Citation Nr: 22019688 Decision Date: 04/02/22 Archive Date: 04/02/22 DOCKET NO. 16-05 591 DATE: April 2, 2022 ORDER Entitlement to a rating of 10 percent, but no higher, for left knee degenerative arthritis with painful motion and limitation of flexion prior to November 2, 2021 is granted subject to the laws and regulations governing monetary awards. Entitlement to a rating in excess of 20 percent from November 2, 2021 onward for left knee degenerative arthritis with painful motion and limitation on flexion is denied. Entitlement to a rating in excess of 10 percent for left knee degenerative arthritis with painful motion and limitation on extension is denied. REMANDED Entitlement to a rating in excess of 10 percent prior to April 25, 2019, and in excess of 20 percent thereafter for left knee degenerative arthritis with instability is remanded. FINDINGS OF FACT 1. Prior to November 2, 2021, the Veteran's left knee symptomology manifested with flexion limited to 55 degrees with painful motion at its most severe with no evidence of greater impairment. 2. From November 2, 2021 onward, the Veteran's left knee symptomology manifested with flexion limited to 20 degrees at its most severe with no evidence of greater impairment. 3. Throughout the entire appeal period, the Veteran's left knee symptomology manifested with extension limited to 14 degrees with painful motion at its most severe with no evidence of greater impairment. CONCLUSIONS OF LAW 1. The criteria for a rating of 10 percent, but no higher, for left knee degenerative arthritis with painful motion and limitation on flexion prior to November 2, 2021 are met. 38 U.S.C. § 1155, 5107 (b); 38 C.F.R. §§ 4.1, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, DC 5260. 2. The criteria for entitlement to a rating in excess of 20 percent from November 2, 2021 for left knee degenerative arthritis with painful motion and limitation on flexion are not met. 38 U.S.C. § 1155, 5107 (b); 38 C.F.R. §§ 4.1, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, DC 5260. 3. The criteria for entitlement to a rating in excess of 10 percent for left knee degenerative arthritis with painful motion and limitation on extension are not met. 38 U.S.C. § 1155, 5107 (b); 38 C.F.R. §§ 4.1, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, DC 5260. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served honorably in the United States Army from April 1997 to May 2001. These issues come before the Board of Veterans' Appeals (Board) on appeal from an April 2014 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Montgomery, Alabama. In December 2018, the Veteran testified at a Board hearing before the undersigned Veterans Law Judge. The transcript is of record. These matters were recently remanded in August 2021 for additional development. A review of the record shows substantial compliance with the Board's prior remand with regard to the limitation of flexion and extension claims; therefore, additional development is not needed. Stegall v. West, 11 Vet. App. 268 (1998). The Board notes that the Veteran's claim for entitlement to service connection for scar, left knee was granted in a November 2021 rating decision. Thus, this claim is no longer on appeal and the Board does not have jurisdiction at this time. See Grantham v. Brown, 114 F.3d 1156, 1158-59 (Fed. Cir. 1997) (holding that where an appealed claim for service connection is granted during the pendency of the appeal, a second NOD must thereafter be timely filed to initiate appellate review of the claim concerning "downstream" issues, such as the compensation level assigned for the disability and the effective date); see also 38 C.F.R. § 20.200. Increased Ratings 1. Entitlement to a compensable rating prior to November 2, 2021, and in excess of 20 percent thereafter for left knee degenerative arthritis with painful motion and limitation on flexion. 2. Entitlement to a rating in excess of 10 percent for left knee degenerative arthritis with painful motion and limitation on extension The Veteran contends that his left knee disability is worse than the ratings currently assigned. By way of history, a June 2001 rating decision granted service connection for a left ankle disability and assigned a 10 percent effective May 29, 2001, the date after the Veteran's separation from active service. The Veteran filed an increased rating claim with VA in September 2013. The April 2014 rating decision on appeal granted service connection for degenerative arthritis left knee (instability) and degenerative arthritis, left knee (painful motion, limitation on extension) and assigned 10 percent ratings, respectfully, effective September 23, 2013. The Veteran timely appealed this determination to the Board. During the pendency of this appeal, a July 2016 rating decision increased assigned a temporary rating of 100 percent effective May 12, 2016 based on surgical convalescence for the left knee. In addition, an October 2020 rating decision granted service connection for degenerative arthritis, left knee with limitation of flexion and assigned a non-compensable rating effective September 23, 2013. The Board also notes that a November 2021 rating decision increased the left knee rating based on limitation of flexion to 20 percent effective November 2, 2021. Law and Regulations 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. §§ 3.321 (a), 4.1. Separate diagnostic codes identify the various disabilities and the criteria for specific ratings. If two disability evaluations are potentially applicable, the higher evaluation will be assigned to the disability picture that more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability will be resolved in favor of the Veteran. 38 C.F.R. § 4.3. Where the question for consideration is the propriety of the initial evaluation assigned, consideration of the medical evidence since the effective date of the award of service connection and consideration of the appropriateness of a "staged" rating is required. Fenderson v. West, 12 Vet. App. 119, 125-26 (1999). VA adjudicators must consider whether to assign different ratings at different times during the rating period to compensate the Veteran for times when the disability may have been more severe than at others. The United States Court of Appeals for Veterans' Claims (the Court) since has extended this practice even to established ratings, not just initial ratings. Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007). The evaluation of the same disability under several diagnostic codes, known as pyramiding, must be avoided; however, separate ratings may be assigned for distinct disabilities resulting from the same injury so long as the symptomatology for one condition is not duplicative of the symptomatology of the other condition. 38 C.F.R. § 4.14; Esteban v. Brown, 6 Vet. App. 259, 262 (1994). The Veteran's left knee disability has been evaluated under Diagnostic Codes 5260 and 5010-5261. 38 C.F.R. § 4.71a. Hyphenated diagnostic codes are used when a rating under one code requires use of an additional diagnostic code to identify the basis for the rating. 38 C.F.R. § 4.27. Here, the hyphenated diagnostic code indicates that the Veteran's left knee disability is rated, by analogy, under the criteria for limitation of extension (Diagnostic Code 5261) and arthritis, due to trauma, substantiated by X-ray findings (Diagnostic Code 5010). Limitation of motion for the knees is evaluated under Diagnostic Codes (DCs) 5260 and 5261. Id. DC 5260 refers to limitation of motion in flexion of the knee and leg. Under this diagnostic code, flexion limited to 60 degrees is non-compensable. Flexion limited to 45 degrees warrants a 10 percent rating. Flexion limited to 30 degrees warrants a 20 percent rating. Flexion limited to 15 degrees warrants the maximum rating under DC 5260 which is 30 percent. 38 C.F.R. § 4.71a, DC 5260. DC 5261 refers to limitation of motion in extension of the knee and leg. Under this diagnostic code, extension limited to 10 degrees warrants a 10 percent rating. Extension limited to 15 degrees warrants a 20 percent rating. Extension limited to 20 degrees warrants a 30 percent rating. Extension limited to 30 degrees warrants a 40 percent rating. Extension limited to 45 degrees warrants the maximum rating under DC 5261, which is 50 percent rating. 38 C.F.R. § 4.71a, DC 5261. VA's General Counsel has held that separate ratings are available for limitation of flexion and limitation of extension under DCs 5260 and 5261. VAOPGCPREC 9-2004 (2004). The Board notes that the regulations for rating musculoskeletal injuries have changed effective February 7, 2021. The only significant change that is relevant to the Veteran's claims is that DC 5010 directs an examiner to rate as limitation of motion, dislocation, or other specified instability under the affected joint. The Board notes that the rating criteria under DCs 5260 and 5261 remained unchanged. In evaluating disabilities of the musculoskeletal system, additional rating factors include functional loss due to pain supported by adequate pathology and evidenced by the visible behavior of the claimant undertaking the motion. 38 C.F.R. § 4.40. Although pain may cause functional loss, pain itself does not constitute functional loss. Rather, pain must affect some aspect of "the normal working movements of the body," such as "excursion, strength, speed, coordination, and endurance," in order to constitute functional loss. Mitchell v. Shinseki, 25 Vet. App. 32, 38-43 (2011) (quoting 38 C.F.R. § 4.40). In addition, inquiry must also be made as to weakened movement, excess fatigability, incoordination, and reduction of normal excursion of movements, including pain on movement. 38 C.F.R. § 4.45. When assigning a disability rating, it is necessary to consider functional loss due to flare-ups. See DeLuca v. Brown, 8 Vet. App. 202 (1995). The Board will focus on the following appeal periods: (1) from September 23, 2012 (one year prior to the increased rating claim being filed) to November 2, 2021, and (2) from November 2, 2021 onward. Prior to November 2, 2021 Factual History A review of the post-service VA treatment records throughout this appeal period note complaints and treatment related to the left knee. Of note, VA physical therapy treatment records from August 2016 through June 2017 noted range of motion (ROM) measurements of 0 to 78 degrees, 0 to 80 degrees, 0 to 92 degrees, 0 to 96 degrees, 0 to 100 degrees, 0 to 105 degrees, 0 to 106 degrees, 0 to 110 degrees, 0 to 112 degrees, 0 to 113 degrees, 0 to 116 degrees, and 0 to 130 degrees with painful motion. In addition, the Veteran reported worsening left knee pain. The Veteran underwent a VA examination in March 2014. He was diagnosed with mild degenerative arthritis of the left knee. He reported "unbearable" pain and swelling while operating a forklift. He also endorsed flare ups due to prolonged sitting, standing, walking, going up and down stairs, and bending. Clinical examination revealed ROM measurements of flexion up to 115 degrees with painful motion. No limitation of extension was noted; however, the examiner noted the Veteran's pain complaints on movement. Repetitive testing revealed the same ROM measurements. The Veteran was noted to have tenderness or pain on palpation for the joint line or soft tissues of the left knee. Decreased muscle strength and left knee anterior joint instability was noted by the examiner. The examiner noted that the Veteran experienced frequent episodes of left knee joint "locking," pain, and effusion. The examiner also noted that the Veteran underwent a left knee meniscectomy with residual symptoms of swelling and locking. The Veteran reported occasional use of a knee brace for ambulation. The examiner described the functional impact of the left knee as follows: Veteran's current knee condition may likely mildly to moderately impact physical and sedentary labor secondary to flareups requiring prolonged sitting, standing, walking, going up and down stairs resulting in pain, limited motion and fatigue. Examiner cannot opine to future limitation of motion without resorting to mere speculation. The Veteran underwent a second VA examination in October 2015. He was diagnosed with degenerative arthritis, left knee. He reported worsening knee pain and difficulty getting in and out of his truck at work. He endorsed flare ups due to standing longer than 15 minutes that improved with rest. Clinical examination revealed ROM measurements of flexion up to 70 degrees and extension up to 14 degrees with pain noted on flexion and extension. Repetitive testing revealed additional ROM limitation of flexion up to 69 degrees and extension up to 12 degrees. The examiner found that pain, weakness, fatigability, or incoordination significantly limited functional ability with repeated use over time. However, she was not able to describe any additional ROM limitations as she observed the Veteran after prolonged use of the left knee. The examiner also found no additional ROM limitations due to flare ups. Clinical examination revealed decreased muscle strength and anterior joint instability. The examiner also noted that the Veteran underwent a meniscectomy with residual pain and reduced ROM. The Veteran denied any use of an assistive device for ambulation. The examiner described the functional impact of the left knee as "[the Veteran] has difficulty climbing stairs, and getting in and out of his truck at [the] workplace." The Veteran underwent a third VA examination in February 2016. Clinical examination revealed ROM measurements of flexion up to 55 degrees and extension up to 5 degrees with pain causing functional loss on both flexion and extension. Joint line tenderness was noted by the examiner. The examiner was unable to perform repetitive use testing due to the Veteran's pain complaints. The examiner did find that pain, weakness, fatigability, and incoordination significantly limited functional ability due to flare ups. However, she did not estimate any additional ROM limitations, stating that it would be speculation. She did note additional functional loss due to disturbance of locomotion and interference with standing and sitting and decreased muscle strength. The examiner also noted frequent episodes of left knee joint "locking" and pain as well as left knee meniscectomy, but did not note any residual symptoms. She also noted that the Veteran's constant use of a knee brace for ambulation. The examiner described the functional impact of the left knee as "[the Veteran] has trouble getting on and off the forklift truck at work." The Veteran underwent a fourth VA examination in April 2019. He was diagnosed with left knee instability and degenerative arthritis. He also reported experiencing "extreme" pain and instability in his left knee, causing him to depend more on his right knee. He endorsed daily flare ups of severe pain (9/10) that would last most of the day and additional functional loss due to walking and standing for too long. Clinical examination revealed ROM measurements of flexion and extension up to 55 degrees with pain noted on flexion and extension that caused functional loss. The examiner also noted evidence of pain on weight bearing and objective evidence of crepitus. Repetitive use testing revealed the same ROM measurements. The examiner found that pain, weakness, fatigability, or incoordination did not significantly limit functional ability of the left knee with repeated use or during flare ups. She noted that there was no basis to offer additional losses of function or motion with repetitive use or during flare ups after reviewing the Veteran's record, physical examination, reported history and subjective complaints. The examiner found decreased muscle strength and slight lateral joint instability. She also noted a left knee meniscal tear with frequent episodes of joint "locking," pain, and effusion. She further noted the Veteran's regular use of knee braces and a cane to ambulate. The examiner described the functional impact of the left knee as "difficulty to walk ot stand for long periods of time." She also found objective evidence of pain on passive ROM testing, but no evidence of pain when used in non-weight bearing. The Board notes that the examiner did not record any passive ROM measurements. Analysis After a review of the evidence of record, the Board finds that a 10 percent rating is warranted for left knee degenerative arthritis with limitation of flexion for the period prior to November 2, 2021 based on painful motion of the left knee. See Sowers v. McDonald, 27 Vet. App. 472, 478-79, 482 (2016) (stating that application of 38 C.F.R. § 4.59 warrants at least the minimum compensable rating for painful motion of a joint). The evidence of record demonstrates that while the Veteran experienced limitation of flexion up to 55 degrees, he has experienced painful motion and functional impairment of the left knee from September 2013 through November 2, 2021. As such, he is entitled to the minimum compensable rating under DC 5260, which is 10 percent. However, he is not entitled to a 20 percent rating for limitation on flexion, as the evidence of record does demonstrate limitation of flexion up to 30 degrees. Regarding limitation of extension, the Board finds that the evidence of record warrants a 10 percent rating throughout this appeal period. Limitation of extension was found to be 14 degrees at its most severe throughout the appeal period. However, the Veteran is not entitled to a 20 percent rating, as the evidence of record does not demonstrate limitation of extension up to 15 degrees. The Board notes that while limitation of extension was found to be 14 degrees during the October 2015 VA examination, the evidence of record demonstrates that limitation of extension has varied between 0 and 12 degrees throughout the appeal period. Indeed, the October 2015 VA examination report demonstrated that ROM measurements on extension improved from 14 to 12 degrees based on repetitive use of the knee. The Board must evaluate the Veteran's left knee disability based on the total severity, duration, and frequency of the symptomology present during the appeal period. As the evidence of record demonstrates that the left knee limitation of extension warrants a 10 percent rating throughout the appeal period, the claim for a higher rating is denied. The Board has considered the 38 C.F.R. §§ 4.40, 4.45, and 4.59, and Mitchell and DeLuca criteria, but finds that the competent and probative evidence weighs against finding weakened movement, excess fatigability, incoordination, and/or pain during flare-ups or after repeated use over time resulting in motion limited to 20 degrees on flexion or 15 degrees on extension. In other words, the Board finds that the Veteran's left knee disability does not more closely approximate the criteria for 20 percent evaluations under DCs 5260 and 5261. See 38 C.F.R. § 4.71a. The Board considered all potentially applicable diagnostic codes in accordance with Schafrath v. Derwinski, 1 Vet. App. 589 (1991); however, the evidence does not show symptoms that could be separately rated higher under another diagnostic code. See 38 C.F.R. § 4.71a. Indeed, the Veteran is already separately rated for limitation of flexion, limitation of extension, and left knee instability. Furthermore, there is no evidence of left knee ankylosis. As such, higher ratings under different diagnostic codes is not warranted. The Board acknowledges that under 38 C.F.R. § 4.59, examination of certain joints should include testing for pain on both active and passive motion, in weight-bearing and non-weight-bearing. Correia v. McDonald, 28 Vet. App. 158 (2016). To the extent that other examinations cited herein did not explicitly provide these findings, the Board reiterates the pertinent ratings of the left knee with or without symptoms such as pain. Thus, any deficiency of the examinations of record in this regard is harmless, as assessment of pain in accordance with 38 C.F.R. § 4.59 would not provide a basis for the assignment of any higher rating. A comparison between the left knee and the right knee range of motion is without probative value as the right knee joint is also damaged. Additionally, to the extent that earlier examinations discussed herein did not explicitly provide findings of passive ROM testing, pain on both active and passive motion, or in weight-bearing and non-weight-bearing, they are nonetheless the most probative evidence available with regard to the severity of the left knee disability at the time those examinations were conducted. Any additional medical opinion with regard to those periods would be retrospective and entitled to less probative value than the contemporaneous range of motion evidence already of record. Therefore, remand for any additional retrospective opinion is not warranted. See Soyini v. Derwinski, 1 Vet. App. 540 (1991) (remand is unnecessary where it would result in unnecessarily imposing additional burdens on VA with no benefit flowing to the claimant). In adjudicating these claims, the competence and credibility of lay statements must be considered by the Board. Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006); Washington v. Nicholson, 19 Vet. App. 362, 368-69 (2005). The Veteran contends that his left knee disability warrants higher ratings. The Board acknowledges that the Veteran is competent to give evidence about what he observes or experiences. Layno v. Brown, 6 Vet. App. 465 (1994). That stated, these allegations of worsening symptomology are undercut by the other evidence of record, which does not favor a finding that the Veteran is entitled to a higher rating than the 10 percent currently assigned for both his left knee limitation of flexion and limitation of extension during this appeal period based on the symptomology present. His current symptomology is encapsulated in the current rating assigned under the Rating Schedule, with no evidence of symptomology warranting extra-schedular consideration. Since the evidence persuasively weights against the Veteran, he is not entitled to the benefit of the doubt. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); see also Ortiz v. Principi, 274 F.3d 1361, 1365 (Fed Cir. 2001). From November 2, 2021 onward Factual History A review of the post service VA treatment records note complaints of left knee pain. However, the Board finds the complaints of left knee pain to be well documented in the record and these reports do not include evidence of any additional rating criteria for the left knee, so the Board will not discuss these reports any further. Gonzalez v. West, 218 F.3d at 1378, 1380-81 (2000). The Veteran underwent a VA examination in November 2021. He was diagnosed with left knee degenerative arthritis with pain motion and limitation of flexion, limitation of extension, and instability status post arthroscopy. He reported symptoms of sharp pain, swelling, and popping of the left knee. He endorsed flare ups of severe pain lasting a couple days at least once a week that are alleviated by wearing a knee brace and doing mild exercise. The Veteran also endorsed additional functional loss due to durability and ROM; however, he denied a history of instability or recurrent subluxation of the left knee. Clinical examination revealed active ROM measurements of flexion up to 30 degrees and extension up to 5 degrees with painful motion. Passive ROM was found to be the same as active ROM. Objective evidence of pain was found on active and passive ROM, weight-bearing, nonweight-bearing, and on rest/non-movement that caused functional loss. Repetitive testing revealed additional ROM limitations of flexion up to 25 degrees and extension up to 5 degrees. The examiner found additional ROM limitations of flexion up to 20 degrees and extension up to 5 degrees due to flare ups. The examiner found no evidence of ankylosis or joint instability. However, he noted knee pain and instability due to left knee arthroscopic knee surgery. The Veteran reported constant use of a left knee brace in order to ambulate. The examiner described the functional impact of the left knee as "no standing for more than 5 minutes, no sitting for more than 10-15 minutes, no walking for more than 25 to 30 yards." Analysis After a review of the evidence of record, the Board finds that a 20 percent rating is warranted for left knee limitation of flexion. The evidence of record demonstrates that the Veteran has experienced limitation of flexion up to 20 degrees at its most severe. However, he is not entitled to a 30 percent rating for limitation on flexion, as the evidence of record does demonstrate limitation of flexion up to 15 degrees. Regarding limitation of extension, the Board finds that the evidence of record warrants a 10 percent rating throughout this appeal period. Limitation of extension was found to be 5 degrees at its most severe throughout the appeal period. However, the Veteran is not entitled to a 20 percent rating, as the evidence of record does not demonstrate limitation of extension up to 15 degrees. The Board has considered the 38 C.F.R. §§ 4.40, 4.45, and 4.59, and Mitchell and DeLuca criteria, but finds that the competent and probative evidence weighs against finding weakened movement, excess fatigability, incoordination, and/or pain during flare-ups or after repeated use over time resulting in motion limited to 15 degrees on flexion and 15 degrees on extension. In other words, the Board finds that the Veteran's left knee disability does not more closely approximate the criteria for a 30 percent evaluation under DC 5260 and a 20 percent evaluation under DC 5261. See 38 C.F.R. § 4.71a. The Board considered all potentially applicable diagnostic codes in accordance with Schafrath v. Derwinski, 1 Vet. App. 589 (1991); however, the evidence does not show symptoms that could be separately rated higher under another diagnostic code. See 38 C.F.R. § 4.71a. Indeed, the Veteran is already separately rated for limitation of flexion, limitation of extension, and left knee instability. Furthermore, there is no evidence of left knee ankylosis. The Board acknowledges that under 38 C.F.R. § 4.59, examination of certain joints should include testing for pain on both active and passive motion, in weight-bearing and non-weight-bearing. Correia v. McDonald, 28 Vet. App. 158 (2016). To the extent that other examinations cited herein did not explicitly provide these findings, the Board reiterates the pertinent ratings of the left knee with or without symptoms such as pain. Thus, any deficiency of the examinations of record in this regard is harmless, as assessment of pain in accordance with 38 C.F.R. § 4.59 would not provide a basis for the assignment of any higher rating. Additionally, to the extent that earlier examinations discussed herein did not explicitly provide findings of passive ROM testing, pain on both active and passive motion, or in weight-bearing and non-weight-bearing, they are nonetheless the most probative evidence available with regard to the severity of the left knee disability at the time those examinations were conducted. Any additional medical opinion with regard to those periods would be retrospective and entitled to less probative value than the contemporaneous range of motion evidence already of record. Therefore, remand for any additional retrospective opinion is not warranted. See Soyini v. Derwinski, 1 Vet. App. 540 (1991) (remand is unnecessary where it would result in unnecessarily imposing additional burdens on VA with no benefit flowing to the claimant). In adjudicating these claims, the competence and credibility of lay statements must be considered by the Board. Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006); Washington v. Nicholson, 19 Vet. App. 362, 368-69 (2005). The Veteran contends that his left knee disability warrants higher ratings. The Board acknowledges that the Veteran is competent to give evidence about what he observes or experiences. Layno v. Brown, 6 Vet. App. 465 (1994). That stated, these allegations of worsening symptomology are undercut by the other evidence of record, which does not favor a finding that the Veteran is entitled to a higher rating than the 20 percent currently assigned for his left knee limitation of flexion and 10 percent rating for left knee limitation of extension during the appeal period based on the symptomology present. His current symptomology is encapsulated in the current rating assigned under the Rating Schedule, with no evidence of symptomology warranting extra-schedular consideration. Since the evidence persuasively weights against the Veteran, he is not entitled to the benefit of the doubt. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); see also Ortiz v. Principi, 274 F.3d 1361, 1365 (Fed Cir. 2001). REASONS FOR REMAND 1. Entitlement to a rating in excess of 10 percent prior to April 29, 2019, and in excess of 20 percent thereafter for left knee degenerative arthritis with instability. The Veteran contends that he is entitled to a higher rating than the one currently assigned for his left knee instability. The Board notes that this matter was remanded in August 2021 for a new VA examination to be conducted. The Board notes that the Veteran underwent a VA examination in November 2021. The VA has a duty to assist veterans in developing their claims for benefits. 38 C.F.R. § 3.159. The duty to assist including providing a medical examination when necessary to decide a claim. 38 C.F.R. § 3.159 (c)(4). When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). Upon review, the Board finds that the VA examination is inadequate for adjudicative purposes. The examination report is internally inconsistent, as the examiner found no evidence of joint instability or a ligament tear in the left knee, but did note residual symptoms of pain and instability due to arthroscopic ligament repair in the left knee. Based on the inadequacy of the VA examination on the issue of joint instability, the Board must remand this matter for an addendum VA medical opinion that addresses the current severity of the Veteran's left knee instability. The matter is REMANDED for the following action: 1. Obtain updated VA and/or private treatment records to the extent possible. If such records are unavailable, the Veteran's claims file must be clearly documented to that effect and the Veteran notified in accordance with 38 C.F.R. § 3.159 (e). 2. Once the above has been completed to the extent possible, obtain a VA medical opinion regarding the stability of the left knee from a medical professional with appropriate expertise. The evidence of record must be made available to and reviewed by the examiner. The examination report must include a notation that this record review took place. Only schedule an examination if the requested opinion cannot be rendered without one. Based on a review of the record, and a new examination if necessary, the examiner must address the following: Please provide an opinion as to the current severity of the Veteran's left knee instability based on a review of the record, including the November 2021 VA examination report which noted pain and instability due to left knee arthroscopic surgery. The examiner should address the left knee instability under both the old and new rating criteria: whether the instability was mild, moderate or severe and whether the sprain, incomplete ligament tear, or complete ligament tear (repaired, unrepaired, or failed repair) caused persistent instability, without a prescription from a medical provider for an assistive device (e.g., cane(s), crutch(es), walker) or bracing for ambulation; whether the Veteran had 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; or whether the Veteran had 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. In rendering this opinion, the examiner is advised that the Veteran is competent to report his symptoms and history. Such reports must be acknowledged and considered in formulating any opinion. The examiner is not to improperly discount the Veteran's lay statements or rely solely on an absence of medical evidence in the record to support his or her conclusions. (Continued on the next page) A complete rationale must be provided for all opinions presented. If the medical professional cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation for why an opinion cannot be rendered. In so doing, the medical professional shall explain whether the inability to provide a more definitive opinion is the result of a need for additional information, or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question(s). G. A. WASIK Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J.T. Massey, 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.