Citation Nr: 21031587 Decision Date: 05/24/21 Archive Date: 05/24/21 DOCKET NO. 14-15 420 DATE: May 24, 2021 ORDER Entitlement to service connection for a right knee disorder is denied. Entitlement to an initial rating in excess of 10 percent for painful flexion and/or extension of the Veteran's left elbow is denied. Entitlement to an initial rating in excess of 10 percent for painful supination and/or pronation of the left elbow prior to October 18, 2018, and 30 percent thereafter, is denied. REMANDED Entitlement to service connection for a left elbow subchondral cyst secondary to service-connected left elbow arthritis is remanded. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is remanded. FINDINGS OF FACT 1. The Veteran's right knee disorder is not etiologically related to service. 2. During the course of the appeal, the Veteran's left forearm flexion has been limited to, at worst, 100 degrees; his left forearm extension has been limited to, at worst, 30 degrees. 3. During the course of the appeal, the Veteran's left forearm supination has not been limited to 30 degrees or less, and left forearm pronation has not manifested motion lost beyond the middle of the arc or motion lost beyond the last quarter of the arc with the hand not approaching full pronation. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for a right knee disorder have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 2. The criteria for entitlement to a rating in excess of 10 percent for painful flexion and/or extension of the Veteran's left elbow have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.321, 4.1-4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes (DC) 5206, 5207. 3. The criteria for entitlement to a rating in excess of 10 percent for painful supination and/or pronation of the left elbow prior to October 18, 2018, and 30 percent thereafter have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.321, 4.1-4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, DC 5213. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from August 1987 to July 1991. In a September 2012 rating decision, the Veteran's left elbow disorder was initially rated as 10 percent disabled from May 8, 2012, for painful motion under DC 5207 (later adjusted to DC 5206) and 38 C.F.R. § 4.59. That issue is currently before the Board. In a March 2018 rating decision, the Agency of Original Jurisdiction (AOJ) added a 10 percent rating from August 26, 2016, for painful motion under DC 5231 and 38 C.F.R. § 4.59. In a January 2019 rating decision, the AOJ increased the rating under DC 5231 to 30 percent disabled as of October 18, 2018. The Veteran has also been diagnosed with a subchondral cyst of the left elbow. As the Veteran's claim relates to an initial rating for his service-connected left elbow disorder, the Board has broadened the appeal to include an increased rating for the left elbow under DC 5231 and secondary service connection for a subchondral cyst of the left elbow. See Clemons v. Shinseki, 23 Vet. App. 1, 9 (2009). 1. Entitlement to service connection for a right knee disorder Service connection will be granted if the Veteran has a disability resulting from personal injury or disease incurred in the line of duty, or for aggravation of a preexisting injury or disease incurred in the line of duty during active service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. To establish service connection, the evidence must show (1) a present disability, (2) an in-service incurrence or aggravation of a disease or injury, and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). A valid service connection claim requires competent evidence of a current disability. Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). However, the presence of a disability at any time during the claim process or relatively close thereto can justify a grant of service connection, even where such disability has become asymptomatic. McClain v. Nicholson, 21 Vet. App. 319 (2007); Romanowsky v. Shinseki, 26 Vet. App. 289 (2013). Service connection for certain chronic disorders such as arthritis may be presumed where demonstrated to a compensable degree within one year following separation from qualifying service. 38 U.S.C. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. For an enumerated "chronic disease" shown in service (or within a presumptive period under § 3.307), subsequent manifestations of the same chronic disease at any later date, however remote, are service-connected, unless clearly attributable to intercurrent causes. See Groves v. Peake, 524 F.3d 1306, 1309 (2008). Whenever there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the Veteran. 38 U.S.C. § 5107(b). The Veteran's April 1991 separation examination does not note any right knee issues and he specifically denied having or ever having a "trick" or locked knee. He also did not note any knee issues in his April 1991 report of medical history. He noted "swollen and painful joints," but the accompanying doctor's note indicates this notation was due to ankle pain and sprain. Service treatment records do indicate the Veteran dealt with obesity during service. See, e.g., April 1990 Service Treatment Records. May 2012 VA treatment records contain imaging reflecting mild degenerative arthritis of the right knee. During a September 2016 VA examination, the Veteran was diagnosed with right knee strain. The examiner also noted that imaging reflected arthritis of the right knee. See also March 2017 VA Examination. The examiner determined that the Veteran's current disorder is less likely than not related to service, opining that the in-service knee strain resolved during service. The examiner further opined that the current knee strain is related to obesity and activity. During a November 2019 VA examination, the Veteran was diagnosed with right knee arthritis. The examiner determined that the Veteran's current disorder is less likely than not related to service. The examiner noted the Veteran's statement of an in-service twisting injury to the right knee, but opined that, upon examination, the current right knee disorder does not indicate a pathology that is consistent with a twisting injury during service. The examiner explained that, as recent as 2012, there were no findings of internal derangement of the right knee. The examiner further explained that the right knee arthritis is very mild and similar to current findings in the left knee, and noted that arthritis alone, without internal derangement, is not consistent with a twisting mechanism of injury. The examiner determined that a severe twisting injury in service would have been reflected with much more severe findings in imaging conducted since 2012. In an August 2012 statement, the Veteran indicated that twisted his right knee during Navy school. During a May 2016 Board hearing, he testified that he had injured his right knee during service and had experienced symptoms since that time. In an August 2016 remand, the Board noted the lack of documentation regarding an in-service injury, but accepted the Veteran's testimony as to the in-service injury in order to obtain a VA examination of the right knee. The Board, however, noted inconsistency with the Veteran's testimony of continuity of symptomatology and his specific denial of knee problems at separation. The best evidence of record is the well-reasoned November 2019 VA examiner's opinion that clearly explains the Veteran's current disorder, the pathology of that disorder, and the reasons why the current disorder is not etiologically related to an in-service right knee twisting injury. The Board further finds that the opinion is based on an accurate factual history as determined by the Board. First, the opinion is consistent with the competent opinion from a military examiner at separation that the Veteran's lower extremities were clinically normal. Additionally, the Board finds below that the most credible lay version is against a finding of continuity of symptomatology since service. The Veteran's separation examination contained notations of several abnormalities reported by the Veteran, but was absent any report of right knee issues. Rather, the Veteran specifically denied having or ever having a "trick" or locked knee. This statements bear the indicia of reliability as they were made in the context of obtaining appropriate medical treatment and/or diagnosis at separation. See Lilly's An Introduction to the Law of Evidence, 2nd Ed. (1987), pp. 245- 46 (many state jurisdictions, including the federal judiciary and Federal Rule 803(4), expand the hearsay exception for physical conditions to include statements of past physical condition on the rational that statements made to physicians for purposes of diagnosis and treatment are exceptionally trustworthy since the declarant has a strong motive to tell the truth in order to receive proper care). This statement is also consistent with the findings from a competent examiner at that time finding a normal clinical evaluation of the lower extremities. On the other hand, the Veteran's recollections of recurrent right knee pain since service comes several decades after his discharge from service and is not consistent with his statement at separation or the results from the separation examination. As such, the Board places greater probative weight to the statement and findings at separation. The only evidence in favor of the Veteran's claim is his own personal opinion. As a lay witness, the Veteran in this case is not competent to provide a nexus opinion regarding this issue of whether his in-service injury resulted in his current right knee disorder. The issue is medically complex, as it requires medical training and knowledge of anatomical relationships. Therefore, it is outside the competence of the Veteran in this case because the record does not show that he has the medical training or credentials to make such a determination. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007); see also Kahana v. Shinseki, 24. Vet. App. 428 (2011). Consequently, the Board gives more probative weight to the well-reasoned VA examiner opinion of record. In addition, the Board finds that service connection on the basis of continuity of symptomatology alone is not warranted under 38 C.F.R. § 3.303(b) as the most credible lay evidence establishes that chronicity first began many years after service. Similarly, there is also no credible lay or medical evidence establishing the onset of arthritis within one year of service discharge of either period of service. As such, service connection on a presumptive basis under 38 C.F.R. § 3.309(a) is also not warranted. Accordingly, the preponderance of the evidence is against the claim. Entitlement to a rating in excess of 10 percent for left elbow arthritis Disability evaluations are determined by the application of the facts presented to VA's Schedule for Rating Disabilities (Rating Schedule) at 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and the residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.321(a), 4.1. Separate diagnostic codes identify various disabilities and the criteria for specific ratings. Relevant regulations do not require that all cases show all findings specified by the Schedule; however, findings sufficient to identify the disease and the resulting disability and, above all, coordination of the rating with impairment of function will be expected in all cases. 38 C.F.R. §§ 4.7, 4.21. If two disability evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining will be resolved in favor of the veteran. 38 C.F.R. § 4.3. In establishing an appropriate initial assignment of a disability rating, the proper scope of evidence includes all medical evidence submitted in support of the veteran's claim. Fenderson v. West, 12 Vet. App. 119 (1999). In cases where an assigned disability rating has been challenged or appealed, it is possible for a veteran to receive a staged rating. A staged rating is an award of separate percentage evaluations for separate periods, based on the facts found during the appeal period. Id. at 126-28; see also Hart v. Mansfield, 21 Vet. App. 505 (2007) (in determining the present level of a disability for any increased evaluation claim, the Board must consider staged ratings). If two disability evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining will be resolved in favor of the veteran. 38 C.F.R. § 4.3. Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance. Functional loss may be due to the absence or deformity of structures or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior in undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. § 4.40. In determining the appropriate evaluation for musculoskeletal disabilities, particular attention is focused on functional loss of use of the affected part. Under 38 C.F.R. § 4.40, functional loss may be due to pain, supported by adequate pathology and evidenced by visible behavior on motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. Under 38 C.F.R. § 4.45, factors of joint disability include increased or limited motion, weakness, fatigability, or painful movement, swelling, deformity or disuse atrophy. Under 38 C.F.R. § 4.59, painful motion is an important factor of joint disability and actually painful joints are entitled to at least the minimum compensable rating for the joint. This regulation also requires that, whenever possible, the joints involved are tested for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with the range of the opposite undamaged joint. See Correia v. McDonald, 28 Vet. App. 158, 168 (2016). Where functional loss is alleged due to pain upon motion, the provisions of 38 C.F.R. § 4.40 and § 4.45 must be considered. DeLuca v. Brown, 8 Vet. App. 202, 207-08 (1995). Within this context, a finding of functional loss due to pain must be supported by adequate pathology and evidenced by the visible behavior of the claimant. Johnston v. Brown, 10 Vet. App. 80, 85 (1997). Pain itself does not rise to the level of functional loss as contemplated by § 4.40 and § 4.45 but may result in functional loss only if it limits the ability to perform the normal working movements of the body with normal excursion, strength, coordination or endurance. Mitchell v. Shinseki, 25 Vet. App. 32, 43 (2011). In Sharp v. Shulkin, the United States Court of Appeals for Veterans Claims (Court) decision addressed what constitutes an adequate explanation for an examiner's inability to estimate motion loss in terms of degrees during periods of flare-ups. 29 Vet. App. 26 (2017). The Court held that a VA examiner must attempt to elicit information from the record and the Veteran regarding the severity, frequency, duration, or functional loss manifestations during flare-ups before determining that an estimate of motion loss in terms of degrees could not be given. It also held that any inability to furnish such an estimate must be predicated on a lack of medical knowledge among the medical community at large, rather than insufficient knowledge by the individual examiner. Id. The intent of the Rating Schedule is to recognize actually painful, unstable or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. In a September 2012 rating decision, the Veteran's left elbow disorder was initially rated as 10 percent disabled from May 8, 2012, for painful motion under DC 5207 and 38 C.F.R. § 4.59. In a March 2018 rating decision, the AOJ added a 10 percent rating from August 26, 2016, for painful motion under DC 5231 and 38 C.F.R. § 4.59. In a January 2019 rating decision, the AOJ increased the rating under DC 5231 to 30 percent disabled as of October 18, 2018. The Veteran is left hand dominant. See, e.g., August 2012 VA Examination. Under DC 5206, a rating of 20 percent disabled is warranted for forearm flexion of the dominant hand limited to 90 degrees. Under DC 5207, a rating of 20 percent disabled is warranted for forearm extension of the dominant hand limited to 75 degrees. 38 C.F.R. § 4.71a. Under DC 5213, a rating of 10 percent disabled is warranted for forearm supination of the dominant hand limited to 30 degrees or less. A rating of 20 percent disabled is warranted for limitation of forearm pronation of the dominant hand to motion lost beyond the last quarter of the arc with the hand not approaching full pronation. A rating of 30 percent disabled is warranted for limitation of forearm pronation of the dominant hand to motion lost beyond the middle of the arc. A rating of 20 percent disabled is warranted for bone fusion resulting in the dominant hand fixed near the middle of the arc or moderate pronation. A rating of 30 percent disabled is warranted the dominant hand fixed in full pronation. A 40 percent rating is warranted for the dominant hand fixed in supination or hyperpronation. Id. May 2012 VA treatment records reflect a diagnosis of advanced arthritis of the Veteran's left elbow. During an August 2012 VA examination, the Veteran was diagnosed with degenerative joint disease of the left elbow. Initial and repetitive range-of-motion measurements indicated left elbow flexion to at least 145 degrees and extension to ten degrees, with no pain. The examiner noted no ankylosis and no flail joint, joint fracture, or impairment of supination or pronation. During a February 2014 VA examination, the Veteran was diagnosed with left elbow arthritis. Initial and repetitive range-of-motion measurements indicated left elbow flexion to at least 145 degrees and extension to five degrees, with no pain. The examiner noted no ankylosis and no flail joint, joint fracture, or impairment of supination or pronation. The examiner did note that left forearm pronation ended at 80 degrees and left forearm supination ended at 85 degrees, with no pain or other contributing factors that would additionally limit functionality over time or during flare-ups. During a July 2015 VA examination, the Veteran was diagnosed with left elbow arthritis and olecranon bursitis. Initial and repetitive range-of-motion measurements indicated left elbow flexion to at least 145 degrees, extension to zero degrees, forearm supination to 85 degrees, and forearm pronation to 80 degrees, with no pain, tenderness, or crepitus. The examiner did note that flare-ups would cause additional functional loss through pain, fatigue, and lack of endurance. The examiner noted no flail joint, joint fracture, or impairment of supination or pronation. The examiner also noted advanced arthritis for the Veteran's age with multiple loose bodies in the left elbow. During a September 2016 VA examination, the Veteran was diagnosed with left elbow arthritis. Initial and repetitive range-of-motion measurements indicated left elbow flexion to at least 145 degrees, extension to five degrees, forearm supination to 70 degrees, and forearm pronation to 70 degrees, with pain that resulted in no functional loss. The examiner noted a reduction in muscle strength directly related to the arthritis, but no muscle atrophy or ankylosis, or flail joint, joint fracture, or impairment of supination or pronation. The examiner also noted advanced arthritis for the Veteran's age with multiple loose bodies in the left elbow. During a March 2017 VA examination, initial and repetitive range-of-motion measurements indicated left elbow flexion to at least 145 degrees, extension to zero degrees, forearm supination to 85 degrees, and forearm pronation to 80 degrees, with pain that resulted in no functional loss. The examiner noted no reduction in muscle strength, no muscle atrophy, no ankylosis, and no flail joint, joint fracture, or impairment of supination or pronation. The examiner also noted that the Veteran reported popping and grinding in his left elbow and pain with any activity. June 2018 VA treatment records contain imaging of the Veteran's left elbow that reflected multiple calcified bodies in the joint space and significant degenerative changes spurring joint space narrowing and "subchondral cyst formation." A June 2018 VA orthopedic examination reflects left elbow range-of-motion measurements of flexion to 125 degrees, extension to 30 degrees, forearm supination to 70 degrees, and forearm pronation to 80 degrees, During a January 2019 VA examination, the Veteran was diagnosed with lateral epicondylitis and degenerative arthritis of the left elbow, as well as subchondral cyst of the left elbow. Initial range-of-motion measurements indicated left elbow flexion to 145 degrees, extension to zero degrees, forearm supination to 50 degrees, and forearm pronation to 70 degrees, with pain that resulted in no functional loss. Repetitive range-of-motion measurements indicated left elbow flexion to 130 degrees, extension to zero degrees, forearm supination to 40 degrees, and forearm pronation to 70 degrees. For repetitive motion over time, the examiner estimated range-of-motion measurements of left elbow flexion to 130 degrees, extension to zero degrees, forearm supination to 35 degrees, and forearm pronation to 40 degrees. For flare ups, the examiner estimated range-of-motion measurements of left elbow flexion to 100 degrees, extension to zero degrees, forearm supination to 35 degrees, and forearm pronation to 35 degrees. The examiner noted no reduction in muscle strength, no muscle atrophy, no ankylosis, and no flail joint, joint fracture, or impairment of supination or pronation. During a November 2020 VA examination, the Veteran was diagnosed degenerative arthritis of the left elbow. Initial and repetitive range-of-motion measurements indicated left elbow flexion to 145 degrees, extension to zero degrees, forearm supination to 60 degrees, and forearm pronation to 80 degrees, with pain that resulted in no functional loss. For repetitive motion over time and flare-ups, the examiner estimated range-of-motion measurements of left elbow flexion to 145 degrees, extension to zero degrees, forearm supination to 30 degrees, and forearm pronation to 80 degrees. The examiner noted a reduction in muscle strength, but noted no muscle atrophy, no ankylosis, and no flail joint, joint fracture, or impairment of supination or pronation. In an August 2012 statement, the Veteran indicated that his left elbow snaps and pops, and "feels like the joint may come apart" if he lifts too much weight. During a May 2016 Board hearing, he testified that his left elbow felt like it was dislocating with repetitive use, such as attempting to use a screwdriver. The Veteran is competent to report experiencing such symptomology. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). The Board finds this testimony credible. The Board also notes that the issue of a subchondral cyst in the left elbow is discussed in the remand section below. During the entire course of the appeal, the Veteran's left forearm flexion has been limited to, at worst, 100 degrees, and his left forearm extension has been limited to, at worst, 30 degrees. In the absence of evidence of left forearm flexion limited to 90 degrees or less, or evidence of left forearm extension limited to 75 degrees or higher, a rating in excess of 10 percent for painful forearm motion under DC 5206 or DC 5207 is not warranted. Prior to August 2016, the claims file reflects that the Veteran's left forearm manifested normal range of motion, and did not manifest any pain on motion. See July 2015, February 2014, and August 2012 VA examinations. The September 2016 VA examination noted range-of-motion pain with both supination and pronation of the left elbow. However, from August 29, 2016, through October 17, 2018, the Veteran did not manifest limitation of forearm pronation of the dominant hand to motion lost beyond the last quarter of the arc with the hand not approaching full pronation. The September 2016 and March 2017 examiners noted no reduction in muscle strength, no muscle atrophy, no ankylosis, and no flail joint, joint fracture, or impairment of supination or pronation. In the absence of impairment of supination or pronation, a rating in excess of ten percent is not warranted from August 29, 2016, through October 17, 2018. Since October 18, 2018, the Veteran has manifested at worst forearm supination to 30 degrees, and forearm pronation to 35 degrees. The January 2019 and November 2020 VA examiners noted no muscle atrophy, no ankylosis, and no flail joint, joint fracture, or impairment of supination or pronation. In the absence of evidence of the dominant hand fixed in supination or hyperpronation, a rating in excess of 30 percent since October 18, 2018, is not warranted under DC 5213. The Board notes that the AOJ awarded a 30 percent rating under DC 5213 from October 18, 2018. See January 2019 Rating Decision. The Board notes that the Veteran submitted a claim of service connection for subchondral cyst of the left elbow on that date. That issue is addressed in the remand below. However, it is unclear why the AOJ chose that date, or how the AOJ determined that the Veteran's pronation reflected loss of motion beyond the middle arc. Id. Every VA examiner determined that the Veteran did not have impairment of supination or pronation upon examination. Nonetheless, the Board will not disturb the favorable finding by the AOJ. The Board is cognizant of the Veteran's descriptions of left elbow snapping and dislocation sensation. The 2020 VA examiner estimated that, with repetitive motion and during flares, range-of-motion would be reduced to left elbow flexion of 145 degrees, extension to zero degrees, forearm supination to 30 degrees, and forearm pronation to 80 degrees. Thus, even with consideration of functional impairment on use pursuant to 38 C.F.R. §§ 4.40 and 4.45, the Veteran's range of motion findings do not meet, or more nearly approximate, the criteria for higher ratings under the applicable diagnostic codes. REASONS FOR REMAND 1. Entitlement to service connection for a left elbow subchondral cyst secondary to service-connected left elbow arthritis is remanded. A January 2019 VA examiner diagnosed the Veteran with subchondral cyst of the left elbow. See also June 2018 VA Treatment Records. The January 2019 VA examiner opined that the Veteran's subchondral cyst of the left elbow is more likely than not caused by the service-connected left elbow degenerative joint disease, noting that the progression of the disease caused the formation of the cyst. However, in a separate statement, the same January 2019 VA examiner opined that the left elbow cyst is less likely than not related to service connected left elbow degenerative joint disease, noting that the cyst had resolved and degenerative joint disease does not cause skin conditions. A remand is needed to obtain a VA medical opinion clarifying these contradictory opinions. 2. Entitlement to a TDIU rating is remanded. Because a decision on the remanded issue and additional issues the Veteran is pursuing before the AOJ could significantly impact a decision on the issue of entitlement to a TDIU rating, the issues are inextricably intertwined. A remand of the claim for entitlement to a TDIU rating is required. Issues are considered to be inextricably intertwined when a determination on one issue could have a significant impact on the outcome of another. Harris v. Derwinski, 1 Vet. App. 180 (1991). The matters are REMANDED for the following action: 1. Obtain VA treatment records since August 2020 and associate them with the claims file. 2. Forward the Veteran's claims file to a qualified examiner for an opinion addressing the nature and etiology of his diagnosed subchondral cyst of the left elbow. The examiner should determine whether it is at least as likely as not (i.e., probability of 50 percent or greater) that the Veteran's service-connected left elbow arthritis caused or aggravated (a medically discernible increase in functional impairment e.g. increase in the severity, frequency or duration of symptoms or additional functional impairment beyond the expected baseline impairment) the subchondral cyst of the left elbow. In making this determination, the examiner should address the conflicting opinions from the January 2019 VA examiner. If an examination is needed, one should be scheduled. A complete rationale must be provided for any opinion offered. 3. After adjudicating the remanded issue and completing the appropriate action regarding the claims currently before the AOJ, adjudicate the claim of entitlement to a TDIU rating. T. MAINELLI Veterans Law Judge Board of Veterans' Appeals Attorney for the Board C. Howell, 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.