Citation Nr: 22016282 Decision Date: 03/21/22 Archive Date: 03/21/22 DOCKET NO. 17-38 757 DATE: March 21, 2022 ORDER Entitlement to an initial rating in excess of 10 percent for cervical spondylosis is denied. Entitlement to an initial rating of 20 percent for right shoulder complete rotator cuff repair prior to February 26, 2020, is granted. Entitlement to an initial rating in excess of 20 percent for right shoulder complete rotator cuff repair is denied. Entitlement to an initial rating of 20 percent for left shoulder complete rotator cuff repair prior to February 26, 2020 is granted. Entitlement to an initial rating in excess of 20 percent for left shoulder complete rotator cuff repair is denied. REMANDED Entitlement to an initial compensable rating for essential tremor is remanded. Entitlement to an initial rating in excess of 10 percent for right knee degenerative joint disease is remanded. Entitlement to a separate compensable rating for right knee instability (or recurrent subluxation) is remanded. Entitlement to a separate compensable rating for right knee meniscus (semilunar cartilage) condition is remanded. Entitlement to an initial compensable rating for left knee degenerative joint disease prior to February 26, 2020 is remanded. Entitlement to an initial rating in excess of 10 percent for left knee degenerative joint disease from February 26, 2020 is remanded. Entitlement to a separate compensable rating for left knee instability (or recurrent subluxation) is remanded. Entitlement to a separate compensable rating for left knee meniscus (semilunar cartilage) condition is remanded. Entitlement to a total disability rating for compensation based on unemployability of the individual is remanded. FINDINGS OF FACT 1. The Veteran's cervical spondylosis is manifest by forward flexion of the cervical spine greater than 30 degrees and a combined range of motion of the cervical spine greater than 170 degrees; ankylosis, muscle spasm or guarding are not demonstrated. 2. Throughout the period on appeal, the Veteran's right shoulder complete rotator cuff repair is manifest by no worse than arm limitation of motion that more nearly approximates flexion and/or abduction limited to 90 degrees (at shoulder level). 3. Throughout the period on appeal, the Veteran's left shoulder complete rotator cuff repair is manifest by no worse than arm limitation of motion that more nearly approximates flexion and/or abduction limited to 90 degrees (at shoulder level). CONCLUSIONS OF LAW 1. The criteria for entitlement to an initial rating in excess of 10 percent for cervical spondylosis have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a. 2. The criteria for entitlement to an initial rating of 20 percent for right shoulder complete rotator cuff repair prior to February 26, 2020 have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a. 3. The criteria for entitlement to an initial rating in excess of 20 percent for right shoulder complete rotator cuff repair have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a. 4. The criteria for entitlement to an initial rating of 20 percent for left shoulder complete rotator cuff repair prior to February 26, 2020 have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a. 5. The criteria for entitlement to an initial rating in excess of 20 percent for left shoulder complete rotator cuff repair have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from August 1974 to April 1977 and from August 1988 to September 2012. In October 2019, the Veteran testified before a Veterans Law Judge (VLJ) at a Board of Veterans' Appeals (Board) hearing. A transcript of the proceeding is of record. The VLJ who conducted that hearing is no longer employed at the Board. The Veteran was informed of this development in a January 2022 letter and was offered the opportunity to have an additional Board hearing before a different VLJ. The Veteran responded that he did not want an additional hearing, and requested the Board consider his case on the evidence of record. Therefore, the Board will proceed without a new hearing. The Board remanded the Veteran's claims in February 2020. The Veteran seeks entitlement a total disability rating for compensation based on unemployability of the individual (TDIU), citing disabilities addressed herein. See March 2017 application for increased compensation based on unemployability. The Agency of Original Jurisdiction has not addressed this application, but the issue of entitlement to a TDIU is part of the Veteran's increased ratings claims and will be addressed below. Increased Rating 1. Entitlement to an initial rating in excess of 10 percent for cervical spondylosis The Veteran contends that he is entitled to a higher rating. Upon review of the evidence of record, the Board finds a rating in excess of 10 percent is not warranted. i. Applicable Law Under the General Rating Formula for Diseases and Injuries of the Spine, a 10 percent rating is warranted for forward flexion of the cervical spine greater than 30 degrees but not greater than 40 degrees; or, combined range of motion of the cervical spine greater than 170 degrees but not greater than 335 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height. A 20 percent rating is warranted for forward flexion of the cervical spine greater than 15 degrees but not greater than 30 degrees; or, the combined range of motion of the cervical spine not greater than 170 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 30 percent rating is warranted for forward flexion of the cervical spine to 15 degrees or less; or favorable ankylosis of the entire cervical spine. A 40 percent rating is warranted for unfavorable ankylosis of the entire cervical spine. A 100 percent rating is warranted for unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine. Any associated objective neurological abnormalities, including, but not limited to, bowel or bladder impairment, are to be evaluated separately under an appropriate diagnostic code. Id. at Note 1. When evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use and, therefore, not be reflected on range-of-motion testing. 38 C.F.R. § 4.45 requires consideration also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Nonetheless, even when the background factors listed in § 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a; a separate or higher rating under § 4.40 or 4.45 itself is not appropriate. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016) ("[I]t is clear that the guidance of § 4.40 is intended to be used in understanding the nature of the veteran's disability, after which a rating is determined based on the § 4.71a criteria."). 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 v. McDonald, 28 Vet. App. 158 (2016), 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." The spine has no opposite joint. In Sharp v. Shulkin, 29 Vet. App. 26 (2017), 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. ii. Evidence and Analysis The Board finds that the evidence of record persuasively weighs against a rating in excess of 10 percent for cervical spondylosis under the General Rating Criteria. The Veteran attended VA cervical spine examinations in August 2013 and February 2020. At worse his combined cervical spine range of motion was 185 degrees with pain and flexion of 45 degrees with pain. Compare August 2013 VA examination report (combined range of motion of 320 and flexion of 45) and February 2020 examination report (combined range of motion of 185 and flexion of 45). There was no additional loss of function or range of motion after three repetition-use testing during either examination, and neither examiner found guarding or muscle spasm of the cervical spine. Furthermore, the Veteran denied having flare-ups or additional loss of motion with repeated use or during flare-ups. See February 2020 VA examination report, pages 5-6. A review of the Veteran's medical records does not reveal range of motion findings worse than found during the February 2020 examination. The Veteran does not have ankylosis or intervertebral disc syndrome (IVDS) of the cervical spine. The Board acknowledges the Veteran's lay reports of symptoms and that there was functional loss due to pain. However, even considering the Veteran's lay reports of symptoms and noted functional loss, the degree of additional limitation reflected by the statements would not result in limitation of motion more nearly approximating forward flexion of 15 degrees but not greater than 30 degrees or the combined range of motion of the cervical spine not greater than 170 degrees. This is consistent with VA examination findings, which considered limitation of motion due to pain. Additionally, the Veteran does not have muscle spasm or guarding of the cervical spine. Given the relevantly recent VA examination and the lack of evidence of worsening since then, the Board finds a remand is not warranted to obtain new medical records, as there is adequate information to adjudicate the Veteran's claim. In his December 2013 notice of disagreement, the Veteran appears to have associated his cervical spondylosis with vertigo and headaches. Since then, the Board denied a compensable rating for vertigo in February 2020, and the Agency of Original Jurisdiction granted service connection for ocular headaches, migraine, and the Veteran has not appealed this rating. Therefore, the Board will not address headaches or vertigo herein. Regarding any other neurological impairment, the Veteran does not contend, and the lay and medical evidence of record is against a finding, that he has any other neurological abnormality associated with his spine disability. See, e.g., August 2013 and February 2020 VA cervical spine examination reports. In the December 2013 notice of disagreement, the Veteran also reported a history of sleep impairment due to "neck pain and associated disability." Similarly, when testifying before the Board, the Veteran indicated back and right shoulder pain affect his sleep. See October 2019 hearing transcript, pages 10-11. However, the Board finds the evidence of record persuasively weighs against finding sleep impairment is due to the Veteran's cervical spine or shoulder disabilities. The Veteran's report of sleep impairment due to spine and shoulder pain is inconsistent with the evidence of record. When describing his cervical spine and shoulder disabilities to VA examiners, the Veteran made no mention of sleep impairment due to neck or shoulder pain. See August 2013 and February 2020 VA cervical spine and shoulder examination reports. Furthermore, during an August 2013 Parkinson's examination, the Veteran denied sleep disturbances. Notably, this was only four months prior to his notice of disagreement being received. Moreover, treatment records before and after this time do not indicate sleep problems related to neck or shoulder pain. See treatment records dated January 12, 2009 (sleep not a concern), March 23, 2009 (problems with sleep cycle related to mefloquine), and July 5, 2017 (no sleep complaints, wakes to go to bathroom). Despite the explicit opportunity to discuss sleep issues with medical professionals, the Veteran consistently denied them, or did not report such issues as related to neck or shoulder pain, except in statements to VA adjudicators. Accordingly, the evidence of record persuasively weighs against finding that the Veteran's reports of sleep impairment due to neck or shoulder pain are credible. For the foregoing reasons, the evidence of record persuasively weighs against the Veteran's claim for a rating in excess of 10 percent for cervical spondylosis. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. 2. Entitlement to an initial rating of 20 percent for right shoulder complete rotator cuff repair prior to February 26, 2020 3. Entitlement to an initial rating in excess of 20 percent for right shoulder complete rotator cuff repair 4. Entitlement to an initial rating of 20 percent for left shoulder complete rotator cuff repair prior to February 26, 2020 5. Entitlement to an initial rating in excess of 20 percent for left shoulder complete rotator cuff repair The Veteran contends that he is entitled to compensable bilateral shoulder disability ratings prior to February 26, 2020, and ratings in excess of 20 percent thereafter. Upon review of the evidence of record, the Board finds compensable ratings are warranted prior to February 26, 2020, but ratings in excess of 20 percent are not warranted for any period of time on appeal. i. Applicable Law The Veteran's disabilities are rated under 38 C.F.R. § 4.71a, Diagnostic Code 5201, for limitation of motion of the arm. Under Diagnostic Code 5201, prior to February 7, 2021, limitation of motion of the arm at shoulder level warrants a 20 percent rating for both the major and minor extremity. Limitation of motion of the arm midway between side and shoulder warrants a 20 percent rating for the minor extremity and a 30 percent rating for the major extremity. Limitation of motion of the arm to 25 degrees from side warrants a maximum 30 percent rating for the minor joint and a maximum 40 percent rating for the major joint. 38 C.F.R. § 4.71a, Diagnostic Code 5201. Diagnostic Code 5201 "does not provide separate ratings for limitation of motion in the flexion and abduction planes, but rather is addressed generically to limitation of motion of the arm." Yonek v. Shinseki, 722 F.3d 1355, 1358 (Fed. Cir. 2013). Effective February 7, 2021, VA amended Diagnostic Code 5201 to reflect that limitation of motion may be shown by flexion and/or abduction and clarified the degrees of limitation of motion that correspond to each rating. Now, limitation of motion at the shoulder level (flexion and/or abduction limited to 90 degrees) warrants a 20 percent rating for both the major and minor extremity. Limitation of motion of the arm midway between side and shoulder level (flexion and/or abduction limited to 45 degrees) warrants a 20 percent rating for the minor extremity and a 30 percent rating for the major extremity. Flexion and/or abduction limited to 25 degrees from the side warrants a maximum 30 percent rating for the minor joint and a maximum 40 percent rating for the major joint. When evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use and, therefore, not be reflected on range-of-motion testing. 38 C.F.R. § 4.45 requires consideration also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Nonetheless, even when the background factors listed in § 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a; a separate or higher rating under § 4.40 or 4.45 itself is not appropriate. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016) ("[I]t is clear that the guidance of § 4.40 is intended to be used in understanding the nature of the veteran's disability, after which a rating is determined based on the § 4.71a criteria."). 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 v. McDonald, 28 Vet. App. 158 (2016), 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." In Sharp v. Shulkin, 29 Vet. App. 26 (2017), 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. ii. Evidence and Analysis The Board finds that the evidence of record persuasively weighs against a rating in excess of 20 percent for the Veteran's shoulder disabilities. The Board acknowledges the Veteran's lay reports of symptoms of pain, weakness, and instability, and that there is functional loss. However, even considering the Veteran's lay reports of symptoms and noted functional loss, the degree of additional limitation reflected by the statements that would not result in symptoms more nearly approximating limitation of motion of the arm midway between side and shoulder level of the major extremity or limitation of motion of the arm to 25 degrees from the side of the major or minor extremity. The Veteran attended VA shoulder examinations in August 2013 and February 2020. During the August 2013 examination, full range of motion was exhibited, with no additional limitation of motion following repetitive use testing. However, with regard to both shoulders, the examiner also noted functional loss and/or functional impairment after repetitive uses due to pain on movement. Despite having full range of motion, the Veteran is not precluded from being awarded compensable ratings, due to 38 C.F.R. § 4.59, notwithstanding the limitations in Diagnostic Code 5201. In Lichtenfels v. Derwinski, 1 Vet. App. 484 (1991), the United States Court of Appeals for Veterans Claims (Court) "held that § 4.59 serves as a bridge linking painful motion and limitation of motion, with the result that a claimant who has painful motion is considered to have limited motion . . . even though actual motion is not limited." See Petitti v. McDonald, 27 Vet. App. 415, 425 (2015). Therefore, painful motion provides for a minimum compensable rating, if a compensable rating is provided under the appropriate diagnostic code. See Sowers v. McDonald, 27 Vet. App. 472, 478 (2016) (footnote 6 illustrates an example). Here, Diagnostic Code 5201 provides for a minimum rating of 20 percent for limitation of motion. In light of the Veteran's reports of painful motion throughout the period on appeal, and the August 2013 examiner's notation of bilateral functional loss and/or functional impairment due to pain on movement, the Board finds painful motion has existed bilaterally throughout the period on appeal. Accordingly, a 20 percent initial rating is warranted bilaterally prior to February 26, 2020. As the Veteran was already assigned 20 percent from February 26, 2020, the remaining question is whether a rating in excess of 20 percent is warranted at any point since October 1, 2012, the date service connection is effective. As noted above, the Veteran had full range of motion during the August 2013 VA shoulder examination. During the February 2020 examination, initial range of motion (ROM) testing revealed right shoulder pain on motion with flexion limited to 90 degrees, abduction limited to 90 degrees, external rotation limited to 35 degrees, and internal rotation had full range of motion (0-90 degrees). There was no additional limitation after repetitive use testing; however, the examiner estimated ROM of 80 degrees flexion and abduction, and 30 degrees external rotation due to pain after repetitive use over time. Initial left shoulder ROM testing revealed pain on motion, with flexion and abduction limited to 90 degrees, and full ROM for internal and external rotation. There was no additional limitation after repetitive use testing; however, the examiner estimated ROM of 80 degrees flexion and abduction, and 85 degrees external rotation due to pain after repetitive use over time. The Veteran denied having flare-ups. The February 2020 examiner's findings and estimated range of motion are consistent with the Veteran's hearing testimony of increased pain just below shoulder level, and observed arm raising to shoulder level while the Veteran was sworn in at the Board hearing. See October 2019 hearing transcript, page 11. A review of the Veteran's medical records does not reveal range of motion findings worse than found during the February 2020 examination. In light of the above, the evidence of record persuasively weighs against finding ratings in excess of 20 percent for the Veteran's left and right shoulder disabilities. Limitation of motion of flexion and/or abduction to 80 degrees, i.e. just below the shoulder level, more nearly approximates limitation of motion at shoulder level than at midway between side and shoulder level. This is the case under both the new and old version of 38 C.F.R. § 4.71a, but is more readily apparent under the new version as flexion and/or abduction limited to 80 degrees is closer to 90 degrees than 45 degrees (major arm) or 25 degrees (minor arm). Given the relevantly recent examination and the lack of evidence of worsening since then, the Board finds a remand is not warranted to obtain up to date medical records, as there is adequate information to adjudicate the Veteran's claims. The Board notes that the Veteran has limitation of rotation, and Diagnostic Code 5201 only explicitly addresses limitation of flexion and abduction. Furthermore, 38 C.F.R. § 4.45 lists "reduction of normal excursion of movements in different planes" as a factor of disability affecting joints. Nevertheless, a separate or increased rating is not warranted for limitation of motion of the shoulder in this separate plane. "[D]iagnostic code 5201 only allows a single rating for limitation of motion, and that the plane in which the limitation of motion manifests itself is irrelevant." Yonek v. Shinseki, 722 F.3d 1355, 1358 (Fed. Cir. 2013) (summarizing conclusion of the United States Court of Appeals for Veterans Claims that separate ratings are not permitted for limitation of flexion and limitation of abduction, before affirming the decision). The Federal Circuit in Yonek addressed 38 C.F.R. § 4.45, finding that this general directive does not require the VA to create separate diagnostic codes. Similarly, as the Veteran's symptom of limitation of motion is contemplated by Diagnostic Code 5201, rating by analogy to other diagnostic codes, such as 5301 through 5306, would be considered impermissible pyramiding. See 38 C.F.R. § 4.14. The Board has considered whether any other diagnostic codes related to disabilities of the shoulder would provide for a higher or separate disability rating. However, the evidence does not reflect that the symptoms would warrant such a rating under a different diagnostic code. See 38 C.F.R. § 4.71a, DC 5200, 5202-03. The VA shoulder examinations and other evidence of record do not reveal the Veteran has ankylosis of the scapulohumeral articulation, impairment of the clavicle or scapula, or other impairment of the humerus. In conclusion, the Board finds that the evidence of record is persuasively weighs against the Veteran's appeal for a rating in excess of 20 percent for left and right shoulder disabilities. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. REASONS FOR REMAND 1. Entitlement to an initial compensable rating for essential tremor is remanded. 2. Entitlement to an initial rating in excess of 10 percent for degenerative joint disease right knee is remanded. 3. Entitlement to a separate compensable rating for right knee instability (or recurrent subluxation) is remanded. 4. Entitlement to a separate compensable rating for right knee meniscus (semilunar cartilage) condition is remanded. 5. Entitlement to an initial compensable rating for degenerative joint disease left knee prior to February 26, 2020 is remanded. 6. Entitlement to an initial rating in excess of 10 percent for degenerative joint disease left knee from February 26, 2020 is remanded. 7. Entitlement to a separate compensable rating for left knee instability (or recurrent subluxation) is remanded. 8. Entitlement to a separate compensable rating for left knee meniscus (semilunar cartilage) condition is remanded. Upon review of the evidence of record, the Board finds remand is warranted to obtain up-to-date medical records and medical opinions. The Veteran attended VA examinations in February 2020 for his essential tremor and knee claims. The examination reports offer conflicting evidence on why the Veteran uses a cane, and other findings in the knee report conflict with other evidence of record. The examination report specific to the Veteran's essential tremor claim notes tremulous voice, essential tremor of hands and neurogenic gait are all from the underlying essential tremor diagnosis. The examiner also specified, "Essential tremor condition is the only pathology contributing to the gait abnormality." See February 2020 VA central nervous system and neuromuscular disease report (hereinafter tremors report), page 8. Additionally, the examiner noted the Veteran uses a cane constantly due to his essential tremor. See February 2020 VA tremors report, page 11. The bilateral knee examination was performed by the same doctor that performed the essential tremor examination. The knee examination report indicates the Veteran uses a cane constantly, and the examiner noted this is due to degenerative joint disease of the knees. The examiner did not reconcile this with the statements contained in the essential tremor examination report, nor did the examiner state whether the Veteran was prescribed use of a cane for his knees. Additionally, during the bilateral knee examination, the examiner did not find objective evidence of instability and also noted the Veteran did not have a history of instability or recurrent subluxation, or a history of a meniscus (semilunar cartilage) condition. However, this conflicts with the evidence or record. See, e.g., treatment records dated July 29, 2013 (intermittent knee locking and right knee suddenly buckled) and January 12, 2015 (complains of fear of right knee giving out with an activity, and recent MRI reveals torn medial and lateral meniscus of left knee); August 2013 VA knee examination report (meniscus condition manifest in frequent episodes of joint pain of the right knee); and October 2019 hearing transcript, page 8 (Veteran testifying to left knee instability); but see October 30, 2014 treatment records (possible left knee meniscus tear found; twisted left knee a year prior and had pain for two months which gradually resolved, but twisted again September 12, 2014 and knee now hurts constantly). The most recent treatment records on file are from 2017. Notably, the Veteran receives his treatment for his essential tremor and knee disabilities at a federal facility and VA has an increased obligation to obtain such records. See 38 C.F.R. § 3.159(c)(2). The Veteran is advised that if he has received relevant treatment for his essential tremor or knees at any other facility, he or his representative should notify VA accordingly. In light of recent changes to the regulation that governs rating of the Veteran's knee disabilities, additional information is required, including medical records, to determine why the Veteran uses a cane and whether use of the cane is prescribed by a medical provider. See 38 C.F.R. § 4.71a. Furthermore, in light of the conflicting evidence noted above, including the reasons given by the February 2020 examiner for the Veteran's use of a cane, additional medical opinions are required before the Board can adjudicate the Veteran's tremor and knee claims. Accordingly, remand is warranted to obtain updated medical records and additional medical opinions from the February 2020 examiner or other qualified professional. 9. Entitlement to a total disability rating for compensation based on unemployability of the individual is remanded. Finally, because a decision on the remanded issues above could significantly impact a decision on the issue of entitlement to a total disability rating for compensation based on unemployability of the individual (TDIU), the issues are inextricably intertwined. Accordingly, remand of the claim for a TDIU is required. The matters are REMANDED for the following action: 1. Obtain the Veteran's federal records from Walter Reed National Military Medical Center, as well as any other treatment records identified by the Veteran or his representative. 2. After the Veteran's medical records have been received, obtain statements from the February 2020 examiner, or other appropriate clinician, on the following. The examiner is asked to review pages 13-14 of this remand (the two pages preceding this page) for a summary of the Veteran's relevant medical history. (a.) Whether it is at least as likely as not the Veteran uses a cane due to his knee disabilities, his essential tremor disability, or a combination of the disabilities? If the examiner finds it is a combination of knee and essential tremor disabilities, the examiner must reconcile this finding with the February 2020 statement that the Veteran's essential tremor condition is the only pathology contributing to the gait abnormality. (b.) Whether it is at least as likely as not the Veteran has a right knee meniscus (semilunar cartilage) disability related to service, or proximately due or aggravated by service-connected disease or injury, including but not limited to bilateral knee degenerative joint disease? (c.) Whether it is at least as likely as not the Veteran has a left knee meniscus (semilunar cartilage) disability related to service, or proximately due or aggravated by service-connected disease or injury, including but not limited to bilateral knee degenerative joint disease? In providing rationale for these opinions, the examiner should address the post-service left knee injuries discussed in the October 30, 2014 treatment records, including whether these injuries are due to service-connected disease or injury. (d.) Whether it is at least as likely as not the Veteran has right knee instability or recurrent subluxation related to service, or proximately due or aggravated by service-connected disease or injury, including but not limited to bilateral knee degenerative joint disease? (e.) Whether it is at least as likely as not the Veteran has left knee instability or recurrent subluxation related to service, or proximately due or aggravated by service-connected disease or injury, including but not limited to bilateral knee degenerative joint disease? In providing rationale for these opinions, the examiner should address the post-service left knee injuries discussed in the October 30, 2014 treatment records, including whether these injuries are due to service-connected disease or injury. (f.) If after review of the medical evidence the examiner finds it is at least as likely as not the Veteran has a history of, or currently suffers from, recurrent subluxation or instability, including patellar instability, the examiner should provide a full and historical description of the disability (or disabilities) and report all signs and symptoms, and changes thereof, necessary for evaluating the Veteran's disability under both the current and pre-February 7, 2021 versions of 38 C.F.R. § 4.71a in effect during the period on appeal. (g.) If after review of the medical evidence the examiner finds it is at least as likely as not the Veteran has a history of, or currently suffers from, a meniscus condition (semilunar cartilage), the examiner should provide a full and historical description of the disability (or disabilities) and report all signs and symptoms, and changes thereof, necessary for evaluating the Veteran's disability under both the current and pre-February 7, 2021 versions of 38 C.F.R. § 4.71a in effect during the period on appeal. (h.) Whether it is at least as likely as not the Veteran had painful motion of the left knee, prior to the post-service injuries discussed in the October 30, 2014 treatment records? If the examiner determines an examination of, or interview with, the Veteran would be beneficial or necessary to address the Board's requests, such an examination should be scheduled. Rationale should be given for each opinion provided. 3. Adjudicate the Veteran's claims. The Agency of Original Jurisdiction is reminded that actual limitation of motion is not required to assign a compensable rating consistent with 38 C.F.R. § 4.59. See, e.g., Petitti v. McDonald, 27 Vet. App. 415, 425 (2015); Sowers v. McDonald, 27 Vet. App. 472, 478 (2016) (footnote 6 is an example specific to a knee with full range of motion). David Gratz Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Gregory T. Shannon, 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.