Citation Nr: 22012603 Decision Date: 03/04/22 Archive Date: 03/04/22 DOCKET NO. 18-00 083 DATE: March 4, 2022 ORDER New and material evidence having been received, the application to reopen the claim for service connection for a right knee disorder is granted. A rating in excess of 40 percent for rupture of the rectus femoris muscle of the left thigh with mild atrophy is denied. REMANDED Entitlement to service connection for a left knee disorder other than chondral fissuring, claimed as secondary to service-connected rupture of the rectus femoris muscle of the left thigh with mild atrophy, is remanded. Entitlement to service connection for a right knee disorder, claimed as secondary to service-connected rupture of the rectus femoris muscle of the left thigh with mild atrophy, is remanded. Entitlement to an initial compensable rating for left knee chondral fissuring is remanded. Entitlement to a rating in excess of 10 percent for residual scars of the left thigh status post quad surgical repair is remanded. FINDINGS OF FACT 1. In a final rating decision issued in April 2006, the Agency of Original Jurisdiction (AOJ) denied service connection for a right knee disorder, characterized as residuals of a right knee injury. 2. Evidence associated with the record since the final April 2006 denial is not cumulative or redundant of the evidence of record at the time of the decision and raises a reasonable possibility of substantiating the claim of entitlement to service connection for a right knee disorder. 3. For the entire appeal period, the Veteran's rupture of the rectus femoris muscle of the left thigh with mild atrophy is manifested by pain, atrophy, weakness, and limitation of knee motion, resulting in an unstable or antalgic gait, difficulty ambulating, and loss of balance, which is fully contemplated in the currently assigned maximum schedular rating for a severe disability of Muscle Group XIV. CONCLUSIONS OF LAW 1. The April 2006 rating decision that denied service connection for a right knee disorder, characterized as residuals of a right knee injury, is final. 38 U.S.C. § 7105(c) (West 2002); 38. C.F.R. §§ 3.104, 3.156, 20.302, 20.1103 (2005). 2. New and material evidence has been received to reopen a claim of entitlement to service connection for a right knee disorder. 38 U.S.C. § 5108; 38 C.F.R. § 3.156(a). 3. The criteria for a rating in excess of 40 percent for rupture of the rectus femoris muscle of the left thigh with mild atrophy have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.3, 4.7, 4.55, 4.56, 4.73, Diagnostic Code (DC) 5314. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from November 2003 to October 2005. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a rating decision issued in April 2016 by a Department of Veterans Affairs (VA) Regional Office. In August 2021, the Veteran testified at a Board hearing before the undersigned Veterans Law Judge. A transcript of the hearing is associated with the record. At such time, the Veteran waived AOJ of the evidence associated with the record since the February 2018 supplemental statement of the case. 38 C.F.R. § 20.1305(c). The undersigned also held the record open for 90 days for the submission of additional evidence, which was received in November 2021. 38 U.S.C. § 7105(e)(1) (2018). With respect to the characterization of the Veteran's claim for service connection for a left knee disorder other than chondral fissuring the Board notes that a May 2014 rating decision original denied such claim. Additionally, following the receipt of new and material evidence later that month, a September 2014 decision confirmed and continued such denial. Thereafter, in August 2015, within one year of the issuance of the September 2014 rating decision, new and material evidence consisting of a favorable medical opinion relating the Veteran's left knee disorder to his service-connected left thigh muscle disability was received. 38 C.F.R. § 3.156(b) (new and material evidence received prior to the expiration of the appeal period, i.e., within one year of the issuance of a rating decision or 60 days of the issuance of a statement of the case, will be considered as having been filed in connection with the claim which was pending at the beginning of the appeal period). Thus, his claim for service connection for a left knee disorder other than chondral fissuring is reviewed on a de novo basis. 1. Whether new and material evidence has been received to reopen the claim of entitlement to service connection for a right knee disorder. Generally, a claim which has been denied in an unappealed Board decision or an unappealed AOJ decision may not thereafter be reopened and allowed. 38 U.S.C. §§ 7104(b), 7105(c). The exception to this rule is 38 U.S.C. § 5108, which provides that if new and material evidence is presented or secured with respect to a claim which has been disallowed, the Secretary shall reopen the claim and review the former disposition of the claim. New evidence means existing evidence not previously submitted to agency decisionmakers. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). New evidence would raise a reasonable possibility of substantiating the claim if, when considered with the old evidence, it would at least trigger the Secretary's duty to assist by providing a medical opinion. Shade v. Shinseki, 24 Vet. App. 110 (2010). For the purpose of establishing whether new and material evidence has been submitted, the credibility of the evidence is to be presumed. Justus v. Principi, 3 Vet. App. 510, 513 (1992). By way of background, VA received the Veteran's original claim for service connection for a right knee disorder in October 2005. In an April 2006 rating decision the AOJ considered the Veteran's service treatment records (STRs), a March 2006 VA examination report, and lay statements of record; however, as his STRs were negative for any treatment, findings, or diagnosis referable to a right knee injury and the March 2006 VA examiner determined that there was no current diagnosis of a right knee disorder, the AOJ denied service connection for a right knee disorder, characterized as residuals of a right knee injury. In April 2006, the Veteran was advised of the decision and of his appellate rights, but he did not enter a notice of disagreement with such decision. Furthermore, no new and material evidence was physically or constructively received within one year of the issuance of the decision, and no relevant service department records have since been received. Therefore, such rating decision is final. 38 U.S.C. § 7105(c) (West 2002); 38. C.F.R. §§ 3.104, 3.156, 20.302, 20.1103 (2005). In March 2013, the Veteran filed an application to reopen his previously denied claim for service connection for a right knee disorder. In a May 2014 rating decision, the AOJ considered the evidence previously of record as well as a May 2014 VA examination report. In this regard, the AOJ observed that the evidence did not show that a right knee disorder was incurred in or aggravated by military service. Furthermore, while the evidence demonstrated a current disorder, the May 2014 VA examiner found that such was less likely than not secondary to the Veteran's left thigh muscle disability. Consequently, while the AOJ reopened the previously denied claim for service connection for a right knee disorder, it was denied on the merits. Later that month, the Veteran was informed of the decision and his appellate rights; however, he did not enter a notice of disagreement with such decision. Nonetheless, in May 2014, within one year of the May 2014 rating decision, he submitted a statement from his private treatment provider, Dr. R.L., in which Dr. R.L. stated that he felt the Veteran's left knee disorder could be related to his original quadriceps tear due to his left quadriceps being weaker from placing more force throughout his left knee joint, and his right knee pain was likely due to compensating for his left knee weakness and putting more weight on his right knee, causing increased stress and wear. Accordingly, the AOJ readjudicated the Veteran's claim for service connection for a right knee disorder in a rating decision issued in September 2014. Specifically, the AOJ considered such newly received private opinion and the remainder of the evidence previously of record, and confirmed the previous denial of such claim as the evidence did not show that the Veteran's right knee disorder resulted from, or was aggravated by, a service-connected disability. Later that month, the Veteran was informed of the decision and his appellate rights; however, he did not enter a notice of disagreement with such decision. Rather he filed another application to reopen such claim in August 2015. Nonetheless, in August 2015, within one year of the September 2014 rating decision, he submitted an additional statement from Dr. R.L. in which Dr. R.L. indicated that the Veteran's in-service thigh muscle injury was the likely root of his orthopedic disorders, which included bilateral patellofemoral syndrome, chondromalacia, and status post meniscectomies, as he developed gait instability and wear patterns on the knee joints due to the in-service thigh muscle tear. While the AOJ issued another rating decision in April 2016 denying the Veteran's application to reopen the previously denied claim for service connection for a right knee disorder, which he subsequently appealed, the Board finds that the May 2014 and September 2014 rating decisions are not final. In this regard, as noted previously, 38 C.F.R. § 3.156(b) provides, as relevant, that new and material evidence received prior to the expiration of the appeal period, i.e., within one year of the issuance of a rating decision or 60 days of the issuance of a statement of the case, it will be considered as having been filed in connection with the claim which was pending at the beginning of the appeal period. Thus, as the opinions received in May 2014 and August 2015 relate the Veteran's current right knee disorder to his service-connected left thigh muscle disability, which was the basis of the prior denials, such are not cumulative or redundant of the evidence of record at the time of the May 2014 and September 2014 rating decisions and raises a reasonable possibility of substantiating the claim of entitlement to service connection for a right knee disorder. Consequently, as new and material evidence was received within one year of such rating decisions, they are not final and the instant appeal stems from the Veteran's March 2013 application to reopen his previously denied claim for service connection for a right knee disorder. Moreover, in light of such favorable opinions, as well as March 2019 and March 2021 opinions from Dr. M.S., another private treatment provider, wherein he reports that: (1) the Veteran had a longstanding left lower extremity service-related injury, which resulted in weakness of the quadriceps; (2) as a result of his chronic left lower extremity weakness and deficiency, the Veteran shifted his weight to the right knee and suffered chronic right knee pain; and (3) his right knee injury is more self-limiting, but is directly related to his service injury and resulting profound weakness in his left lower extremity, and July 2020 and August 2021 opinions from Dr. M.S. indicating that, provided with profound weakness in his lower extremity, he believed that the weakness to the Veteran's right knee is an injury that is 100 percent related to his service-connected disability, the Board finds that the evidence associated with the record since the final April 2006 denial is not cumulative or redundant of the evidence of record at the time of the decision and raises a reasonable possibility of substantiating the claim of entitlement to service connection for a right knee disorder. Therefore, new and material evidence has been received, and the Veteran's claim is reopened. 2. Entitlement to a rating in excess of 40 percent for rupture of the rectus femoris muscle of the left thigh with mild atrophy. Disability ratings are determined by applying a schedule of ratings that is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Each disability must be viewed in relation to its history, and the limitation of activity imposed by the disabling condition should be emphasized. 38 C.F.R. § 4.1. Examination reports are to be interpreted in light of the whole recorded history, and each disability must be considered from the point of view of the veteran working or seeking work. 38 C.F.R. § 4.2. All reasonable doubt will be resolved in the claimant's favor. 38 C.F.R. § 4.3. Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. 38 C.F.R. § 4.7. Separate ratings can be assigned for separate periods based on the facts found - a practice known as "staged" ratings. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Staged ratings are appropriate whenever the factual findings show distinct periods where the service-connected disability exhibits symptoms that would warrant different ratings. Id. The appeal period before the Board begins on August 12, 2015, the date VA received the Veteran's application to reopen his claims for service connection for left and right knee disorders secondary to his service-connected rupture of the rectus femoris muscle of the left thigh with mild atrophy, which was construed as a claim for an increased rating for such disability, plus the one-year look-back period. Gaston v. Shinseki, 605 F.3d 979, 982 (Fed. Cir. 2010). For the entire appeal period, the Veteran's left thigh muscle disability is rated as 40 percent disabling pursuant to 5314 in contemplation of a severe muscle injury. In this regard, under 38 C.F.R. § 4.73, DCs 5301 to 5323 prescribe the evaluation of disabilities manifested by muscle injuries based upon the classifications of slight, moderate, moderately severe, or severe. 38 C.F.R. § 4.56(d)(1)-(4). The corresponding level of severity of a service-connected muscle injury is determined to a significant extent by the presence or absence of cardinal signs and symptoms of muscle disability, which consist of loss of power, lowered threshold of fatigue, weakness, pain, impairment of coordination, and uncertainty of movement. 38 C.F.R. § 4.56(c). A severe disability of muscles contemplates the following: (i) Type of injury. Through and through or deep penetrating wound due to high-velocity missile, or large or multiple low velocity missiles, or with shattering bone fracture or open comminuted fracture with extensive debridement, prolonged infection, or sloughing of soft parts, intermuscular binding and scarring. (ii) History and complaint. Service department record or other evidence showing hospitalization for a prolonged period for treatment of wound. Record of consistent complaints of cardinal signs and symptoms of muscle disability as defined in paragraph (c) of this section, worse than those shown for moderately severe muscle injuries, and, if present, evidence of inability to keep up with work requirements. (iii) Objective findings. Ragged, depressed and adherent scars indicating wide damage to muscle groups in missile track. Palpation shows loss of deep fascia or muscle substance, or soft flabby muscles in wound area. Muscles swell and harden abnormally in contraction. Tests of strength, endurance, or coordinated movements compared with the corresponding muscles of the uninjured side indicate severe impairment of function. If present, the following are also signs of severe muscle disability: (A) X-ray evidence of minute multiple scattered foreign bodies indicating intermuscular trauma and explosive effect of the missile. (B) Adhesion of scar to one of the long bones, scapula, pelvic bones, sacrum or vertebrae, with epithelial sealing over the bone rather than true skin covering in an area where bone is normally protected by muscle. (C) Diminished muscle excitability to pulsed electrical current in electrodiagnostic tests. (D) Visible or measurable atrophy. (E) Adaptive contraction of an opposing group of muscles. (F) Atrophy of muscle groups not in the track of the missile, particularly of the trapezius and serratus in wounds of the shoulder girdle. (G) Induration or atrophy of an entire muscle following simple piercing by a projectile. 38 C.F.R. § 4.56(d). Specifically, DC 5314 provide the criteria for rating injuries affecting Muscle Group XIV, which affects extension of the knee, simultaneous flexion of the hip and flexion of the knee, tension of the fascia lata and iliotibial band, acts with Group XVII in postural support of the body and with the hamstrings in synchronizing the hip and the knee, and includes the anterior thigh group: sartorius, rectus femoris, vastus externus, vastus intermedius, vastus internus, and tensor vaginae femoris. Under DC 5314, a 40 percent rating is provided for a severe disability. Turning to the evidence of record, a January 2016 VA examination report reflects the Veteran's complaint of weakness in the left thigh, and the inability to stand longer than 20-30 minutes. He further reported that he could walk one mile, but had to walk steps one at a time and could not run. Upon physical examination, the Veteran had left knee flexion limited to 85 degrees and full extension. The examiner noted that, as the Veteran extended his left knee against gravity while sitting, his left thigh and leg quivered, suggesting weakness of the left thigh muscle. Additionally, the examiner reported that the Veteran had a deformity of the left quadriceps muscle described as a palpable muscle bulge, proximal thigh, proximal half of the anterior scar. The examiner further reported that there was a disturbance of station; a disturbance of locomotion with lump favoring the left leg; and by history, interference with standing, sitting, and weightbearing. Muscle strength testing showed 2/5 of quadriceps strength with marked and obvious quivering (shaking of the left thigh and lower leg) as the Veteran extended his knee and maintained his left knee in extension. Joint stability testing was normal. The examiner noted that the Veteran had scars from a quadricep surgery: (1) a 13 centimeter by 1 centimeter free movable scar in the mid left thigh; and (2) a 4 centimeter by 3 millimeter scar distal to the aforementioned scar. Here, the examiner explained that such scars were nontender, freely movable, and nonadherent. A January 2018 VA examination report reveals the Veteran's complaint of left thigh muscle pain. The examiner noted that he had a non-penetrating muscle injury and identified the injury to Muscle Group XIV. It was further observed that the Veteran had scar(s) associated with his muscle injury and no known fascial defects or evidence of fascial defects associated with his muscle injury. The examiner reported that the Veteran's muscle injury affected muscle substance or function, to include muscles swell and harden abnormally in contraction, and adaptive contraction of an opposing group of muscles. The Veteran had consistent loss of power; consistent weakness; fatigue-pain; consistent impairment of coordination; and uncertainty of movement attributable to his left thigh muscle disability (XIV, rectus femoris). Muscle strength testing was normal except for a 4/5 of left hip flexion, 4/5 of left knee flexion, and 4/5 of left ankle dorsiflexion. The Veteran had muscle atrophy (XIV, thigh, rectus femoris; 64 centimeters for the atrophied side). Further, he regularly used a brace and his left thigh muscle disability impacted his ability to work as prolonged walking and standing would be problematic. During his August 2021 Board hearing, the Veteran reported that he experienced muscle atrophy and constant pain. He further reported that he uses a cane or crutch depending on the severity of his pain; that he had difficulty with balance and ambulation, to include using steps; and that he had caving of the muscle. Based on the above, the Board finds the evidence demonstrates that the Veteran's left thigh muscle disability is manifested by pain, atrophy, weakness, and limitation of knee motion, resulting in an unstable or antalgic gait, difficulty ambulating, and loss of balance, most nearly approximating a severe injury to Muscle Group XIV. However, the Board finds a rating in excess of 40 percent for the Veteran's left thigh muscle disability is not warranted pursuant to DC 5314 as such is the maximum schedular rating allowed under such DC. The Board has considered whether such service-connected disability may be rated under other DCs. In this regard, the only muscle group shown to be affected is Muscle Group XIV as such involves the quadricep muscle (rectus femoris), with resulting functional impairment of the knee. Indeed, there is no indication that there is any involvement of the hip or pelvis. Further, the Board notes that the Veteran is already service-connected for left knee chondral fissuring and scarring related to his left thigh muscle disability. The Board acknowledges that the Veteran experiences limited range of motion in his left knee; however, he is separately service-connected for chondral fissuring, which is rated based on dislocated semilunar cartilage with limitation of flexion. Thus, the Board finds that assigning another separate rating for such musculoskeletal impairment resulting from such injury would be tantamount to pyramiding. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). Thus, the only avenue for the Veteran to obtain a rating in excess of 40 percent for his left thigh muscle disability is on an extraschedular basis. In this regard, an extra-schedular rating is warranted if the case presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization that application of the regular schedular standards would be impracticable. 38 C.F.R. § 3.321(b)(1). In Thun v. Peake, 22 Vet. App. 111, 115-16 (2008), the United States Court of Appeals for Veterans Claims (Court) stated that the determination of whether a claimant is entitled to an extra-schedular rating under 38 C.F.R. § 3.321 is a three-step inquiry. First, it must be determined whether the evidence presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. In this regard, the Court indicated that there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. Under the approach prescribed by VA, if the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. Second, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as "marked interference with employment" and "frequent periods of hospitalization." Third, when an analysis of the first two steps reveals that the rating schedule is inadequate to evaluate a claimant's disability picture and that picture has attendant thereto related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service to determine whether, to accord justice, the Veteran's disability picture requires the assignment of an extra-schedular rating. Id. However, the Court has held that VA's duty to maximize benefits requires it to first exhaust all schedular alternatives for rating a disability that are expressly raised or are reasonably raised by the record including, but not limited to, secondary service connection, analogous ratings, the requirement to assign a higher schedular rating if a veteran's disability more nearly approximates the higher rating, the requirement that VA resolve doubt in favor of claimants, ratings based on individual unemployability, special monthly compensation, and the ability to rate a single disability under multiple diagnostic codes without pyramiding, before the extra-schedular analysis is triggered. Morgan v. Wilkie, 31 Vet. App. 162 (2019). Additionally, the Court has provided six non-exhaustive or mandatory guiding principles to aid in conducting an analysis under Thun's first step: First, the sole focus of Thun's first step is on the ability of the rating schedule to evaluate the veteran's symptomatology; extra-schedular consideration is not applicable to claims that may be properly evaluated with conventional schedular rating tools. See Morgan supra. Second, Thun's first step deals exclusively with whether the veteran's symptomsinterchangeably referred to by the Court as "functional impairments"are exceptional, whereas Thun's second step considers the functional effects of those symptoms. See Yancy v. McDonald, 27 Vet. App. 484, 494 (2016). Third, where a symptom or impairment is not compensable under the rating schedule, as is the case for psychiatric conditions without a valid DSM-5 diagnosis, see Martinez-Bodon v. Wilkie, 32 Vet. App. 393, 404 (2020), it also does not warrant extra-schedular consideration as this would amount to a backdoor means to obtaining compensation for a condition the rating schedule intends to exclude. Fourth, extra-schedular consideration is not warranted for symptoms or effects that lack a nexus to service or to a service-connected disability. Fifth, the Board is only required to discuss the theories of entitlement raised by the veteran or reasonably raised by the record. Sixth, in reviewing the Board's analysis of referral for extra-schedular consideration, the Court will be mindful of the rule against prejudicial error. Long v. Wilkie, 33 Vet. App. 167 (2020) (en banc). The Board has carefully compared the level of severity and symptomatology of the Veteran's service-connected left thigh muscle disability with the established criteria found in the rating schedule. In the instant case, the Board finds that such disability is fully addressed by the rating criteria under which it is rated. Specifically, the Veteran is in receipt of a 40 percent rating for his rupture of the rectus femoris muscle of the left thigh, which includes symptoms of pain, atrophy, weakness, and limitation of knee motion. Further, such rating contemplates the functional impairment resulting from such symptomatology, to include an unstable or antalgic gait, difficulty ambulating, and loss of balance. Therefore, the record does not reflect additional symptomatology or resulting functional impairment that is not contemplated by the rating criteria. Thus, the Board finds that the rating criteria reasonably describe the Veteran's disability level and symptomatology for his service-connected disability and referral for consideration of an extra-schedular rating is not warranted. Consequently, a rating in excess of 40 percent for the Veteran's left thigh muscle disability is not warranted. 38 C.F.R.§ 3.321(b)(1). The Board has considered whether staged ratings under Hart, supra, are appropriate for the Veteran's service-connected left thigh muscle disability; however, the Board finds that his symptomatology had been stable throughout the appeal period. Therefore, assigning staged ratings is not warranted. Furthermore, neither the Veteran nor his representative have raised any other issues, nor have any other issues been reasonably raised by the record, with regard to the increased rating claims adjudicated herein. See Doucette v. Shulkin, 28 Vet. App. 366 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). Therefore, the Board finds that an increased rating for the Veteran's left thigh muscle disability is not warranted. Consequently, as the evidence of record persuasively weighs against such claim, the benefit-of-the-doubt doctrine is inapplicable and his increased rating claim must be denied. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. REASONS FOR REMAND 3. Entitlement to service connection for a left knee disorder other than chondral fissuring, claimed as secondary to service-connected rupture of the rectus femoris muscle of the left thigh with mild atrophy. 4. Entitlement to service connection for a right knee disorder, claimed as secondary to service-connected rupture of the rectus femoris muscle of the left thigh with mild atrophy. The Veteran contends that his left and right knee disorders are secondary to his service-connected left thigh muscle disability. In this regard, he reports that his bilateral knee disorders are a result of his limp, altered gait, and favoring one knee in comparison to the other in order to compensate for the difference in strength in both of his legs due to his left thigh weakness. At the March 2006 VA examination, the examiner determined that there was no current diagnosis of a left or right knee disorder. At the May 2014 VA examination, following a review of the record and an examination, the examiner diagnosed bilateral knee osteoarthritis and medial meniscus injuries, which were less likely than not proximately due to or the result of the Veteran's service-connected left thigh muscle disability. In support thereof, the examiner simply indicated that such was based on reports from the Veteran's personal orthopedist. At the January 2016 VA examination, the examiner reported diagnoses of post-operative status left and right knee arthroscopies. Here, he indicated that updated X-rays did not show evidence of degenerative joint disease. Additionally, the examiner reported that he was unable to provide an opinion regarding causation of the Veteran's left and right knee disorders and their relationship to his left thigh muscle disability as there was insufficient data available and, of the data that was available, there was a disparity in the description of the Veteran's range of motion, activities, and history. To the contrary, as noted above, in May 2014, Dr. R.L. stated that he felt the Veteran's left knee disorder could be related to his original quadriceps tear due to his left quadriceps being weaker from placing more force throughout his left knee joint, and his right knee pain was likely due to compensating for his left knee weakness and putting more weight on his right knee, causing increased stress and wear. Additionally, in August 2015, Dr. R.L. indicated that the Veteran's in-service thigh muscle injury was the likely root of his orthopedic disorders, i.e., bilateral patellofemoral syndrome, chondromalacia, and status post meniscectomies, as the Veteran developed gait instability and wear patterns on the knee joints due to the in-service thigh muscle tear. Further, in March 2019 and March 2021, Dr. M.S. reported that the Veteran was being treated for chondromalacia of both knees and that: (1) he had a longstanding left lower extremity service-related injury, which resulted in weakness of the quadriceps; (2) as a result of his chronic left lower extremity weakness and deficiency, the Veteran shifted his weight to the right knee and suffered chronic right knee pain; (3) he was also left with a left knee that was weak with chronic pain in the patella; and (4) his right knee injury is more self-limiting, but is directly related to his service injury and resulting profound weakness in his left lower extremity and, in July 2020 and August 2021, Dr. M.S. indicated that, provided with profound weakness in his lower extremity, he believed that the weakness to the Veteran's right knee is an injury that is 100 percent related to his service-connected disability. However, while Drs. R.L. and M.S. indicated that the Veteran's service-connected left thigh muscle disability resulted in weakness in the left lower extremity, which, in turn, caused a shift in weight and an altered gait with increased pain in the bilateral knees, they do not explain the mechanism by which such caused or aggravated his currently diagnosed bilateral knee disorders, identified as patellofemoral syndrome, chondromalacia, status post meniscectomies, and possibly osteoarthritis. Thus, the Board cannot rely on such opinions to award service connection. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). Nonetheless, in light of the conflicting evidence as to whether the Veteran has osteoarthritis of the left and/or right knees, and the lack of a detailed rationale as to whether his left and right knee disorders are caused or aggravated by his service-connected left thigh muscle disability, the Board finds that a remand is necessary in order to afford the Veteran a VA examination addressing the nature and etiology of his left and right knee disorders. 5. Entitlement to an initial compensable rating for left knee chondral fissuring. 6. Entitlement to a rating in excess of 10 percent for residual scars of the left thigh status post quad surgical repair. The Board finds that a remand is necessary in order to afford the Veteran contemporaneous VA examinations so as to determine the current nature and severity of his left knee and left thigh scars disabilities. In this regard, his left knee and left thigh scars disabilities were most recently examined by VA in January 2016 and January 2018, respectively. However, since such time, the Veteran has reported increased and additional symptomatology of such disabilities. With respect to his left knee disability, he testified at the August 2021 Board hearing that he experienced pain, limitation of motion, and weakness, which resulted in an inability to stand for long periods of time. As pertinent to the Veteran's scars, he reported that he had two scars, with one larger than the other, measuring approximately 7 or 8 inches long and 2 or 3 inches long. He further indicated that his scars turned red, were occasionally itchy, raised, sore, and/or tender to the touch, and sometimes caused an induration to his skin. Therefore, as the evidence suggests that the Veteran's left knee and scar symptomatology may have increased since the January 2016 and January 2018 VA examinations, respectively, a remand is necessary in order to schedule him for appropriate VA examinations in order to assess the current nature and severity of such service-connected disabilities. See Snuffer v. Gober, 10 Vet. App. 400 (1997); Caffrey v. Brown, 6 Vet. App. 377 (1994); VAOPGCPREC 11-05 (1995). The matters are REMANDED for the following action: 1. Afford the Veteran an appropriate VA examination to determine the current nature and etiology of his claimed left and right knee disorders, and the nature and severity of his service-connected left knee chondral fissuring. The record, to include a copy of this Remand, must be made available to the examiner, and all indicated tests and studies should be accomplished. (A) Identify all left and right knee disorders other than chondral fissuring found to be present, to include patellofemoral syndrome, chondromalacia, status post meniscectomies, and possibly osteoarthritis. In this regard, the examiner should specifically indicate whether the Veteran has osteoarthritis of the left and right knees. In this regard, please address the discrepancy between the findings of record that the Veteran does not have degenerative joint disease and the March 2014 VA examination report noting a diagnosis of bilateral osteoarthritis. (B) The examiner should identify the current nature and severity of all manifestations of the Veteran's left knee chondral fissuring, separate and distinct from any other left knee disorder found to be present. (C) The examiner should record the range of motion of the left knee on flexion and extension as observed on clinical evaluation in terms of degrees. If there is evidence of pain on motion, the examiner should indicate the degree of range of motion at which such pain begins, as well as whether such pain on movement results in any loss of range of motion. The examiner should record the results of range of motion testing for pain on both active and passive motion, on weight-bearing and non-weight-bearing, in terms of degrees, if possible. If the examiner is unable to conduct the required testing or concludes that the required testing is not necessary in this case, he or she should clearly explain why that is so. (D) It is also imperative that the examiner comment on the functional limitations of the left knee caused by flare-ups and repeated use over time. In this regard, the examiner should indicate whether, and to what extent, the Veteran's range of motion is additionally limited during flare-ups and on repeated use over time, expressed, if possible, in terms of degrees. If the Veteran is not being examined during a flare-up or after repeated use over time, the examiner should obtain information regarding the frequency, duration, characteristics, severity, and/or functional loss related to such factors and estimate her range of motion, if possible. If it is not possible to provide a specific measurement without speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). (E) The examiner should also indicate whether the Veteran's left knee chondral fissuring results in recurrent subluxation, lateral instability, and/or patellar instability, or dislocated or removed semilunar cartilage and, if so, the nature and severity of such impairment. (F) The examiner should comment upon the functional impairment resulting from the Veteran's left knee chondral fissuring. (G) For each left and right knee disorder other than chondral fissuring found to be present, is it at least as likely as not (i.e., a 50 percent or greater probability) that such is caused or aggravated by the Veteran's service-connected rupture of the rectus femoris muscle of the left thigh with mild atrophy? For any aggravation found, the examiner should state, to the best of their ability, the baseline of symptomatology and the amount, quantified if possible, of aggravation beyond the baseline symptomatology. In offering such opinion, the examiner should consider Drs. R.L.'s and M.S.'s opinions, which suggest that the Veteran's left and right knee disorders are related to the weakness and altered gait caused by his service-connected left thigh muscle disability. A rationale for any opinion offered should be provided. 2. Afford the Veteran an appropriate VA examination to determine the current nature and severity of his service-connected left thigh scars. The record, to include a copy of this Remand, must be made available to the examiner, and all indicated tests and studies should be accomplished. The examiner should identify the current nature and severity of all manifestations of the Veteran's left thigh scars, to include the size of such scars, and whether they are painful and/or unstable. The examiner should also comment upon the functional impairment resulting from the Veteran's left thigh scars. A rationale for any opinion offered should be provided. A. JAEGER Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Koria B. Stanton, Associate 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.