): (1) from May 11, 2002 to August 15, 2002 (deployed); (2) from January 6, 2003 to January 10, 2003; (3) from January 16, 2003 to February 1, 2003; (4) from February 10, 2003 to February 20, 2003; (5) from July 10, 2004 to July 24, 2004; and (6) from October 24, 2004 to October 12, 2005 (deployed). This case is before the Board of Veterans' Appeals (Board) on appeal from March 2012, September 2013, and April 2015 Department of Veterans Affairs (VA) Regional Office (RO) rating decisions. In the March 2012 rating decision, the RO assigned a temporary total evaluation for left shoulder rotator cuff tear with impingement, effective from December 13, 2007 to February 1, 2008, and a 20 percent disability rating from February 1, 2008, denied a disability rating in excess of 20 percent for right shoulder rotator cuff tear with impingement, and assigned a temporary total disability rating for right knee DJD status post arthroscopy, effective from April 5, 2010 to June 1, 2010, and a 10 percent disability rating from June 1, 2010. The Veteran received notification of the decision in April 2012. In March 2013, VA received the Veteran's Notice of Disagreement (NOD). In June 2016, the RO issued a Statement of the Case (SOC). In August 2016, VA received the Veteran's VA Form 9 appeal to the Board. In the interim, in a September 2013 rating decision, the RO granted service connection for right knee instability and assigned an initial disability rating of 10 percent, effective January 1, 2013, and denied service connection for diabetes mellitus. In July 2014, VA received the Veteran's NOD. In May 2016, the RO issued a SOC solely as to the issue of service connection for diabetes mellitus. In June 2016, VA received the Veteran's VA Form 9 appeal to the Board. The June 2016 SOC issued by the RO also addressed the issue of entitlement to an initial disability rating in excess of 10 percent for right knee instability. As noted above, in August 2016, the Veteran submitted a timely VA Form 9 following the June 2016 SOC. Finally, in the April 2015 rating decision, the RO granted service connection for lumbar DDD and assigned an initial noncompensable rating effective from May 21, 2014 but denied a temporary total evaluation for convalescence under 38 C.F.R. § 4.30 and denied entitlement to a TDIU. In May 2015, VA received the Veteran's NOD. However, the claim of service connection for lumbar DDD had remained pending since the Veteran's original claim filed within one year of separation from service. In pertinent part, VA received a March 11, 2010 informal claim for service connection for lumbar DDD within one year of notification of a May 2009 rating decision, which denied service connection for lumbar DDD. As of the May 2009 decision, the Veteran's original August 31, 2007 claim for service connection for lumbar DDD remained pending. The March 11, 2010 claim remained unadjudicated until the April 2015 rating decision. Therefore, in an August 2016 rating decision, the RO concluded that assignment of the May 21, 2014 effective date for service connection lumbar DDD was clear and unmistakable error (CUE) and instead granted an effective date of August 26, 2007, the day following the Veteran's separation from service. Furthermore, the RO assigned an increased disability rating of 20 percent, effective from August 26, 2007, granted service connection for right lower extremity radiculopathy of the sciatic nerve and assigned an initial disability rating of 10 percent, effective August 26, 2007, and a disability rating of 20 percent, effective from June 1, 2016, and service connection for left lower extremity radiculopathy of the sciatic nerve and an initial disability rating of 20 percent, effective from June 1, 2016. Furthermore, the RO revised the effective date of the grant of service connection for right knee instability from January 1, 2013 to January 11, 2013 based on a finding of CUE. Finally, the RO granted entitlement to a TDIU, effective from June 1, 2010 (and reinstated from October 1, 2011 following a period of a temporary total evaluation). The June 2016 SOC addressed the issue of entitlement to a disability rating in excess of 20 percent for the service-connected lumbar DDD, but not the issue of a TDIU. As noted above, VA received the Veteran's timely VA Form 9 in August 2016. In a March 2019 decision, the Board assumed jurisdiction over a claim for a TDIU prior to April 5, 2010 the date of assignment of a temporary total evaluation for the right knee as part and parcel of the Veteran's claim for increased rating for lumbar DDD. See Rice v. Shinseki, 22 Vet. App. 447 (2009). The Board remanded the case for further development and adjudication. In an October 2020 rating decision, the RO increased the disability rating for the lumbar DDD (including IVDS) from 20 percent to 40 percent, effective January 28, 2020, increased the disability rating for right lower extremity radiculopathy of the sciatic nerve from 20 percent to 40 percent, effective January 28, 2020, increased the disability rating for left lower extremity radiculopathy of the sciatic nerve from 20 percent to 40 percent, effective January 28, 2020, granted service right lower extremity radiculopathy of the femoral nerve and assigned an initial disability rating of 20 percent, effective from January 28, 2020, granted service connection for left lower extremity radiculopathy and assigned an initial disability rating of 20 percent, effective January 28, 2020, increased the disability rating for the right shoulder rotator cuff tear with impingement from 20 percent to 40 percent, effective January 28, 2020, increased the disability rating for the left shoulder rotator cuff tear with impingement from 20 percent to 40 percent, effective January 28, 2020, increased the disability rating for right knee instability from 10 percent to 20 percent, effective January 28, 2020, and granted service connection for scars on the low back, right knee, and right and left shoulders, assigning noncompensable initial disability ratings effective from January 28, 2020. Increased Rating Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. See 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. Any reasonable doubt regarding a degree of disability will be resolved in favor of the veteran. 38 C.F.R. § 4.3. When the evidence is in relative equipoise, the veteran is accorded the benefit of the doubt. 38 U.S.C. § 5107(b). When an appeal arises from the initially assigned disability rating, consideration must be given as to whether staged ratings should be assigned to reflect entitlement to a higher rating at any point during the pendency of the claim. Fenderson v. West, 12 Vet. App. 119 (1999). Moreover, staged ratings are appropriate in any increased-rating claim in which distinct time periods with different ratable symptoms or differing levels of severity can be identified. Hart v. Mansfield, 21 Vet. App. 505 (2007). 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."). A finding of functional loss due to pain, however, must be supported by adequate pathology and evidenced by the visible behavior of the claimant. 38 C.F.R. § 4.40; Johnston v. Brown, 10 Vet. App. 80, 85 (1997). Under 38 C.F.R. § 4.59, painful motion is a factor to be considered with any form of arthritis; however, 38 C.F.R. § 4.59 is not limited to disabilities involving arthritis. See Burton v. Shinseki, 25 Vet. App. 1 (2011). The intent of the rating schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. It is the intention to recognize actual painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. In Correia v. McDonald, 28 Vet. App. 158 (2016), the Court held that the final sentence of 38 C.F.R. § 4.59 requires that the examiner record the results of range of motion (ROM) testing "for pain on both active and passive motion [and] in weight-bearing and non-weight-bearing and, if possible, with ROM measurements of the opposite undamaged joint." In Sharp v. Shulkin, 29 Vet. App. 26 (2017), the Court held that VA examiners must obtain information about the severity, frequency, duration, precipitating and alleviating factors, and extent of functional impairment of flares from the veterans themselves, when a flare-up is not observable at the time of examination. 1. Entitlement to an initial disability rating in excess of 20 percent for the service-connected lumbar DDD with IVDS for the period on appeal prior to January 28, 2020. 2. Entitlement to a disability rating in excess of 40 percent for the service-connected lumbar DDD with IVDS for the period on appeal from January 28, 2020. The Veteran's service-connected lumbar DDD is currently rated as 20 percent disabling prior to January 28, 2020 and 40 percent disabling from January 28, 2020 under 38 C.F.R. § 4.71a, Diagnostic Code 5243. Currently, disabilities of the spine are rated pursuant to the General Rating Formula for Diseases and Injuries of the Spine (General Rating Formula) under Diagnostic Codes 5237 through 5243. 38 C.F.R. § 4.71a, Diagnostic Code 5243. In addition, IVDS, under Diagnostic Code 5243 may also be rated based on Incapacitating Episodes (IVDS Formula). 38 C.F.R. § 4.71a, Diagnostic Code 5243. Under the General Rating Formula, a 10 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 60 degrees, but not greater than 85 degrees; or, combined range of motion of the entire thoracolumbar spine greater than 120 degrees, but not greater than 235 degrees. A 20 percent evaluation is warranted for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or combined range of motion of the thoracolumbar spine not greater than 120 degrees; or muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent evaluation is warranted where forward flexion of the thoracolumbar spine is 30 degrees or less or there is favorable ankylosis of the entire thoracolumbar spine. The only higher schedular evaluations under the General Rating Formula are 50 percent for unfavorable ankylosis of the entire thoracolumbar spine and 100 percent for ankylosis of the entire spine. Id. Note (1) to the General Rating Formula directs VA to evaluate any associated objective neurologic abnormalities separately, under an appropriate Diagnostic Code. Id. Under the Formula for Rating IVDS Based on Incapacitating Episodes (IVDS Formula), a 20 percent evaluation is warranted for incapacitating episodes having a total duration of at least two weeks but less than four weeks during the past 12 months. A 40 percent disability evaluation is warranted for incapacitating episodes having a total duration of at least four weeks, but less than six weeks during the past 12 months; and a 60 percent disability evaluation is warranted for incapacitating episodes having a total duration of at least six weeks during the past 12 months. 38 C.F.R. § 4.71a, Diagnostic Code 5243. An "incapacitating episode" under this formula is defined as "period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician." Id. at Note 1. Diagnostic Code 5243, which rates IVDS, specifically instructs to evaluate IVDS under both Diagnostic Code 5243 and the General Rating Formula and apply whichever method results in the higher evaluation when all disabilities are combined under 38 C.F.R. § 4.25. Effective February 7, 2021, Diagnostic Code 5243 instructs assignment of a rating under its provisions only when there is disc herniation and/or irritation of the adjacent nerve root and to apply Diagnostic Code 5242 for all other disc diagnoses. 38 C.F.R. § 4.71a, Diagnostic Code 5243 (effective February 7, 2021). The United States Supreme Court has held that statutes generally may not be construed to have retroactive effect unless their language requires that result. See Landgraf v. USI Film Products, 511 U.S. 244 (1994). As it pertains to veterans law, in Kuzma v. Principi, the Federal Circuit held that the Board may not apply a current regulation prior to its effective date, unless the regulation explicitly provides otherwise. Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). Thus, the amended regulation cannot be applied prior to the effective date unless the regulation explicitly provides otherwise. In other words, the old and new regulations are for consideration with regard to rating the Veteran's disability, and he is entitled to the more favorable regulation; however, if the revised criteria are more favorable to the Veteran, the revised criteria may not be applied until the effective date of the change. See 38 U.S.C. § 5110(g). Here, the amendments to the rating schedule do not have any retroactive application. At the outset, although the Veteran has a diagnosis of IVDS, there is no evidence of any incapacitating episodes requiring bedrest prescribed by a physician. See January 2020 VA examination report. Accordingly, no further discussion of IVDS is warranted. The Veteran received an initial VA examination for his low back in November 2007. At that time, the Veteran reported "pain 9/10 in severity associated with weakness and stiffness, precipitated by lifting, alleviated by topical heat." He denied flare-ups. However, the Veteran reported functional impairments including sleep interference and inability to drive or walk long distances. Moreover, he indicated radiation of pain down the right leg, but not the left leg. The examiner did not test range of motion (ROM) during this examination. Unfortunately, no VA examination containing ROM measurements was completed until June 2016. Nevertheless, the Veteran consistently complained of and received treatment for low back pain during the nearly nine-year interval between examinations. Furthermore, the evidence shows that the Veteran first complained of "left sided radiation" of low back pain in August 2013; however, the August 2013 private medical record fails to show that the low back pain radiated to the left lower extremity. See private radiologist's report dated August 2, 2013. During the June 2016 VA examination, the examiner completed ROM testing. Forward flexion of the thoracolumbar spine was limited to 60 degrees and extension was to no more than 10 degrees. Both ROMs exhibited pain. After 3 repetitions, forward flexion decreased to 55 degrees and extension was again to 10 degrees. The Veteran reported flare-ups occurring "when I am sitting too long, bending or getting out of the tub, or getting out of the chair at times," lasting "3-4 hours" and occurring "every day." However, regarding additional functional loss following repeated use over time and during flare-ups, the examiner stated that, "this examiner cannot make comments about additional loss of range of motion, fatigue, pain, and weakness or incoordination during flare ups without resorting to mere speculation." Notwithstanding, as to flare-ups, the examiner indicated that the "Veteran reports a flare up today while being examined." There was no evidence of muscle atrophy, but deep tendon reflexes (DTRs) were hypoactive (1+) and senses in the bilateral upper anterior thighs, thighs/knees, lower legs/ankles, and feet/toes were absent. The examiner noted radicular symptoms in both lower extremities, with moderate constant pain in the left lower extremity, moderate intermittent pain in the right lower extremity, moderate paresthesias and/or dysesthesias in both lower extremities, mild numbness in the right lower extremity, and moderate numbness in the left lower extremity. The examiner indicated only sciatic nerve involvement and overall severity of the radiculopathy was moderate bilaterally. However, there was no evidence of ankylosis and no diagnosis of IVDS. Although the examiner noted that there was pain on weight-bearing, the examiner did not state whether there was pain on nonweight-bearing or that testing was conducted on both active and passive ROM. Finally, during the June 2016 examination, the Veteran reported undergoing lumbosacral spine fusion surgery in 2013. Pursuant to this statement, in the March 2019 decision, the Board instructed the RO to obtain all missing VA and private treatment records relevant to the claimed surgery. In this regard, private treatment records show that the Veteran underwent a microdiscectomy at the L4-L5 vertebrae in January 2014. See private history & physical note dated October 15, 2014. However, the evidence does not show that any period of convalescence was required following this surgery. Furthermore, the Veteran underwent a cervical, rather than lumbosacral, spine fusion (anterolateral cervical foraminotomy) in 2013. See private post-operative note dated June 26, 2013. The Veteran most recently received a VA examination of his low back in January 2020. The Veteran stated that flare-ups occurred 3 times a week and were "severe," lasting "1.5 hrs"; they were precipitated by "lifting heavy objects, sudden movements and prolonged sitting and were "alleviated by readjusting, ice and heat applications and [Percocet]." During the examination, forward flexion of the thoracolumbar spine was limited to 40 degrees and extension was to 5 degrees, with pain on both ROMs. After 3 repetitions, forward flexion was reduced to 35 degrees. Following repeated use over time and flare-ups, the examiner estimated that forward flexion would deteriorate to 5 degrees, and further, that extension would decrease to 0 degrees during flare-ups. Per the examination report, there was no evidence of muscle atrophy but DTRs were absent (0) bilaterally in the knees and ankles. Regarding radicular symptoms, the examiner indicated that the Veteran experienced moderate constant pain, severe intermittent pain, severe paresthesias and/or dysesthesias, and severe numbness in both lower extremities; furthermore, the examiner recorded that there was loss of hair on both lower extremities. The examiner concluded that the Veteran's radicular symptoms were severe bilaterally and noted both sciatic and femoral nerve involvement. At the time of the examination, the Veteran relied on constant use of a walker. Functional impairments included "difficulty bending over, lifting/carrying objects > 5 lbs, sitting/driving > 30 mins, walking > 10 mins, using the stairs, standing > 10 mins." Regarding Correia, there was objective evidence of pain on active (see above) and passive ROM testing of the back, and on weight-bearing and nonweight-bearing. Based on the foregoing, a disability rating of 40 percent is warranted from June 1, 2016, the date of the Veteran's June 2016 VA examination for his low back. As noted by the March 2019 Board decision, the June 2016 examination failed to comply with Correia and, therefore, is inadequate to serve as a basis for a rating based on limitation of motion. However, the Veteran's low back symptomatology during that examination is substantially consistent with the symptoms observed during the January 2020 examination. Therefore, with consideration of additional functional loss following repeated use over time and during flare-ups, the Veteran's lumbar DDD with IVDS was manifested by symptoms most closely approximating limitation of forward flexion of the thoracolumbar spine to 30 degrees as of June 1, 2016. Accordingly, the criteria for a 40 percent disability rating for the service-connected lumbar DDD with IVDS have been met from June 1, 2016. A disability rating in excess of 20 percent prior to June 1, 2016, for the service-connected lumbar DDD with IVDS, and a rating in excess of 40 percent thereafter is remanded pursuant to the instructions below. Regarding the possibility of a temporary total rating following the January 2014 lumbosacral microdiscectomy, there is no evidence of any period of convalescence following that surgery. For VA purposes, a minimum of one month of convalescence following surgery related to a service-connected disability, as established by report of hospital discharge (regular discharge or release to non-bed care) or outpatient release, is required for assignment of a temporary total rating. 38 C.F.R. § 4.30(a). In this case, there is no evidence of any inpatient or outpatient period of convalescence following the January 2014 lumbosacral microdiscectomy. As such, assignment of a temporary total rating for convalescence following that surgery is not warranted. Finally, regarding the Veteran's service-connected neurological disabilities, the Veteran has never expressed disagreement with any of the ratings assigned for his radiculopathy. Therefore, the issues of increased rating for right and left lower extremity radiculopathy of the sciatic and femoral nerves will not be addressed by this decision. Nonetheless, one point related to the Veteran's evaluation for left lower extremity radiculopathy warrants further discussion. The Veteran is in receipt of a separate 20 percent disability rating for left lower extremity radiculopathy of the sciatic nerve from June 1, 2016 to January 28, 2020, and a 40 percent rating for left lower extremity radiculopathy of the sciatic nerve and 20 percent rating for left lower extremity radiculopathy of the femoral nerve from January 28, 2020. Therefore, the Veteran has been in receipt of a separate disability rating for left lower extremity radiculopathy for only part of the period on appeal. However, prior to June 1, 2016, there is no indication of left lower extremity radiculopathy. As noted above, the November 2007 examination gave no indication of left leg radiculopathy. Additionally, although the August 2013 private record indicated that the Veteran experienced left-sided radiation, there is no evidence that this was experienced as radiation to the left lower extremity. As such, there is no probative evidence of left lower extremity radiculopathy until the June 2016 examination. Accordingly, no separate rating for left lower extremity radiculopathy is warranted prior to the current June 1, 2016 effective date. 3. Entitlement to an initial disability rating in excess of 10 percent for the service-connected right knee DJD status post arthroscopy. 4. Entitlement to a separate disability rating for right knee instability for the period on appeal prior to January 11, 2013. The Veteran's service-connected right knee DJD is currently rated as 10 percent disabling under 38 C.F.R. § 4.71a, Diagnostic Code 5010-5260. His service-connected right knee instability is currently rated as 10 percent disabling from January 11, 2013 to January 28, 2020 and as 20 percent disabling from January 28, 2020 under 38 C.F.R. § 4.71a, Diagnostic Code 5003-5257. Diagnostic Code 5260 rates limitation of leg flexion and Diagnostic Code 5261 rates limitation of leg extension. Under Diagnostic Code 5260, (limitation of flexion), a 10 percent disability rating is warranted for flexion limited to 45 degrees. Limitation of flexion to 30 degrees warrants a 20 percent disability rating. A 30 percent disability rating is assigned for flexion limited to 15 degrees or less. In order for the Veteran to receive a 10 percent rating under Diagnostic Code 5261 (limitation of leg extension), the evidence must show that his knee disability is manifested by leg extension limited to 10 degrees. A 20 percent rating under Diagnostic Code 5261 is warranted if the evidence shows leg extension limited to 15 degrees. The Veteran is entitled to a 30 percent disability rating for leg extension limited to 20 degrees. Extension limited to 30 degrees warrants a 40 percent rating. Finally, extension limited to 45 degrees warrants a 50 percent rating. A veteran who has both compensable limitation of flexion and compensable limitation of extension of the same leg must be rated separately under Diagnostic Codes 5260 and 5261 to be adequately compensated for functional loss associated with injury to the leg. See VAOPGCPREC 9-04 (September 17, 2004). During the pendency of the appeal, the rating criteria for evaluating recurrent subluxation or lateral instability of the knee under 38 C.F.R. § 4.71a, Diagnostic Code 5257 were amended, effective February 7, 2021. 85 Fed. Reg. 76453. Prior to February 7, 2021, Diagnostic Code 5257 evaluated recurrent subluxation or lateral instability of the knee. It provided a 10 percent disability rating for slight recurrent subluxation or lateral instability. A 20 percent disability rating was warranted for moderate recurrent subluxation or lateral instability. Severe recurrent subluxation or lateral instability warranted a 30 percent disability rating. The United States Court of Appeals for Veterans Claims recently held that nothing in Diagnostic Code 5257, under the pre-amendment rating criteria, provided that objective medical evidence is required or is to be favored over lay evidence in determining whether to assign a rating for lateral instability of the knee. English v. Wilkie, 30 Vet. App. 347, 349 (2018). The words "slight," "moderate" and "severe" are not defined in the VA Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are equitable and just.38 C.F.R. § 4.6. According to MERRIAM WEBSTER'S COLLEGIATE DICTIONARY 999 (11th Ed. 2007), "slight" means small in amount. "Moderate" means limited in scope or effect. "Severe" means very painful or harmful or of a great degree. Under the amended criteria for rating recurrent subluxation or instability, a 10 percent disability rating is warranted for a 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. A 20 percent disability rating is warranted for either: (a) 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) an 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), walker) or bracing for ambulation. 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 maximum 30 percent disability rating. Under the amended criteria for rating patellar instability, a 10 percent rating is warranted for 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. 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. A maximum 30 percent rating is warranted for 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 a walker. Diagnostic Code 5257, Note (1), as amended, defines the patellofemoral complex as consisting of the quadriceps tendon, the patella, and the patellar tendon. Note (2) instructs that 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). In this case, prior to February 7, 2021, only the old rating criteria for rating instability of the knee may be considered; however, from February 7, 2021, both the old and new criteria may be considered, and the criteria that is more favorable to the Veteran will be applied. As the outset, for the entire period on appeal, or from March 2010, the Veteran has a history of meniscus tear with later surgical repair in 2011. See, e.g. January 2020 VA examination report. During the period on appeal, the Veteran received an initial VA examination for his right knee in November 2010. Regarding ROM, right knee flexion was limited to 100 degrees and extension was normal (to 0 degrees), with pain on ROM. There were no decreases after 3 repetitions. The examiner noted right knee stiffness, weakness, and incoordination, and daily (or more often) locking episodes, but no episodes of dislocation/subluxation and only one instance of joint effusion. Flare-ups were severe, occurred weekly, and lasted for a duration of "hours." The Veteran reported that flare-ups were precipitated by "walking for too long, standing for too long, driving, [and] going up stairs." During flare-ups, he stated that he was "unable to use his legs," had to "rest knee completely," and was "unable to sleep at night often due to pain." The flare-ups were relieved by medication and ice. Functional limitations (outside of a flare-up) included ability to stand for no more than "15-30 minutes" and ability to walk 1/4 mile but not more than one mile. The examiner noted that the Veteran's right knee was negative for instability. A January 2012 private treatment record reflects that the Veteran denied right knee locking, giving way, or buckling. Lachman and drawer tests were negative for instability. See private primary care noted dated January 5, 2012. The Veteran next received a VA examination for his right knee in January 2013. At the time of examination, the Veteran reported pain "triggered by weight bearing, certain body positions, bending, walking, it is alleviated somewhat by elevation, pain medication, cold, rest." He indicated experiencing flare-ups when he attempted to change positions. Forward flexion of the right knee was limited to 80 degrees and extension was to 0 degrees. After 3 repetitions, forward flexion of right knee was decreased to 75 degrees. Contributing factors of disability included less movement than normal, weakened movement, excess fatiguability, incoordination, pain on movement, and interference with sitting, standing and weight-bearing. Medial-lateral instability of the right knee was 1+ but the examiner stated that there was no history of recurrent patellar subluxation/dislocation. Regarding functional impact, the Veteran reported that "he cannot climb up or down stairs, [and] he has instability in any change of position..." In June 2016, the Veteran received a new VA examination of his right knee. During the examination, the Veteran reported functional loss and impairment when standing 5-10 minutes, sitting over 20 minutes, climbing stairs ("I try to avoid"), squatting ("I can't"), kneeling ("I can't"), and after walking 5-10 minutes. Flexion of the right knee was limited to 80 degrees and extension was again to 0 degrees, with pain on both flexion and extension. After 3 repetitions, flexion was reduced to 75 degrees and extension remained normal. However, the examiner declined to offer opinions regarding additional functional loss following repeated use over time "without resorting to mere speculation." Nonetheless, the examiner noted that the examination was being conducted during a flare-up and also "reduced ROM with repeated movement." There was no evidence of ankylosis. The Veteran was unable to perform joint stability tests of the right knee due to fatigue from repetitive use testing. Regarding meniscal conditions, the examiner noted a history of a torn right knee meniscus and repair in 2011. At the time of examination, the Veteran relied on occasional use of a brace, cane, and walker. Finally, although the examiner noted that there was pain on weight-bearing, the examiner did not state whether there was pain on nonweight-bearing or that testing was conducting on both active and passive ROM. Finally, the Veteran received a VA examination of his right knee in January 2020. During the examination, the Veteran reported constant "8/10" pain in the right knee. Furthermore, he indicated that his right knee buckles, swells, and "pops and clicks." The Veteran stated that flare-ups of the right knee occurred 3 times per week, were "severe" and lasted "30 mins." The flare-ups were precipitated by "buckling and falling" and alleviated by pain patched, a TENS unit, and pain medication. Functional impairments reported by the Veteran included "difficulty walking, lifting/carrying, driving/sitting, standing, showering, using stairs, standing from a sitting position, squatting/kneeling, getting in and out of the car, household chores, yardwork, and playing sports" as well as inability to run or jog. ROM measurements for the right knee were limited to 90 degrees for flexion and extension to 0 degrees with pain on both flexion and extension. However, following repeated use over time, the examiner estimated that flexion would decrease to 40 degrees due to pain, fatigue, weakness, and lack of endurance. Moreover, during flare-ups, the examiner opined that flexion of the right knee would be to 0 degrees due to pain, fatigue, weakness, and lack of endurance. Muscle strength was reduced but there was no evidence of atrophy. Joint stability testing revealed up to 2+ using the Lachman and lateral instability tests. However, there was no evidence of ankylosis. Furthermore, the January 2020 examiner noted that the Veteran had a diagnosis of bilateral shin splints. However, the examiner noted that the shin splints affected ROM of the knee. Like the June 2016 examiner, the January 2020 examiner noted a history of meniscal tear, but also noted frequent episodes of joint "locking," joint pain, and joint effusion. At the time of examination, the Veteran relied on constant use of a walker. Regarding functional impact, the examiner concluded that the Veteran would have difficulty walking for more than 10 minutes, lifting or carrying items that are more than 5 pounds, driving or sitting for over 30 minutes, or standing for over 10 minutes. Finally, regarding Correia, there was objective evidence of pain on passive ROM testing of the right knee and pain on weight-bearing and nonweight-bearing. Based on the foregoing, for the full period on appeal, a 30 percent disability rating is warranted for service-connected right knee DJD. In this regard, the evidence shows that the Veteran's right knee DJD was manifested by symptoms more closely approximating limitation of flexion of the right knee to 15 degrees, to include consideration of additional functional loss following repeated use and during flare-ups. Notably, the Veteran did not receive a Correia-compliant VA examination until January 2020. However, the Veteran's symptoms have remained consistent throughout the period on appeal. Specifically, the Veteran's reports to the November 2010 examiner of being completely unable to use his legs during a flare-up are consistent with the January 2020 examiner's opinion that the Veteran would be unable to flex his knee during a flare-up. Significantly, during the June 2016 examination, the Veteran was unable to complete joint stability testing of the right knee due to fatigue from ROM testing. Furthermore, the Veteran's credible descriptions of difficulties with prolonged standing, sitting, walking, and driving, as well as lifting, bending, and climbing stairs are more consistent with the 30 percent rating criteria. Accordingly, the criteria for a disability rating of 30 percent for the right knee DJD have been met. An initial disability in excess of 30 percent for service-connected right knee degenerative joint disease status post arthroscopy, an initial disability rating in excess of 10 percent right service-connected right knee instability from January 11, 2013, to January 28, 2020, and a rating in excess of 20 percent for right knee instability from January 28, 2020, is remanded as discussed below. Finally, the applicability of other diagnostic codes has been considered. Notably, the Veteran has a history of meniscal tear, which may be rated under Diagnostic Codes 5258 (removal of semilunar cartilage) and 5259 (dislocation of semilunar cartilage with frequent episodes of "locking," joint pain, and effusion). Here, a separate 10 percent rating for removal of semilunar cartilage under Diagnostic Code 5259 is warranted from the date of claim March 3, 2010 to the January 11, 2013 effective date of the separate 10 percent disability rating for right knee instability. In this regard, has a history of meniscal tear and surgical repair dating to 2010. Accordingly, resolving reasonable doubt in the Veteran's favor, a separate 10 percent disability rating for removal of semilunar cartilage under Diagnostic Code 5259 is warranted for the period on appeal from March 3, 2010 to January 11, 2013. The 10 percent rating is the maximum rating available under Diagnostic Code 5259. REASONS FOR REMAND 1. Entitlement to service connection for diabetes mellitus, to include as secondary to the Veteran's service-connected musculoskeletal disabilities (of the low back, right and left knees, right and left shoulders). The Veteran seeks service connection for diabetes mellitus, contending in-service onset. However, in the March 2019 Board remand, the Board on its own initiative stated that consideration of a secondary theory of entitlement based on nexus to the Veteran's service-connected musculoskeletal disabilities was warranted. Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 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). Pursuant to 38 C.F.R. § 3.303(b), where a chronic disease, such as diabetes mellitus, is shown as such in service, subsequent manifestations of the same chronic disease are generally service-connected; if a chronic disease is noted in service but chronicity in service is not adequately supported, a showing of continuity of symptomatology after separation is required. Entitlement to service connection based on chronicity or continuity of symptomatology pursuant to 38 C.F.R. § 3.303(b) applies only to a disease enumerated on the list of chronic diseases in 38 U.S.C. § 1101(3) or 38 C.F.R. § 3.309(a). Walker v. Shinseki 708 F.3d 1331 (Fed. Cir. 2013). In addition, such chronic diseases are presumed to have been incurred in service if they manifested to a compensable degree within one year of separation from service. 38 U.S.C. §§ 1101(3), 1112(a)(1), 1113; 38 C.F.R. §§ 3.307(a), 3.309(a). Service connection for a claimed disability may be established on a secondary basis if that disability that is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection as secondary to a service-connected disability requires a current disability that was either caused or aggravated by a service-connected disability. 38 C.F.R. § 3.310(a). Regarding aggravation, 38 C.F.R. § 3.310(b) provides that any increase in severity of a nonservice-connected disease or injury proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the disease, will be service connected. In reaching this determination as to aggravation of a nonservice-connected disability, consideration is required as to the baseline level of severity of the nonservice-connected disease or injury (prior to the onset of aggravation by service-connected condition), in comparison to the current level of severity of the nonservice-connected disease or injury. The Veteran has a current diagnosis of diabetes mellitus (Type II). See January 2020 VA examination report. During his January 2020 examination for diabetes mellitus, the Veteran indicated onset of diabetes mellitus in approximately 1998. Specifically, he recalled: I [was] stationed at Fort Lewis at this time when I was sweating, I was lightheaded, my vision was going in and out, I told my wife I wasn't feeling well and she took to me to the hospital on base where I was admitted to the ICU for about 4-5 days, I had blood work done and it showed my A1c level was at a 600. I was kept in the hospital to be monitored until My numbers went back down. I was then told I have Diabetes Mellitus Type II. Since then I was given insulin to take, and Metformin. In 2016 I had constant blurred vision, I was having trouble seeing at night, I was told I have glaucoma and I would need surgery. I had surgery on both my eyes in 2009 at the VA in Martinez due to my diabetes. However, service records provide no evidence that the Veteran was diagnosed with diabetes mellitus during a period of active duty, or even during a period of reserve or National Guard service. In this regard, none of the Veteran's service treatment records (STRs) provide any evidence of a diagnosis of diabetes mellitus, list diabetes as an ongoing problem, or note any treatments (insulin, metformin, etc.) for diabetes. Notably, in a September 2006 report of medical history, the Veteran denied high blood sugar. See STRs dated September 13, 2006. The only other notation in STRs related to diabetes is in the same report of medical history; specifically, the Veteran reported a family history of diabetes mellitus but not a current diagnosis. See id. Medical Examination Board records from August 2007 dated just prior to separation from service also provide no evidence of a diagnosis of diabetes mellitus. See STRs dated September 21, 2006. Post-service treatment records provide no evidence of a diagnosis of diabetes mellitus until June 2010, when the Veteran was diagnosed by VA providers. See VA primary care noted dated June 10, 2010. Significantly, the Veteran denied having a diabetes mellitus diagnosis in February 2009, March 2009, and May 2010. Private treatment records similarly provide no evidence of a diagnosis of diabetes mellitus prior to June 2010, although impaired fasting glucose is noted as an ongoing problem as early as 2009. See Private primary care note dated May 27, 2010; private angiogram report dated March 20, 2009; February 2009 VA audiological examination report Furthermore, post-service treatment records do confirm a diagnosis of bilateral early cataracts as early as October 2009. See VA ophthalmology note dated October 9, 2009. However, subsequent records reveal that the Veteran did not have diabetic retinopathy as of 2017. See VA ophthalmology note dated December 12, 2017. Moreover, his records are negative for glaucoma until December 2017, and for ocular surgery until later that month, when the Veteran had bilateral cataract extraction surgery. See id. The Veteran's initial claim for service connection for diabetes mellitus was not received until August 2010. No prior written statement or phone contact reflects that the Veteran reported a diagnosis of diabetes mellitus prior to June 2010. The January 2020 examiner for the Veteran's diabetes mellitus prepared opinions for direct and secondary theories of entitlement. Regarding direct nexus, the examiner opined that the Veteran's diabetes mellitus was at least as likely as not incurred in or caused by an in-service injury, event, or illness. The examiner reasoned that "[t]he veteran did not have diabetes prior to service. The veteran was diagnosed and began treatment while in service." However, as discussed above, there is no evidence to support this inaccurate premise about the Veteran's medical history. Accordingly, the January 2020 opinion for direct nexus is afforded no probative value. The January 2020 examiner also provided opinions for proximate causation and aggravation. The examiner opined that the Veteran's diabetes mellitus was less likely than not proximately due to the service-connected musculoskeletal disabilities because the Veteran was diagnosed with diabetes during service. This rationale again relies on the erroneous factual assumption described above. Therefore, the opinion for proximate causation is afforded no probative value. Most notably, however, the January 2020 examiner concluded that the Veteran's diabetes mellitus was aggravated beyond its natural progression by the service-connected musculoskeletal disabilities. Although the examiner could not establish a baseline level of severity for the diabetes mellitus, the examiner reasoned that "[c]hronic pain and decreased ROM of his service connected conditions caused the veteran to struggle with exercise. The veteran is in pain even with short distances of walking." The RO sought further clarification for this opinion. In October 2020, the January 2020 examiner completed an addendum opinion in support of the positive opinion for aggravation. The examiner cited a study from Leicester, England (specific citation not given) purporting to show that lack of exercise, or excessive sedentary activity, can cause decreased insulin sensitivity, thereby affecting blood glucose levels and, as a result, causing (or aggravating, according to the examiner) diabetes mellitus. Later in October 2020, the RO sought an opinion from a different examiner for further clarification. The October 2020 examiner opined that the Veteran's diabetes mellitus was "neither secondarily caused nor aggravated beyond the normal course of the disease" by the Veteran's multiple service-connected musculoskeletal disabilities. In the opinion, the examiner noted the claimed 1998 diagnosis of diabetes mellitus, for which the record provides no support. However, the examiner provided additional reasoning that is not reliant upon that premise. In this regard, as to both causation and aggravation, the examiner noted that, in addition to his musculoskeletal disabilities and diabetes mellitus, the Veteran was known to have hypertension, peripheral vascular disease (PVD), coronary artery disease (CAD), gastroesophageal reflux disease (GERD), and obesity, which also are "medically contributing to his inability to exercise." The opinion also cited "advancing age" as a factor. Furthermore, the examiner cited a December 2015 private medical record documenting a stroke and carotid surgery. Additionally, the examiner noted that the Veteran's medical history was significant for "surgical interventions to improve the Veteran's quality of life to include some mobility." After a review of the conflicting opinions, the Board finds that an addendum medical opinion is warranted from the January 2020 examiner. In this regard, although the examiner indicated that diabetes mellitus was aggravated beyond its natural progression by his service-connected musculoskeletal disabilities, he failed to provide an opinion as to the baseline severity prior to aggravation pursuant to 38 C.F.R. § 3.310(b). Moreover, the examiner did not provide a sufficient rationale as to why he provided an opinion that the Veteran's diabetes mellitus, type II, was incurred during service. Accordingly, an addendum opinion is warranted on remand. 2. An initial disability rating in excess of 20 percent for the service-connected lumbar degenerative disk disease (DDD) with intervertebral disc disease (IVDS) for the period on appeal prior to June 1, 2016 is remanded. 3. An initial disability rating in excess of 30 percent for the service-connected right knee degenerative joint disease (DJD) status post arthroscopy is remanded. 4. An initial disability rating in excess of 10 percent for the service-connected right knee instability for the period on appeal from January 11, 2013 to January 28, 2020 is remanded. 5. A disability rating in excess of 20 percent for the service-connected right knee instability for the period on appeal from January 28, 2020 is remanded. 6. Entitlement to an initial disability rating in excess of 20 percent for the service-connected right shoulder rotator cuff tear with impingement for the period on appeal prior to January 28, 2020. 7. Entitlement to a disability rating in excess of 40 percent for the service-connected right shoulder rotator cuff tear with impingement for the period on appeal from January 28, 2020. 8. Entitlement to an initial disability rating in excess of 20 percent for the service-connected left shoulder rotator cuff tear with impingement for the period on appeal prior to January 28, 2020. 9. Entitlement to a disability rating in excess of 40 percent for the service-connected left shoulder rotator cuff tear with impingement for the period on appeal from January 28, 2020. The Board notes that VA examinations were performed in January 2020 to assess the severity of the Veteran's service-connected right knee, lumbar spine, right shoulder, and left shoulder disabilities. However, the Board finds that these examinations are insufficient to determine the present claims. In this regard, the examiner noted that there was pain with passive range of motion. However, the examiner failed to provide correlating range of motion findings in compliance with Correia v. McDonald, 28 Vet. App. 158 (2016). Accordingly, the Board finds that new VA examinations are warranted on remand in order to assess the severity of the Veteran's service-connected lumbar spine and right knee disabilities. Moreover, as noted above, the Board remanded these issues in March 2019 for further evidentiary development. Pursuant to the Board remand directives, the Veteran was afforded VA examinations for his right and left shoulder rotator cuff tears with impingement. The reports from these examinations have been uploaded to the claims file. Furthermore, in the October 2020 rating decision, the RO increased the disability ratings for the right and left from 20 percent to 40 percent, effective from January 28, 2020. However, the RO failed to issue a Supplemental Statement of the Case (SSOC) for the denied issues of initial disability ratings in excess of 20 percent for the service-connected right and left shoulder rotator cuff tears with impingement for the period on appeal prior to January 28, 2020 or disability ratings in excess of 40 percent for the service-connected right left shoulder rotator cuff tears with impingement for the period on appeal from January 28, 2020. Issuance of a SSOC was required as a matter of regulatory compliance because the October 2020 rating decision did not constitute a full grant of all benefits sought on appeal for the right and left shoulder issues, or in other words, because a portion of the appeal remained denied. See 38 C.F.R. §§ 19.31, 19.37, 19.38, 20.1000(a)(3). Accordingly, the claims must be remanded for readjudication in light of the new evidence associated with the claims file. 10. Entitlement to a TDIU due to service-connected disabilities for the period on appeal prior to April 5, 2010. Given that the claim for a TDIU for the period on appeal prior to April 5, 2010 is inextricably intertwined with the issues of entitlement to initial disability ratings in excess of 20 percent for right and left shoulder rotator cuff tear with impingement for the period on appeal prior to January 28, 2020, and increased ratings for his service-connected lumbar spine and right knee disabilities, adjudication of the TDIU claim must be deferred pending RO adjudication of the claims. See Harris v. Derwinski, 1 Vet. App. 180 (1991). The matters are REMANDED for the following actions: 1. Forward the claims file to the January 2020 examiner for an addendum opinion to determine the etiology of his diabetes mellitus, type II. The claims file, including a copy of this remand, must be reviewed and such review should be noted in the examination report. A VA examination is only necessary if deemed so by the examiner. The examiner should respond to the following questions: A. Is it at least as likely as not (probability of at least 50 percent) that the Veteran's diabetes mellitus, type II, had its onset in and/or is otherwise etiologically related to his period(s) of active service? B. If not directly related, is it at least as likely as not (probability of at least 50 percent) that his disabilities mellitus, type II, was caused by any of his service-connected musculoskeletal disabilities? If not, is it at least as likely as not (probability of at least 50 percent) that his diabetes mellitus, type II, has been aggravated (any incremental increase in disability) as a result of his service-connected musculoskeletal disabilities? If aggravation is found, is there evidence created prior to the aggravation or between the aggravation and diabetes mellitus, type II, that shows a baseline of his diabetes mellitus, type II, prior to aggravation? If so, please identify. If service connection is found, the examiner should discuss the impact, if any, on his ability to work. The examiner must provide a comprehensive rationale for each opinion provided. The examiner is advised that the Veteran is competent to report his symptoms and history, and such reports are to be considered in formulating any opinion. If any opinion cannot be given without resorting to speculation, the examiner should explain why and state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), the record (additional facts are required), or the examiner does not have the knowledge or training. As appropriate, the AOJ should conduct additional development or supplement the record. 2. Schedule the Veteran for a VA examination to determine the nature and severity of his service-connected lumbar spine disability. The claims file, including this remand, should be reviewed by the examiner to become familiar with the Veteran's pertinent medical history. Complete range of motion testing should be accomplished and the examiner should note the point at which there is pain on motion, if any. Specifically, active and passive range of motion testing as well as weight-bearing and non-weight-bearing testing must be conducted and recorded. If possible, the examiner should indicate how far back (i.e., one year, two years, etc.) these results would apply. The examiner should also note any additional loss of function with repetition due to factors such as pain, weakness, fatigability, and pain on movement. The extent of additional limitation should be expressed in degrees. Flare-ups have been reported throughout the rating period on appeal and the examiner must express an opinion on whether the flare-ups are associated with additional functional loss. If so, he or she should estimate the degree of lost motion during such flare-ups. The 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 cannot be given. Any inability to furnish such an estimate must be predicated on a lack of medical knowledge among the medical community at large and not the insufficient knowledge of the examiner. If the examiner provides an estimate, he or she may indicate their level of confidence in such estimate on a scale of 1 to 5, with 1 being least confident and 5 being the most confident. The examiner should discuss the impact of his lumbar spine disability, if any, on his ability to work. The examiner must provide a comprehensive rationale for each opinion provided. The examiner is advised that the Veteran is competent to report his symptoms and history, and such reports are to be considered in formulating any opinion. If any opinion cannot be given without resorting to speculation, the examiner should explain why and state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), the record (additional facts are required), or the examiner does not have the knowledge or training. As appropriate, the AOJ should conduct additional development or supplement the record. 3. Schedule the Veteran for a VA examination to determine the nature and severity of his service-connected left and right shoulder disabilities. The claims file, including this remand, should be reviewed by the examiner to become familiar with the Veteran's pertinent medical history. Complete range of motion testing should be accomplished and the examiner should note the point at which there is pain on motion, if any. Specifically, active and passive range of motion testing as well as weight-bearing and non-weight-bearing testing must be conducted and recorded. If the examiner is unable to conduct this testing, he or she should explain the reasoning and attempt to elicit this information from the record and provide an estimate. If possible, the examiner should indicate how far back (i.e., one year, two years, etc.) these results would apply. The examiner should also note any additional loss of function with repetition due to factors such as pain, weakness, fatigability, and pain on movement. The extent of additional limitation should be expressed in degrees. Flare-ups have been reported throughout the rating period on appeal and the examiner must express an opinion on whether the flare-ups are associated with additional functional loss. He or she should estimate the degree of lost motion during such flare-ups. The 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 cannot be given. Any inability to furnish such an estimate must be predicated on a lack of medical knowledge among the medical community at large and not the insufficient knowledge of the examiner. If the examiner provides an estimate, he or she may indicate their level of confidence in such estimate on a scale of 1 to 5, with 1 being least confident and 5 being the most confident. The presence of ankylosis must be noted. Additionally, the examiner should report if there is humerus impairment, fibrous union, malunion, and/or nonunion of the joint. If the examiner is unable to conduct any of 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 discuss the impact, if any, of the Veteran's right and left shoulder disabilities on his ability to work. The examiner must provide a comprehensive rationale for each opinion provided. The examiner is advised that the Veteran is competent to report his symptoms and history, and such reports are to be considered in formulating any opinion. If any opinion cannot be given without resorting to speculation, the examiner should explain why and state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), the record (additional facts are required), or the examiner does not have the knowledge or training. As appropriate, the AOJ should conduct additional development or supplement the record 4. After completion of # 1, schedule the Veteran for a VA examination by an appropriate clinician to determine the severity of his service-connected right knee disability. The claims file, including this remand, should be reviewed by the examiner to become familiar with the Veteran's pertinent medical history and such review should be noted in the examination report. Complete range of motion testing should be accomplished and the examiner should note the point at which there is pain on motion, if any. Specifically, active and passive range of motion testing as well as weight-bearing and non-weight-bearing testing must be conducted and recorded. The examiner should indicate how far back (i.e., one year, two years, etc.) these results would apply if possible. The examiner should also note any additional loss of function with repetition due to factors such as pain, weakness, fatigability, and pain on movement. The extent of additional limitation should be expressed in degrees. Flare ups have been reported and the examiner must express an opinion on whether the flare-ups are associated with additional functional loss. If so, he or she should estimate the degree of lost motion during such flare-ups. The examiner is to 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 cannot be given. Should the examiner maintain that they cannot do so without resorting to speculation, they must explain why this is so. Note: Any inability to furnish such an estimate must be predicated on a lack of medical knowledge among the medical community at large and not the insufficient knowledge of the examiner. The presence or absence of ankylosis should be noted. The examiner is to assess the severity of the lateral instability and/or recurrent subluxation in the Veteran's right knee. The examiner is to state whether such instability is slight, moderate, or severe. From February 7, 2021, and ongoing, the examiner should also state whether instability manifests in a sprain, incomplete ligament tear, complete ligament tear (repaired, unrepaired, or failed repair), causing persistent instability and/or whether a medical provider prescribed an assistive device and/or bracing for ambulation. If a diagnosed patellar instability is found involving the patellofemoral complex (quadriceps tendon, the patella, and the patellar tendon), the examiner should discuss whether it manifests in recurrent instability, required surgical repair, and/or requires a prescription from a medical provider for a brace, cane, or walker. Further, the examiner must indicate whether there is cartilage, semilunar, dislocated, with frequent episodes of locking, pain, and effusion of the joint or partial removal of the semilunar cartilage. The examiner must also indicate whether there is an impairment of the tibia and fibula. If so, the examiner should discuss whether there is nonunion of, with loose motion, requiring a brace or malunion of with marked, moderate, or slight knee or ankle disability. If so, from February 7, 2021, and ongoing, the examiner should also discuss whether it requires treatment, the duration of such treatment, and whether it is responsive to such treatment, including conservative, surgical, or shoe orthotics treatment. The examiner should discuss the impact of his right knee disability, if any, on his ability to work. The examiner must provide a comprehensive rationale for each opinion provided. The examiner is advised that the Veteran is competent to report his symptoms and history, and such reports are to be considered in formulating any opinion. If any opinion cannot be given without resorting to speculation, the examiner should explain why and state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), the record (additional facts are required), or the examiner does not have the knowledge or training. As appropriate, the AOJ should conduct additional development or supplement the record. 5. Readjudicate the issues on appeal based on a review of the entire evidentiary record (with specific consideration of the evidence associated with the claims file since the March 2019 Board remand). If any of the benefits sought on appeal remain denied, provide the Veteran and his representative with a Supplemental Statement of the Case and the opportunity to respond thereto. Thereafter, subject to current appellate procedure, the case should be returned to the Board for further consideration, if in order. 6. Readjudicate the claim for a TDIU for the period on appeal prior to April 5, 2010. S. Merrick Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board D. Small, Attorney Advisor 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.