Citation Nr: 21029817 Decision Date: 05/17/21 Archive Date: 05/17/21 DOCKET NO. 14-09 781 DATE: May 17, 2021 ORDER Entitlement to service connection for gout, to include as secondary to service-connected disabilities, is denied. Entitlement to an initial rating in excess of 20 percent disabling for lumbar spine disability is denied. Entitlement to an initial rating in excess of 10 percent disabling for right knee disability is denied. Entitlement to an initial rating in excess of 10 percent disabling for left knee disability is denied. REMANDED Entitlement to service connection for an acquired psychiatric disorder is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. FINDINGS OF FACT 1. The Veteran's gout did not originate in service, within a year of service, and is not otherwise etiologically related to his active service or to another service-connected disability. 2. Throughout the period on appeal, the Veteran's lumbar spine disability was not manifested by forward flexion limited to 30 degrees or less, ankylosis, or intervertebral disc syndrome (IVDS) with incapacitating episodes having a total duration of at least 4 weeks, but less than 6 weeks during the past 12 months. 3. Throughout the period on appeal, the Veteran's right knee disability was not manifested by ankylosis, flexion limited to 60 degrees or less, or extension limited to 15 degrees or less, a meniscal condition with frequent episodes of joint locking pain and effusion, or instability. 4. Throughout the period on appeal, the Veteran's left knee disability was not manifested by ankylosis, flexion limited to 60 degrees or less, or extension limited to 15 degrees or less, a meniscal condition with frequent episodes of joint locking pain and effusion, or instability. CONCLUSIONS OF LAW 1. The criteria for service connection for gout have not been met. 38 U.S.C. §§ 1131, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310. 2. Throughout the period on appeal, the criteria for an initial rating in excess of 20 percent disabling for right shoulder disability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.14, 4.40, 4.45, 4.71a, DCs 5003, 5019, 5200 to 5203. 3. Throughout the period on appeal, the criteria for an initial rating in excess of 10 percent disabling for right knee disability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.14, 4.40, 4.45, 4.71a, DCs 5256-5263. 4. Throughout the period on appeal, the criteria for an initial rating in excess of 10 percent disabling for left knee disability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.14, 4.40, 4.45, 4.71a, DCs 5256-5263. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from August 1976 to August 1979. This matter is before the Board of Veterans' Appeals (Board) on appeal from April 2012 (bilateral knee), June 2012 (lumbar spine) and March 2015 (gout and acquired psychiatric disorder) rating decisions by a Department of Veterans Affairs Regional Office (RO). In May 2018, the Veteran testified at a Travel Board hearing before the undersigned. A copy of the transcript of that hearing has been associated with the claims file. In October 2018, the Board remanded this case and instructed the Agency of Original Jurisdiction (AOJ) to obtain Social Security Administration (SSA) records. The AOJ was further instructed to obtain VA examinations. The Board notes that SSA records and the requested VA examinations have been obtained and associated with the claims file. Accordingly, with regard to the issues decided below, the Board finds there was substantial compliance with the requested development. Dyment v. West, 13 Vet. App. 141 (1999); Stegall v. West, 11 Vet. App. 268 (1998). Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated during service. 38 U.S.C. § 1131; 38 C.F.R. § 3.303. In order to establish entitlement to service connection, there must be (1) evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) a causal connection between the claimed in-service disease or injury and the current disability. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). Service connection may also be established on a secondary basis for a disability which is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). To prevail on the issue of entitlement to secondary service connection, there must be: (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) nexus evidence establishing a connection between the service-connected disability and the current disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995). The Board must determine whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either case, or whether the preponderance of the evidence is against the claim, in which case, service connection must be denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 1. Gout The Veteran seeks entitlement to service connection for gout. Specifically, he asserts his gout is secondary to his service-connected bilateral knee disability. See May 2018 Board Hearing Transcript. Initially, the Board notes that the service treatment records (STRs) are completely silent for any complaints or treatment for gout. Post-service medical records show that the Veteran was treated for gout involving his left big toe in December 2011. In February 2012, a VA medical record noted a two-day gout flare-up. The Veteran reported that his gout flare-ups began after he broke his foot. See VA Medical Records Received April 2012. The Veteran was treated for another gout attack in June 2012, affecting his right first metacarpophalangeal joint (MPJ). See VA Medical Records Received July 2017. In his August 2014 claim, the Veteran asserted his gout was secondary to traumatic arthritis. In July 2015, the Veteran was seen for a gout attack affecting his right wrist. Another July 2015 VA medical record shows the Veteran was seen for a gout flare-up affecting his left great toe and right foot. The physician noted a history of gout in the right foot and left wrist. VA medical records also show treatment for gout attacks involving the left foot in July 2015, April and August 2016, and involving the right wrist in January and July 2015, and January 2017. See VA Medical Records Received July 2017. In July 2017, the Veteran was treated for a gout attack involving his right knee. See VA Medical Records Received September 2017. The Veteran underwent a VA non-degenerative arthritis examination in September 2019. The examiner noted a diagnosis for gout that was treated with medication and that affected the right and left great toes at times, and more recently the hand and wrist. Gout was not noted to affect the bilateral knee. The examiner opined that there was less than a 50 percent probability that the Veteran's gout was etiologically related to his service. In support of this opinion, the examiner noted no evidence of gout during active duty service. In June 2020, the examiner additionally opined that it was "less likely than not (less than 50% probability)" that gout was caused or aggravated by the service-connected disabilities, including bilateral knee arthritis, or tinnitus. In support of this opinion, the examiner noted that based on a review of the Computerized Patient Record System (CPRS), Joint Legacy Viewer (JLV), an electronic health record including data from VA and the Department of Defense, and the "Up To Date" medical research tool, there were no repeated peer review studies to date listing arthritis of the knees or tinnitus as causes or aggravating factors of gout. Instead, the examiner noted that the Veteran had non-service-connected risk factors for gout including diabetes and renal insufficiency. After a review of the evidence of record, the Board finds that entitlement to service connection for gout is not warranted. In the present case, there is sufficient evidence the Veteran meets the threshold criterion for service connection of a current disability. Boyer v. West, 210 F.3d 1351 (Fed. Cir. 2000). Specifically, VA medical records and the September 2019 VA examination report reveal diagnoses for gout. Accordingly, the remaining question is whether the Veteran's gout is otherwise related to service. Initially, the Board has considered whether service connection is warranted on a direct basis. However, a review of the STRs does not evidence any complaints or treatment related to gout. The Board further finds the September 2019 VA examiner's negative nexus opinion with regard to direct service connection probative in this matter. That opinion was also based on a lack of evidence of gout during service. Finally, the Board notes that the Veteran has consistently asserted that his gout is secondary to his service-connected disabilities, and has not asserted that his gout is directly related to service. Accordingly, with regard to the September 2019 negative nexus opinion, there is no probative evidence to the contrary. Turning to whether entitlement to service connection on a secondary basis is warranted, the Board finds the September 2019 VA examination report and the June 2020 negative nexus opinion the most probative evidence of record. The examiner considered the evidence in the claims file as well as the Veteran's lay statements. However, the examiner concluded that it was "less likely than not (less than 50% probability)" that the Veteran's gout was caused or aggravated by his service-connected disabilities. In support of this opinion, the examiner noted no medical studies or research showing arthritis of the knees or tinnitus as causes or aggravating factors of gout. Instead, the examiner noted that the Veteran had other risk factors relevant to the etiology of gout, including his non-service-connected diabetes and renal insufficiency. The Board does recognize that the examiner did not provide a secondary opinion with regard to the service-connected lumbar spine disability. However, throughout the period on appeal, the Veteran has specifically asserted that his gout was secondary to his bilateral knee condition. This includes the May 2018 Board hearing where he provided testimony. Additionally, the evidence of record does not show gout affecting his lumbar spine. Accordingly, the Board finds that the September 2019 VA examination adequately addressed the inquiry on appeal. The Board does recognize the Veteran's lay statements linking his gout to his service-connected bilateral knee disability. The Veteran is competent to report purported symptoms such as pain and where his gout affects his body. 38 C.F.R. § 3.159(a)(2); Barr v. Nicholson, 21 Vet. App. 303 (2007). However, without evidence showing that he has medical training or expertise, he cannot competently provide a medical nexus opinion between his gout and his service-connected bilateral knee disability. 38 C.F.R. § 3.159(a)(1)-(2); Jandreau v. Nicholson, 492 F.3d 1372 (2007). In any event, to the extent the Veteran may be competent to opine as to medical etiology, the Board finds that the Veteran's lay assertions in the present case are outweighed by the VA medical examiner's opinion, who determined that the there was no etiological association between his gout and his service-connected disabilities, to include on an aggravation basis. The examiner has training, knowledge, and expertise on which he relied to form his opinion, and he provided a persuasive rationale. Importantly, there is no medical evidence to the contrary. Although the Veteran is entitled to the benefit-of-the-doubt where the evidence is in approximate balance, the benefit-of-the-doubt doctrine is inapplicable where, as here, the preponderance of the evidence is against the claim for service connection for gout. The claim is denied. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 58 (1990). 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. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. The basis of disability ratings is the ability of the body as a whole, or of the psyche, or of a system or organ of the body, to function under the ordinary conditions of daily life, including employment. 38 C.F.R. § 4.10. Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability more nearly approximates the criteria required for that particular rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. When a reasonable doubt arises regarding the degree of disability, that reasonable doubt will be resolved in favor of the Veteran. 38 C.F.R. § 4.3. In determining the severity of a disability, the Board is required to consider the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the Veteran, and the entire history of the Veteran's disability. 38 C.F.R. §§ 4.1, 4.2; Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Staged ratings are appropriate for an increase rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). 2. Lumbar Spine Disability The Veteran filed a service connection claim for lumbar spine disability in March 2011. That claim was granted in a June 2012 rating decision and assigned a 20 percent evaluation pursuant to 38 C.F.R. § 4.71a, DC 5237-5243; effective March 2011. The Veteran has appealed the initial rating. During the period on appeal, the Veteran underwent a lumbar spine examination in January 2012. The examiner noted a diagnosis for degenerative disc disease (DDD). The Veteran reported chronic low back pain and flare-ups. No diagnostic testing, to include range of motion (ROM), muscle strength, reflex or sensory testing was performed. The Veteran reported missing work often due to low back pain. At an April 2012 examination, the lumbar spine disability was found manifested by extension and forward flexion to 80 degrees with painful motion found beginning at 10 degrees. Repetitive use testing produced the same ROM results, although extension, which was initially limited to 20 degrees was further limited to 10 degrees. The examiner noted functional loss due to pain on movement. The examiner also found guarding or muscle spasms resulting in an abnormal gait. Muscle strength, reflex and sensory testing was normal. No radiculopathy was found. The Veteran's lumbar spine disability was not found manifested by intervertebral disc syndrome (IVDS). In a December 2015 addendum to the April 2012 VA examination, the examiner noted that a determination as to further loss of ROM of the lumbar spine due to pain on use, repeated use over a period of time, or flare-ups, could not be provided without resorting to mere speculation. In this regard, the examiner noted that such a finding would require an examination during a flare-up. An April 2017 private medical record noted a back manifested by normal ROM. See Private Medical Records Received July 2017. During a May 2018 Board hearing, the Veteran testified that his lumbar spine disability had worsened, and that due to his lumbar spine and bilateral knee disabilities, he had been prescribed a wheelchair. An October 2018 VA medical record noted the Veteran was wheelchair bound due to a stroke. See VA Medical Records Received July 2019. Additionally, during a September 2019 VA knee examination, the Veteran reported that he had used a wheelchair as a regular assistive device secondary to a stroke. The Veteran last underwent a VA lumbar spine examination in September 2019. The Veteran reported flare-ups and functional loss with activities. ROM testing revealed forward flexion to 60 degrees and extension to 25 degrees. Repetitive use testing did not result in further loss of ROM. The examiner additionally found that pain, weakness, fatigability and/or incoordination did not significantly limit functional ability with repeated use over a period of time or during flare-ups. In this regard, the Veteran reported that his ROM remained the same during flare-ups. The lumbar spine disability was not found manifested by guarding, muscle spasm, or ankylosis. Muscle strength, reflex and sensory testing were normal. The lumbar spine was not manifested by any signs or symptoms due to radiculopathy, other neurological abnormalities, or IVDS. As noted above, throughout the period on appeal, the Veteran's lumbar spine disability has been rated 20 percent disabling pursuant to 38 C.F.R. § 4.71a, DC 5237-5243. Schedular ratings for disabilities of the spine are provided by application of the General Rating Formula for Diseases or Injuries of the Spine or by application of the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes. 38 C.F.R. § 4.71a. The General Formula specifies that the criteria and ratings apply with or without symptoms such as pain, whether or not it radiates, stiffness, or aching in the area affected by residuals of injury or disease. 38 C.F.R. § 4.71a. The Board notes that during the pendency of the appeal, the rating criteria for evaluating musculoskeletal disabilities under 38 C.F.R. § 4.71a were amended effective February 7, 2021. 85 Fed. Reg. 230 (Nov 30, 2020). These amendments revised select diagnostic codes "to ensure that this portion of the rating schedule uses current medical terminology and provides detailed and updated criteria for the evaluation of musculoskeletal disabilities." Id. Therefore, the Board will consider the Veteran's claim under the old criteria prior to February 7, 2021, and both the old and new rating criteria from February 7, 2021. The criteria that is more favorable to the Veteran will be applied. Prior to February 7, 2021, the General Rating Formula for Diseases or Injuries of the Spine pertained to diagnostic codes 5235 to 5243. 38 C.F.R. § 4.71a, General Rating Formula for Diseases or Injuries of the Spine. Under this rating criteria, a 20 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; a 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 rating is warranted for forward flexion 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is warranted for unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent rating is warranted for unfavorable ankylosis of the entire spine. Under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, a 60 percent rating is assigned where there are incapacitating episodes having a total duration of at least six weeks during the past 12 months. A 40 percent rating is assigned where there are incapacitating episodes having a total duration of at least four weeks but less than six weeks during the past 12 months. A 20 percent rating is assigned where there are incapacitating episodes having a total duration of at least two weeks but less than four weeks during the past 12 months. A 10 percent rating is assigned where there are incapacitating episodes having a total duration of at least one week but less than 2 weeks during the past 12 months. 38 C.F.R. § 4.71a, Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes. An incapacitating episode is defined as a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician. 38 C.F.R. § 4.71a; Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, Note (1). Effective February 7, 2021, DC 5242, applies to degenerative arthritis and DDD other than IVDS. DC 5243 applies to IVDS and directs the rater to assign that diagnostic code only when there is disc herniation with compression of the adjacent nerve root, and to assign DC 5242 for all other disc diagnoses. However, throughout the period on appeal, the Veteran's lumbar spine disability has not been manifested by IVDS. Accordingly, the rating criteria pertaining to the Veteran's service-connected lumbar spine disability has not substantially changed as a result of the February 7, 2021 amendments. Turning to the rating criteria relevant to the claim on appeal, after a review of the evidence of record, the Board finds that throughout the period on appeal, a rating in excess of 20 percent disabling is not warranted. In this regard, ROM has been shown manifested by forward flexion to, at worst, 60 degrees. See September 2019 VA Examination Report. Importantly, at the time the 60 degrees of flexion was recorded, the Veteran stated that his ROM remained the same during flare-ups. 38 C.F.R. §§ 4.40 and 4.45. While the Board recognizes that the April 2012 VA examination also shows that pain began at 10 degrees, and that the examiner noted functional loss due to pain on movement, there is no evidence, nor has the Veteran asserted, that his ROM has been limited to less than 30 degrees at any time during the period on appeal. Accordingly, throughout the period on appeal, the Board finds that the lumbar spine disability has not been shown to be manifested by forward flexion limited to 30 degrees or less. The Board further notes that throughout the period on appeal, the lumbar spine has not been found manifested by ankylosis. The Board has also considered rating the Veteran's lumbar spine disability pursuant to the Formula for Rating Intervertebral Disc Syndrome. However, throughout the period on appeal, the lumbar spine disability has not been shown to be manifested by IVDS, nor has the Veteran asserted such. The Board has further considered assigning separate ratings based on neurogenic impairments. Initially, the Board notes that throughout the period on appeal, the Veteran has not been shown to have any other impairments, such as bowel or bladder impairment or radiculopathy, in connection with his lumbar spine disability. Accordingly, the Board concludes that separate ratings based on associated neurogenic impairments are not warranted. See 38 C.F.R. § 4.71a, General Rating Formula, Note (1). The Board additionally recognizes that during his May 2018 Board hearing, the representative asked the Veteran whether it was fair to say that his lumbar spine disability, in connection with his bilateral knee condition, was the reason he had been placed in a wheelchair, to which he responded affirmatively. However, the evidence of record clearly shows that his use of a wheelchair is directly related to residuals of a stroke. The Veteran confirmed this during his September 2019 VA knee examination, and during VA medical appointments. Accordingly, the Board concludes that throughout the period on appeal, the preponderance of the evidence is against the assignment of a rating in excess of 20 percent. The claim is denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 58 (1990). 3.-4. Bilateral Knee Disability The Veteran filed service connection claims for bilateral knee disability in March 2011. Those claims were granted in an April 2012 rating decision, with each knee assigned 10 percent evaluations pursuant to 38 C.F.R. § 4.71a, DC 5237-5243; effective March 2011. The Veteran has appealed the initial ratings. Shortly prior to the period on appeal, an August 2010 VA medical record shows the Veteran was issued and instructed on the use and safety of an adjustable cane secondary to a left foot proximal 2nd metatarsal fracture. See VA Medical Records Received July 2017. During the period on appeal, the Veteran underwent a knee examination in January 2012. The examiner noted a diagnosis for degenerative knees. The Veteran reported chronic pain, swelling and frequent falls. The bilateral knee was found manifested by extension and flexion between 0 and 140 degrees with objective evidence of painful motion beginning at 35 degrees, and extension to 0 degrees. The Veteran was able to perform repetitive use testing with no change in ROM. The examiner noted bilateral knee functional loss due to pain on movement. Muscle strength and stability testing was normal. No subluxation, dislocation, or a meniscal condition was found for either knee. In May 2012, the Veteran reported that his left knee symptoms had worsened including symptoms of swelling and giving out occasionally. The physician ordered a knee brace and the Veteran was fitted for a left hinged knee brace later that month. In August 2013, the Veteran was fitted for bilateral knee braces. Another August 2013 VA medical record shows the Veteran reported that both knees gave out, locked and popped, and that he sometimes used a cane. See VA Medical Records Received July 2017. A September 2013 VA physical therapy record noted pain rated a 6 to 8 on a scale to 10 for the left knee and 4 to 5 for the right knee. ROM testing revealed flexion to 135 degrees and extension to 0 degrees bilaterally. Muscle strength testing was normal. Additionally, ligament and meniscus integrity testing were all noted as negative including varus/valgus stress test, anterior drawer test, posterior drawer test and McMurray's test. Functional mobility was noted as within normal limits. The Veteran was noted to use a cane and bilateral knee brace. See VA Medical Records Received July 2017. In February 2014, the Veteran reported worsening bilateral knee symptoms including pain rated a 10 on a scale to 10, and difficulty bending and squatting. See VA Medical Records Received July 2017. In August 2014, the Veteran reported pain in his left knee rated between 5 and 9. In addition, the left knee reportedly gave way occasionally after prolonged sitting and walking. The physician noted a mild antalgic gait with minimal swelling. No palpable effusion was found. Additionally, no ligamental laxity with valgus/varus stress testing was found. ROM was noted as 110 degrees flexion and 0 degrees extension. No knee locking was noted. Negative McMurray's, anterior, and posterior drawer tests were also noted. See VA Medical Records Received March 2015. A June 2016 VA medical record noted an X-ray study revealing worsening osteoarthritis in the medial joint compartment of the left knee. A left knee examination noted full ROM with some pain. No joint effusion was found. See VA Medical Records Received July 2017. In July 2017, the Veteran reported that he was unable to stand on his own due to his knee giving out. An examination of the left knee revealed no deformity, effusion, or joint laxity to varus or valgus stress testing. ROM was noted as good. He was diagnosed with leg weakness due to deconditioning. See VA Medical Records Received September 2017. At a May 2018 Board hearing, the Veteran testified that his bilateral knee disability had worsened, and that his physician had prescribed him a wheelchair due to the severity of his bilateral knee and back disability. The Veteran further testified that following a stroke, he went to rehabilitation and the doctor told him he would never walk again due to his bilateral knee disability. A June 2019 VA medical record shows the Veteran used a cane, wheelchair and a motorized scooter as assistive devices. See VA Medical Records Received July 2017. The Veteran last underwent a VA knee examination in September 2019. The Veteran reported flare-ups with and without activity, and functional loss causing him to not be active on his legs. ROM testing revealed bilateral flexion and extension between 0 to 120 degrees with pain. There was no objective evidence of localized tenderness or pain. Repetitive use testing did not result in further loss of ROM. The examiner determined that pain, weakness, fatigability or incoordination did not significantly limit functional ability of either knee with repeated use over a period of time or during a flare-up. In this regard, the examiner noted that the Veteran reported that his ROM remained the same during flare-ups. The bilateral knee was not found manifested by ankylosis. Muscle strength testing was normal. Joint stability testing was also normal. In addition, the examiner noted that the bilateral knee was not manifested by a meniscal condition, history of recurrent subluxation, lateral instability or recurrent effusion. The Veteran was noted to use a wheelchair as a regular assistive device due to a stroke. Included within 38 C.F.R. § 4.71a are multiple DCs that evaluate impairment resulting from service-connected knee disorders, including DC 5256 (ankylosis), DC 5257 (other impairment, including recurrent subluxation or instability, and patellar instability), DC 5258 (cartilage, semilunar, dislocated with frequent episodes of "locking" pain, and effusion into the joint), DC 5259 (symptomatic removal of semilunar cartilage), DC 5260 (limitation of flexion), DC 5261 (limitation of extension), DC 5262 (impairment of the tibia and fibula), and DC 5263 (genu recurvatum). Initially, the Board notes that the bilateral knee disability has not been manifested by ankylosis, cartilage removal, impairment of the tibia and fibula, or genu recurvatum at any time during the period on appeal; therefore, DCs 5256, 5259, 5262 and 5263 are not for application. Additionally, as noted above, the rating criteria for evaluating musculoskeletal disabilities under 38 C.F.R. § 4.71a were amended effective February 7, 2021. 85 Fed. Reg. 230 (Nov 30, 2020). With regard to ratings concerning the knee, the revisions revised DC 5257 and 5262. As noted above, DC 5262 is not for application. DC 5257 is addressed below. Under DC 5258, a 20 percent rating is warranted for dislocation of semilunar cartilage with frequent episodes of "locking," pain, and effusion into the joint. 38 C.F.R. § 4.71a. Under DC 5260, limitation of flexion to 60 degrees warrants a non-compensable evaluation, and limitation of flexion to 45 degrees warrants a 10 percent evaluation. Limitation of flexion to 30 degrees warrants a 20 percent evaluation, and limitation of flexion to 15 degrees warrants a 30 percent evaluation. 38 C.F.R. § 4.71a. DC 5261 provides the rating criteria for limitation of extension of the leg. Under this diagnostic code, extension that is limited to 5 degrees is noncompensable; extension that is limited to 10 degrees warrants a 10 percent disability rating; and extension limited to 15 degrees warrants a 20 percent disability rating. Extension limited to 20 degrees warrants a 30 percent disability rating; extension limited to 30 degrees warrants a 40 percent disability rating; and extension limited to 45 degrees warrants a 50 percent disability rating. 38 C.F.R. § 4.71a. VA's General Counsel (GC) has interpreted that a veteran who has arthritis and instability of the knee could receive separate ratings under DCs 5003 and 5257. VAOPGCPREC 23-97. In VAOPGCPREC 9-98, the VA GC explained that, when a veteran has a knee disability evaluated under DC 5257, to warrant a separate rating for arthritis based on X-ray findings, the limitation of motion need not be compensable under DC 5260 or DC 5261; rather, such limited motion must at least meet the criteria for a zero-percent rating. In VAOPGCPREC 9-2004, the VA GC held that, when considering DCs 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 separate ratings for limitations in both flexion and extension under DC 5260 and DC 5261. Additionally, the United States Court of Appeals for Veterans Claims has addressed whether separate ratings could be assigned under DCs 5257 and DC 5258, which evaluates dislocated semilunar cartilage with frequent episodes of "locking," pain, and effusion in the joint, and DC 5259 (semilunar cartilage removal, symptomatic). The Court held that evaluation of a knee disability under DC's 5257 or 5261 or both does not, as a matter of law, preclude separate evaluation of a meniscal disability of same knee under DC 5258 or 5259, and vice versa. Lyles v. Shulkin, 29 Vet. App. 107, 112-113 (2017). The Court further held that entitlement to a separate evaluation in a given case depends on whether the manifestations of disability for which a separate evaluation is being sought have already been compensated by an assigned evaluation under a different DC. Id. After a review of the evidence of record, the Board finds that initial ratings in excess of 10 percent disabling based on limitation of motion is not warranted. In this regard, throughout the period on appeal, the evidence of record does not demonstrate a bilateral knee disability manifested by forward flexion limited to 30 degrees or less. Even if the Board were to consider the January 2012 VA examination noting painful forward flexion beginning at 35 degrees, the highest rating available would be 10 percent. Thus, a rating in excess of 10 percent under DC 5260 is not for application. Additionally, throughout the period on appeal, the Veteran's bilateral knee disability did not demonstrate extension limited to 10 degrees or less. Accordingly, a compensable rating under DC 5261 is not for application. The Board has also considered rating the bilateral knee pursuant to DC 5258. In this regard, the Board recognizes VA medical records showing the Veteran reported symptoms of locking. See August 2013 VA Medical Record. However, throughout the period on appeal, VA medical records and VA examination reports have consistently found the bilateral knee disability not manifested by a meniscal condition, or by effusion into the joint. Accordingly, the Board finds that separate ratings under DC 5258 are not for application. The Board has further considered ratings under DC 5257, which, as noted above, was recently revised effective February 7, 2021. Under the rating criteria in effect prior to February 7, 2021, under DC 5257, ratings were provided for subluxation or lateral instability. Effective February 7, 2021, DC 5257 provides ratings for recurrent subluxation or instability, and patellar instability. In this regard, the Board recognizes the Veteran's reports that his knees have "given way." See May 2012, August 2013, August 2014, and July 2017 VA Medical Records. While the Veteran is competent to report observed symptoms such as giving way, he is not competent to provide a medical finding as to joint instability as such is a complicated medical issue. 38 C.F.R. § 3.159(a)(1)-(2); Jandreau v. Nicholson, 492 F.3d 1372 (2007). In any event, the Board finds the cumulative VA medical records and examination reports throughout the period on appeal the most probative evidence of record; all of which found the bilateral knee condition not manifested by instability. With regard to the VA examinations, those examinations specifically included diagnostic testing to determine whether the bilateral knee was manifested by instability. Diagnostic testing was also performed in January 2012, September 2013, August 2014, and July 2017. All such diagnostic tests were consistently negative. Moreover, the July 2017 VA medical record found leg weakness due to deconditioning, not due to any knee instability. The Board concludes that if the Veteran had instability that more nearly approximated the criteria for a compensable rating under either the old or new rating criteria, such would have been shown upon objective testing at some point during the period on appeal. Therefore, with regard to instability, the Board finds the VA medical records and examinations the most probative evidence of record, and a separate rating based on reported symptoms of giving way is not warranted under either the old or new rating criteria. The Board further finds no basis for assigning any higher rating based on consideration of functional loss of the bilateral knee during this period on appeal. 38 C.F.R. §§ 4.40, 4.45, 4.59; Deluca, 8 Vet. App. at 204-06; Mitchell v. Shinseki, 25 Vet. App. 32, 38 (2011); Correia, 28 Vet. App. at 158. Here, the Veteran's bilateral knee disability has been assigned a compensable rating based on painful motion. See DeLuca v. Brown, 8 Vet. App. 202 (1995). In this regard, limitation of flexion has been shown to be, at worst, 35 degrees. Accordingly, as limitation of motion does not warrant a rating in excess of 10 percent, the criteria for a higher rating based on functional loss have not been met. 38 C.F.R. §§ 4.40, 4.45, 4.71a, DC 5260. In sum, the Board finds that throughout the period on appeal, the preponderance of the evidence is against the assignment of bilateral knee ratings in excess of 10 percent disabling, and those claims are denied. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 4.7, 4.71a, DCs 5256-5263; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). REASONS FOR REMAND 5. Acquired Psychiatric Disorder As noted above, this matter was remanded in October 2018 for further development of the reported in-service stressor, and to obtain a VA examination. The VA examiner was asked to provide medical opinions as to direct and secondary service connection. With regard to further development of the reported in-service stressor, the AOJ was requested to ask the Veteran to provide information necessary to verify his stressor event. In a July 2019 letter, VA requested that the Veteran provide more specific details of his stressor event. The Veteran has not responded to this letter and has not otherwise provided any further details regarding his reported stressor event. The Veteran did undergo a VA mental disorder examination in September 2019. The examiner noted a diagnosis for adjustment disorder with depressed mood. The examiner opined that the diagnosed psychiatric disorder was "as likely as not" related to a 2017 stroke and physical limitations that have persisted since that time. No rationale was provided. Thereafter, a VA PTSD examination was obtained in January 2021. The examiner noted diagnoses for adjustment disorder with depressed mood, and other specified trauma and stressor related disorder. The examiner noted that it was not possible to differentiate what symptoms were attributable to each diagnosis. The Veteran reported a stressor event that occurred while he was on night maneuvers in California when his jeep flipped over and crushed his friend. In addition, he reported that his depression had intensified as his health had deteriorated. With regard to the diagnosed other specified trauma and stressor related disorder, the examiner opined that it was "at least as likely as not (50 percent or greater probability)" that the diagnosed psychiatric disorder was etiologically related to service. In support of this opinion, the examiner noted that the Veteran appeared to experience some psychological difficulties including increased depressed mood, anxiety and intrusive memories, that were secondary to an event in which he saw the remains of a fellow service member. In this regard, the examiner found that exposure to the gruesome scene of the accident likely impacted the Veteran's psychological health since that time as evidenced by increased substance use and intrusive memories. The examiner further opined that the diagnosed adjustment disorder with depressed mood was less likely than not etiologically related to service. In support of this opinion, the examiner noted that the condition was related to the Veteran's 2017 stroke and related health difficulties. The Board finds the September 2019 and January 2021 VA examination reports inadequate. First, as noted above, the September 2019 VA examiner provided no rationale with regard to the nexus opinion provided. The examiner additionally did not address whether the diagnosed psychiatric disorder was aggravated by the service-connected disabilities as requested. With regard to the January 2021 VA examination, the examiner provided a positive nexus opinion with regard to direct service connection based on an inaccurate factual predicate. Namely, that the other trauma related disorder was etiologically related to the reported in-service stressor event. However, as noted above, no in-service stressor event has been verified. Instead, the Veteran failed to respond to the July 2019 VA letter requesting more specific details in order to verify his reported in-service stressor event. Additionally, a March 2015 VA Administrative Decision determined that information required to corroborate the reported stressor event was insufficient to send to the U.S. Army and Joint Services Records Research Center (JSRRC) and/or insufficient to allow for meaningful research of Marine Corps of National Archives and Records Administration (NARA) records. Prior to that decision, and similar to the development requested in the Board's October 2018 Remand, in a January 2015 letter VA requested that the Veteran provide more specific details regarding his reported in-service stressor event, including providing a two month time frame. The Veteran failed to respond to this letter. The Veteran is advised that VA's duty to assist in developing the facts and evidence pertinent to his claim is not a one-way street. See Wood v. Derwinski, 1 Vet. App. 190, 193 (1991) (further holding that "[i]f a Veteran wishes help, he cannot passively wait for it in those circumstances where he may or should have information that is essential in obtaining the putative evidence"). Rather, it is his responsibility to cooperate with VA, including with any efforts to develop his claim. See Caffrey v. Brown, 6 Vet. App. 377, 383 (1994); Olson v. Principi, 3 Vet. App. 480, 483 (1992). The Veteran has additionally provided conflicting statements as to his reported stressor event. In this regard, during his September 2019 VA examination, he reported that the incident occurred in Panama. Other reports note that the incident occurred in California. Therefore, a Remand is necessary to obtain an adequate VA examination. 6. TDIU Lastly, the claim for a TDIU is inextricably intertwined with the remaining claim on appeal. See Parker v. Brown, 7 Vet. App. 116 (1994); Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (two issues are "inextricably intertwined" when they are so closely tied together that a final Board decision cannot be rendered unless both are adjudicated). As the claims should be considered together, it follows that, any Board action on the TDIU claim, at this juncture, would be premature. Hence, a remand of this matter is warranted, as well. The matters are REMANDED for the following action: 1. With any necessary identification of sources by the Veteran, request all VA treatment records not already associated with the file from the Veteran's VA treatment facilities, and all private treatment records not already associated with the file. 2. Afford the Veteran and his attorney an additional opportunity to provide additional details on his claimed stressor involving witnessing the death of a fellow service member following a Jeep accident. 3. After the development above has been completed, schedule the Veteran for a VA examination with a psychiatrist or a psychologist (or telehealth interview, review of the record, etc., if an in-person examination is not feasible). The examiner must determine whether the Veteran currently suffers from an acquired psychiatric disorder, to include PTSD, depression and/or anxiety. All necessary special studies or tests, to include psychological testing and evaluation, should be accomplished. The examiner should provide the following information: (a) Provide a full multiaxial diagnosis. Specifically, state whether each criterion for a diagnosis of PTSD is met. Otherwise, provide a diagnosis for any acquired psychiatric disorder. (b) If a diagnosis of PTSD is appropriate, identify each stressor event upon which the diagnosis is based. (c) With respect to any psychiatric disorder found upon examination or identified during a review of the claims folder, the examiner should provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that each such psychiatric disability was caused by active duty service. (d) With respect to any psychiatric disorder found upon examination or identified during a review of the claims folder, the examiner should provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that each such psychiatric disability was (i) caused or (ii) aggravated by a service-connected disability, to include tinnitus, lumbar spine, and bilateral knee disabilities. The examiner is asked to consider the Veteran's lay statements that his service-connected disabilities cause and/or affect his depression. See September 2013 VA Medical Record, April 2017 Social Security Administration Claim, and May 2018 Board Hearing Transcript. The examiner should review pertinent documents in the Veteran's claims file in connection with the examination. All indicated studies should be completed. Reasons should be provided for any opinion rendered. If the examiner is unable to provide an opinion without resort to speculation, an explanation as to why this is so should be provided and any additional evidence that would be necessary before an opinion could be rendered should be identified. 4. Thereafter, the RO should readjudicate the claims on appeal, to include the claim for a TDIU. S. HENEKS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board C. Lamb, 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.