Citation Nr: 22016206 Decision Date: 03/21/22 Archive Date: 03/21/22 DOCKET NO. 14-21 938 DATE: March 21, 2022 ORDER Service connection for an acquired psychiatric disorder, to include anxiety and major depression, is denied. A rating in excess of 10 percent prior to October 9, 2013, for status post medial meniscectomy of the right knee with residual scar is denied. A rating in excess of 10 percent prior to October 9, 2013, for degenerative joint disease of the right knee is denied. REMANDED Entitlement to service connection for obstructive sleep apnea is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. FINDINGS OF FACT 1. Clear and unmistakable evidence demonstrates that an acquired psychiatric disorder pre-existed service and clearly and unmistakably did not increase in severity beyond its natural progression during service. 2. The Veteran has not been shown to have an acquired psychiatric disorder related to his service-connected right knee or headache disabilities. 3. Prior to October 9, 2013, the Veteran's right knee disability was manifested by degenerative joint disease with subjective complaints of pain, instability, and objective findings of slight instability prior to October 9, 2013, painful flexion limited to 110 degrees at worst, extension not limited to 10 degrees, and no objective evidence of ankylosis, or malunion of the tibia or fibula, or genu recurvatum. CONCLUSIONS OF LAW 1. A psychiatric disorder clearly and unmistakably preexisted service and clearly and unmistakably was not aggravated therein. The presumption of soundness at entrance is rebutted. 38 U.S.C. §§ 1111, 1137. 2. An acquired psychiatric disorder was not incurred in or aggravated by service. 38 U.S.C. §§ 1111, 1131, 1137, 1153; 38 C.F.R. §§ 3.102, 3.303, 3.304(b), 3.306. 3. The criteria for service connection for a psychiatric disorder as secondary to service-connected right knee or headache disabilities have not been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. 4. The criteria for a rating in excess of 10 percent prior to October 9, 2013, for status post medial meniscectomy of the right knee with residual scar have not been met. 38 U.S.C. § 1155; 38 C.F.R. § 4.71a, Diagnostic Code 5257. 5. The criteria for a rating in excess of 10 percent prior to October 9, 2013, for degenerative joint disease of the right knee with limitation of extension are not met. 38 U.S.C. § 1155; 38 C.F.R. § 4.71a, Diagnostic Codes 5010, 5261. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from August 1975 to August 1983. This matter comes before the Board of Veterans' Appeals (Board) on appeal from October 2012, November 2012, and August 2018 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO). In his May 2020 and October 2020 appeals to the Board, the Veteran requested a Board videoconference hearing at an RO. However, in October 2021, the Veteran, through his representative, waived the hearing request. See Document Evidence Submission received October 7, 2021. Therefore, the request is deemed withdrawn and the Board may proceed with adjudication. 1. Service connection for an acquired psychiatric disorder, to include anxiety and major depression, Service connection may be established for disability resulting from personal injury suffered or disease contracted in the line of duty in the active military, naval, or air service. 38 U.S.C. § 1131. To establish a right to compensation for a present disability, a Veteran must show: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship, i.e., a nexus, between the claimed in-service disease or injury and the current disability. 38 C.F.R. § 3.303(a); Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303(d). Every veteran shall be taken to have been in sound condition when examined, accepted, and enrolled for service, except as to defects, infirmities, or disorders noted at the time of the examination, acceptance, and enrollment, or where clear and unmistakable evidence demonstrates that the injury or disease existed before acceptance and enrollment and was not aggravated by such service. 38 U.S.C. § 1111. The burden falls on the government to rebut the presumption of soundness by clear and unmistakable evidence that the veteran's disability was both pre-existing and not aggravated by service. Id. Clear and unmistakable evidence means evidence that "cannot be misinterpreted and misunderstood, i.e., it is undebatable." Quirin v. Shinseki, 22 Vet. App. 390, 396 (2009). A pre-existing injury or disease will be considered to have been aggravated by service where there is an increase in disability during such service, unless there is a specific finding that the increase in disability is due to the natural progress of the disease. 38 U.S.C. § 1153. Aggravation may not be conceded where the disability underwent no increase in severity during service on the basis of all the evidence of record pertaining to the manifestations of the disability prior to, during, and subsequent to service. 38 C.F.R. § 3.306(b). The Veteran's July 1975 service entrance examination reveals normal psychiatric findings. There were also no reports or findings of psychiatric problems reported on the Veteran's July 1975 service enlistment report of medical history. If a disorder was not "noted" on entering service, the government must show clear and unmistakable evidence of both a preexisting condition and a lack of in-service aggravation to overcome the presumption of soundness. A lack of aggravation may be shown by establishing that there was no increase in disability during service or that the "increase in disability [was] due to the natural progress of the preexisting condition." 38 C.F.R. § 3.306; Wagner v. Principi, 370 F.3d 1089, 1096 (Fed. Cir. 2004). If the government fails to rebut the presumption of soundness, the claim is one for service connection, not aggravation. Wagner, 370 F.3d at 1097. In this regard, the Board notes that the October 2020 examiner found the Veteran denied a history of psychiatric symptoms upon entrance into the military, other than problems sleeping, and there was clear and unmistakable evidence throughout the claims gile that these psychiatric conditions manifested prior to enlistment. Therefore, the examiner opined the Veteran's acquired psychiatric disorder was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. During the psychological evaluation conducted in June 1983, during his military service, he described a history of generally unstable pattern of relationships in which he maintained a somewhat passive, aloof, and withdrawn stance. There was a history of problems maintaining his behavior within societal levels including using marijuana, which led to reduction in rank, and minor involvement in street gangs, thefts, and violence. The examiner noted these were symptoms of conduct disorder associated with Antisocial Personality Disorder that pre-dated his military service. Psychological testing revealed considerable somatizing of conflict, a somewhat schizoid adjustment, and passive-dependent features. Anger tended to be suppressed, with a very poor insight regarding the sources of his frustration. The examiner noted these longstanding symptoms, patterns of behavior, and personality characteristics were consistent with a personality disorder, and the psychologist, Dr. E. diagnosed Mixed Personality Disorder with histrionic and dependent features, based upon DSM-III criteria. The psychological evaluation report by Dr. E. commented that the Veteran displayed a character disorder which appeared to interfere with his functioning in military environment in that he demonstrated multiple difficulties in relationships and had difficulty maintaining his behavior in societal levels. The Veteran has continued to evidence behavioral problems associated with a personality disorder since discharging from the military and has been diagnosed with a variety of personality disorders and traits, including the Antisocial Personality Disorder, which he was diagnosed with by Dr. M. during the 2012 and 2018 Mental Disorder examinations. The evidence throughout the claims file shows antisocial behaviors began prior to enlisting in the military (e.g., skipping school, physical altercations, substance abuse), continued during his military service (e.g., irritability, occupational problems including failure to report and being late, marijuana related loss of rank, relationship problems), and persisted throughout his adult life after he discharged from the military (e.g., irritability, drug and alcohol use, physical altercations including domestic violence, homicidal ideation toward his ex-wife, behavior flags at VA due to threatening a treating provider). Therefore, his problematic behavioral patterns with inability to conform to societal standards have been present since adolescence and have persisted throughout adulthood. The examiner noted personality disorders are enduring patterns of inner experience and behavior that deviate from the expectations of the individual's culture, are pervasive and inflexible, have their onset in adolescence or early adulthood, are stable over time, and lead to distress and impairment. The scientific literature shows personality disorders form during childhood and occur due to an interaction between genetics and childhood environment. The examiner noted risk factors for developing or triggering personality disorders included family history of personality disorders or other mental illness, abusive, unstable, or chaotic family life during childhood, being diagnosed with childhood conduct disorder, and variations in brain chemistry and structure. The examiner noted the Veteran reported a childhood environment consistent with these risk factors as well as symptoms of personality disorder that manifested during childhood. Therefore, there is no nexus between his personality disorder and his active-duty service. The Veteran had also been diagnosed with Alcohol, Cocaine, and Marijuana Use Disorders, in remission. The evidence also shows the Veteran began using alcohol and drugs during his teen years, prior to enlisting in the military (e.g., 2012 VA examination). This behavior also continued during service, leading to loss of rank, and continued throughout much of his adulthood, with a current period of remission. Therefore, there is no nexus between his substance use disorders and his active-duty service. The Veteran was also diagnosed with an Adjustment Disorder with mixed disturbance in emotions and conduct during the June 1983 evaluation, and had also been seen for anxiety, insomnia without depression, situational reaction, and Adult Situational Reaction with anxiety during his military service. His depression and sleep disturbance were said to have resolved on May 1983. While the Veteran did not report problems with anxiety and depression upon enlistment, since then the Veteran has contended that his depression began during childhood and has been a chronic problem since then (July 1997 Psychological Evaluation). The examiner further noted that during the July 1997 examination, he also reported signs of anxiety and irritability that began during childhood as follows: "Overwhelming emotions including fear, profound helplessness, and rage" related to his childhood abuse. The Veteran had repeatedly reported that he was raised in a chaotic, tumultuous, and abusive household where he witnessed domestic violence (e.g., April 1997, June 1997, July 1997, and November 2011 treatment records), and the symptoms he reported beginning in childhood including depressed mood, fear, profound helplessness, and rage are consistent with depression and anxiety symptoms that develop following trauma exposure. Further, the frequent trouble sleeping he reported upon enlistment is also a symptom of depression and anxiety associated with trauma exposure. The examiner noted it was not surprising that the Veteran was never evaluated for nor diagnosed with a mental condition during childhood given the environment he was raised in, an abusive household where both parents abused alcohol, was not conducive to noticing that one's child is emotionally struggling and willingness or motivation to seek help for that child. Even though he was not evaluated during childhood due to his chaotic home life, the Veteran has clearly described symptoms of anxiety and depression that developed in response to his abusive and chaotic childhood environment, which first manifested during childhood. Therefore, the examiner opined there was no nexus between the Veteran's Major Depressive Disorder and Unspecified Anxiety Disorder and his active-duty service. The October 2020 examiner opined the Veteran's acquired psychiatric disorder clearly and unmistakably existed prior to service and was clearly and unmistakably not aggravated beyond its natural progression by service. The examiner found that the Veteran had clear and unmistakable evidence of Major Depressive Disorder, Unspecified Anxiety Disorder, Alcohol, Cocaine, and Marijuana Use Disorders, and Antisocial Personality Disorder prior to military service, as described in the 2012, 2018, and 2020 examinations. There was evidence to indicate that the Veteran continued to suffer from the mental health disorders during military service, with occasional waxing and waning of depression, anxiety, and substance abuse, which is typical of the disorders. The examiner noted the Veteran's current depression and anxiety were improved compared to what they were prior to his military service, and therefore, it was apparent that the current mental disorders were not permanently aggravated by service. To this point, the examiner noted that the July 2018 and July 2020 psychiatry examinations showed the Veteran's mental status examinations were within normal limits and he was not depressed or anxious. Further, all of the Veteran's substance use disorders were improved compared to what they were prior to and during service. Therefore, there was no evidence that his depression, anxiety, or substance use disorders were permanently aggravated by service. The examiner further noted that there was evidence of the Veteran's personality disorder prior to and during service, but this condition persisted at approximately the same level throughout adulthood with occasional exacerbation of antisocial behaviors within the context of active substance abuse over the years. During his most recent period of remission from substance use disorders, his symptoms of antisocial personality disorder have somewhat improved, though remain a stable and persistent component of his personality based upon recent records. The examiner opined that given a personality disorder is stable over time, and the Veteran continues to evidence these problems currently, though at a lesser degree than when he was actively using substances, it was apparent that the Veteran's pre-existing personality disorder was not permanently aggravated by military service. Based upon the above findings, the record is clear that the Veteran had an acquired psychiatric disorder prior to service. Accordingly, there is clear and unmistakable evidence that a psychiatric disorder pre-existed service. As noted above, the examiner, following a comprehensive review of the file and a thorough examination of the Veteran provided the opinion that that there was clear and unmistakable evidence that the condition was not aggravated beyond its natural progress in the service. The Board is placing greater weight upon the VA opinion as it was rendered after a thorough review of the record with detailed rationale being set forth to support the opinion. There was no indication that the VA examiner was not fully aware of the Veteran's past medical history or that he misstated any relevant fact. The Veteran has provided competent lay statements regarding his psychiatric symptoms, but the Board does not find these assertions that the underlying disabilities were worsened by service to be competent. In this particular case, such conclusions are not capable of lay observation and require expertise in determining whether the presence of symptoms indicates a worsening, which is a complicated psychiatric question. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007) ("sometimes the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer"); Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (unlike varicose veins or a dislocated shoulder, rheumatic fever is not a condition capable of lay diagnosis); Layno v. Brown, 6 Vet. App. 465, 469 (1994) (noting that personal knowledge is knowledge acquired through the senses-that which the veteran heard, felt, saw, smelled, or tasted). Furthermore, even if the assertions were competent, they are outweighed by the October 2020 VA examiner's thorough and fully supported etiological opinions. In sum, there is clear and unmistakable evidence both that the Veteran's psychiatric disorders pre-existed his active service and were not aggravated thereby. As to the Veteran's claim that any current psychiatric disorder is caused or aggravated by the service-connected knee or headache disabilities, the November 2012 examiner opined that the Veteran's psychiatric diagnoses were not likely proximately due to his service-connected knee or headaches. The examiner noted the Veteran's anxiety, depression, addiction, and personality disorder more likely than not pre-dated service. Further, subsequent treatment notes did not support this as there seemed to be no significant or consistent mention of the Veteran's knee or headache disabilities causing or significantly exacerbating his acquired psychiatric disorders. Furthermore, the December 2018 VA examiner opined the Veteran's depression and anxiety were not likely proximately due to his service-connected knee and/or headache disabilities as the mental health treatment notes do not indicate that these issues are the cause or a significantly aggravating factor in the Veteran's depression and anxiety conditions. The examiner opined it was more likely that the Veteran's mood problems were due to numerous other conditions. Further, the examiner noted the Veteran's depression condition was present well before his physical health problems became worse and more incapacitating. The examiner also noted that the Veteran's mental health conditions had been quite severe at times in the past independent of any effects of health problems. The examiner noted that some of the Veteran's mental health symptoms, such as hallucinations and paranoid feelings, were not at all likely to be related to headache and knee problems. Finally, the examiner noted that the Veteran most recently sought mental health care for significant life stressors including finances, his wife having alcohol problems, and shooting a woman in self-defense and was not due to any knee or headaches issues. The Board is placing greater weight upon the VA opinions as they were rendered after a thorough review of the record with detailed rationale being set forth to support the opinions. There was no indication that the VA examiner was not fully aware of the Veteran's past medical history or that he misstated any relevant fact. In sum, the evidence is against the claim that the Veteran's current psychiatric disorders are caused and/or aggravated by his service-connected knee or headaches. The Board has been mindful of the "benefit-of-the-doubt" rule, but, in this case, there is not such an approximate balance of the positive and negative evidence to permit a more favorable determination. Increased Rating The Veteran filed a claim for a higher rating for his right knee disabilities in March 2012. During the pendency of his claim for a higher rating, he underwent a right knee total arthroplasty in October 2013. The AOJ granted a temporary total disability rating from October 9, 2013. In March 2020, the Board granted an increased rating for the right knee status post total arthroplasty. The adequacy of these ratings is not on appeal. 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. § 4.1. Although all the evidence has been reviewed, only the most relevant and salient evidence is discussed below. See Gonzales v. West, 218 F.3d 1378 (Fed. Cir. 2000) (holding that the Board must review the entire record but does not have to discuss each piece of evidence). In determining the degree of limitation of motion, the provisions of 38 C.F.R. §§ 4.10, 4.40, and 4.45 are for consideration. See DeLuca v. Brown, 8 Vet. App. 202 (1995). The basis of disability evaluation is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. Functional loss may be due to the absence or deformity of structures or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior in undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. § 4.40. In Mitchell v. Shinseki, 25 Vet. App. 32 (2011), the Court held that, although pain may cause a functional loss, "pain itself does not rise to the level of functional loss as contemplated by VA regulations applicable to the musculoskeletal system." Rather, pain may result in functional loss, but only if it limits the ability "to perform the normal working movements of the body with normal excursion, strength, speed, coordination, or endurance." Id., quoting 38 C.F.R. § 4.40. With respect to joints, in particular, the factors of disability reside in reductions of normal excursion of movements in different planes. Inquiry will be directed to more or less than normal movement, weakened movement, excess fatigability, incoordination, pain on movement, swelling, deformity or atrophy of disuse. 38 C.F.R. § 4.45. Normal range of knee motion is 140 degrees of flexion and zero degrees of extension. 38 C.F.R. § 4.71, Plate II. Limitation of motion of the knee is contemplated in 38 C.F.R. § 4.71a, Diagnostic Codes 5260 and 5261. Diagnostic Code 5260 provides for a zero percent rating where flexion of the leg is only limited to 60 degrees. For a 10 percent rating, flexion must be limited to 45 degrees. For a 20 percent rating is warranted where flexion is limited to 30 degrees. A 30 percent rating may be assigned where flexion is limited to 15 degrees. Diagnostic Code 5261 provides for a zero percent rating where extension of the leg is limited to five degrees. A 10 percent rating requires extension limited to 10 degrees. A 20 percent rating is warranted where extension is limited to 15 degrees. A 30 percent rating may be assigned where the evidence shows extension limited to 20 degrees. For a 40 percent rating, extension must be limited to 30 degrees. And finally, where extension is limited to 45 degrees a 50 percent rating may be assigned. 38 C.F.R. § 4.71a, Diagnostic Code 5257 provides for assignment of a 10 percent rating when there is slight recurrent subluxation or lateral instability, a 20 percent rating when there is moderate recurrent subluxation or lateral instability, and a 30 percent evaluation for severe recurrent subluxation or lateral instability. VA's General Counsel has stated that when a knee disorder is rated under 38 C.F.R. § 4.71a, Diagnostic Code 5257 and an appellant also has limitation of knee motion which at least meets the criteria for a noncompensable evaluation under 38 C.F.R. § 4.71a, Diagnostic Code 5260 or 5261, separate evaluations may be assigned for arthritis with limitation of motion and for instability. However, General Counsel stated that if an appellant does not meet the criteria for a noncompensable rating under either Diagnostic Code 5260 or Diagnostic Code 5261, there is no additional disability for which a separate rating for arthritis may be assigned. VAOPGCPREC 23-97 (July 1, 1997), published at 62 Fed. Reg. 63,604 (1997). If a rating is assigned under the provisions for other knee impairment (38 C.F.R. § 4.71a, Diagnostic Code 5257) a separate 10 percent rating may be assigned where some limitation of motion, albeit noncompensable, has been demonstrated. See VAOPGCPREC 9-98, 63 Fed. Reg. 56,704 (1998). VA's General Counsel has also stated that separate ratings under Diagnostic Code 5260 (limitation of flexion of the leg) and Diagnostic Code 5261 (limitation of extension of the leg) may be assigned for disability of the same joint. VAOPGCPREC 9-04 (September 17, 2004), published at 69 Fed. Reg. 59,990 2004). The rating schedule also provides that dislocation of semilunar cartilage, with frequent episodes of "locking," pain, and effusion into the joint, warrants a 20 percent evaluation. 38 C.F.R. § 4.71a, Diagnostic Code 5258. Diagnostic Code 5259 provides for the assignment of a maximum 10 percent rating based on symptomatic removal of the semilunar cartilage. Genu recurvatum is rated under Diagnostic Code 5263, with a maximum rating of 10 percent. 2. A rating in excess of 10 percent prior to October 9, 2013, for status post medial meniscectomy of the right knee with residual scar 3. A rating in excess of 10 percent prior to October 9, 2013, for degenerative joint disease of the right knee In this case, the Veteran filed a claim for increased ratings for his right knee disabilities, in March 2012. The Veteran's right knee degenerative joint disease was rated 10 percent disabling prior to October 9, 2013, under Diagnostic Code 5010. The Veteran's right knee instability was rated 10 percent disabling under Diagnostic Code 5257 prior to October 9, 2013. The Veteran maintains that he is entitled to higher ratings for each right knee disability. A June 2011 VA treatment record noted that h Veteran had full range of motion of the bilateral knees without impairment of gait. A December 2011 VA treatment record noted the Veteran's complaint of knee pain. A May 2012 VA treatment record noted the Veteran had bilateral knee pain and instability and was evaluated for bracing. However, there was full range of motion of all joints without tenderness or warmth to palpation. X-ray impression of the right knee was stable mild degenerative joint disease. An August 2012 VA treatment record noted the Veteran complained that all of his medications were ineffective, and he had new onset knee pain. A September 2012 VA treatment record noted the Veteran expressed discomfort with ambulation and mounting and dismounting the examination table but did not need assistance and had full range of motion of the knee. He was given a consultation with physical therapy for a cane. The Veteran was provided with a VA examination in October 2012. The Veteran reported that he had flare-ups of right knee pain that hurt every day. On objective examination, range of motion testing revealed full extension in the right knee, with no objective evidence of painful motion. The examiner also noted flexion to 140 degrees or greater on the right, with painful motion beginning at 115 degrees. The Veteran was able to complete repetitive testing with no additional loss of range of motion. Functional loss was noted as pain on movement. Tenderness of pain on palpation for the joint line or soft tissues was noted. Muscle strength testing was normal. Joint stability tests were normal and there was no evidence or history or recurrent patellar subluxation or dislocation. Degenerative traumatic arthritis was noted. The examiner opined the Veteran's knee disability did not impact his ability to work. A March 2013 VA treatment record noted the Veteran had bilateral knee pain. There was full range of motion of all joints without tenderness or warmth to palpation. A consultation was given to orthopedics. An August 2013 VA treatment record noted the Veteran's primary complaint centered on the medial, lateral, anterior and posterior aspect of the knee. It was exacerbated by going up and down stairs, standing, walking, running, squatting, kneeling, sitting, lying, rising after sitting, any weight bearing, lifting and relieved by rest, pain medication, injections, and brace. On examination, there was mild general limb malalignment with varus posture. Range of motion was 7 to 110 degrees. McMurray's test was negative. Swelling was present and mild. The Veteran complained of tenderness to palpation located over the patella and with patellar compression. There was medial joint line tenderness to palpation. Ligament examination showed MCL was stable, LCL was stable, PCL was stable, and ACL was stable with negative Lachman test. Patella was stable with normal quadrant translation. Patellar grind test was present. The quadricep did not fire well. Strength and bulk were equal to contralateral side. The Veteran was counseled on operative and non-operative modalities and opted to have total right knee arthroplasty. A September 2013 VA treatment record noted the Veteran complained of knee pain that limited his activity. An October 2013 VA treatment record indicated the Veteran's right knee condition had not changed since August 2013. At all points pertinent to the entire period on appeal, objective testing revealed that, at worst, the Veteran's right knee flexion was limited to 110 degrees. Additionally, the Veteran's right knee extension was not limited to 10 degrees. Given these range of motion findings, the Veteran is not entitled to a 20 percent disability rating for limitation of motion in the right knee as his flexion was not limited to 30 degrees or worse. Similarly, a separate rating for limitation of extension is not warranted in the right knee as extension is not shown to be limited to 10 degrees or worse. The Board has considered the DeLuca provisions in reaching these conclusions. The Board notes the Veteran's complaints of pain, exacerbated by going up and down stairs, standing, walking, running, squatting, kneeling, sitting, lying, rising after sitting, any weight bearing, and lifting, in determining that the Veteran is not entitled to a higher rating for the right knee due to limitation of motion. The Board has also considered the lay statements from the Veteran as well as treatment records. The Board notes that the October 2012 VA examiner noted the Veteran's functional loss was pain on movement, but there was no additional limitation in range of motion with repetitive use testing. Further, the examiner noted painful motion of the right knee began at 115 degrees flexion had full extension without pain. Even in contemplation of the Veteran's complaints of pain during range of motion testing and upon repetitive motion testing, and during flare-ups and following repetitive use over time, the Board finds that the Veteran's right knee disability does not warrant higher ratings for limitation of flexion or extension. See DeLuca, Mitchell, supra. Higher ratings for limitation of motion are not warranted. As discussed above, VA's General Counsel has held that if limitation of motion does not reach the compensable level described in the diagnostic codes, then a separate rating for instability is not for application. In this case, VA has already afforded the Veteran the benefit of the doubt that his flexion is limited to a compensable degree and granted the Veteran a separate disability rating for instability of the right knee. A rating in excess of 10 percent for instability is not warranted prior to October 9, 2013, as there are no objective findings of moderate instability in the right knee. The October 2012 VA examiner conducted tests for instability, which resulted in normal findings for anterior stability, posterior stability, and medial-lateral instability. Treatment records do not indicate more than slight instability prior to October 2013. As there are no objective findings of more than slight instability, an initial rating in excess of 10 percent under Diagnostic Code 5257 is not warranted at any point prior to October 9, 2013. The record does not show that the Veteran has a meniscal condition. Therefore, a higher or separate rating under Diagnostic Code 5258, semilunar cartilage that is dislocated with frequent episodes of locking, pain, and effusion into the joint is not warranted. As for other potentially applicable Diagnostic Codes, the Veteran, does not have ankylosis, has not had removal of semilunar cartilage, there is no malunion of the tibia or fibula, and he does not have genu recurvatum. Therefore, Diagnostic Codes 5256, 5259, 5262, and 5263 do not apply. 38 C.F.R. § 4.71a. For the entire appeal period, the Board has carefully reviewed and considered the Veteran's statements regarding the severity his right knee disability. The Board acknowledges that the Veteran, in advancing this appeal, believed that the disability on appeal was more severe than reflected by the previously assigned disability ratings for degenerative arthritis and instability. Moreover, the Veteran is competent to report observable symptoms. Layno v. Brown, 6 Vet. App. 465 (1994). However, with respect to the requirements for higher ratings, the competent medical evidence offering detailed, specific, specialized determinations pertinent to the rating criteria are the most probative evidence with regard to evaluating the pertinent symptoms for the disability on appeal; the medical evidence also largely contemplates the Veteran's descriptions of symptoms. The lay statements have been considered together with the probative medical evidence clinically evaluating the severity of the pertinent disability symptoms. The Board has considered whether additional staged ratings are appropriate, under Hart, supra; however, as discussed above, the Board finds that the Veteran's right knee disability was stable throughout the respective appeal periods and did not more nearly approximate higher ratings for limitation of motion or instability at any point. Therefore, additional staged ratings for the right knee disability are not warranted. REASONS FOR REMAND 1. Entitlement to service connection for obstructive sleep apnea is remanded. Relevant to this appeal, the United States Court of Appeals for Veterans Claims (CAVC) issued a panel decision holding that service connection may be granted on a secondary basis where the claimed disability would not have occurred but for obesity caused or aggravated by a service-connected disability. See Walsh v. Wilkie, 32 Vet. App. 300 (2020). As General Counsel Precedent Opinion 1-2017 determined that obesity can constitute an "intermediate step" between a service-connected disability and a disability that may be service connected on a secondary basis, it not only applies when a service-connected disability causes obesity, but also when a service-connected disability aggravates obesity. When raised by the record, the Board must consider whether obesity was caused or aggravated by a service-connected disability, consistent with 38 C.F.R. § 3.310. While the July 2018 examiner opined that the Veteran's service-connected right knee status post total arthroplasty did not cause or aggravate his sleep apnea, the examiner did not discuss the Veteran's weight gain possibly due to the service-connected right knee disabilities prior to the right knee total arthroplasty. The examiner noted that risk factors for sleep apnea include obesity but failed to discuss if the Veteran's sleep apnea would not have occurred but for obesity caused or aggravated by the Veteran's service-connected disabilities. Further, the March 2020 examiner opined the Veteran's obstructive sleep apnea was less likely than not proximately due to or the result of the Veteran's service-connected status post right knee total arthroplasty as there was not medical literature that showed evidence that linked status post right knee total arthroplasty as a cause of obstructive sleep apnea. The Board concludes that the July 2018 and March 2020 VA opinions addressing the cause of the Veteran's obstructive sleep apnea are inadequate for the purpose of readjudicating the appealed issue as they failed to discuss if the Veteran's sleep apnea would not have occurred but for obesity caused or aggravated by the Veteran's service-connected disabilities. 2. Entitlement to a TDIU is remanded. In the March 2020, the Board remanded the issue of TDIU for an opinion that addressed the impact of all the Veteran's service-connected disabilities on employability. The record does not reflect that the requested development was accomplished. A remand is necessary to obtain a VA examination and medical opinion to fully describe the functional effects of his individual and combined service-connected disabilities, and their impact on the Veteran's employability during the appeal period. See Stegall v. West, 11 Vet. App. 268 (1998). The matters are REMANDED for the following action: 1. Obtain updated VA treatment records. 2. Provide the Veteran's entire claims file to an appropriate person and obtain an addendum opinion that addresses the following: (a.) Whether the Veteran's service connected knee disabilities and/or his service connected spine disability and/or the medications used to treat these disabilities caused the Veteran to become obese; and if so, whether obesity as a result of the service connected disability/ies and/or the medications used to treat them was a substantial factor in causing obstructive sleep apnea, and whether obstructive sleep apnea would not have occurred but for the obesity caused by the service connected knee and/or spine disability and/or the medications used to treat them. (b.) Whether the Veteran's service connected knee disabilities and/or his service connected spine disability and/or the medications used to treat them caused the Veteran's obesity to be worse than it otherwise would have been; and if so, whether this increase in severity of the obesity as a result of the service connected disability/ies and/or the medications used to treat them was a substantial factor in causing the obstructive sleep apnea, and whether obstructive sleep apnea would not have occurred but for the aggravation of obesity caused by service connected disability/ies and/or the medications used to treat them. (c.) The examiner should state if the Veteran's medications prescribed for his service-connected disabilities, have aggravated the Veteran's sleep apnea beyond its natural progression. A complete rationale must be provided for all opinions presented. The examiner should connect all opinions made to the evidence of record and any medical literature referenced. If the examiner cannot provide the requested opinion without resorting to speculation, he or she should provide an explanation stating why that is the case. The examiner should explain whether the inability to provide a more definitive opinion is the result of a need for additional information or whether the examiner has exhausted the limits of current medical knowledge. 3. Refer the Veteran's claims folder to an appropriate examiner to conduct a complete review of the medical evidence that takes into consideration all of the Veterans service-connected disabilities in rendering an opinion as to whether the Veteran is unable to engage in substantially gainful employment because of these disabilities, either singly or when considered in combination. The examiner must review the entire claims folder and such review must be noted in the examination report. The examiner must provide a complete rationale for any opinions expressed. If an opinion cannot be made without resort to mere speculation, this must also be fully explained. 4. After completing the above actions, to include any other development as may be indicated by any response received as a consequence of the actions taken in the preceding paragraphs, the Veteran's claim should be readjudicated based on the entirety of the evidence. MARJORIE A. AUER Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Gastoukian, Kelly 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.