Citation Nr: 22012107 Decision Date: 03/02/22 Archive Date: 03/02/22 DOCKET NO. 11-31 846 DATE: March 2, 2022 ORDER Prior to September 11, 2021, a 60 percent evaluation for a right knee disability, to include chondromalacia of the right patella with torn medial meniscus repair and osteomalacia status post total knee replacement is granted. Entitlement to an evaluation greater than 60 percent for a right knee disability, to include chondromalacia of the right patella with torn medial meniscus repair and osteomalacia status post total knee replacement since September 11, 2021, is denied. Prior to September 12, 2016, a 10 percent evaluation for left knee limitation of flexion, associated with left knee strain and degenerative joint disease is granted. Since September 12, 2016, entitlement to an evaluation greater than 10 percent for left knee limitation of flexion, associated with left knee strain and degenerative joint disease is denied. REMANDED Entitlement to a separate rating for urinary incontinence as a possible neurological manifestation of the service-connected degenerative disc disease of the lumbar spine is remanded. FINDINGS OF FACT 1. Throughout the entire appeal period, the Veterans right knee disability, to include chondromalacia of the right patella with torn medial meniscus repair and osteomalacia status post total knee replacement has been manifested by chronic residuals of severe painful motion or weakness. 2. Throughout the appeal period, the Veteran's left knee limitation of flexion, associated with the left knee strain with degenerative joint disease, has been manifested by flexion greater than 30 degrees. CONCLUSIONS OF LAW 1. Prior to September 11, 2021, the criteria for a 60 percent evaluation, but no higher, for a right knee disability, to include chondromalacia of the right patella with torn medial meniscus repair and osteomalacia status post total knee replacement prior to September 11, 2021 have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.40, 4.45, 4.59 and 4.71a, Diagnostic Code 5055. 2. The criteria for an evaluation greater than 60 percent for a right knee disability, to include chondromalacia of the right patella with torn medial meniscus repair and osteomalacia status post total knee replacement since September 11, 2021, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.40, 4.45, 4.59 and 4.71a, Diagnostic Code 5055. 3. Prior to September 12, 2016, the criteria for a 10 percent evaluation, but no higher, for left knee limitation of flexion, associated with left knee strain and degenerative joint disease are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.40, 4.45, 4.59 and 4.71a, Diagnostic Code 5260. 4. The criteria for an evaluation greater than 10 percent for left knee limitation of flexion, associated with left knee strain and degenerative joint disease since September 12, 2016, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.40, 4.45, 4.59 and 4.71a, Diagnostic Code 5260. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from August 1984 to June 1987, from August 1989 to August 1990, and from January 1991 to May 1991. These matters are on appeal from a January 2010 rating decision. In January 2020, the Board of Veteran's Appeals (Board) denied the appeal. The Veteran appealed the decision to the United States Court of Appeals for Veterans Claims (Court). In October 2020, the Court granted an Amended Joint Motion for Partial Remand (JMPR). In May 2021, the Board remanded the appeal for evidentiary development consistent with the October 2020 JMPR. The October 2020 stipulated that the March 2019 VA examination is inadequate because it did not indicate the point at which pain begins during range of motion testing and it did not disclose ranges of motion for both knees during flare-ups. In September 2021, the Veteran was afforded a VA examination. The VA examiner disclosed the point at which pain begins. In December 2021, he provided an addendum opinion that includes the ranges of motion of the bilateral knees during flare-ups. Based upon the forgoing, the Board finds that there has been substantial compliance with the May 2021 remand directives. Increased Ratings Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Schedule), found in 38 C.F.R. Part 4. The Schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. In resolving this factual issue, the Board may only consider the specific factors as are enumerated in the applicable rating criteria. See Massey v. Brown, 7 Vet. App. 204, 208 (1994); Pernorio v. Derwinski, 2 Vet. App. 625, 628 (1992). In considering the severity of a disability, it is essential to trace the medical history of the veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41. Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of any disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Although the regulations do not give past medical reports precedence over current findings, the Board is to consider the veteran's medical history in determining the applicability of a higher rating for the entire period in which the appeal has been pending. Powell v. West, 13 Vet. App. 31, 34 (1999). Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55 (1994). If later evidence indicates that the degree of disability increased or decreased following the assignment of the initial rating, "staged" ratings may be assigned for separate periods of time. Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007). Additionally, if two evaluations are potentially applicable, the higher evaluation is assigned if the disability picture more nearly approximates the criteria required for that evaluation; otherwise, the lower rating is assigned. 38 C.F.R. § 4.7. 1. Entitlement to an evaluation greater than 30 percent for a right knee disability, to include chondromalacia of the right patella with torn medial meniscus repair and osteomalacia status post total knee replacement prior to September 11, 2021. 2. Entitlement to an evaluation greater than 60 percent for a right knee disability, to include chondromalacia of the right patella with torn medial meniscus repair and osteomalacia status post total knee replacement since September 11, 2021. 3. Entitlement to an evaluation greater than 10 percent for left knee limitation of flexion, associated with left knee strain and degenerative joint disease. The Board notes that some of the Diagnostic Codes pertaining to the knee were amended effective February 7, 2021. Relevant to the discussion in this case, Diagnostic Codes 5055 and 5257 were amended. The criteria that are most favorable to the Veteran's pending claim will apply; however, an award based on the amended regulations may not be made effective before the effective date of the change. See 38 U.S.C. § 5110(g); 38 C.F.R. § 3.114; Kuzma v. Principi, 341 F.3d 1327 Fed. Cir. 2003). The appropriate limitation of motion codes for the knee are Diagnostic Codes 5260 and 5261. 38 C.F.R. § 4.71a. Under Diagnostic Code 5260, a 0 percent rating is warranted for flexion of the knee limited to 60 degrees. A 10 percent rating is warranted for flexion of the knee limited to 45 degrees. A 20 percent rating is warranted for flexion of the knee limited to 30 degrees. A 30 percent rating is warranted for flexion of the knee limited to 15 degrees. A 30 percent rating is the maximum schedular disability rating. 38 C.F.R. § 4.71a. Diagnostic Code 5261 provides the criteria for limitation of extension of the leg. Under Diagnostic Code 5261, a noncompensable (0 percent) rating is assigned for limitation of extension of the leg to 0 degrees. A 10 percent rating is assigned for limitation of extension of the leg to 10 degrees. A 20 percent rating is assigned for limitation of extension of the leg to 15 degrees. A 30 percent rating is assigned for limitation of extension of the leg to 20 degrees. A 40 percent rating is assigned for limitation of extension of the leg to 30 degrees. 38 C.F.R. § 4.71a. For comparison, normal range of motion in the knee is from 0 degrees of extension to 140 degrees of flexion. See 38 C.F.R. § 4.71, Plate II. Additionally, under VAOPGCPREC 23-97, a veteran may be assigned separate ratings for limitation of motion under Diagnostic Code 5260 (limitation of flexion) or 5261 (limitation of extension) and for instability/subluxation under Diagnostic Code 5257. See VAOPGCPREC 23-97 (July 1, 1997). In VAOPGCPREC 23-97 (July 1, 1997; revised July 24, 1997), VA's General Counsel held that a claimant who has arthritis and instability of the knee may be rated separately under Diagnostic Codes 5003-5010 (for the arthritis of the knee) and Diagnostic Code 5257 (for the instability of the knee) based on additional disability. It was specified that, for a knee disability already rated under Diagnostic Code 5257, a claimant would have additional disability justifying a separate rating if there is limitation of motion under Diagnostic Code 5260 (flexion) or Diagnostic Code 5261 (extension). Hence, if a claimant has a disability rating under Diagnostic Code 5257 for instability of the knee and there is also X-ray evidence of arthritis and resulting limitation of motion, a separate rating is available under Diagnostic Code 5003-5010. It is also possible to receive separate ratings for limitation of flexion (Diagnostic Code 5260) and limitation of extension (Diagnostic Code 5261) for a disability of the same joint. See VAOPGCPREC 9-2004 (Sept. 17, 2004). Under Diagnostic Code 5257, a 10 percent rating is warranted for recurrent subluxation or lateral instability that is productive of slight impairment of the knee. A 20 percent rating is warranted for recurrent subluxation or lateral instability that is productive of moderate impairment of the knee. A 30 percent rating is warranted for recurrent subluxation or lateral instability that is productive of severe impairment of the knee. A 30 percent rating is the maximum schedular disability rating available under this code. 38 C.F.R. § 4.71a, Diagnostic Code 5257. Descriptive words such as "slight," "moderate," and "severe," as used in the various diagnostic codes, are not defined in VA's Rating Schedule. Thus, rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6. In other words, the use of these descriptive terms is not altogether dispositive of the rating that should be assigned, but it is nonetheless probative evidence to be considered in making this important determination. 38 C.F.R. §§ 4.2, 4.6. Under the criteria effective since February 7, 2021, Diagnostic Code 5257 provides that recurrent subluxation or instability will be assigned a 10 percent rating for a 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. A 20 percent rating will be assigned if there is 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 for ambulation; or (b) unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribes either an assistive device or bracing for ambulation. A 30 percent rating requires an unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribes both an assistive device and bracing for ambulation. Id. There are also new criteria for patellar instability under Diagnostic Code 5257. 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. 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 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. Id. The patellofemoral complex consists of the quadriceps tendon, the patella, and the patellar tendon. Id. at Note (1). A surgical procedure that does not involve repair of one or more patellofemoral components that contribute to the underlying instability shall not qualify as surgical repair for patellar instability (including, but not limited to, arthroscopy to remove loose bodies and joint aspiration). Id. at Note (2). Under both versions of the rating criteria, Diagnostic Code 5055 provides for a 100 percent temporary total rating period from the date surgery until a specified date after the surgery, followed by ratings from 30 to 60 percent. The minimum rating is 30 percent; and a 60 percent maximum rating will be assigned if there are chronic residuals of severe painful motion or weakness in the affected extremity. If there are intermediate degrees of residual weakness, pain, or limitation of motion, the disability will be rated by analogy to Diagnostic Codes 5256 (ankylosis of the knee), 5261 (limitation of extension of the knee), or 5262 (impairment of the tibia or fibula). 38 C.F.R. § 4.71a. The rating replaces any prior separate ratings. Ankylosis under Diagnostic Code 5256 requires fixation of the joint, or impairment approaching fixation. Effective prior to February 7, 2021, under Diagnostic Code 5262, nonunion of the tibia or fibula, with loose motion, requiring a brace was assigned a 40 percent rating. Malunion was assigned a 30 percent rating. 38 C.F.R. § 4.71a. Effective since February 7, 2021, under Diagnostic Code 5262, nonunion of the tibia or fibula, with loose motion, requiring a brace is still assigned a 40 percent rating. However, malunion is to be evaluated under Diagnostic Codes 5256 (ankylosis), 5257 (subluxation or instability), 5260 (limitation of flexion), or 5261 (limitation of extension) for the knee, whichever results in the highest evaluation. 38 C.F.R. § 4.71a (2021). The new version of Diagnostic Code 5262 also adds criteria for medial tibial stress syndrome (MTSS) or shin splints. Under 38 C.F.R. § 4.59, painful motion is a factor to be considered with any form of arthritis; however, 38 C.F.R. § 4.59 is not limited to disabilities involving arthritis. See Burton v. Shinseki, 25 Vet. App. 1 (2011). In Correia, the Court held that the final sentence of 38 C.F.R. § 4.59 requires that the examiner record the results of range of motion testing "for pain on both active and passive motion [and] in weight-bearing and non-weight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint." See Correia v. McDonald, 28 Vet. App. 158 (2016). In Sharp, the Court held that VA examiners must obtain information about the severity, frequency, duration, precipitating and alleviating factors, and extent of functional impairment of flares from the veterans themselves, when a flare-up is not observable at the time of examination. Sharp v. Shulkin, 29 Vet. App. 26 (2017). Factual Background The Veteran was first afforded a VA knee examination in November 2009. She endorsed flare-ups four times per week that precluded walking for extended periods of time and reduced the ranges of motion of her bilateral knees. Bilateral knee tenderness without signs of instability, abnormal movement, effusion, weakness, redness, heat, deformity, guarding on movement, malalignment, and drainage was documented. There was no subluxation. There was locking pain and crepitus bilaterally. Bilateral knee flexion was to 140 degrees with pain beginning at 140 degrees. Bilateral knee extension was to zero degrees with pain beginning at zero degrees. The Veteran was able to complete repetitive use testing without any additional limitation of range of motion. In April 2015, the Veteran underwent another VA knee examination. The VA examiner reported that the Veteran underwent a total right knee replacement in 2012. The left knee had never been operated on. The Veteran endorsed flare-ups. The right knee had flexion to 130 degrees and extension to zero degrees. There was pain on weight-bearing. The left knee demonstrated normal ranges of motion with flexion to 140 degrees and extension to zero degrees. There was pain on weight-bearing. The Veteran was able to complete repetitive use testing without additional functional loss or range of motion. The VA examiner was unable to provide an opinion regarding the Veteran's functional impairment and additional loss of range of motion after repeated use over time and during flare-ups. Joint stability testing was normal. The Veteran was afforded another VA knee examination in September 2016. The Veteran endorsed flare-ups that were manifested by a popping and locking sensation in the right knee. Left knee flare-ups occurred weekly and were manifested by pain that affected her left knee range of motion. She avoided squatting and kneeling. Right knee active non-weight bearing range of motion studies demonstrated flexion to 70 degrees and extension to 10 degrees. The right knee was able to extend to zero degrees on passive motion. There was pain with passive range of motion. There was tenderness of the medial and lateral joints lines. Left knee active non-weight bearing range of motions studies showed flexion to 60 degrees and extension to zero degrees. There was no pain or functional impairment with passive ranges of motion. The Veteran was unable to complete repetitive use testing due to pain. The VA examiner was unable to provide an estimate regarding the Veteran's ranges of motion with repeated use over time or during flare-ups without resorting to speculation. The Veteran's knee disability caused difficulty with mobility and lifting, which affected her ability to perform any type of occupational task. The VA examiner found that the Veteran's ranges of motion for the bilateral knees had decreased during the course of the appeal period. There was a history of slight recurrent subluxation bilaterally, but joint stability testing was normal. In July 2017, the Veteran had another VA knee examination. There was no evidence of pain on non-weight bearing bilaterally and passive ranges of motion testing were not medically appropriate bilaterally. Range of motion studies showed bilateral knee flexion to 100 degrees and extension to zero degrees. There was pain on weight-bearing and with flexion. The Veteran was able to perform repetitive-use testing without additional loss of function or range of motion. The examination findings were consistent with the Veteran's statements describing functional loss with repetitive use over time and during flare-ups. There was no history of joint instability and stability testing was normal bilaterally. The Veteran's knee disabilities limited prolonged standing and walking, which impacted her job as a social worker. The Veteran underwent another VA examination in March 2019. The VA examiner indicated that there was pain on passive range of motion testing and evidence of pain when the knees were used on non-weight bearing. The Veteran endorsed flare-ups of the right knee that occurred weekly and left knee flare-ups that occurred daily. The flare-ups were manifested by severe pain. She was only able to walk from her car to the building. Range of motion studies showed right knee flexion to 85 degrees and extension to zero degrees. Left knee flexion was to 90 degrees and extension was to zero degrees. There was pain with weight-bearing and flexion. She was able to complete repetitive-use testing without any additional functional loss or range of motion. With repeated use over time and flare-ups, the Veteran's functional loss was moderately severe bilaterally. Right knee stability testing was not indicated. Left knee stability testing was indicated but the Veteran was unable to perform the testing due to pain. In September 2021, the Veteran was afforded her most recent VA knee examination. The Veteran endorsed flare-ups and functional impairment with repeated use over time. She denied a history of instability, recurrent subluxation, and frequent effusion of the knee. Initial range of motion studies showed flexion to 90 degrees and extension to zero degrees bilaterally with pain on flexion. Pain did not limit the Veteran's ranges of motion. Passive and active ranges of motion were the same. The Veteran was able to perform repetitive use testing without additional loss of motion or range of motion. The VA examiner estimated that the Veteran's ranges of motion would be unchanged with repeated use over time. However, he did not provide range of motion estimates during flare-ups. There was no joint instability, ankylosis, muscle atrophy, tibial or fibular impairment. The Veteran had a left meniscal condition. However, the condition was asymptomatic. She worked as a home health nurse and was unable to perform hospital nursing due to her knee pain. In December 2021, VA obtained an addendum opinion. The VA examiner estimated that ranges of motion during flare-ups would be flexion to 70 degrees and extension to zero degrees bilaterally. The VA treatment records associated with the file are consistent with the findings documented during the examinations. Right Knee Prior to September 11, 2021, the Veteran's right knee disability, to include chondromalacia of the right patella with torn medial meniscus repair and osteomalacia, is currently rated 30 percent disabling under 38 C.F.R. § 4.71a, Diagnostic Code 5055. Effective September 11, 2021, the Veteran was awarded a 60 percent evaluation. Id. The Board finds that the Veteran's pain upon range of motion and weakness are accounted for under Diagnostic Code 5055 and that separately applying Diagnostic Codes 5260 or 5261 would result in pyramiding. See 38 C.F.R. § 4.14. Throughout the appeal period, the Veteran has experienced frequent painful flare-ups of her right knee that have been manifested by severe painful motion. Therefore, a 60 percent evaluation for the Veteran's right knee disability, to include chondromalacia of the right patella with torn medial meniscus repair and osteomalacia is warranted prior to September 11, 2021. 38 C.F.R. § 4.71a, Diagnostic Code 5055. A 60 percent evaluation is the highest rating available beyond the initial period of convalescence. Therefore, an evaluation greater than 60 percent must be denied. Id. Additionally, the Veteran's right knee stability has been evaluated as normal throughout the appeal period. Therefore, a separate rating is not warranted under Diagnostic Code 5257. Left Knee The Veteran's left knee disabilities are rated 10 percent disabling under 38 C.F.R. § 4.71a, Diagnostic Code 5257 and Diagnostic Code 5260. The Veteran is in receipt of a 10 percent evaluation for limitation of flexion effective September 12, 2016. In the October 2020 JMPR, the Veteran indicated that she was no longer pursuing her appeal for an increased evaluation for her left knee strain with degenerative joint disease under Diagnostic Code 5257. Therefore, this issue is no longer before the Board. Prior to September 12, 2016, the VA examinations of record do not include range of motion estimates for left knee ranges of motion during flare-ups or with repeated use over time. Therefore, these examinations are inadequate for rating purposes. The Veteran has specifically endorsed flare-ups that are manifested by reduced ranges of motion. Based upon the forgoing, prior to September 12, 2016, the Board finds that a 10 percent evaluation for limitation of flexion is granted. The Board has considered whether a 20 percent evaluation for limitation of flexion is warranted at any point of the appeal period. However, when considering pain on active motion, passive motion, flare-ups and pain on weight-bearing, the evidence of record does not establish that the Veteran's left knee disability is manifested by flexion limited to 30 degrees to warrant a 20 percent disability rating for flexion or extension limited to 10 degrees to warrant a compensable rating. 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 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). In conclusion, prior to September 12, 2016, a 10 percent evaluation for left knee limitation of flexion is granted. An evaluation greater than 20 percent for left knee limitation of flexion is denied. See 38 C.F.R. § 4.71a., Diagnostic Code 5260. Bilateral Knees The Board has considered the application of the remaining Diagnostic Codes under the current version of the regulation in an effort to determine whether a higher or separate rating may be warranted for the Veteran's bilateral knee disabilities but finds none are raised by the medical evidence. Specifically, the evidence does not establish that the Veteran's bilateral knees are ankylosed to warrant higher disability ratings under 38 C.F.R. § 4.71a, Diagnostic Code 5256. Throughout the appeal, the Veteran has displayed ranges of motion in the bilateral knees, which demonstrate that her bilateral knees are not ankylosed. 38 C.F.R. § 4.71a, Diagnostic Code 5256. Under Diagnostic Code 5258, a 20 percent rating is warranted for semilunar cartilage of the knee that is dislocated with frequent episodes of locking, pain, and effusion into the joint. 38 C.F.R. § 4.71a. Under Diagnostic Code 5259, a 10 percent rating is warranted for symptomatic removal of semilunar cartilage. Id. The Veteran is not entitled to separate or higher disability ratings for her bilateral knee disabilities under Diagnostic Code 5258. While the evidence of record does document pain and slight instability of the left knee, frequent episodes of locking of the bilateral knees are not documented during the appeal period. Locking was not documented at any of the VA examinations or in the treatment records, and the Veteran does not argue that she experiences frequent episodes of locking. The Veteran is also not entitled to separate or higher disability ratings for her bilateral knee disabilities under Diagnostic Code 5259 because the evidence does not document symptomatic removal of semilunar cartilage. Thus, the Veteran is not entitled to higher or separate disability ratings for her bilateral knee disabilities under 38 C.F.R. § 4.71a, Diagnostic Codes 5258 and 5259. Additionally, Diagnostic Codes 5262 and 5263 are inapplicable because the evidence of record does not document that the Veteran has impairment, to include malunion or nonunion, of the tibia and fibula of her bilateral legs, or genu recurvatum. This was not documented at the VA examinations or in the treatment records. Thus, the Veteran's claim cannot be granted under these alternate codes. 38 C.F.R. § 4.71a. In reaching its decision, the Board has considered the Veteran's lay statements. The Veteran's lay statements are outweighed by the examination reports of record that were based on an interview with the Veteran, examinations, and the medical expertise of the examiners. The VA examiners have specialized training to assess the severity of the Veteran's knee disabilities. REASONS FOR REMAND Entitlement to a separate rating for urinary incontinence as a possible neurological manifestation of the service-connected degenerative disc disease of the lumbar spine is remanded. In May 2021, the Board remanded the issue of entitlement to a separate rating for urinary incontinence as a possible neurological manifestation of the service-connected degenerative disc disease of the lumbar spine to obtain a medical opinion to determine whether the Veteran's back disability is productive of urinary incontinence. In September 2021, the Veteran was afforded a VA examination. The Veteran was diagnosed with urinary incontinence. The VA examiner opined that it was less likely than not that the Veteran's urinary incontinence was caused or aggravated by her degenerative disc disease of the lumbar spine. The VA examiner's sole rationale was that the Veteran did not have a neurogenic bladder. The Board finds that this opinion is inadequate. It does not explain why the Veteran's urinary incontinence is not caused or aggravated by her service-connected degenerative disc disease of the lumbar spine. A remand is required to obtain an adequate VA medical opinion. The matters are REMANDED for the following actions: 1. Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran's urinary incontinence is at least as likely as proximately due to or aggravated beyond its natural progression by the service-connected degenerative disc disease of the lumbar spine. A rationale must be provided for the opinion. 2. After the above development, and any additionally indicated development, has been completed, readjudicate the issue on appeal. If the benefit sought is not granted to the Veteran's satisfaction, send the Veteran and her representative a Supplemental Statement of the Case and provide an opportunity to respond. If necessary, return the case to the Board for further appellate review. DAVID L. WIGHT Veterans Law Judge Board of Veterans' Appeals Attorney for the Board R.R. Watkins, 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.