Citation Nr: 21042285 Decision Date: 07/12/21 Archive Date: 07/12/21 DOCKET NO. 16-38 013 DATE: July 12, 2021 ORDER Entitlement to a compensable rating for patellofemoral pain syndrome, left knee, before October 19, 2020 is denied. Entitlement to a rating in excess of 10 percent for patellofemoral pain syndrome, left knee, from October 19, 2020 is denied. Entitlement to a rating in excess of 20 percent from September 30, 2013, to October 1, 2015 for patellofemoral pain syndrome, right knee, is denied. Entitlement to a rating in excess of 10 percent for patellofemoral pain syndrome, right knee, from October 1, 2015 is denied. REMANDED Entitlement to service connection for fibromyalgia is remanded. Entitlement to service connection for lumbosacral strain, to include as secondary to left knee disorder, is remanded. Entitlement to service connection for fibroids is remanded. Entitlement to service connection for an acquired psychiatric disorder, to include bipolar disorder and multiple personality disorder, is remanded. Entitlement to service connection for hypertension is remanded. Entitlement to a rating in excess of 50 percent from September 30, 2013, to October 1, 2015, and in excess of 30 percent thereafter for migraines is remanded. Entitlement to a separate rating for left knee lateral instability is remanded. Entitlement to a separate rating for right knee lateral instability is remanded. Entitlement to a total disability rating based on individual unemployability due to service connected disabilities (TDIU) is remanded. FINDING OF FACT Throughout the period on appeal, the Veterans bilateral knees patellofemoral pain syndrome was limited in flexion to, at their worse, 100 degrees with full extension. CONCLUSIONS OF LAW 1. The criteria for a compensable rating for patellofemoral pain syndrome, left knee, before October 19, 2020 are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5260. 2. The criteria for a rating in excess of 10 percent for patellofemoral pain syndrome, left knee, from October 19, 2020 are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5260. 3. The criteria for a rating in excess of 20 percent from September 30, 2013, to October 1, 2015 for patellofemoral pain syndrome, right knee, are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5260. 4. The criteria for a rating in excess of 10 percent for patellofemoral pain syndrome, right knee from October 1, 2015 are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5260. REASONS AND BASES FOR FINDING AND CONCLUSIONS The Veteran served on active duty from September 1988 to October 1996. This case comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions issued by the Department of Veterans Affairs (VA) Regional Office (RO). Increased Rating 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. Where the question for consideration is the propriety of the initial evaluation assigned, consideration of the medical evidence since the effective date of the award of service connection and consideration of the appropriateness of a "staged" rating is required. See Fenderson v. West, 12 Vet. App. 119, 125-26 (1999). VA adjudicators must consider whether to assign different ratings at different times during the rating period to compensate the Veteran for times when the disability may have been more severe than at others. The Court since has extended this practice even to established ratings, not just initial ratings. See Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007). The evaluation of the same disability under several diagnostic codes, known as pyramiding, must be avoided; however, separate ratings may be assigned for distinct disabilities resulting from the same injury so long as the symptomatology for one condition is not duplicative of the symptomatology of the other condition. 38 C.F.R. § 4.14; Esteban v. Brown, 6 Vet. App. 259, 262 (1994). When evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use and, therefore, not be reflected on range-of-motion testing. 38 C.F.R. § 4.45 requires consideration also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Nonetheless, even when the background factors listed in § 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a (musculoskeletal system) or § 4.73 (muscle injury); a separate or higher rating under § 4.40 or 4.45 itself is not appropriate. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016) ("[I]t is clear that the guidance of § 4.40 is intended to be used in understanding the nature of the veteran's disability, after which a rating is determined based on the § 4.71a [or 4.73] criteria."). 1. Entitlement to a compensable rating for patellofemoral pain syndrome, left knee, before October 19, 2020 is denied. 2. Entitlement to a rating in excess of 10 percent for patellofemoral pain syndrome, left knee from October 19, 2020 is denied. 3. Entitlement to a rating in excess of 20 percent from September 30, 2013, to October 1, 2015 for right knee, patellofemoral pain syndrome is denied. 4. Entitlement to a rating in excess of 10 percent for right knee, patellofemoral pain syndrome from October 1, 2015 is denied. The Veteran filed a claim for increase in her knee disability ratings that was received by the VA on September 30, 2013. The Veteran was granted an increase of 20 percent to her right knee condition, effective September 30, 2013 in a September 2014 rating decision. The RO also denied an increase to the Veteran's service-connected left knee condition in this decision. These appeals arise from disagreement with this decision. While these appeals were pending, the Veteran's right knee disability rating was decreased to 10 percent in a July 2015 rating decision, effective October 1, 2015 and a January 2021 rating decision increased the left knee rating to 10 percent effective, October 19, 2020. The Veteran's right knee disability is rated under Diagnostic Code 5260 during the period on appeal and her left knee is rated under Diagnostic Code 5257 until October 19, 2020 when it is under Diagnostic Code 5260 thereafter. Separate ratings can be assigned for knee disabilities when none of the symptomatology overlaps and the separate rating is based on additional disabling symptomatology; this includes separate ratings based on limitation of flexion (Diagnostic Code 5260), limitation of extension (Diagnostic Code 5261), lateral instability or recurrent subluxation (Diagnostic Code 5257), and meniscal conditions (Diagnostic Codes 5258, 5259). See VAOPGCPREC 23-97, 62 Fed. Reg. 63,603 (1997); VAOPGCPREC 9-98, 63 Fed. Reg. 56,703 (1998); VAOPGCPREC 9-2004; 69 Fed. Reg. 59,988 (2004); Lyles v. Shulkin, 29 Vet. App. 107 (2017). The normal range of motion of the knee is from 0 degrees extension to 140 degrees flexion. 38 C.F.R. § 4.71, Plate II. Limitation of flexion warrants 10, 20, and 30 percent ratings when limitation is to 45 degrees, 30 degrees, and 15 degrees, respectively. 38 C.F.R. § 4.71a, Diagnostic Code 5260. Limitation of extension warrants 10, 20, 30, 40, and 50 percent ratings when limitation is to 10 degrees, 15 degrees, 20 degrees, 30 degrees, and 45 degrees, respectively. 38 C.F.R. § 4.71a, Diagnostic Code 5261. A 10 percent rating can also be assigned for the knee joint if there is painful motion without compensable limitation of motion. 38 C.F.R. §§ 4.59, 4.71a, Diagnostic Code 5003; see also Burton v. Shinseki, 25 Vet. App. 1 (2011) (holding that the applicability of 38 C.F.R. § 4.59 is not limited to arthritis claims). Evidence A November 2013 VA recreational therapy consultation reports the Veteran had limited knee flexion, but range of motion measurements were not reported. A March 2014 VA medical record reports the Veteran stated he had fallen twice in the past year, but it was due to lost balance. The Veteran underwent a VA examination for knees in July 2014. The examination reports only diagnosis for the right knee, of patellofemoral knee pain. Physical examination revealed the initial range of motion in her right knee flexion to 140 degrees or greater and extension to 0 degrees. Range of motion testing results for the left knee were the same. There was no evidence of painful motion. There was no additional functional loss of motion after repetition testing but pain on palpation were displayed. Muscle strength testing and joint stability were normal. A history patellar subluxation/ dislocation was not shown. A meniscal (semilunar cartilage condition) was noted by the examiner, with frequent episodes of joint pain and joint effusion being reported for the right knee. A previous meniscectomy in the right knee in 1995 was also noted but residuals were denied. There were no other pertinent physical findings, complications, conditions, signs or symptoms, including scars. The use of assistive devices was denied. Also the examiner opined there was no functional impairment of an extremity such that no effective function remains other than that which would be equally well served by an amputation with prosthesis; and a diagnosis of arthritis or patellar subluxation was denied. X-rays of the knee did not indicate arthritis. Another VA examination of the knees was conducted in January 2015. Flare-ups of knee symptoms were reported including anterior knee pain in the right knee which was greater than her left. The symptoms were unchanged since her July 2014 examination. She wore a brace. The Veteran reported experiencing intermittent swelling but no mechanical symptoms. Functional loss reported by the Veteran was increased pain which limited her ability to perform repetitive activity or prolonged walking. Physical examination revealed the range of motion of the right knee was flexion to 120 degrees with normal extension to 0 degrees. The range of motion of the left knee was full from 140 degrees of flexion to 0 degrees of extension. While the right knee range of motion was abnormal, the examiner determined it did not contribute to functional loss. Pain with weight bearing was reported in the right knee along with objective evidence of localized tenderness or pain on palpation in the anterior knee. There was no pain with weight bearing in the left knee. Repetitive use testing in both knees was conducted and there was no additional functional loss after the repetitive testing. The examiner opined that the right knee pain significantly limited the Veteran's functional ability with repeated use over a period of time, which estimated in terms of range of motion the right knee flexion was to 100 degrees, with normal extension to 0 degrees. While the examination was not conducted during a flare-up, the Veteran reported weekly flare-ups of knee symptoms, with moderate severity, that would last a day in her right knee. It was reported, for both knees, the examination neither supported nor contradicted the Veteran's statements describing functional loss during flare-ups. Muscle strength continued to be normal and the examiner found that muscle atrophy and ankylosis were not present. Physical examination revealed there was no recurrent subluxation, lateral instability, recurrent effusion, and joint instability, recurrent patellar dislocation, medial tibial stress syndrome ("shin splints"), stress fractures, chronic exertional compartment syndrome, or any other tibial and/or fibular impairment, meniscal conditions, or crepitus. Regular use of a brace was reported. Imaging studies were referenced as showing that neither traumatic nor degenerative arthritis was present. The examiner opined that there was no functional impairment of an extremity such that no effective function remains other than that which would be equally well served by an amputation with prosthesis; and a diagnosis of arthritis or patellar subluxation was denied. Functional impact of the knee disabilities on the Veteran's occupational functioning was opined to be difficulty with performing heavy labor or a job with prolonged standing due to the reported pain. The examiner opined the Veteran could still perform sedentary work. In August 2019, the Veteran testified at her Board hearing that she was experiencing falls and her knees were giving out. She reported that she had fallen at least 8 times in the past year, and she would use a cane as an assistive device. A February 2020 clinical record indicated the Veteran exhibited a mild antalgic gait. No swelling or palpable effusion was observed. Alignment was normal. There was no ligamental laxity with valgus/valrus stress testing. No patellar tenderness to percussion was observed. Knee active/passive ranges of motion were 0 to 110 degrees. Mild patellofemoral crepitus was observed with flexion and extension. There was no ligamental laxity with valgus/varus stress testing. Locking of the knee was not found. Medial/ lateral joint line tenderness was verbalized by the Veteran. The knees were negative for anterior or posterior drawer sign. Motor strength of 5-/5 in knee flexion and extension was reported. The Veteran was neurovascularly intact. The resulting impression was bilateral knee pain and degenerative joint disease. The Veteran received an injection in both knees. In April 2020, a fall assessment risk was conducted for the Veteran. She reported that she had had two or more falls within the past 12 months. The falls were reported to be due to a loss of balance. An August 2020 VA medical record reveals the Veteran again was treated with injections in her knees. She reported she was experiencing pain in both knees at a severity of 7+/10. She denied locking, but she complained of buckling of her knees. On physical examination, there was no swelling or palpable effusion noted with normal alignment. No patellar tenderness to percussion was noted. Active and passive range of motion were to 100 degrees. Mild patellofemoral crepitus was observed with flexion and extension. Medial and lateral joint line tenderness was verbalized. The knees were negative for anterior or posterior drawer sign. Motor strength of 5-/5 in knee flexion and extension was reported. At her most recent VA examination, which was conducted in October 2020, the Veteran reported that she had daily pain in her bilateral knees. Due to this, she could not stand, sit, or walk for any extended periods of time. Intermittent pain of 9 out of 10 was also reported along with falls due to her knees giving out and buckling. She was being treated with intermittent injections every 6 months and using a lidocaine rub. Flare-ups of knee symptoms were denied. While functional loss was reported for the right knee, including her knee giving out and buckling, no functional loss was reported for the left knee. Initial range of motion in her right knee was to 100 degrees flexion and 0 degrees extension (normal). While there was pain reported on flexion, it did not result in functional loss. Sharp pain of a 6 out of 10 severity was reported on palpation on the bilateral joint lines. Pain with weight bearing was denied, but crepitus was reported. As for the Veteran's left knee, the initial range of motion was flexion to 100 degrees and extension to 0 degrees (normal). Pain was reported on flexion, but it did not result in functional loss. Like the right knee, pain was denied with weight bearing, but crepitus was reported. Repetitive use testing was conducted on both knees and there was no additional functional loss after the repetitive testing. The examination reported it was neither medically consistent nor inconsistent with the Veteran's statements during a flare-up; yet, as noted, flare-ups were denied. No additional contributing factors of disability were reported. Muscle strength continued to be normal and atrophy and ankylosis were not present. Recurrent subluxation and lateral instability were not observed but recurrent effusion was reported by the examiner. It was explained that the Veteran reported frequent swelling in the bilateral knees. Joint instability, recurrent patellar dislocation, medial tibial stress syndrome ("shin splints"), stress fractures, chronic exertional compartment syndrome, or any other tibial and/or fibular impairment, and meniscal conditions were not found, and the examiner denied assistive device usage. The examiner opined that there was no functional impairment of an extremity such that no effective function remains other than that which would be equally well served by an amputation with prosthesis; and a diagnosis of arthritis was denied. The Veteran had lost less than one week of work time in the last 12 months. She was unable to walk/stand/sit for prolonged periods or perform activities that required bending. This, in turn, interfered with her ability to do household chores and things out outside the home. On review of the medical evidence of record, a compensable rating for the left knee is not warranted under Diagnostic Code 5003, as there is not x-ray evidence of arthritis of any kind. See Diagnostic Code 5003 for degenerative arthritis; Diagnostic Code 5010 (arthritis due to trauma, substantiated by x-ray findings, rate as degenerative arthritis). Even, under the new criteria she would only be rated based on limitation of motion, dislocation, or instability. 85 Fed. Reg. 76453 (Nov. 30, 2020) (codified at 38 C.F.R. § 4.71a, Diagnostic Code 5010 (2021)). To the extent a February 2020 VA medical reports the impression of degenerative joint disease, this was based on a physical examination of the knees and not x-rays. A higher rating based on limited flexion for either knee is not warranted under Diagnostic Code 5260. To warrant a higher rating for the left knee, the evidence would need to establish that flexion was limited to 45 degrees prior to October 19, 2020; and limited to 30 degrees thereafter. For the right knee, the evidence would need to establish flexion limited to 30 degrees before October 1, 2015 and limited to 45 degrees thereafter. The medical evidence shows that flexion in the bilateral knees was most severely limited to 100 degrees, as noted on examination in October 2020. Thus, notwithstanding the findings of significant pain in the bilateral knees, and that it contributed to functional loss, it does not result in a higher rating for either knee. While separate evaluations may be assigned for both flexion and extension of the knee joint, it is only where the evidence demonstrates that both limitations rise to a compensable degree (i.e. meet the criteria for a 10 percent rating or higher under both Diagnostic Code 5260 and 5261). See VAOPGCPREC 9-2004. That is not the case for either knee during the period on appeal, as the Veteran's extension was full to 0 degrees the entire appeal period. The Board has also considered the other Diagnostic Codes pertaining to the knee and leg. Other disability ratings may be assigned only if the symptomatology for a disability is not duplicative or overlapping with the symptomatology of any other disability. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994); Lyles v. Shulkin, 29 Vet. App. 107 (2017) (holding that 38 C.F.R. § 4.14 prohibits paying compensation twice for the same symptoms or functional impairment). The medical evidence does not show any ankylosis of either knee at any time during the period on appeal. Thus, a rating under Diagnostic Code 5256 does not apply. A separate rating under Diagnostic Code 5258 for dislocated semilunar cartilage is not warranted either. While the June 2014 VA examiner reported a meniscal (semilunar cartilage condition) with frequent episodes of joint pain and joint effusion being for the right knee, this was denied by the subsequent VA examiners. Moreover, on physical examination the Veteran continuously denied locking during the period on appeal, as recent as February 2020. True locking of the knee is defined as a "mechanical block to full extension due to a displaced bucket handle meniscal tear with incarceration" that is either episodic, with reduction of the fragment by manipulation or motion of the knee, or persistent. DeLee and Drez, Orthopedic Sports Medicine 1601 (3rd ed. 2009). "Locking" is the sudden loss of ability to extend the knee and is usually painful and may be associated with an audible noise, such as a click or pop. Firestein, Kelley's Textbook of Rheumatology 571 (9th ed. 2012). As observed at all her VA examinations, her extension continued to be normal, to 0 degrees. Symptoms associated with locking were not reported or observed. The Board finds the preponderance of the probative evidence demonstrates that the Veteran does not have a meniscal condition with frequent episodes of joint pain and joint effusion. Accordingly, a separate rating under this Diagnostic Code is not warranted either. As for a 10 percent rating under Diagnostic Codes 5262 and 5263, impairment of the tibia and fibula, and genu recurvatum, respectively, the record does not contain evidence of such manifestations in either knee, during the entire period on appeal. The issues of entitlement to separate ratings based on instability of the knees is addressed in the remand portion of the decision below. REASONS FOR REMAND 1. Entitlement to service connection for fibromyalgia is remanded. The Veteran testified at her Board hearing that she began experiencing symptoms related to her fibromyalgia shortly after she returned from Desert Shield/Desert Storm. She reported that, initially, it was not properly diagnosed, but she was taking gabapentin for the symptoms associated with the condition, prior to a proper diagnosis. In October 2020, a VA examiner reported that there is no indication of a diagnosis of fibromyalgia or significant symptoms to indicate the she had fibromyalgia during service. It was further explained, that per the claims file, the Veteran was diagnosed with the condition in 2013, 17 years after discharge. Accordingly, a nexus had not been established. A remand is needed as this October 2020 VA opinion is inadequate. The Veteran testified that she experienced symptoms in service, but she was not diagnosed with fibromyalgia until after discharge. Thus, to find that an opinion that relies on absence of a diagnosis or significant symptoms is inadequate. Late onset of a condition does not preclude service connection. Notably as the Veteran served in Southwest Asia, this theory of entitlement must be addressed by the examiner on remand. 2. Entitlement to service connection for lumbosacral strain to include as secondary to left knee disorder is remanded. The claim was previously remanded by the Board for a direct service connection opinion as to the Veteran's inservice medical records that report she was injured in a motor vehicle accident during service. As a result, she underwent physical therapy for her injuries, including her back, in the same month. The post-remand December 2020 opinion does not address these medical records. It specifically reports that there is no evidence of care for a back condition while in service or approximate to service. As it relies on an inaccurate factual premise and does not address the pertinent medical records, it is inadequate. Accordingly, a remand for an opinion consistent with the previous Board's instructions is still needed. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (Board remand confers a right on a claimant to compliance with the remand order). 3. Entitlement to service connection for fibroids is remanded. This claim was previously remanded as the Veteran's inservice records reported in a September 1995 medical record from an ob-gyn appointment that she was assessed to have uterine fibroids, but the prior March 2014 VA opinion did not address this medical record. Unfortunately, in the December 2020 post-remand opinion, the examiner reported that despite the Veteran's claims, there is no evidence of fibroids while in service, and that it is clear the fibroids were not present at least as late as October 1994. Thus, this opinion, too, does not address the inservice September 1995 medical record, and does not comply with the previous remand instructions. Accordingly, a remand for an addendum opinion is needed. 4. Entitlement to service connection for an acquired psychiatric disorder, to include bipolar disorder and multiple personality disorder is remanded. The Veteran sought treatment one time during active duty with complaints of depression linked to her father's death. A VA examination conducted in December 2003 included an annotation that the Veteran's allegations of having manifested a depressive disorder and bipolar illness linked to service are now supported by consistent objective clinical findings and longitudinal history. The VA examiner further stated that the Veteran did well while in the military, and she began to present symptomatology much after her discharge from service. It is not apparent to the Board if the examiner is linking the current bipolar disorder to active duty or an opinion on direct service connection which addresses the in-service symptomology is required. The examiner who completed the most recent VA examination which addressed the question of secondary service connection for a psychiatric disorder indicated that the most recent records available for their review was 2014. A remand is required to have the examiner review the most recent evidence of record to see if this changes the etiology opinions. 5. Entitlement to service connection for hypertension is remanded. This claim was previously remanded by the Board so that the Veteran could undergo VA examinations she previously missed. The October 2020 post-remand opinion reports that the Veteran's blood pressure was elevated with an isolated visit to the ER for a mental health crisis. As this evidence suggests the Veteran's hypertension claim is intertwined with her claim for acquired psychiatric condition, adjudication on this claim is deferred. The appropriate remedy where a pending claim is inextricably intertwined with a claim/ claims currently on appeal is to remand the claim on appeal pending the adjudication of the inextricably intertwined claim. See Harris v. Derwinski, 1 Vet. App. 180 (1991) (two issues are "inextricable intertwined" when they are so closely tied together that a final decision on one issue cannot be rendered until a decision on the other issue has been rendered). 6. Entitlement to a rating in excess of 50 percent from September 30, 2013, to October 1, 2015, and in excess of 30 percent thereafter for migraines is remanded. This claim was previously remanded by the Board so that the RO may first review additional relevant evidence added to the claims file since the previous SOC in June 2016. However, the Veteran has not undergone a VA examination for her headaches since February 2015, and there is evidence in the claims file that the condition has worsened since this examination. Specifically, in October 2017, the Veteran reported chronic migraines that were complicated by nephrolithiasis. Also, VA records as recent as July 2020 report the Veteran is receiving Botox injections to treat the chronic migraine condition. 7. Whether entitlement to a separate rating for patellofemoral pain syndrome, left knee, for lateral instability is warranted, is remanded. 8. Whether entitlement to a separate rating for patellofemoral pain syndrome, right knee, for lateral instability is warranted, is remanded. Under Diagnostic Code 5257, which pertains to other knee impairment based upon recurrent subluxation and/or lateral instability, a 10 percent disability rating is warranted for slight disability, a 20 percent disability rating is warranted for moderate disability, and a maximum 30 percent disability rating is warranted for severe disability. 38 C.F.R. § 4.71a, DC 5257. However, the VA amended the criteria for rating the knee under Diagnostic Code 5257 effective from February 7, 2021. 85 Fed. Reg. 76453 (Nov. 30, 2020). Under the new rating criteria, a 30 percent rating is assigned for recurrent subluxation or lateral instability, unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribes both an assistive device (e.g., cane(s), crutch(es), walker) and bracing for ambulation. A 20 percent rating is assigned for one of the following: (a) sprain, incomplete ligament tear, or repaired complete ligament tear causing persistent instability, and a medical provider prescribes a brace and/or assistive device (e.g., cane(s), crutch(es), walker) for ambulation; or (b) unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribes either an assistive device (e.g., cane(s), crutch(es), walker) or bracing for ambulation. A 10 percent rating is warranted for sprain, incomplete ligament tear, or complete ligament tear (repaired, unrepaired, or failed repair) causing persistent instability, without a prescription from a medical provider for an assistive device (e.g., cane(s), crutch(es), walker) or bracing for ambulation. For patellar instability, a 30 percent rating is assigned for a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for a brace and either a cane or a walker. A 20 percent rating is assigned for a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for one of the following: a brace, cane, or walker. A 10 percent rating is assigned for a diagnosed condition involving the patellofemoral complex with recurrent instability (with or without history of surgical repair) that does not require a prescription from a medical provider for a brace, cane, or walker. There is evidence that suggests subluxation and/or lateral instability may exist for each knee. However, it is not clear to the Board whether the Veteran's reported knee brace was prescribed for treatment of knee subluxation or lateral instability. A remand is needed for clarification. 9. Entitlement to TDIU is remanded. The Board finds that the Veteran's claim for a TDIU is inextricable intertwined with the claims remanded herein. See Harris v. Derwinski, 1 Vet. App. 180 (1991). Accordingly, adjudication is deferred. The matters are REMANDED for the following action: 1. In remanding this case, the Board makes no credibility determination, expressed or implied, at this juncture. 2. Obtain update VA and private medical records and associate them with the record. 3. Obtain an addendum opinion from an appropriate clinician regarding the etiology of the fibromyalgia condition. The examiner should review the Veteran's claims file. If the examiner determines that an opinion cannot be provided without an examination, the Veteran should be scheduled for one. Based on a review of the record, and a new examination if necessary, the examiner must address the following: (a.) Is at least as likely as not that that the Veteran's fibromyalgia had its onset during service or is otherwise causally related to any event or circumstance of the Veteran's service, to include as part of medically unexplained chronic multi-symptom illness based on Gulf War exposures? In answering this question, the examiner must address, to the extent possible, her testimony regarding symptoms inservice. The term "at least as likely as not" does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a certain conclusion is so evenly divided that it is as medically sound to find in favor of such a conclusion as it is to find against it. In all opinions rendered, the examiner is advised that the Veteran is competent to report her symptoms. The examiner must consider any lay statements of record. A complete rationale for all medical opinions is required. The examiner should identify and explain the relevance or significance, as appropriate, of any history, clinical findings, medical knowledge or literature, etc., relied upon in reaching the conclusion(s). 4. Obtain an addendum opinion from an appropriate clinician regarding the etiology of the back condition. The examiner should review the Veteran's claims file. If the examiner determines that an opinion cannot be provided without an examination, the Veteran should be scheduled for one. Based on a review of the record, and a new examination if necessary, the examiner must address the following: (a.) Is at least as likely as not that the Veteran has a back condition as a result of her active duty service? In answering this inquiry, the examiner must address, to the extent possible, the inservice records noting an injury to her back in March 1995 after a motor vehicle accident and the physical therapy she subsequently underwent. The examiner must also address the reports of continuous symptoms since the accident. The term "at least as likely as not" does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a certain conclusion is so evenly divided that it is as medically sound to find in favor of such a conclusion as it is to find against it. In all opinions rendered, the examiner is advised that the Veteran is competent to report her symptoms. The examiner must consider any lay statements of record. A complete rationale for all medical opinions is required. The examiner should identify and explain the relevance or significance, as appropriate, of any history, clinical findings, medical knowledge or literature, etc., relied upon in reaching the conclusion(s). 5. Obtain an addendum medical opinion from a medical professional with appropriate expertise regarding the nature and etiology of the Veteran's uterine condition. The examiner should review the Veteran's claims file. If the examiner determines that an opinion cannot be provided without an examination, the Veteran should be scheduled for one. Based on a review of the record, and a new examination if necessary, the examiner must address the following: (a.) Is it at least as likely as not that any uterine condition is related to her active service or is caused by or aggravated by military service, to include inservice reports of uterine fibroids? In answering this inquiry, the examiner should address the inservice treatment records reporting uterine fibroids in June 1995, September 1995, and October 1995. Also, her prior inservice history of uterine cysts should be discussed. The term "at least as likely as not" does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a certain conclusion is so evenly divided that it is as medically sound to find in favor of such a conclusion as it is to find against it. In all opinions rendered, the examiner is advised that the Veteran is competent to report her symptoms. The examiner must consider any lay statements of record. A complete rationale for all medical opinions is required. The examiner should identify and explain the relevance or significance, as appropriate, of any history, clinical findings, medical knowledge or literature, etc., relied upon in reaching the conclusion(s). 6. Obtain an addendum medical opinion from a medical professional with appropriate expertise regarding the nature and etiology of the Veteran's acquired psychiatric condition. The examiner should review the Veteran's claims file. If the examiner determines that an opinion cannot be provided without an examination, the Veteran should be scheduled for one. Based on a review of the record, and a new examination if necessary, the examiner must address the following: (a.) Is it at least as likely as not that any acquired psychiatric condition is related to her active service or is caused by or aggravated by military service, to include inservice reports of depression and tearful episodes? In answering this inquiry, the examiner should address the December 2003 VA opinion and the most recent VA medical records, which report, in pertinent part the Veteran is still experiencing tearful episodes. The term "at least as likely as not" does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a certain conclusion is so evenly divided that it is as medically sound to find in favor of such a conclusion as it is to find against it. In all opinions rendered, the examiner is advised that the Veteran is competent to report her symptoms. The examiner must consider any lay statements of record. A complete rationale for all medical opinions is required. The examiner should identify and explain the relevance or significance, as appropriate, of any history, clinical findings, medical knowledge or literature, etc., relied upon in reaching the conclusion(s). 7. Schedule the Veteran for a VA medical examination to determine the current severity of her service-connected migraines disability using the most recent DBQ examination form. The electronic claims file must be reviewed in conjunction with the examination. The examiner should report all signs and symptoms necessary for evaluating the Veteran's condition under the rating criteria and address the Veteran's recent treatment of Botox to treat her migraine condition. (Continued on the next page) Any appropriate evaluations, studies, and testing deemed necessary by the examiner should be conducted, and the results included in the examination report. 8. Obtain clarification from a medical professional with appropriate expertise to determine as to whether the Veteran's reported knee brace(s) are prescribed for any knee instability or subluxation. G. A. WASIK Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Wade 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.