Citation Nr: 21029691 Decision Date: 05/14/21 Archive Date: 05/14/21 DOCKET NO. 17-37 975 DATE: May 14, 2021 ORDER For the initial rating period on appeal from March 8, 2017 through July 7, 2020, a staged higher initial disability rating of 10 percent for the service connected limitation of motion due to right knee degenerative joint disease (DJD) is granted. REMANDED Entitlement to a separate compensable disability rating for instability of the right knee is remanded. FINDINGS OF FACT 1. From March 8, 2017 through May 17, 2017, the Veteran's right knee DJD manifested as painful limitation of motion that would not be compensable under Diagnostic Codes 5260 or 5261. 2. From May 18, 2017 through July 7, 2020, the Veteran's right knee DJD manifested as painful limitation of extension limited to 10 degrees. 3. For the entire initial rating period on appeal, from May 4, 2010, other than the period in which the Veteran was in receipt of a temporary total disability rating following right knee surgery, the right knee DJD did not manifest as painful limitation of flexion limited to 45 degrees or less, or painful limitation of extension limited to 15 degrees or more, even when accounting for flare-ups of pain. CONCLUSIONS OF LAW 1. Resolving reasonable doubt in favor of the Veteran, for the rating period from March 8, 2017 through July 7, 2020, the criteria for a 10 percent disability rating for right knee limitation of motion have been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5003, 5010, 5256-5263. 2. For the entire initial rating period on appeal, from May 4, 2010, other than the period in which the Veteran was in receipt of a temporary total disability rating, the criteria for a higher initial disability rating in excess 10 percent for limitation of motion of the right knee have not been met or more nearly approximated. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5003, 5010, 5256-5263. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran, who is the appellant, had active service from August 1967 to August 1971. This matter came before the Board of Veterans' Appeals (Board) on appeal from an August 2014 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Phoenix, Arizona. The procedural history of the instant matter is discussed in detail below. The Veteran testified at a September 2020 virtual Board hearing before the undersigned Veterans Law Judge. The hearing transcript has been associated with the record. Since the issuance of the April 2017 statement of the case (SOC), additional evidence has been received by the Board. Per a September 2020 post-hearing brief, a waiver of initial RO consideration was provided in writing. 38 C.F.R. § 20.1304. The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C. §§ 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.159, 3.326(a). As the instant decision remands the issue of a separate compensable disability rating for instability of the right knee, no further discussion of VA's duties to notify and assist is necessary as to that issue. Concerning the issue of a higher initial disability rating for limitation of motion of the right knee, as the rating issue arises from the Veteran's disagreement with the initial rating assigned following the grant of service connection, no additional notice is required regarding this downstream element of the service connection claim. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007); 38 C.F.R. § 3.159(b)(3). Regarding the duty to assist, the record reflects that VA obtained all relevant documentation and provided the Veteran with multiple adequate VA knee examinations. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). As such, the Board finds that the duties to notify and assist the Veteran in this case have been fulfilled. 1. Rating Right Knee DJD Disability Procedural History At the outset, the Board will review the procedural history of this matter. In May 2010, VA received the Veteran's claim to reopen service connection for a right knee disability. Following development of the matter, to include a June 2012 VA examination and opinion, in an August 2014 rating decision, VA granted service connection for DJD and residual scarring of the right knee. An initial disability rating of 10 percent was assigned for the right knee DJD disability from May 4, 2010, the date of claim to reopen service connection. The right knee DJD disability was rated 10 percent disabling under the substantive criteria of Diagnostic Code 5010, which in turn rates under Diagnostic Code 5003, for painful but noncompensable limitation of motion of the knee. Subsequently, in July 2015, the Veteran filed a notice of disagreement (NOD) with the initial disability rating assigned. While the NOD was pending, the Veteran underwent right knee surgery in May 2016, and in June 2016 the Veteran filed a supplemental claim asking that the right knee rating be reevaluated in light of the surgical procedure. Following receipt of the supplemental claim, a new VA knee examination was performed in March 2017. In a March 2017 rating decision, the RO granted a temporary total (100 percent) rating for the right knee from May 18, 2016 (date of surgery) through August 31, 2016 (end of convalescence period). Following the end of the convalesce period, the prior 10 percent disability rating was reinstated for the period from September 1, 2016 through March 7, 2017. A noncompensable (0 percent) rating was then assigned from March 8, 2017. The 0 percent rating was based upon a finding that the March 2017 VA knee examination showed no residuals following the May 2016 knee surgery. One month later, in April 2017, a statement of the case (SOC) on the initial right knee disability rating was issued, and VA received a VA Form 9 perfecting the appeal in May 2017. In April 2019, the Veteran filed a new claim for service connection for a leg length discrepancy, as secondary to the service-connected right knee DJD. Following the claim, a new VA knee and lower leg examination was performed in May 2019. In a subsequent May 2019 rating decision, the RO denied service connection for a leg length discrepancy. The Veteran subsequently filed a VA Form 20-0995, Decision Review Request: Supplemental Claim, in March 2020, requesting reconsideration of the denial of service connection for a leg length discrepancy. Following the request, yet another VA knee and lower leg examination was performed in July 2020, and service connection was again denied in an August 2020 rating decision. To date, as the Veteran has not appealed the denial of the issue of service connection for a leg length discrepancy, that issue is not before the Board. Relevant to the instant matter, in the August 2020 rating decision, the RO granted a staged initial disability rating of 10 percent under Diagnostic Code 5261 for painful limitation of extension of the right knee, effective July 8, 2020, the date of the most recent VA knee and lower leg examination. In the August 2020 rating decision, the RO purported to grant service connection for right knee limitation of flexion and assign a noncompensable disability rating from July 8, 2020. This purported grant of service connection was a mischaracterization, as the RO was merely making a finding that the Veteran's painful limitation of flexion in the right knee did not meet a compensable level under Diagnostic Code 5260. Further, the RO also granted service connection for noncompensable scarring of the right knee related to the May 2016 knee surgery. During the course of this appeal, in March 2019, the Veteran's representative submitted an argument brief. Per the brief, the representative reviewed some of the evidence of record and argued 1) that the Veteran was entitled to a separate compensable 20 percent disability rating for instability of the right knee during the rating period prior to the May 2016 partial right knee replacement surgery, and 2) that the Veteran was entitled to a 10 percent disability rating for limitation of extension from May 18, 2017. Following the September 2020 virtual Board hearing, an amended post-hearing brief was submitted by the representative in September 2020 in response to the RO's actions in the August 2020 rating decision, and in response to the Veteran's testimony in September 2020. Per the post-hearing brief, the representative again argued that a 10 percent disability rating was warranted for painful limitation of extension from May 18, 2017. As to the question of a separate compensable disability rating for instability of the right knee, in the September 2020 brief, the representative argued that a 30 percent rating for severe instability is warranted for the period prior to the May 2016 knee surgery, and a 20 percent disability rating for moderate instability is warranted from the date of surgery. In the aforementioned briefs the representative does not argue, and the evidence of record does not support, that higher initial and/or separate compensable disability ratings for the right knee are warranted under Diagnostic Codes 5256, 5258, 5259, 5262, or 5263. Further, the representative does not argue, and the evidence of record does not support, that any scarring related to the Veteran's prior knee surgeries are symptomatic. Based upon the above, the Board finds that in the instant decision it need only consider whether a higher initial disability rating is warranted for painful limitation of motion of the right knee under Diagnostic Codes 5010, 5260, and/or 5261 (addressed directly below), and whether a separate compensable disability rating is warranted for instability of the right knee under Diagnostic Code 5257, either prior to, or following, the May 2016 partial right knee replacement surgery (addressed in the remand section below). Disability Rating Legal Authority Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule) found in 38 C.F.R. Part 4. 38 U.S.C. § 1155. It is not expected that all cases will show all the findings specified; however, findings sufficiently characteristic to identify the disease and the disability therefrom and coordination of rating with impairment of function will be expected in all instances. 38 C.F.R. § 4.21. Where there is a question as to which of two disability ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. It is the defined and consistently applied policy of VA to administer the law under a broad interpretation, consistent, however, with the facts shown in every case. When after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability such doubt will be resolved in favor of the claimant. 38 C.F.R. § 4.3. In general, all disabilities, including those arising from a single disease entity, are rated separately, and all disability ratings are then combined in accordance with 38 C.F.R. § 4.25. Pyramiding, the rating of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when rating a veteran's service-connected disabilities. 38 C.F.R. § 4.14. It is possible for a veteran to have separate and distinct manifestations from the same injury which would permit rating under several diagnostic codes; however, the critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the conditions is duplicative or overlapping with the symptomatology of the other condition. Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). When an unlisted condition is encountered it will be permissible to rate under a closely related disease or injury in which not only the functions affected, but the anatomical localization and symptomatology are closely analogous. Conjectural analogies will be avoided, as will the use of analogous ratings for conditions of doubtful diagnosis, or for those not fully supported by clinical and laboratory findings. Nor will ratings assigned to organic diseases and injuries be assigned by analogy to conditions of functional origin. 38 C.F.R. § 4.20. When evaluating disabilities of the musculoskeletal system, 38 C.F.R. § 4.40 allows for consideration of functional loss due to pain and weakness causing additional disability beyond that reflected on range of motion measurements. DeLuca v. Brown, 8 Vet. App. 202 (1995). Further, 38 C.F.R. § 4.45 provides that consideration also be given to decreased movement, weakened movement, excess fatigability, incoordination, and pain on movement, swelling, and deformity or atrophy of disuse. Painful motion is considered limited motion at the point that pain actually sets in. See VAOPGCPREC 9-98. With any form of arthritis, painful motion is an important factor of disability, the facial expression, wincing, etc., on pressure or manipulation, should be carefully noted and definitely related to affected joints. Muscle spasm will greatly assist the identification. Sciatic neuritis is not uncommonly caused by arthritis of the spine. The intent of the schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. It is the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. Crepitation either in the soft tissues such as the tendons or ligaments, or crepitation within the joint structures should be noted carefully as points of contact which are diseased. Flexion elicits such manifestations. The joints involved should be 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. 38 C.F.R. § 4.59. The Veteran has appealed from the initial rating assigned for the service connected right knee limitation of motion. In Fenderson v. West, 12 Vet. App. 119, 125 26 (1999), the United States Court of Appeals for Veterans Claims (Court) addressed a similar appeal and directed that such appeal of the initial rating assigned following a grant of service connection was specifically not a claim for an increased disability rating. The Court also directed that separate ratings may be assigned for separate periods of time based on the facts found, a practice known as "staged" ratings. A veteran is competent to report symptoms because this requires only personal knowledge, not medical expertise, as it comes to him through his senses. See Layno v. Brown, 6 Vet. App. 465, 470 (1994). Lay testimony is competent to establish the presence of observable symptomatology, where the determination is not medical in nature and is capable of lay observation. Barr, 21 Vet. App. 303. The Board has thoroughly reviewed all the evidence in the Veteran's claims file and adequately addresses the relevant evidence in the instant decision. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, every piece of evidence of record. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). During the pendency of this appeal, various portions of 38 C.F.R. § 4.71a were amended, effective February 7, 2021. The Board has considered whether these changes could result in a staged higher initial disability rating based on limitation of motion from the effective date of the regulation changes; however, the Board does not find the February 7, 2021 amendments to be relevant to the instant decision. 38 C.F.R. § 4.71a (2021). The appropriate diagnostic codes for rating limitation of motion of the right knee are Diagnostic Codes 5260 and 5261. 38 C.F.R. § 4.71a. Normal range of motion of the knee is from 0 degrees of extension to 140 degrees of flexion. 38 C.F.R. § 4.71, Plate II. In VAOPGCPREC 9-2004, the VA General Counsel interpreted that, when considering Diagnostic Codes 5260 and 5261 together with 38 C.F.R. § 4.71, a veteran may receive a rating for limitation in flexion only, limitation of extension only, or, if the 10 percent criteria are met for both limitations of flexion and extension, separate 10 percent ratings for limitations in both flexion and extension under Diagnostic Code 5260 (leg, limitation of flexion) and Diagnostic Code 5261 (leg, limitation of extension). Under Diagnostic Code 5260, limitation of knee flexion is rated 30 percent disabling where flexion is limited to 15 degrees; 20 percent disabling where flexion is limited to 30 degrees; 10 percent disabling where flexion is limited to 45 degrees; and noncompensable where flexion is limited to 60 degrees. 38 C.F.R. § 4.71a. Under Diagnostic Code 5261, limitation of knee extension is rated 50 percent disabling where extension is limited to 45 degrees; 40 percent disabling where extension is limited to 30 degrees; 30 percent disabling where extension is limited to 20 degrees; 20 percent disabling where extension is limited to 15 degrees; 10 percent disabling where extension is limited to 10 degrees; and noncompensable where extension is limited to 5 degrees. Id. As discussed above, prior to, and just following, the May 2016 right knee surgery, the Veteran's service-connected right knee DJD was rated under Diagnostic Code 5010. Diagnostic Code 5010 represents arthritis due to trauma, substantiated by x ray findings, which in turn is to be rated under Diagnostic Code 5003 as degenerative arthritis (hypertrophic or osteoarthritis). 38 C.F.R. § 4.71a. Degenerative arthritis established by X-ray findings will be rated based on limitation of motion under the appropriate diagnostic code(s) for the specific joint(s) involved. When, however, the limitation of motion of the specific joint(s) involved is noncompensable under the appropriate diagnostic code(s), a 10 percent rating is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under Diagnostic Code 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. In the absence of limitation of motion, a 10 percent rating is warranted if there is X-ray evidence of involvement of two or more major joints or two or more minor joint groups and a 20 percent rating is authorized if there is X-ray evidence of involvement of two or more major joints or two or more minor joint groups and there are occasional incapacitating exacerbations. Id., Diagnostic Code 5003. Ten Percent Disability Rating for Right Knee Limitation of Motion From March 8, 2017 through July 7, 2020 As discussed in the procedural history above, prior to the May 2016 partial knee replacement surgery, the Veteran was in receipt of a 10 percent disability rating for noncompensable limitation of motion of the right knee under Diagnostic Code 5010. Following the end of the temporary total rating period, the 10 percent disability rating was continued from September 1, 2016 until March 8, 2017, when the rating was lowered to noncompensable following a March 2017 VA knee examination. Specifically, the RO lowered the disability rating based upon a finding that the May 2016 right knee surgery had eliminated the Veteran's right knee symptoms. Eventually, the Veteran was again awarded a staged 10 percent disability rating for limitation of motion of the right knee from July 8, 2020. In March 2019 and September 2020 briefs, the Veteran's representative argued that a 10 percent disability rating under Diagnostic Code 5261 for limitation of extension was warranted from May 18, 2017. The Board agrees. During the course of this appeal VA received a private right knee treatment record dated May 18, 2017. Per the private treatment record, range of motion testing showed limitation of extension 10 degrees, which warrants a 10 percent disability rating under Diagnostic Code 5261. As such, the evidence reflects that a 10 percent rating was warranted from at least May 18, 2017. The Board has also considered whether a 10 percent rating was warranted for limitation of motion of the right knee for the period from March 8, 2017 through May 17, 2017. As discussed above, following a March 2017 VA knee examination, the RO reduced the Veteran's limitation of motion disability rating from 10 percent to noncompensable because the VA examination report indicated that the Veteran had full range of motion without pain. Per the examination report, however, the Veteran conveyed having flare-ups of pain in the right knee following exercise. The VA examiner did not opine as to any additional range of motion lost during a flare-up, as the examiner would be unable to do so without resorting to mere speculation. Per the most recent VA examination in July 2020, during a flare-up of pain the Veteran loses an additional 30 degrees of flexion in the right knee (the flare-ups do not reduce right knee extension). As such, it can be presumed that at the time of the March 2017 VA knee examination, a flare-up of pain would have reduced the Veteran's right knee flexion from 140 degrees (full range of motion) to approximately 110 degrees. While limitation of flexion to 110 degrees is not compensable under Diagnostic Code 5260, it is compensable to 10 percent under Diagnostic Code 5010. For these reasons, the Board finds that the report from the March 2017 VA knee examination supports that a 10 percent distality rating for painful limitation of motion of the right knee was warranted from March 8, 2017. Such a finding is supported by the Veteran's testimony at the September 2020 virtual Board hearing, where the Veteran testified to having some painful limitation of flexion following the May 2016 right knee surgery. For the above reasons, the Board finds that the evidence of record, both lay and medical, supports that a 10 percent disability rating for limitation of motion of the right knee was warranted for the staged initial rating period from March 8, 2017 through July 7, 2020. 38 C.F.R. §§ 4.3, 4.7, Diagnostic Codes 5010 and 5261. Specifically, the evidence reflects that from March 8, 2017 through May 17, 2017, the Veteran's right knee DJD manifested as painful limitation of motion that would not be compensable under Diagnostic Codes 5260 or 5261, to warrant a 10 percent disability rating under Diagnostic Code 5010-5003. Further, from May 18, 2017 through July 7, 2020, the evidence reflects that the Veteran's right knee DJD manifested as painful limitation of extension limited to 10 degrees, to warrant a 10 percent disability rating under Diagnostic Code 5261. Initial Disability Rating for Limitation of Motion in Excess of 10 Percent Based upon the Board's actions above, the Veteran is now in receipt of a 10 percent disability rating based on limitation of motion of the right knee for the entire initial rating period on appeal, except for the period of temporary total disability rating. The Board has also considered whether a disability rating in excess of 10 percent was warranted at any time during the initial rating period on appeal. Having reviewed the evidence of record, lay and medical, the Board finds that, for the entire initial rating period on appeal, from May 4, 2010, other than the period in which the Veteran was in receipt of a temporary total disability rating following right knee surgery, the right knee DJD did not manifest as painful limitation of flexion limited to 45 degrees or less, or painful limitation of extension limited to 15 degrees or more. Again, as discussed above, per the report from the July 2020 VA knee examination, during a flare-up of pain right knee flexion is reduced an additional 30 degrees. The painful flare-ups do not affect the Veteran's right knee extension. During the course of this appeal, VA received a private medical record review dated September 2011. Per the record review report, at that time the Veteran appeared to have extension limited to 5 degrees, and flexion limited 115 to 120 degrees. Even when accounting for an additional 30 degrees of flexion lost during a flare-up of pain, such range of motion measurements did not warrant a compensable disability rating for limitation of motion under Diagnostic Codes 5260 or 5261. The Veteran first received a VA knee examination in June 2012. At that time, the Veteran had full extension and flexion limited to 115 degrees in the right knee. Upon repetitive use testing, flexion was reduced an additional 5 degrees and extension remained full. These range of motion readings do not warrant a compensable disability rating for limitation of motion under Diagnostic Codes 5260 or 5261, even when accounting for an additional 30 degrees of flexion lost during a flare-up of pain. Per a September 2014 private treatment record, upon range of motion testing of the right knee flexion was limited to 127 degrees. Thus, even when accounting for an additional 30 degrees of flexion lost during a flare-up of pain, such a reading did not warrant a compensable disability rating under Diagnostic Code 5260. Extension at that time was limited to 7 degrees. Even if that reading were to be rounded up to 10 degrees, it would still only warrant a 10 percent disability rating under Diagnostic Code 5261, and not a disability rating of 20 percent or higher. A second VA knee examination was performed in March 2017. At that time, the Veteran was found to have both full extension and full flexion in the right knee. Repetitive use testing was not performed at that time. Such range of motion readings do not warrant a compensable disability rating for limitation of motion under Diagnostic Codes 5260 or 5261, even when accounting for an additional 30 degrees of flexion lost during a flare-up of pain. In May 2017, the Veteran again underwent range of motion testing from a private treatment provider. As to extension, the Veteran's right knee was limited to 10 degrees, which, as discussed above, warrants a 10 percent disability rating under Diagnostic Code 5261. Further, upon examination the Veteran's flexion was limited to 120 degrees. Again, even when accounting for an additional 30 degrees of flexion lost during a flare-up of pain, this would not result in a compensable disability rating under Diagnostic Code 5260. A third VA knee examination was performed in May 2019. At that time, the Veteran was found to have both full extension and full flexion in the right knee; however, upon repetitive use testing, while extension remained full, flexion was reduced to 115 degrees. Such range of motion readings do not warrant a compensable disability rating for limitation of motion under Diagnostic Codes 5260 or 6261, even when accounting for an additional 30 degrees of flexion lost during a flare-up of pain. Finally, the Veteran received yet another VA knee examination in July 2020. Upon range of motion testing, the Veteran had full extension, with flexion limited to 90 degrees in the right knee. Upon repetitive use testing, extension remained full, and flexion was further limited to 70 degrees. The VA examiner went on to opine that, during a flare-up of pain, extension would remain full, but flexion would be further limited to 60 degrees. Again, such range of motion readings do not warrant compensable disability ratings for limitation of motion under Diagnostic Codes 5260 or 5261. The Board has reviewed the extensive medical evidence of record. Nothing in the evidence of record supports that, even during a flare-up of pain, the Veteran's right knee flexion was limited to 45 degrees or less, or that extension was limited to at least 15 degrees. Further, as discussed above, in the March 2019 and September 2020 briefs, the Veteran's representative did not argue that the medical evidence of record supported a disability rating in excess of 10 percent for limitation of motion of the right knee at any point during the initial rating period on appeal, based on either limitation of extension or limitation of flexion. In sum, during the entire initial rating period on appeal, from May 4, 2010, other than the period in which the Veteran was in receipt of a temporary total disability rating following right knee surgery, the right knee DJD did not manifest as painful limitation of flexion limited to 45 degrees or less, or painful limitation of extension limited to 15 degrees or more, even when accounting for flare-ups of pain. As such, the evidence does not support that the Veteran was entitled to a 20 percent, or higher, initial disability rating for right knee limitation of motion at any point during the initial rating period on appeal. Further, the evidence also does not support that a separate compensable rating could have been assigned for painful limitation of flexion of the right knee at any point during the initial rating period on appeal. As the preponderance of the evidence is against a higher initial disability rating in excess of 10 percent for right knee limitation of motion, the appeal for a higher initial disability rating in excess of 10 percent, other than during the period in which the Veteran was in receipt of a temporary total disability rating, for right knee limitation of motion must be denied. 38 C.F.R. §§ 4.3, 4.7, 4.71A, Diagnostic Codes 5010, 5260 and 5261. Extraschedular Claim Not Raised The Board finds that neither the Veteran nor the record has raised a claim for extraschedular rating under 38 C.F.R. § 3.321(b) for any period for the increased rating issues on appeal. See Thun v. Peake, 22 Vet. App. 111 (2008); Doucette v. Shulkin, 28 Vet. App. 366 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record); Yancy v. McDonald, 27 Vet. App. 484, 494 (2016), citing Dingess v. Nicholson, 19 Vet. App. 473, 499 (2006), aff'd, 226 Fed. Appx. 1004 (Fed. Cir. 2007) (holding that when 38 C.F.R. § 3.321(b)(1) is not "specifically sought by the claimant nor reasonably raised by the facts found by the Board, the Board is not required to discuss whether referral is warranted"). Further, the evidence of record does not reflect that the issue of entitlement to a total disability rating for compensation purposes based on individual unemployability due to service-connected disabilities (TDIU) was raised during the course of this appeal. REASONS FOR REMAND 2. Separate Compensable Disability Rating for Right Knee Instability VA's duty to assist includes, in appropriate cases, the duty to conduct a thorough and contemporaneous medical examination which is accurate and fully descriptive. Floyd v. Brown, 9 Vet. App. 88, 93 (1996). VA must afford a veteran a medical examination and/or obtain a medical opinion when it is necessary to make a decision on the claim. 38 U.S.C. § 5103A(d); 38 C.F.R. § 3.159(c)(4). As discussed above, in a September 2020 post-hearing brief, the Veteran's representative argued that a separate compensable disability rating of 30 percent for severe instability of the right knee is warranted during the period prior to the May 2016 knee surgery, and a 20 percent disability rating for moderate instability is warranted following the date of surgery. Review of the evidence of record reflects that at the time of the June 2012, March 2017, May 2019, and July 2020 VA knee examinations, the VA examiners found that the Veteran did not have instability in the right knee; however, in various lay statements throughout the course of this appeal, and in testimony at the September 2020 virtual Board hearing, the Veteran has advanced having instability symptoms in the right knee. Further, an October 2015 private treatment record indicates that the Veteran may have had some instability in the right knee at that time. Significantly, VA received a private medical record review/medical opinion from a sports medicine specialist in September 2011. Review of the private report reflects that the specialist reviewed the evidence of record and interviewed the Veteran. While the specialist did not examine the Veteran, the specialist specifically found that an examination was not necessary, as the available medical records were sufficiently informative, and examination of the Veteran would not elicit any additional information. Per the opinion report, the specialist found that the injury sustained by the Veteran in service was the kind of injury that would result in instability of the knee. After reviewing the medical evidence of record, the specialist went on to opine that the Veteran's right knee instability, stemming from the in service knee injury, was the eventual cause of the service-connected right knee DJD. Again, there is significant conflicting medical evidence of record concerning whether the Veteran had instability of the right knee at any point during the initial rating period on appeal. As such, the Board finds remand for an opinion would be helpful in determining whether the Veteran had instability of the right knee at any point during the rating period on appeal, and if so, the level of severity of the instability symptoms. The issue of a separate compensable disability rating for instability of the right knee is REMANDED for the following action: 1. Obtain a medical opinion from an appropriate examiner. A rationale for all opinions and a discussion of the facts and medical principles involved should be provided. The examiner should provide the following opinions: A) Is it at as likely as not (50 percent or higher degree of probability) that, prior to the May 2016 partial knee replacement surgery, the Veteran had instability in the right knee? If the examiner assesses that the Veteran did not have instability in the right knee, the examiner should address the evidence to the contrary, to include the September 2011 report from a sports medicine specialist and the October 2015 private treatment record that appears to indicate some level of instability. B) If the examiner does assess that the Veteran had instability in the right knee prior to the May 2016 surgical procedure, were the instability symptoms best described as slight, moderate, or severe in severity? C) The examiner should opine as to whether it is as likely as not (50 percent or higher degree of probability) that, at any point following to the May 2016 partial knee replacement surgery, the Veteran had instability in the right knee. D) If the examiner does assess that the Veteran had instability in the right knee at any point after the May 2016 surgical procedure, were the instability symptoms best described as slight, moderate, or severe in severity? 2. Then, readjudicate the issue of a separate compensable disability rating for instability of the right knee. J. PARKER Veterans Law Judge Board of Veterans' Appeals Attorney for the Board E. Blowers, 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.