Citation Nr: 22018339 Decision Date: 03/29/22 Archive Date: 03/28/22 DOCKET NO. 17-42 260 DATE: March 29, 2022 ORDER A rating in excess of 10 percent prior to November 10, 2021, and in excess of 20 percent thereafter for patellar tendinitis, status post meniscectomy, of the left knee is denied. The separate rating for left knee instability, evaluated as 20 percent disabling as of November 10, 2021, is proper; the appeal is denied. REMANDED Entitlement to service connection for a right knee disorder, to include as secondary to service-connected degenerative disc disease of the lumbar spine and/or patellar tendinitis, status post meniscectomy, of the left knee is remanded. Entitlement to a rating in excess of 10 percent from April 25, 2018, to November 10, 2021, and in excess of 20 percent thereafter for degenerative disc disease of the lumbar spine is remanded. Propriety of the assignment of the separate rating for radiculopathy of the right lower extremity (RLE), evaluated as 10 percent disabling as of November 10, 2021, is remanded. Propriety of the assignment of the separate rating for radiculopathy of the left lower extremity (LLE), evaluated as 20 percent disabling as of November 10, 2021, is remanded. FINDINGS OF FACT 1. Prior to November 10, 2021, the Veteran's patellar tendinitis, status post meniscectomy, of the left knee, is manifested by symptomatic removal of semilunar cartilage with frequent episodes of joint pain and weakness, and flexion limited to, at most, 60 degrees and full extension, even in contemplation of functional loss due to symptoms such as pain, fatigue, weakness, lack of endurance, or incoordination, or as a result of repetitive motion and/or flare-ups, without ankylosis, recurrent subluxation, lateral instability, patellar instability, dislocation of semilunar cartilage, impairment of the tibia and fibula, or genu recurvatum. 2. As of November 10, 2021, the Veteran's patellar tendinitis, status post meniscectomy, of the left knee is manifested by symptomatic removal of semilunar cartilage with frequent episodes of joint pain and weakness, flexion limited to, at most, 30 degrees and full extension, even in contemplation of functional loss due to symptoms such as pain, fatigue, weakness, lack of endurance, or incoordination, or as a result of repetitive motion and/or flare-ups, and incomplete/partial ligament tear requiring a cane and brace, without severe subluxation or lateral instability, patellar instability, or unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribes both an assistive device and bracing for ambulation, ankylosis, dislocation of semilunar cartilage, impairment of the tibia and fibula, or genu recurvatum. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 10 percent prior to November 10, 2021, and in excess of 20 percent thereafter for patellar tendinitis, status post meniscectomy, of the left knee have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71A, Diagnostic Code (DC) 5260. 2. The separate rating for left knee instability, evaluated as 20 percent disabling as of November 10, 2021, is proper. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, DC 5257. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from July 1984 to October 1987. This matter comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions issued in September 2013 (left knee disability), December 2015 (right knee disorder), and May 2018 (low back disability) by a Department of Veterans Affairs (VA) Regional Office. In March 2021, the Veteran testified before the undersigned Veterans Law Judge. A transcript of the hearing is of record. In June 2021, the case was remanded for additional development. While on remand, a November 2021 rating decision awarded an increased rating of 20 percent for the Veteran's low back disability, an increased rating of 20 percent for his left knee disability, a separate 20 rating for left knee instability, and separate 10 percent ratings for RLE and LLE radiculopathy, all effective November 10, 2021. As the increased ratings awarded therein do not constitute a complete grant of the benefits sought on appeal, such claims remain on appeal. See AB v. Brown, 6 Vet. App. 35 (1993). Further, while the Veteran did not enter a notice of disagreement with respect to the propriety of the assigned ratings or effective dates for his left knee instability, or RLE and LLE radiculopathy, such issues are part and parcel of his claims for increased ratings for his left knee disability and DDD of the lumbar spine, respectively. See e.g., 38 C.F.R. § 4.71A, General Rating Formula for Diseases and Injuries of the Spine, Note (1). Therefore, such issues will be addressed herein. 1. Entitlement to a rating in excess of 10 percent prior to November 10, 2021, and in excess of 20 percent thereafter for patellar tendinitis, status post meniscectomy, of the left knee. 2. Propriety of the assignment of the separate rating for left knee instability, evaluated as 20 percent disabling as of November 10, 2021. 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. In general, all disabilities, including those arising from a single disease entity, are rated separately, and all disability ratings are then combined in accordance with 38 C.F.R. § 4.25. Pyramiding, the evaluation of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when rating a Veteran's service-connected disability. 38 C.F.R. § 4.14. It is possible for a Veteran to have separate and distinct manifestations from the same injury which would permit rating under several diagnostic codes, however, the critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the conditions is duplicative or overlapping with the symptomatology of the other condition. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). 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, 44 (2011), the United States Court of Appeals for Veterans Claims (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; DeLuca v. Brown, 8 Vet. App. 202 (1995). The intent of the Rating Schedule is to recognize actually painful, unstable or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint, even in the absence of arthritis. 38 C.F.R. § 4.59; Burton v. Shinseki, 25 Vet. App. 1, 5 (2011). In this regard, 38 C.F.R. § 4.59 requires that "[t]he joints involved should be tested for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with the range of the opposite undamaged joint." Correia v. McDonald, 28 Vet. App. 158 (2016). Further, 38 C.F.R. § 4.59 is applicable to the evaluation of musculoskeletal disabilities involving actually painful, unstable or malaligned joints or periarticular regions, regardless of whether the DC under which the disability is evaluated is predicated on range of motion measurements. Southall-Norman v. McDonald, 28 Vet. App. 346 (2016). The appeal period before the Board begins on October 21, 2012, the date VA received the Veteran's claim for an increased rating for his left knee disability, plus the one-year look-back period. Gaston v. Shinseki, 605 F.3d 979, 982 (Fed. Cir. 2010). Such disability is rated as 10 percent disabling prior to November 10, 2021, and 20 percent thereafter, based on painful limitation of motion pursuant to DC 5260, which pertains to limitation pertains to limitation of flexion. 38 C.F.R. § 4.71A. Additionally, as of November 10, 2021, the Veteran is in receipt of separate 20 percent rating for instability of the left knee pursuant to DC 5257. During the pendency of the appeal, the rating criteria for evaluating musculo-skeletal disabilities under 38 C.F.R. § 4.71A were amended effective February 7, 2021. 83 Fed. Reg. 230 (Nov. 30, 2020). These amendments revised select diagnostic codes "to ensure that this portion of the rating schedule uses current medical terminology and provides detailed and updated criteria for the evaluation of musculoskeletal disabilities." Id. If a law or regulation changes during the course of a claim or an appeal, the version more favorable to the veteran will apply, to the extent permitted by any stated effective date in the amendment in question. 38 U.S.C. § 5110(g). If the former version is more favorable, VA can apply the earlier version of the regulation for the period prior to, and from, the effective date of the change. 38 U.S.C. § 5110. Therefore, the Board will consider the Veteran's claim for an increased rating for his left knee disability under the old criteria prior to February 7, 2021, and both the old and new rating criteria from February 7, 2021, applying the criteria that is more favorable to the Veteran. In this regard, under both sets of regulations, normal range of knee motion is 140 degrees of flexion and zero degrees of extension. 38 C.F.R. § 4.71, Plate II. Additionally, DC 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. DC 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. Finally, where extension is limited to 45 degrees a 50 percent rating may be assigned. VA's General Counsel has also stated that separate ratings under DC 5260 (limitation of flexion of the leg) and DC 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). Prior to February 7, 2021, DC 5257 provides for the 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 rating for severe recurrent subluxation or lateral instability. As of February 7, 2021, DC 5257 provides ratings for patellar instability and recurrent subluxation or lateral instability. For the former, a 10 percent rating for a diagnosed condition involving the patellofemoral complex with recurrent instability (with or without history of surgical repair) that does not require a prescription from a medical provider for a brace, cane, or walker. A 20 percent rating is provided for a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for one of the following: a brace, cane, or walker. A 30 percent rating is assigned for a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for a brace and either a cane or a walker. With regard to recurrent subluxation or lateral instability, a 10 percent rating is warranted for a sprain, incomplete ligament tear, or complete ligament tear (repaired, unrepaired, or failed repair) causing persistent instability, without a prescription from a medical provider for an assistance device (e.g., cane(s), crutch(es), walker) or bracing for ambulation. A 20 percent rating is assigned for one of the following: (a) sprain, incomplete ligament tear, or repaired complete ligament tear causing persistent instability, and a medical provider prescribes a brace and/or assistive device (e.g., cane(s), crutch(es), walker) for ambulation, or (b) unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribes either an assistive device (e.g., cane(s), crutch(es), walker) or bracing for ambulation. A 30 percent rating is warranted for unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribes both an assistive device (e.g., cane(s), crutch(es), walker) and bracing for ambulation. Note (1) provides that for patellar instability, the patellofemoral complex consists of the quadriceps tendon, the patella, and the patellar tendon. Note (2) states that a surgical procedure that does not involve repair of one or more patellofemoral components that contribute to the underlying instability shall not qualify as surgical repair for patellar instability (including, but not limited to, arthroscopy to remove loose bodies and joint aspiration). Turning to the evidence of record, VA treatment records reflect the Veteran complained of worsening left knee pain with scant swelling in July 2013, and knee pain with popping and swelling in April 2014. X-rays taken at that time reflect no evidence of fracture or dislocation, and soft tissue outlines were within normal limits. There was mild degenerative arthritis, but no periosteal reaction or bone erosion was noted. The impression was left degenerative joint disease with moderate medial compartment narrowing. In May 2014, the Veteran again reported left knee pain, and had active range of motion (ROM) to 120 degrees of flexion with full extension. At a November 2015 VA examination, the Veteran reported flare-ups described as increased pain and weakness in the left knee that worsened with prolonged use, and resulting functional impairment manifested by a decreased capacity for prolonged standing, prolonged walking, and physical training. Active ROM testing showed left knee flexion to 60 degrees and full extension with pain, to include on weight-bearing, that caused functional loss. There was no additional loss in the ROM after repetitive-use testing. The examiner stated that she was unable to say without mere speculation whether pain, weakness, fatigability or incoordination significantly limited the Veteran's functional ability following repeated use over time or during flare-ups as the measurement of future functional loss was beyond the scope of the examination. See Sharp, supra; Jones v. Shinseki, 23 Vet. App. 382 (2010) (a medical opinion that cannot be provided without resort to speculation is adequate only when it is clear that it is predicated on a lack of knowledge among the medical community at large and not the insufficient knowledge of the specific examiner). His muscle strength was normal and there was no ankylosis. Upon joint stability testing, it was noted that the Veteran did not have a history of recurrent subluxation or lateral instability, and objective stability testing was normal. It was noted that the Veteran had underwent a left knee arthroscopy in 2009 for a meniscal tear with residuals of continued pain and weakness. The examiner further observed that the Veteran regularly used a brace and cane. Private treatment records dated August 2016 reflect left knee ROM was to 130 degrees of flexion with full extension. See SE Ortho Specialists records. VA treatment records dated January 2017 and August 2018 reflect the Veteran wore bilateral hinged knee braces and reported they reduced pain and provided stability. In April 2017 and March 2018, the Veteran again complained of left knee pain. On VA examination in April 2018, the Veteran reported constant left knee pain, which limited his physical activity, going up/down stairs, side to side motion, and playing with his grandchildren, and buckling, which resulted in wearing a brace 5 days a week. However, he denied flare-ups. ROM testing of the left knee revealed flexion to 130 degrees and full extension with pain, but such did not result in or cause functional loss. There was no pain on weight-bearing or additional loss in the ROM after repetitive-use testing. The examiner stated that she was unable to say without mere speculation whether pain, weakness, fatigability or incoordination significantly limited the Veteran's functional ability following repeated use over time. His muscle strength was normal and there was no ankylosis. Upon joint stability testing, it was noted that the Veteran did not have a history of recurrent subluxation or lateral instability, and objective stability testing was normal. It was noted that the Veteran's residuals of his meniscectomy included frequent episodes of joint pain and he had four stable and well-healed scars measuring 1.0 cm by 0.1 cm, 1.5 cm by 0.1 cm, 1.0 cm by 0.1 cm, and 1.5 cm by 0.1 cm. The examiner further observed that the Veteran regularly used a brace. VA treatment records reflect that, in February 2019, November 2019, and January 2020, the Veteran again complained of left knee pain. During his March 2021 Board hearing, the Veteran testified his left knee disability was worsening, to the point where it was "bone on bone," and cracking and popping. He testified that instability was not really an issue, as his knee had only given out one time, but not recently. At an April 2021 VA examination completed at the Veteran's request, he reported constant left knee pain and stiffness in the morning. In this regard, he indicated that he wore a brace, iced his knee, used Bengay, stretched his knee, and walked twice a week. However, he denied flare-ups. Active and passive ROM testing of the left knee revealed flexion to 100 degrees with pain and full extension. There was no pain on weight-bearing or nonweight-bearing, or additional loss in the ROM after repetitive-use testing or repeated use over time. There was no muscle atrophy or ankylosis. Upon joint stability testing, it was noted that the Veteran did not have a history of recurrent subluxation, persistent instability, ligament tear, or patellar instability. It was observed that the Veteran's residuals of his meniscectomy included frequent episodes of joint pain. The examiner further indicated that he regularly used a brace and cane. At a November 10, 2021, VA examination conducted pursuant to the June 2021 remand, the Veteran reported experiencing daily pain and popping in the left knee, which affected walking, standing, and sitting, and an inability to bend it. He also described experiencing flare-ups that occurred 2 to 3 times a week with sitting, walking, or standing more than one hour or going up an incline that lasted for 2 hours. Upon active and passive ROM testing, the Veteran had flexion limited to 35 degrees with pain, to include on weight-bearing and nonweight-bearing, that resulted in functional loss and full extension. There was no additional loss in the ROM after repetitive-use testing or repeated use over time, but the Veteran's flexion was further reduced to 30 degrees during a flare-up. There was no muscle atrophy or ankylosis. Upon joint stability testing, it was noted that the Veteran did not have a history of recurrent subluxation, persistent instability, or patellar instability, but had an incomplete/partial ligament tear that required a cane and brace. However, the Veteran declined joint stability testing due to fear of increased pain. It was also noted that he had no residuals of his meniscectomy. Based on the foregoing, the Board finds that, prior to November 10, 2021, the Veteran's left knee flexion was limited to, at most, 60 degrees with full extension, even in contemplation of functional loss due to symptoms such as pain, fatigue, weakness, lack of endurance, or incoordination, or as a result of repetitive motion and/or flare-ups. In fact, ROM of motion testing reflected marked improvement in the knee during such time period. Thus, prior to November 10, 2021, the Board finds a rating in excess of 10 percent is not warranted under DC 5260, and a higher or separate rating is not warranted under DC 5261, for the Veteran's left knee disability. The Board further finds that, as of November 10, 2021, the Veteran's left knee flexion was limited to, at most, 30 degrees with full extension, even in contemplation of functional loss due to symptoms such as pain, fatigue, weakness, lack of endurance, or incoordination, or as a result of repetitive motion and/or flare-ups. Thus, as of November 10, 2021, the Board finds a rating in excess of 20 percent is not warranted under DC 5260, and a higher or separate rating is not warranted under DC 5261, for the Veteran's left knee disability. As noted above, the Veteran is also in receipt of a separate 20 percent rating for left knee instability as of November 10, 2021, under DC 5257 as in effect as of February 7, 2021, for lateral instability manifested by a sprain, incomplete ligament tear, or repaired complete ligament tear causing persistent instability, and a medical provider prescribes a brace and/or assistive device for ambulation. In this regard, the Court has held that DC 5257, as in effect prior to February 7, 2021, does not require objective medical evidence of lateral instability for a rating to be assigned. English v. Wilkie, 30 Vet. App. 347 (2018). However, the Veteran only reported a single episode of giving way. Moreover, he is not competent as a lay person to diagnose lateral instability, recurrent subluxation, or patellar instability, or relate such feelings to a specific diagnosis, as such requires the administration and interpretation of specialized testing of the ligaments and patella, respectively. Woehlaert v. Nicholson, 21 Vet. App. 456 (2007) (although the claimant is competent in certain situations to provide a diagnosis of a simple condition such as a broken leg or varicose veins, the claimant is not competent to provide evidence as to more complex medical questions). Rather, joint stability testing performed at the November 2015, April 2018, and April 2021 VA examinations revealed no history of recurrent subluxation, lateral or persistent instability, ligament tear, or patellar instability, and objective stability testing was normal. In this regard, such examiners have the training to administer and interpret ligament and patellar testing. Thus, the Board affords greater probative weight to the VA examiners who found no lateral instability, recurrent subluxation, or patellar instability in the left knee than the Veteran's generalized statement regarding a single occasion of giving way. See, e.g., Waters v. Shinseki, 601 F.3d 1274, 1278 (2010). Therefore, a higher or separate rating under DC 5257 is not warranted prior to November 10, 2021. The Board further finds that, as of such date, a rating in excess of 20 percent under DC 5257 is not warranted. In this regard, at the November 2021 VA examination, it was noted that the Veteran had an incomplete/partial ligament tear of the left knee that required a cane and brace. However, as there is no evidence of severe subluxation or lateral instability, patellar instability, or unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribes both an assistive device (e.g., cane(s), crutch(es), walker) and bracing for ambulation, a rating in excess of 20 percent under such DC is not warranted. The Board further notes that, prior to the appeal period, the Veteran underwent a meniscectomy in 2009. Therefore, the Board has considered the applicability of DC 5259, which provides a single 10 percent rating for symptomatic removal of semilunar cartilage. In this regard, the foregoing VA examinations reflects that the Veteran's residuals of his meniscectomy include frequent episodes of joint pain and weakness. However, the Board finds that, to assign a separate rating under DC 5259 would be tantamount to pyramiding as the Veteran would be compensated twice for the same symptomatology. 38 C.F.R. § 4.14; Esteban, supra. Specifically, under DC 5259, the criteria is based on symptomatic residuals, which in plain language, means the Veteran reports residuals. There is no objective findings required other than the removal of the cartilage. In the instant case, the Veteran's reported residuals of frequent episodes of joint pain and weakness. In this regard, pain and weakness may limit the Veteran's range of knee motion pursuant to 38 C.F.R. §§ 4.40, 4.45, 4.59. Specifically, 38 C.F.R. § 4.45 indicates that, with respect to joints, 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. Moreover, pursuant to VAOPGCPREC 9-98, limitation of motion is contemplated in DC 5259, pertinent to the removal of the semilunar cartilage or meniscus. The opinion finds that such removal may resolve restriction of movement caused by tears and displacements of the menisci; however, the procedure may result in complications such as reflex sympathetic dystrophy, which can produce loss of motion. Therefore, the opinion states that limitation of motion is a relevant consideration under DC 5259. Therefore, the Board finds that the Veteran's residuals of frequent episodes of joint pain and weakness are considered in the evaluation assigned under DC 5260. Consequently, a separate rating under DC 5259 is not warranted as such would result in impermissible pyramiding. Additionally, as there is no evidence of ankylosis, dislocation of semilunar cartilage, impairment of the tibia or fibula, or genu recurvatum, DCs 5256, 5258, 5262, and 5263 are not for application. Moreover, while the Veteran has scarring associated with his left knee disability, such are asymptomatic and not of a size to warrant a compensable rating. Therefore, a separate rating for such residual scarring is not warranted. In reaching the foregoing conclusions, the Board acknowledges the Veteran's belief that his left knee disability is more severe than as reflected by the current disability ratings. However, the Board must consider the entire evidence of record when analyzing the criteria laid out in the rating schedule. While the Board recognizes that the Veteran is competent to describe his observable symptomatology, he is not competent to provide an opinion regarding the severity of his symptomatology in accordance with the rating criteria. See Woehlaert, supra. Ultimately, the Board finds the medical evidence in which professionals with medical expertise examined the Veteran, acknowledged his reported symptoms, and described the manifestations of his left knee disability in light of the rating criteria to be more persuasive than his own reports regarding the severity of such disability. The Board has also considered whether additional staged ratings under Hart, supra, are appropriate for the Veteran's service-connected left knee disability; however, the Board finds that his symptomatology has been stable throughout each period on appeal. Therefore, assigning additional staged ratings for such disabilities are not warranted. Further, 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 claim adjudicated herein. See Doucette v. Shulkin, 28 Vet. App. 366 (2017). Thus, the Board finds that an increased rating for the Veteran's left knee disability is not warranted. In reaching such determination, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the weight of the probative evidence is against such claim, the benefit of the doubt doctrine is not applicable in such regard and the Veteran's 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 right knee disorder, to include as secondary to service-connected degenerative disc disease of the lumbar spine and patellar tendinitis, status post meniscectomy, of the left knee. As noted in the June 2021 remand, at his March 2021 Board hearing, the Veteran testified that his right knee disorder developed as a result of the rigorous nature of his physical training during service or, in the alternative, is caused or aggravated by his service-connected back and left knee disabilities. In regard to the latter theory of entitlement, he reported that, due to overcompensating for his left knee disability, he always stands on the right side, which put more pressure and weight on the right knee. The Veteran also indicated that, as a result of his back and left knee disabilities, he had an altered gait, which further adversely affected his right knee. At such time, the Board noted that the record included current diagnoses of patellofemoral pain syndrome and osteoarthritis of the right knee. Additionally, while the Veteran's service treatment records are negative for any complaints, treatment, or diagnosis referable to a right knee disorder, he is competent to report the nature of his training activities. Further, he is currently service-connected for back and left knee disabilities. However, the Board found that neither the November 2015 or the April 2018 VA examiners addressed whether the Veteran's right knee disorder is directly related to his military service or secondary to his service-connected back disability. Further, in offering their respective opinions, neither VA examiner considered whether the Veteran's reported overcompensation for his service-connected disabilities or altered gait caused or aggravated his right knee disorder. Finally, while the April 2018 VA examiner suggested that the Veteran's right knee disorder may be related to obesity, she did not address whether the Veteran's service-connected back and left knee disabilities caused him to become obese and, if so, whether such resulting obesity was a substantial factor in causing or aggravating his right knee disorder and whether such would not have occurred or worsened but for the obesity caused by his service-connected disabilities. Thus, the Board remanded the claims to obtain an addendum opinion addressing the aforementioned matters. Thereafter, in September 2021, a VA examiner reviewed the record and opined that it was less likely than not that the Veteran's current right knee disorder is related to his military service, or his service-connected back or left knee disabilities. In this regard, she noted he had a contusion to the right knee in 1985, but it healed as contusions do, and the Veteran's onset of right knee pain was decades later. The examiner determined the Veteran's sole right knee diagnosis was primary osteoarthritis and stated that the previous diagnosis of patellofemoral pain syndrome was incorrect, and noted the Veteran was not a runner and was sedentary. The VA examiner further explained that osteoarthritis was a normal finding in a male his age with a history of diabetes mellitus, type II. Because his right knee osteoarthritis is following a natural progression, there's no evidence it has been aggravated beyond such by his service-connected low back or left knee disabilities. However, the examiner did not consider or discuss the Veteran's contention that overcompensation for his service-connected disabilities or altered gait, as evidenced by his November 2021 VA lumbar spine examination, caused or aggravated his right knee disorder. Thus, the Board finds a remand is warranted to obtain an addendum opinion that addresses such matter. Further, the examiner noted that with a body mass index (BMI) of 28, the Veteran was not obese, and thus she was unable to answer the question about obesity. However, in January 2021, the Veteran was noted to have lost 21 pounds in the last 2 years, such that earlier in the appeal period he had been heavier. Further, the Board notes that just prior to and throughout the appeal period, the Veteran's BMI has been in the obese range (over 30). See November 2013, April 2014, July 2015, March 2019, November 2019, and April 2021 VA treatment records. Thus, the Board finds a remand is warranted to obtain an addendum opinion that addresses whether the Veteran's service-connected back and left knee disabilities caused him to become obese and, if so, whether such resulting obesity was a substantial factor in causing or aggravating his right knee disorder and whether such would not have occurred or worsened but for the obesity caused by his service-connected disabilities. VAOPGCPREC 1-2017; Walsh v. Wilkie, 32 Vet. App. 300 (2020). Moreover, at his November 2021 VA knee examination, the Veteran alleged that his right knee pain with popping began in 1987 while playing basketball in service. However, no etiological opinion was provided at this examination, thus, a remand is necessary to obtain an addendum opinion that address this new contention. 3. Entitlement to a rating in excess of 10 percent from April 25, 2018 to November 10, 2021, and in excess of 20 percent thereafter, for degenerative disc disease of the lumbar spine. The record reflects that the Veteran most recently underwent VA examinations in April 2021 and November 2021. However, at both examinations, he declined to complete ROM testing, citing severe back pain. However, at his November 2021 VA examination, he stated he had done ROM testing just 2 months before at the Gainesville VA Medical Center, which would be in September 2021. However, the most recent VA treatment records on file are dated in August 2021. Therefore, a remand is necessary in order to obtain updated VA treatment records, to include the results of ROM testing conducted in approximately September 2021. 4. Propriety of the separately assigned rating for radiculopathy of the RLE, evaluated as 10 percent disabling as of November 10, 2021. 5. Propriety of the separately assigned rating for radiculopathy of the LLE, evaluated as 20 percent disabling as of November 10, 2021. The claims for entitlement to increased ratings for radiculopathy od the RLE and LLE are inextricably intertwined with the Veteran's claim for an increased rating for his back disability remanded herein. See Tyrues v. Shinseki, 23 Vet. App. 166, 177 (2009) (en banc) (explaining that claims are inextricably intertwined where the adjudication of one claim could have a significant impact on the adjudication of another claim). As such, consideration of such claims must be deferred pending the outcome of the claim for an increased rating for his back disability. Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (where a claim is inextricably intertwined with another claim, the claims must be adjudicated together in order to enter a final decision on the matter). The matters are REMANDED for the following action: 1. Forward the record, to include a copy of this remand, to an appropriate VA examiner so as to obtain an addendum opinion addressing the nature and etiology of the Veteran's right knee disorder. Following a review of the record, the examiner should address the following inquiries: (A) For the Veteran's right knee disorder, currently diagnosed as osteoarthritis, the examiner should offer an opinion as to whether it is at least as likely as not that such disorder had its onset in, or is otherwise related to, the Veteran's military service, to include that the rigorous nature of his physical training therein and/or his report of pain and popping beginning in 1987 while playing basketball in service. (B) For the Veteran's right knee disorder, currently diagnosed as osteoarthritis, the examiner should offer an opinion as to whether it is at least as likely as not that such disorder is caused or aggravated by his service-connected back and left knee disabilities, to include as a result of overcompensation and/or an altered gait. (C) If the examiner finds that the Veteran's right knee disorder is a result of weight gain/obesity at any point during the appeal period (i.e., prior to his recent weight loss), he or she should address whether it at least as likely as not that (1) the Veteran's service-connected back and left knee disabilities caused him to become obese and, if so, (2) whether such resulting obesity was a substantial factor in causing or aggravating his right knee disorder and (3) whether his right knee would not have occurred or worsened but for the obesity caused by his service-connected back and left knee disabilities. For any aggravation found, the examiner should state, to the best of his or her ability, the baseline of symptomatology and the amount, quantified if possible, of aggravation beyond the baseline symptomatology. A rationale for any opinion offered should be provided. 2. Obtain all outstanding VA treatment records from the Gainesville VAMC dated from August 2021 to the present, to include the results of ROM testing of the Veteran's lumbar spine conducted in approximately September 2021. A. JAEGER Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. M. Kelly, 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.