Citation Nr: 21030689 Decision Date: 05/19/21 Archive Date: 05/19/21 DOCKET NO. 17-37 595 DATE: May 19, 2021 ORDER New and material evidence having been received by VA sufficient to reopen a previously-denied claim to establish service connection for a low back disability, the claim is reopened. New and material evidence having been received by VA sufficient to reopen a previously-denied claim to establish service connection for a disability manifested bilateral wrist pain, the claim is reopened. Entitlement to an effective date prior to August 22, 2002, for the award of service connection for patellofemoral syndrome of the right knee is denied. Entitlement to an effective date prior to July 13, 2005, for the assignment of a 20 percent evaluation for a service-connected right shoulder strain is denied. Entitlement to a 20 percent initial evaluation, at least, for a painful, unstable scar of the left knee from May 12, 2014, to June 2, 2014, is granted, subject to the applicable regulations concerning the payment of monetary benefits. REMANDED Entitlement to an evaluation in excess of 20 percent for service-connected patellofemoral syndrome of the left knee July 1, 2015 to the present, to include the propriety of a separate evaluation for instability of the joint, is remanded. Entitlement to an evaluation in excess of 10 percent for service-connected patellofemoral syndrome and degenerative changes of the right knee, to include the propriety of a separate evaluation for subluxation of the joint is remanded. Entitlement to an increased evaluation a service-connected left shoulder strain currently evaluated 10 percent disabling prior to May 23, 2014, and 20 percent disabling, thereafter, is remanded. Entitlement to an evaluation in excess of 20 percent for a service-connected right shoulder strain is remanded. Entitlement to an initial evaluation in excess of 20 percent for a service-connected for a painful, unstable scar of the left knee is remanded. Entitlement to service connection for a disability manifested by left ankle pain is remanded. Entitlement to service connection for a low back disability, to include as secondary to a service-connected disability, is remanded. Entitlement to service connection for a disability manifested bilateral wrist pain is remanded. Entitlement to an effective date earlier than February 12, 2016, for the grant of a total evaluation based on individual unemployability due to service-connected disabilities (TDIU) is remanded. FINDINGS OF FACT 1. A December 2002 rating decision established service connection for a right knee disability and denied the Veteran's claim to establish service connection for bilateral carpal tunnel syndrome; the Veteran did not appeal any determination within that decision, nor was any new and material evidence submitted within the appeal period. 2. A May 2006 rating decision denied the Veteran's claim to establish service connection for a low back disability and increased the evaluation for the Veteran's service-connected right shoulder disability from 10 percent to 20 percent, effective from July 13, 2005; the Veteran did not appeal any determination within that decision, nor was any new and material evidence submitted within the appeal period. 3. Evidence received since the final December 2002 and May 2006 rating decisions raises a reasonable possibility of substantiating the issues to establish service connection for bilateral carpal tunnel syndrome and a low back disability, respectively. 4. The issues seeking earlier effective dates for the grant of service connection for a right knee disability and the assignment of a 20 percent evaluation for a service-connected right shoulder disability are "freestanding" claims for earlier effective dates. 5. The most probative evidence reflects that the Veteran's service-connected left knee scar has been, at least, painful and stable from May 12, 2014, to June 2, 2014. CONCLUSIONS OF LAW 1. The December 2002 rating decision that established service connection for a right knee disability and denied the Veteran's claim to establish service connection for bilateral carpal tunnel syndrome is final. 38 U.S.C. § 7105(c); 38 C.F.R. §§ 3.104, 20.302, 20.1103. 2. The May 2006 rating decision that denied the Veteran's claim to establish service connection for a low back disability and increased the evaluation for the Veteran's service-connected right shoulder disability from 10 percent to 20 percent, effective from July 13, 2005, is final. 38 U.S.C. § 7105(c); 38 C.F.R. §§ 3.104, 20.302, 20.1103. 3. Evidence received to reopen the previously-denied claims to establish service connection for bilateral carpal tunnel syndrome and a low back disability, is new and material, and the claims are reopened. 38 U.S.C. §§ 5108, 7105; 38 C.F.R. § 3.156(a). 4. The criteria for an effective date prior to August 22, 2002, for the award of service connection for a right knee disability have not been met. 38 U.S.C. §§ 5110; 38 C.F.R. §§ 3.105, 3.400(b)(2); Rudd v. Nicholson, 20 Vet. App. 296 (2006). 5. The criteria for an effective date prior to July 13, 2005, for the assignment of a 20 percent evaluation for a service-connected right shoulder disability have not been met. 38 U.S.C. §§ 5110; 38 C.F.R. §§ 3.105, 3.400(b)(2); Rudd v. Nicholson, 20 Vet. App. 296 (2006). 6. The criteria for a 20 percent initial evaluation, at least, for the Veteran's service-connected painful, unstable left knee scar are met from May 12, 2014, to June 2, 2014. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.118, Diagnostic Codes 7804, Note (2). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Navy from June 1991 to August 2000. This matter comes to the Board of Veterans' Appeals (Board) from a July 2014 and July 2016 rating decisions by a Department of Veterans Affairs (VA) Regional Office (RO) of the Veterans Benefits Administration (VBA), which is the Agency of Original Jurisdiction (AOJ). The Veteran expressed timely disagreement with this determination, and the present appeal ensued. During the lengthy pendency of the Veteran's claims on appeal, the AOJ has recharacterized and partially granted many of the issues currently before the Board, resulting in the assignment of "staged" evaluations. As these actions did not result in full allowances of the benefits sought regarding any individual issue, the appealed issues have been recharacterized as stated on the title page to reflect the AOJ's actions, staged evaluations, and residual entitlement being sought. Hart v. Mansfield, 21 Vet. App. 505 (2007); AB v. Brown, 6 Vet. App. 35, 38-39 (1993); see also Rice v. Shinseki, 22 Vet. App. 447, 453-54 (2009). In April 2020, the Veteran presented testimony in support of his appeal at a Board hearing conducted by the undersigned Veterans Law Judge via videoconferencing equipment. A transcript of the April 2020 hearing is associated with the file. Additional matter In June 2020, the Veteran's private attorney sent a statement to the Board that moves for revision of a portion of a December 2002 rating decision that denied entitlement to service connection for bilateral carpal tunnel syndrome based on Clear and Unmistakable Error (CUE) in the same. While it appears that this motion was filed in furtherance of the petition to reopen the previously-denied claim to establish service connection for this disability, which is currently before the Board, the United States Court of Appeals for Veteran's Claims (Court) has made clear that claims and appeals seeking service connection for disabilities are not intertwined with CUE motions seeking the same benefit under a separate legal theory. See e.g., Phillips v. Brown, 10 Vet. App. 25 (1997). In light of the Court's holding in Phillips and the fact that the AOJ has not addressed this motion for CUE in the first instance, the Board concludes that the June 2020 CUE motion is not within the Board's jurisdiction at this time. The Veteran and his private attorney are advised that a formal CUE motion must be filed with the AOJ on the VA Form prescribed by the Secretary. 1. New and material evidence having been received by VA sufficient to reopen a previously-denied claim to establish service connection for a low back disability, the claim is reopened. 2. New and material evidence having been received by VA sufficient to reopen a previously-denied claim to establish service connection for a disability manifested bilateral wrist pain, the claim is reopened. Pertinent procedural regulations provide that "[n]othing in [38 U.S.C. § 5103A] shall be construed to require [VA] to reopen a claim that has been disallowed except when new and material evidence is presented or secured, as described in [38 U.S.C. § 5108]." 38 U.S.C. § 5103A (f) (West 2002). Reopening a claim for service connection which has been previously and finally disallowed requires that new and material evidence be presented or secured since the last final disallowance of the claim. 38 U.S.C. § 5108; Evans v. Brown, 9 Vet. App. 273, 285 (1996). Service connection may be established for a disability resulting from diseases or injuries which are clearly present in service or for a disease diagnosed after discharge from service, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 U.S.C. §§ 1110, 1131 (West 2002); 38 C.F.R. § 3.303 (2017). Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). Service connection may also be granted for any disease initially diagnosed after service when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303 (d). New evidence means existing evidence not previously submitted to VA. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a) (2017). In Hodge v. West, 155 F.3d 1356, 1363 (Fed. Cir. 1998), the Federal Circuit noted that new evidence could be sufficient to reopen a claim if it could contribute to a more complete picture of the circumstances surrounding the origin of a claimant's injury or disability, even where it would not be enough to convince the Board to grant a claim. In determining whether evidence is new and material, the credibility of the evidence is generally presumed. Justus v. Principi, 3 Vet. App. 510, 512-513 (1992). In Elkins v. West, 12 Vet. App. 209 (1999), the United States Court of Appeals for Veterans Claims (the Court) held the Board must first determine whether the appellant has presented new and material evidence under 38 C.F.R. § 3.156(a) in order to have a finally denied claim reopened under 38 U.S.C. § 5108. Then, if new and material evidence has been submitted, the Board may proceed to evaluate the merits of the claim, but only after ensuring that VA's duty to assist has been fulfilled. See Vargas-Gonzalez v. West, 12 Vet. App. 321, 328 (1999). The Court has also held that the law should be interpreted to enable reopening of a claim, rather than to preclude it. See Shade v. Shinseki, 24 Vet. App. 110 (2012). Even if no appeal is filed, a rating decision is not final if new and material evidence is submitted within the appeal period and has not yet been considered by VA. 38 C.F.R. § 3.156(b) (2017); Bond v. Shinseki, 659 F.3d 1362 (Fed. Cir. 2011). Petitions to reopen In the interest of economy, the Board will discuss the above petitions to reopen these previously-denied claims together. As will be fully addressed below, the Board concludes that, since the AOJ's prior final denials of these claims in final December 2002 and May 2006 rating decisions, VA has received evidence which is new and material and raises a reasonable possibility of substantiating the claims. As such, these claims are reopened. Pertinently, in the December 2002 and May 2006 rating decisions, the AOJ denied the Veteran's to establish service connection for bilateral carpal tunnel syndrome and a low back disability, respectively, because the evidence at the time did not reflect a diagnosis of either claimed disability. The Veteran did not submit a timely expression of disagreement with the AOJ's denials of these claims, nor did he submit pertinent new and material evidence within the appeal period of these rating decisions. As such, the December 2002 and May 2006 rating decisions are final regarding the AOJ's denial of these claims. 38 U.S.C. §§ 5108, 7105; 38 C.F.R. § 3.156 (a), (b); Bond v. Shinseki, 659 F.3d 1362 (Fed. Cir. 2011). In order for these previously-denied claims to be reopened, evidence must have been added to the record since the prior final denials of these claims that addresses these bases. The AOJ's determinations during the pendency of the present appeal concerning whether or not new and material evidence has been received by VA since the prior final denials are not binding on the Board. Jackson v. Principi, 265 F.3d 1366 (Fed. Cir. 2001). Evidence received by VA since the prior final denials in December 2002 and May 2006 includes the Veteran's assertions that he has experienced hand/wrist pain during and since service and that his low back pain, claimed to be due to a herniated disc or degenerative disc disease, was caused or aggravated by an antalgic gait resulting from his service-connected knee disabilities. The Board acknowledges these assertions and also observes that, while several provisional diagnoses have been discussed to account for the Veteran's pain in his hands, wrists, and low back, the evidence of record is still tenuous regarding the nature of the Veteran's claimed disabilities. To the above point, the United States Court of Appeals for the Federal Circuit's (Federal Circuit's) holding in Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018), providing that the term "disability" as used in 38 U.S.C. § 1110 "refers to the functional impairment of earning capacity, not the underlying cause of said disability," and held that "pain alone can serve as a functional impairment and therefore qualify as a disability." While the Board notes that there were subjective reports of hand, wrist, and low back pain from the Veteran of record at the time of the final December 2002 and May 2006 rating decisions, the Court's recent holding in Saunders sheds new light on the evidentiary importance of these statements, to specifically include whether such raise a reasonably possibility of substantiating his claims. The above evidence and contentions are "new," as they were not before VA at the time of the December 2002 and May 2006 rating decisions, and "material" as they raise the reasonable possibility of substantiating the previously-denied claims. The Board thus finds that new and material evidence has been submitted to reopen the issues to establish service connection for bilateral carpal tunnel syndrome and a low back disability since the prior final denials in December 2002 and May 2006, respectively. On that basis, the previously-denied claims are reopened, and the Veteran's appeal is granted to that extent only. As will be discussed below, further development is necessary prior to readjudication of the merits of the underlying appeal in order to ensure that VA fulfills its duty to assist the Veteran. 3. Entitlement to an effective date prior to August 22, 2002, for the award of service connection for patellofemoral syndrome of the right knee is denied. 4. Entitlement to an effective date prior to July 13, 2005, for the assignment of a 20 percent evaluation for a service-connected right shoulder strain is denied. By rating decisions dated in December 2002 and February 2003, the AOJ, among other actions, established service connection for right knee and right shoulder disabilities; initial evaluations were assigned from August 22, 2002 the date that the AOK received the Veteran's initial claim for disability benefits. The Veteran did not express disagreement or submit new and material evidence within the appellate period of these decisions, and thus, they became final regarding these matters. 38 U.S.C. § 7105 (c); 38 C.F.R. §§ 3.104, 3.156(b), 20.302, 20.1103. On July 13, 2005, the AOJ received from the Veteran a claim seeking an increased evaluation for his service-connected right shoulder disability, among other benefits. This claim was partially granted by the AOJ in a May 2006 rating decision; the 10 percent evaluation was increased to 20 percent, effective from February 23, 2005. The Veteran did not express disagreement or submit new and material evidence within the appellate period of this rating decision, and thus, it became final regarding these matters. 38 U.S.C. § 7105 (c); 38 C.F.R. §§ 3.104, 3.156(b), 20.302, 20.1103. On May 23, 2014, the Veteran filed claims seeking, among other benefits, increased evaluation for his service-connected right knee and right shoulder disabilities. These claims were adjudicated by the AOJ in the July 2016 rating decision, and the Veteran initiated the present appeal. It appears that there was a disconnect between the AOJ and the Veteran's prior private attorney regarding the which issues were being appealed. Nonetheless, these issues were readjudicated by the AOJ in the June 2017 Statement of the Case (SOC), and the Veteran subsequently perfected such to the Board. In passing, the Board observes that the Veteran's current private attorney has not made any assertions in furtherance of these appealed issues, and the Veteran did not offer any testimony regarding such at the April 2020 Board hearing. As outlined above, the effective dates for the award of service connection for a right knee disability and for the 20 percent evaluation for a service-connected right shoulder disability were assigned by the AOJ in the December 2002 and May 2006 rating decisions, respectively. Since these rating decisions became final, the issues currently before the Board are "freestanding" claims for earlier effective dates. In Rudd v. Nicholson, 20 Vet. App. 296 (2006), the Court ruled that such a "freestanding" claim "vitiates the rule of finality," and seeks a benefit not provided by law. Therefore, these appealed issues must be denied as a matter of law. 4. Entitlement to a compensable initial evaluation for a painful, unstable scar of the left knee prior to June 3, 2014 Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R. Part 4. The percentage ratings are based on the average impairment of earning capacity as a result of a service-connected disability, and separate diagnostic codes identify the various disabilities and the criteria for specific ratings. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. VA has a duty to consider all regulations that are potentially applicable through the assertions and issues raised in the record. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). 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. 38 C.F.R. § 4.7. The Board will consider whether separate ratings may be assigned for separate periods of time based on facts found, a practice known as "staged ratings." Hart v. Mansfield, 21 Vet. App. 505 (2007). Diagnostic Code 7800 provides compensation for disfigurement of the head, face, or neck. 38 C.F.R. § 4.118. As the Veteran's service-connected scars at issue in this case are not of the head, neck, or face, the provisions of this Diagnostic Code need not be discussed. Similarly, Diagnostic Code 7801 provides compensation for burn scar(s), other than on the head, face, or neck, that are associated with underlying soft tissue damage. 38 C.F.R. § 4.118. As the Veteran's service-connected scars are not associated with underlying tissue damage, this Diagnostic Code and the associated Notes are not for consideration. The rating criteria for Diagnostic Code 7801 were not changed by the recent amendments but the Notes have been amended. Diagnostic Code 7802 provides compensation for burn scar(s) or scar(s) due to other causes, not of the head, face, or neck, that are superficial and nonlinear. 38 C.F.R. § 4.118. A 10 percent rating is provided for area or areas of 144 square inches (929 square centimeters) or greater. Id. Note (1) states that the six (6) zones of the body are defined as each extremity, anterior trunk, and posterior trunk. 38 C.F.R. § 4.118. The midaxillary line divides the anterior trunk from the posterior trunk. Note (2) states that a separate evaluation may be assigned for each affected zone of the body under Diagnostic Code 7802 if there are multiple scars, or a single scar, affecting multiple zones of the body. 38 C.F.R. § 4.118. Under such circumstances, separate evaluations are to be combined under § 4.25. Id. Alternatively, if a higher evaluation would result from adding the areas affected from multiple zones of the body, a single evaluation may also be assigned under Diagnostic Code 7802. Id. Diagnostic Code 7804 provides compensation for painful or unstable scars. 38 C.F.R. § 4.118. A 10 percent rating is provided for one or two scars that are unstable or painful. Id. A 20 percent rating is provided for three or four scars that are unstable or painful. Id. A 30 percent rating is provided for five or more scars that are unstable or painful. Id. Note (1) states that an unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. 38 C.F.R. § 4.118. Note (2) states that if one or more scars are both unstable and painful, 10 percent is to be added to the evaluation that is based on the total number of unstable or painful scars. Id. Note (3) states that scars evaluated under Diagnostic Codes 7800, 7801, 7802, or 7805 may also receive an evaluation under Diagnostic Code 7804, when applicable. Id. Diagnostic Code 7805 provides that disabling effects of scars not considered in a rating under Diagnostic Codes 7800 to 7804 are evaluated under other appropriate diagnostic codes. 38 C.F.R. § 4.118. Diagnostic Code 7805 does not include linear scars. Id. Diagnostic Code 7806 and the General Formula for Rating the Skin provides that dermatitis or eczema are evaluated under the General Rating Formula for the Skin. 38 C.F.R. § 4.118. A 0 percent rating is provided for no more than topical therapy required over the past 12-month period and at least one of the following: (i) characteristic lesions involving less than 5 percent of the entire body affected; or (ii) characteristic lesions involving less than 5 percent of exposed areas affected. Id. A 10 percent rating is provided for at least one of the following: (i) characteristic lesions involving at least 5 percent, but less than 20 percent, of the entire body affected; (ii) at least 5 percent, but less than 20 percent, of exposed areas affected; or (iii) intermittent systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, PUVA, or other immunosuppressive drugs required for a total duration of less than 6 weeks over the past 12-month period. 38 C.F.R. § 4.118. A 30 percent rating is provided for at least one of the following: (i) characteristic lesions involving 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected; or (ii) systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, PUVA, or other immunosuppressive drugs required for a total duration of 6 weeks or more, but not constantly, over the past 12-month period. 38 C.F.R. § 4.118. A 60 percent rating is provided for at least one of the following: (i) characteristic lesions involving more than 40 percent of the entire body or more than 40 percent of exposed areas affected; or (ii) constant or near-constant systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, psoralen with long-wave ultraviolet-A light (PUVA), or other immunosuppressive drugs required over the past 12-month period. 38 C.F.R. § 4.118. Alternatively, dermatitis or eczema can be rated as disfigurement of the head, face, or neck (Diagnostic Code 7800) or scars (Diagnostic Codes 7801, 7802, 7804, or 7805), depending upon the predominant disability. 38 C.F.R. § 4.118. The General Rating Formula for the Skin does not apply to Diagnostic Code 7824. Id. Analysis By way of background, the Veteran underwent left bursectomy surgery at a VA facility on May 12, 2014, in connection with his service-connected left knee disability. On May 23, 2014, the Veteran filed a claim seeking an increased evaluation for his service-connected left knee disability, among other benefits. Shortly after filing this claim, he developed a staph infection at the left knee surgical site, resulting in hospitalization at a VA facility from June 3, 2014, to June 7, 2014, for debridement of this infected wound. These events have resulted in a painful, unstable 3 x 3 centimeter wound over the left patellar area. Based on the above, by the July 2014 rating decision, the AOJ among other actions, established service connection for a surgical scar of the left knee; a noncompensable (zero percent) initial evaluation was assigned from May 23, 2014 the date that the AOJ received the Veteran's claim seeking an increased evaluation for his service-connected left knee disability. During the appeal period of this rating decision, the Veteran submitted evidence showing that his left knee surgical scar remained unhealed and had worsened in severity. Based on this evidence and the findings of a January 2015 VA examination, by a January 2015 rating decision, the AOJ increased the noncompensable initial evaluation for this disability to 20 percent from June 5, 2014. The 20 percent initial evaluation assigned by the AOJ from June 3, 2014, represents a combined evaluation for one painful (10 percent) and unstable (10 percent) scar under Diagnostic Code 7804, Note (2). 38 C.F.R. § 4.25. Although the AOJ stated in the rating decision that the Veteran's informal claim for these benefits was received on June 5, 2014, there is no evidence or submission in the Veteran's file that was received by the AOJ on this date. The Veteran subsequently initiated the present appeal. By a May 2017 DRO decision, the AOJ partially granted this appealed issue; the 20 percent initial evaluation for the Veteran's painful, unstable left knee surgical scar was assigned from June 3, 2014, 2014 the date that the Veteran was hospitalized for or the staph infection affecting the surgical wound. As stated by the AOJ, this partial allowance (two days earlier than previously assigned) represented "a substantial grant of the benefits sought on appeal;" however, the issue remains in appellate status because it was not a full grant of the benefits sought. AB v. Brown, 6 Vet. App. 35, 38 (1993). The Veteran's left knee scar is undoubtedly associated with the May 12, 2014, left knee surgery; however, the effective date for the award of service connection for this scar is from the date that the AOJ received the Veteran's claim for an increased evaluation for his service-connected left knee disability. To this point, the law is clear that service-connected disabilities, especially disabilities of the knee, must be rated in totality. As such, the claim for an increased evaluation for the Veteran's left knee disability included a left knee scar, and the proper effective date for the award of service connection for the Veteran's left knee scar is May 12, 2014 the date of the surgery from which the scar resulted. While the Veteran's claim was received after this surgery, the Board's finding in this matter is congruent with the Court's holding in Gaston v. Shinseki, 605 F.3d 979, 984 (Fed. Cir. 2010), and the AOJ's assignment of a 100 percent temporary total evaluation for the Veteran's left knee disability based on the same surgery and subsequent claim. Armed with the above, the matter before the Board regarding this issue involves entitlement to a compensable evaluation for the Veteran's service-connected left knee scar from May 12, 2014, to June 2, 2014. As outlined above, it appears that the Veteran's left knee scar did not heal prior to contracting the staff infection. As such, resolving all reasonable doubt in the Veteran's favor, the Board finds that his left knee scar has been both unstable and painful since the May 12, 2014, surgery. Accordingly, the criteria for at least a 20 percent initial evaluation from May 12, 2014, to June 2, 2014, are met under Diagnostic Code 7804, Note (2). To that extent the Veteran's appeal is granted; however, as will be discussed below, further development is necessary prior to readjudication of the Veteran's appeal seeking further entitlement. REASONS FOR REMAND 1. Entitlement to an evaluation in excess of 20 percent for service-connected patellofemoral syndrome of the left knee July 1, 2015 to the present, to include the propriety of a separate evaluation for instability of the joint, is remanded. 2. Entitlement to an evaluation in excess of 10 percent for service-connected patellofemoral syndrome and degenerative changes of the right knee, to include the propriety of a separate evaluation for subluxation of the joint is remanded. 3. Entitlement to an initial evaluation in excess of 20 percent for a service-connected for a painful, unstable scar of the left knee is remanded. The Veteran was most recently provided VA examinations to determine the frequency, severity, and durations, of the symptoms associated with his service-connected knee disabilities and left knee scar in June 2016 nearly five years ago. At the April 2020 Board hearing, the Veteran asserted that these disabilities have worsened since the June 2016 VA examination. Accordingly, the Board concludes that a remand is necessary to determine the current frequency, severity, and durations, of the symptoms associated with these service-connected disabilities. Further, the Veteran is seeking separate evaluations for recurrent instability and subluxation of his knees. It appears that such symptoms have been previously noted on examination and rated; however, the AOJ's recharacterization of the Veteran's service-connected disabilities for rating purposes make it unclear whether separate evaluations are assigned and/or warranted. These matters must be clarified on remand based on the evidence of record. Additionally, the Board observes that the January 2015 VA examination report reflects that the Veteran experiences flare-ups of knee symptoms; however, his increased functional impairment during a flare-up of symptoms was not quantified as necessary under the Court's holding in Sharp v. Shulkin, 29 Vet. App. 26, 34 (2017). As such, a remand is necessary to obtain a retrospective opinion concerning this matter. Chotta v. Peake, 22 Vet. App. 80 (2008). 4. Entitlement to an increased evaluation a service-connected left shoulder strain currently evaluated 10 percent disabling prior to May 23, 2014, and 20 percent disabling, thereafter, is remanded. 5. Entitlement to an evaluation in excess of 20 percent for a service-connected right shoulder strain is remanded. Congruent with the January 2015 VA knee examination report, the January 2018 VA shoulder examination report reflects that the Veteran reported experiencing flare-ups of shoulder symptoms; however, the increased functional impairment during flare-ups were not quantified. As such, a remand is necessary. Sharp v. Shulkin, 29 Vet. App. 26, 34 (2017); Chotta v. Peake, 22 Vet. App. 80 (2008). 6. Entitlement to service connection for a disability manifested by left ankle pain is remanded. 7. Entitlement to service connection for a low back disability, to include as secondary to a service-connected disability, is remanded. 8. Entitlement to service connection for a disability manifested bilateral wrist pain is remanded. The Veteran has reported, to include at the April 2020 Board hearing, that he has experienced left ankle and bilateral wrist pain during and since service and that an antalgic gait secondary to his service-connected knee disabilities have resulted in low back pain. The Veteran's service treatment records are replete with evidence showing that the Veteran sought in-service treatment for pain in his left ankle and wrists. Moreover, his VA treatment records show that he has reported experiencing pain in his left ankle, wrists, and low back throughout the appeal period; however, definitive testing to determine the nature and existence of the Veteran's claimed disabilities has not been performed. Based on the above, the Board concludes that the low threshold to provide the Veteran a VA examination to determine the nature and etiology of the Veteran's claimed disabilities of the left ankle, wrists, and low back have been met. 38 C.F.R. § 3.159 (c)(4); McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006); Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018). 9. Entitlement to an effective date earlier than February 12, 2016, for the grant of a TDIU is remanded. As an initial matter, the Board notes that the appeal period for consideration regarding this appealed issue is from May 23, 2013, to February 11, 2016, and this appeal period may be further truncated by the assignment of a temporary total evaluation from May 12, 2014, to June 30, 2015, based on the Veteran's left knee surgery. Rice v. Shinseki, 22 Vet. App. 447, 452 (2009); Bradley v. Peake, 22 Vet. App. 280, 294 (2008); Buie v. Shinseki, 24 Vet. App. 242, 248 (2010). With the above in mind, the Board observes that the Veteran was employed full-time until his May 12, 2014, left knee surgery, and his employment from May 12, 2014, to February 12, 2016, may have been "marginal" rather than substantially gainful under the meaning of 38 C.F.R. § 4.16 (a). The record is currently insufficient to clearly delineate whether the Veteran's income from May 12, 2014, to February 12, 2016, provided income above or below the poverty threshold as per the standards of the U.S. Department of Commerce, Bureau of the Census, at any time during the period. As such, further development to clarify this critical matter is necessary. The matters are REMANDED for the following actions: 1. The AOJ must obtain and associate with the file all updated records of VA treatment pertaining to the Veteran. 2. The AOJ must request that the Veteran identify the names, addresses, and approximate dates of treatment for all of the non-VA health care providers who have treated him for the disabilities subject to the issues being remanded. After securing appropriate release(s) from the Veteran, the AOJ must make two attempts to obtain any identified private treatment records which are not already associated with the file or make a formal finding that a second request for such records would be futile. The Veteran must be notified of the results of the record requests. If records are not received from any source, follow the notification procedures of 38 C.F.R. § 3.159(e). 3. The AOJ must contact the Veteran and ask that he verify his personal income from May 12, 2014, to February 12, 2016, to include the submission of supporting documentation, pay stubs, and/or any other means available. *The Veteran is encouraged to comply with the AOJ's efforts is these matters, as his failure to do so may result in VA's inability to grant the benefits that he is seeking. 4. After the completion of above, the AOJ must determine whether the Veteran's income May 12, 2014, to February 12, 2016, was above or below the poverty threshold as per the standards of the U.S. Department of Commerce, Bureau of the Census. 5. Thereafter, the AOJ must request that the Veteran be scheduled for appropriate VA examinations to evaluate his service-connected shoulder disabilities, knee disabilities, and left knee scar, and determine the nature and etiology of his claimed disabilities of the left ankle, wrists, and low back. The complete electronic record must be made available to, and reviewed by, the VA examiner prior to conducting the examination. All necessary studies and tests should be conducted. The examiner must describe the frequency and severity of the manifestations of the Veteran's service-connected knee disabilities and shoulder disabilities, to include during flare-ups of symptoms, on repetitive motion testing, on passive and active motion, and in weight-bearing and nonweight-bearing positions. -The examiner is asked to review the January 2015 knee examination report and January 2018 shoulder examination report and provide retrospective findings for the additional functional impairment during a flare-up of symptoms that he experienced at that time. *The Board observes the inherent difficulty in providing such a retrospective opinion; however, the examiner is encouraged to make an effort to provide such findings, to the extent possible, based on the evidence of record contemporaneous to the January 2015 and January 2018 VA examination reports and the retrospective statement from the Veteran. -The examiner is asked to specifically state whether the evidence supports that the Veteran has experienced recurrent subluxation and/or instability of either knee at any time since May 2013. -The examiner is asked to describe the frequency, severity, and durations, of the symptoms associated with the Veteran's left knee scar. *In addressing the above, the examiner is asked to comment on the size (length, width, and depth) of the Veteran's left knee scar, whether such limits the Veteran's left knee motion, and whether the Veteran's treatment regimen includes systemic therapy as that term has been defined by the courts in the above cases, including Johnson v. Shulkin, 862 F.3d 1351 (Fed. Cir. 2017), Warren v. McDonald, 28 Vet. App. 194, 197 (2016), and Burton v. Wilkie, 30 Vet. App. 286 (2018). Specifically, the examiner should consider whether any topical therapy such as skin cream is systemic in its scale, method, or side effects. Thereafter, the VA examiner is requested to address the following: a. Identify or rule out disabilities affecting the below body parts: i. Either wrist or nerve impacting the wrists/hands; *The Board is particularly interested whether a diagnosis of carpal tunnel syndrome is appropriate. ii. Left ankle; iii. Low back. b. If the Veteran's reported pain in his left ankle, wrists, and/or low back are not found to be manifestations of any disability, please describe the functional impairment resulting from such. In doing so, the examiner is requested, to the extent possible, to describe any and all effects of the Veteran's pain on his ability to lift, squat, grasp, manipulate objects, stand, walk, run, and sit for extended periods. c. For each disability identified in any subpart of part (a) and/or part (b), provide an opinion concerning whether such is at least as likely as not proximately due to or the result of the Veteran's service. d. For each low back disability identified in any subpart of part (a) and/or part (b), provide opinions concerning whether such is at least as likely caused or aggravated by a service-connected disability, to include an antalgic gait resulting from the Veteran's service-connected knee disabilities. If the examiner cannot provide an opinion without resorting to mere speculation, this should be so stated along with supporting rationale. In so doing, the examiner shall explain whether the inability to provide a more definitive opinion is the result of a need for additional information, or that he or she has exhausted the limits of current medical knowledge in providing an answer to the particular question. 6. Thereafter, the AOJ must complete any additional evidentiary development necessary to adjudicate the Veteran's claim for TDIU prior to February 12, 2016, to specifically include collecting and verifying information concerning his complete educational and occupational history, and scheduling him for additional VA examination(s) necessary for adjudicating the issue. 7. Thereafter, the AOJ must readjudicate the Veteran's appealed issues in light of the totality of the record. If any benefit is not granted to the fullest extent, the Veteran and his private attorney must be furnished with a copy of the readjudication and be afforded the applicable opportunity to respond. Michael J. Skaltsounis Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Scott W. Dale, 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.