LIMITATION OF EXTENSION

ERIC S. LEBOFF · 2026 · Case ID: 26004981

MIXED

Summary

The veteran, who served in the United States Marine Corps from October 2008 to January 2011, appeals the denial of an increased rating for his left knee disability and service connection for an acquired psychiatric disorder. The Board granted a 30 percent rating for residuals of a left patellar fracture prior to September 4, 2024, based on limited extension, applying the benefit of the doubt. However, the Board denied a higher rating for this condition and denied a higher rating for left knee instability, finding the evidence did not support moderate or severe instability. Service connection for Morton's neuroma of the left foot was granted due to conflicting medical evidence and the Board's finding that the evidence was in equipoise, resolving doubt in the veteran's favor. The claim for an acquired psychiatric disorder, including PTSD, was remanded for further examination and opinion. The Board found previous VA examinations inadequate, noting conflicting evidence regarding the diagnosis and nexus to service, and the failure to adequately discuss the Veteran's reported symptoms and stressors. The remand directs a new examination to assess the etiology of the psychiatric disorder, its relation to service, and potential secondary connection to the service-connected left knee disability, requiring a comprehensive rationale.

Rationale

Evidence supports 30% rating for limitation of extension prior to Sep 4, 2024; December 2018 evidence showed 22 degrees extension; Higher rating denied as evidence did not support further limitation

Service Branch

MARINE CORPS

Special Benefit

NO SPECIAL BENEFIT

Diagnostic Code

5261

Docket No.

19-07 436

Full Decision Text

Citation Nr: 26004981
Decision Date: 04/28/26 Archive Date: 04/28/26

DOCKET NO. 19-07 436
DATE: April 28, 2026

ORDER

A 30 percent rating for residuals of left patellar fracture prior to September 4, 2024, subject to the law and regulations governing the award of monetary benefits, is granted.

A rating in excess of 30 percent for residuals of left patellar fracture from September 4, 2024, is denied.

Entitlement to a rating in excess of 10 percent for left knee instability is denied.

Entitlement to service connection for a left foot disability (Morton's Syndrome) is granted, subject to the law and regulations governing the award of monetary benefits.

REMANDED

Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD), to include as secondary to a service-connected left knee disability, is remanded.

FINDINGS OF FACT

1. During the period on appeal prior to September 4, 2024, the Veteran had left knee extension limited to 22 degrees.

2. During the period on appeal from September 4, 2024, the Veteran's left knee extension was limited to 20 degrees.

3. Throughout the period on appeal, the evidence shows that the Veteran's left knee disability has been manifested by slight instability.

4. The Veteran has been diagnosed with a left foot disability, identified as Morton's neuroma; it is at least as likely as not that the disorder is etiologically related to service.

CONCLUSIONS OF LAW

1. The criteria for a 30 percent rating for residuals of left patellar fracture (limitation of extension) have been met for the entire period on appeal prior to September 4, 2024. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.20, 4.71a, Diagnostic Code (DC) 5261.

2. The criteria for a rating in excess of 30 percent for residuals of left patellar fracture (limitation of extension) from September 4, 2024, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.20, 4.71a, DC 5261.

3. The criteria for a rating in excess of 10 percent for left knee instability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.71a, DC 5257.

4. Resolving reasonable doubt in the Veteran's favor, the criteria for an award of service connection for a left foot disability have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303.

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran served on active duty in the United States Marine Corps from October 2008 to January 2011. His decorations include the Global War on Terrorism Medal and the National Defense Service Medal.

These matters initially came before the Board of Veterans' Appeals (Board) on appeal of a January 2016 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO).

In May 2023, the Board of Veterans' Appeals (Board) issued a decision that, in pertinent part, denied the claims for entitlement an increased rating for left knee disability and entitlement to service connection for an acquired psychiatric disorder, to include PTSD, while remanding the claim of entitlement to service connection for Morton's neuroma of the left foot. The Veteran appealed the Board's decision to the U.S. Court of Appeals for Veterans Claims (Court). In January 2024, the Court granted a Joint Motion for Partial Remand (JMPR) filed by the parties to the appeal (the Veteran, through an attorney, and representatives from VA General Counsel), thereby vacating the Board's May 2023 decision to the extent that it denied entitlement to an increased rating for a left knee disability and entitlement to service connection for an acquired psychiatric disorder and remanding those matters for readjudication.

In July 2024, the Board issued a decision denying entitlement to a rating in excess of 10 percent for residuals of left patellar fracture and granting a separate 10 percent rating for instability of the left knee. The Board remanded the
Court of Appeals for Veterans Claims (Court). In January 2024, the Court granted a Joint Motion for Partial Remand (JMPR) filed by the parties to the appeal (the Veteran, through an attorney, and representatives from VA General Counsel), thereby vacating the Board's May 2023 decision to the extent that it denied entitlement to an increased rating for a left knee disability and entitlement to service connection for an acquired psychiatric disorder and remanding those matters for readjudication.

In July 2024, the Board issued a decision denying entitlement to a rating in excess of 10 percent for residuals of left patellar fracture and granting a separate 10 percent rating for instability of the left knee. The Board remanded the claims of entitlement to service connection for an acquired psychiatric disorder and Morton's neuroma of the left foot for further adjudication. The Veteran again appealed the Board's decision to the Court. In June 2025, the Court granted a second JMPR filed by the parties to the appeal, thereby vacating the Board's July 2024 decision to the extent that it denied a rating in excess of 10 percent for residuals of left patellar fracture and a rating in excess of 10 percent for left knee instability.

In December 2024, while the Veteran's appeal was pending, the agency of original jurisdiction (AOJ) increased the rating for residuals of left patellar fraction from 10 to 30 percent, effective September 4, 2024. This issue on appeal has been characterized accordingly. See AB v. Brown, 6 Vet. App. 35 (1993).

The Board notes that in December 2024, the AOJ granted service connection for left knee limitation of flexion and assigned a 0 percent rating under Diagnostic Code 5260, effective September 4, 2024. To date, the Veteran has not appealed either the assigned rating or the effective date of that award. As such, that matter is not before the Board at present. See Grantham v. Brown, 114 F.3d 1156, 1158-59 (Fed. Cir. 1997) (indicating that a veteran must separately appeal "downstream" issues in order to place them in appellate status).

As a final introductory matter, the Board most recently remanded the claims of entitlement to service connection for a left foot disability and psychiatric disorder to the AOJ in July 2024. As to the psychiatric disorder claim, although the Board regrets the additional delay, as will be discussed below, further development is necessary to ensure substantial compliance with the prior remand directives. See Stegall v. West, 11 Vet. App. 268, 271 (1998).

Higher Rating

Disability evaluations (ratings) are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing the symptomatology with the criteria set forth in the Schedule for Rating Disabilities (Rating Schedule). 38 U.S.C. §§ 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10.

In evaluating a disability, the Board considers the current examination reports in light of the whole recorded history to ensure that the current rating accurately reflects the severity of the condition. The Board has a duty to acknowledge and consider all regulations that are potentially applicable. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). The medical and industrial history is to be considered, and a full description of the effects of the disability upon ordinary activity is also required. 38 C.F.R. §§ 4.1, 4.2, 4.10.

Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. Reasonable doubt regarding the degree of disability will be resolved in the veteran's favor. 38 C.F.R. § 4.3.

In view of the number of atypical instances it is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified. Findings sufficiently characteristic to identify the disease and the disability therefrom, and above all, coordination of rating with impairment of function will, however, be expected in all instances. 38 C.F.R. § 4.21. At the time of an initial rating, separate ratings can be assigned for separate periods of time based on facts found, a practice known as "staged" ratings. Fenderson v
doubt regarding the degree of disability will be resolved in the veteran's favor. 38 C.F.R. § 4.3.

The evaluation of the same disability under various diagnoses, known as pyramiding, is generally to be avoided. 38 C.F.R. § 4.14. 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 disabilities is duplicative or overlapping with the symptomatology of the other disability. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994).

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 (musculoskeletal system) or § 4.73 (muscle injury); 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 [or 4.73] criteria.").

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. 38 C.F.R. § 4.59. As such, painful motion should be considered to determine whether a higher rating is warranted on such basis, whether or not arthritis is present. See Burton v. Shinseki, 25 Vet. App. 1 (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 Diagnostic Code under which the disability is evaluated is predicated on range of motion measurements. Southall-Norman v. McDonald, 28 Vet. App. 346 (2016).

When determining the severity of musculoskeletal disabilities, which are at least partly rated on the basis of range of motion, VA must consider the extent of additional functional impairment a veteran may have above and beyond the limitation of motion objectively demonstrated due to pain, limited or excess movement, weakness, incoordination, and premature or excess fatigability, etc., particularly when symptoms "flare up,' to include periods of prolonged use, and assuming these factors are not already contemplated in the governing rating criteria. See 38 C.F.R. §§ 4.40, 4.45, 4.59; Sharp v. Shulkin, 29 Vet. App. 26 (2017).

In Cor
346 (2016).

In Correia v. McDonald, 28 Vet. App. 158 (2016), the United States Court of Appeals for Veterans Claims (Court) held that to be adequate, examination reports involving the joints must include testing for pain on both active and passive motion, in weight-bearing and non-weight-bearing and, if possible, with range of motion of the opposite undamaged joint. See 38 C.F.R. § 4.59. The Court has also held that if a Veteran is not exhibiting functional loss due to factors such as flare-ups and/or repeated use over time, examiners will nevertheless offer opinions with respect to functional loss based on estimates derived from information procured from relevant sources, including lay statements of the Veteran. See, e.g., Sharp v. Shulkin, 29 Vet. App. 26 (2017); DeLuca v. Brown, 8 Vet. App. 202, 206 (1995).

Included within 38 C.F.R. § 4.71a are multiple diagnostic codes that evaluate impairment resulting from service-connected knee disorders, including DC 5256 (ankylosis), DC 5257 (other impairment, including recurrent subluxation or lateral instability), DC 5258 (dislocated semilunar cartilage), DC 5259 (symptomatic removal of semilunar cartilage), DC 5260 (limitation of flexion), DC 5261 (limitation of extension), DC 5262 (impairment of the tibia and fibula), and DC 5263 (genu recurvatum).

DC 5256, which governs ankylosis of the knee permits a 30 percent rating for favorable angle in full extension, or in slight flexion between 0 degrees and 10 degrees, while a veteran will garner a 40 percent rating with flexion between 10 and 20 degrees. Ankylosis is an objective finding or symptom and not a diagnosis. Chavis v. McDonough, 34 Vet. App. 1 (2021). Notably, multiple definitions of "ankylosis" were discussed in Chavis including general medical dictionary definitions as follows: "[i]mmobility and consolidation of a joint due to disease, injury, or surgical procedure" (citing DORLAND'S ILLUSTRATED MEDICAL DICTIONARY 94 (33rd ed. 2019)), "[s]tiffening or fixation of a joint as the result of a disease process, with fibrous or bony union across the joint" (citing STEADMAN'S MEDICAL DICTIONARY 95 (28th ed. 2006)) and "[a] stiffening or immobilization of a joint as a result of injury, disease, or surgical intervention" (citing CHURCHILL'S ILLUSTRATED MEDICAL DICTIONARY 91 (1989).

Under DC 5260, a noncompensable rating is assigned when flexion of the leg is limited to 60 degrees; a 10 percent rating is assigned when flexion is limited to 45 degrees; a 20 percent rating is assigned when flexion is limited to 30 degrees; and a 30 percent rating is assigned when flexion is limited to 15 degrees. 38 C.F.R. § 4.71a.

Pursuant to DC 5261, a noncompensable rating is assigned when extension of the leg is limited to 5 degrees; a 10 percent rating is assigned when extension is limited to 10 degrees; a 20 percent rating is assigned when extension is limited to 15 degrees; a 30 percent rating is assigned when extension is limited to 20 degrees; a 40 percent rating is warranted for extension limited to 30 degrees; and a 50 percent rating is assigned when extension is limited to 45 degrees.

Under DC 5258, a maximum 20 percent rating is warranted for semilunar cartilage, dislocated, with frequent episodes of 'locking," pain, and effusion into the joint. Finally, under 38 C.F.R
, a noncompensable rating is assigned when extension of the leg is limited to 5 degrees; a 10 percent rating is assigned when extension is limited to 10 degrees; a 20 percent rating is assigned when extension is limited to 15 degrees; a 30 percent rating is assigned when extension is limited to 20 degrees; a 40 percent rating is warranted for extension limited to 30 degrees; and a 50 percent rating is assigned when extension is limited to 45 degrees.

Separate ratings under DCs 5260 and 5261 may be assigned for disability of the same knee joint. See VAOPGCPREC 9-2004. Additionally, for a knee disability already rated under DCs 5260 and/or 5261, a claimant would have additional disability justifying a separate rating if there is instability and/or subluxation of the knee joint under DC 5257. See generally VAOPGCPREC 23-97. Furthermore, the rating criteria do not preclude separate ratings for meniscal injury under DCs 5258 and 5259 where there are separate ratings for limitation of motion under DCs 5260 and/or 5261, or instability under DC 5257. Lyles v. Shulkin, 29 Vet. App. 107 (2017).

For the musculoskeletal system and muscle injuries, the applicable rating criteria, found at 38 C.F.R. § 4.71a, were amended effective February 7, 2021. The old rating criteria applies to rating periods prior to February 7, 2021; however, whichever set of criteria is more favorable applies to periods after February 7, 2021, if the claim was pending prior to this date. See Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). As the Veteran's claim was pending prior to this date, the more favorable criteria will apply as between the old criteria and new criteria.

For the ratings under the old criteria for DC 5257, it provides the rating criteria for impairment of the knee manifested by recurrent subluxation and lateral instability. Under this diagnostic code provision, a 10 percent disability rating is warranted where there is slight recurrent subluxation or lateral instability of the knee. A 20 percent disability rating is warranted where the recurrent subluxation or lateral instability of the knee is moderate. The maximum 30 percent disability rating is warranted where there is severe recurrent subluxation or lateral instability of the knee. 38 C.F.R. § 4.71a, DC 5257.

Under the new rating criteria for DC 5257, other impairments of the knee are rated under either recurrent subluxation or instability, or patellar instability. Under recurrent subluxation or instability, a 10 percent rating is warranted for 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 assistive device (e.g., cane(s), crutch(es), walker) or bracing for ambulation. A 20 percent rating is warranted 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.

Under patellar instability, a 10 percent rating is warranted 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 warranted for a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires
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.

Under patellar instability, a 10 percent rating is warranted 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 warranted 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 warranted 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.

Note 1 of the Diagnostic Code indicates for patellar instability, the patellofemoral complex consists of the quadriceps tendon, the patella, and the patellar tendon. Note 2 indicates 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.

The normal range of knee motion is 140 degrees of flexion and zero degrees of extension. 38 C.F.R. § 4.71, Plate II.

The Board notes that VA regulations did not define the terms "slight," "moderate," or "severe" as used in 38 C.F.R. § 4.71a, DC 5257. Absent an express definition, it is presumed that VA regulations employ words using their ordinary dictionary meanings. The Board notes that "mild"-as relevant to a physical condition-is defined as "not severe" or temperate, with "temperate" being defined as "keeping or held within limits" and "not extreme or excessive." Merriam-Webster's Dictionary (merriam-webster.com/dictionary, accessed January 12, 2025). "Moderate" is defined as "tending toward the mean or average amount," "not violent, severe, or intense," and "limited in scope or effect." Id. "Severe" is defined as "very painful or harmful" or "of a great degree." Id. The term "severe" is used throughout the Rating Schedule to indicate a very great degree of the specific listed disability, in order to differentiate between lesser (or sometimes greater) cases of that same disability within the specific Diagnostic Code. The Board must consider all factors that result in an equitable and just determination.

The "slight" definition contemplates a degree of knee instability or subluxation symptoms that are minor or small on a symptom spectrum between a nonexistent extreme and greatly symptomatic extreme. The "moderate" definition contemplates a medium degree of knee instability or subluxation symptoms in size, degree or amount on a symptom spectrum between a nonexistent extreme and greatly symptomatic extreme. The "severe" definition implies significant size, degree or amount of knee instability or subluxation symptoms that are beyond moderate on a symptom spectrum and are more akin to a greatly symptomatic extreme.

By way of background, the Veteran fell and fractured his knee, which was thereafter repaired in service. His file was subsequently reviewed when he was being processed for his discharge from service following the end of his enlistment contract. When examined, the DES/VA Internal Medicine Evaluation from March 2010 noted that he walked with an antalgic gait and favored the left leg, which produced knee pain. A knee brace was documented along with limited and painful motion with crepitus. There was no evidence of swelling, inflammation, edema, effusion, tenderness, redness, heat, or guarding of movement. Also, there were no signs of drainage, subluxation, instability, or weakness. Both the drawer and McMurray tests were negative. On range of motion testing the left knee had flexion to 90 degrees and extension to 0 degrees. Additional functional loss with repetitive movement was not found. X-rays show an old fracture site with internal screws and sutures in place.

An April 2011 VA consult indicated that the Veteran had left knee pain and locking in the knee. An April 2011 VA orthopedic consult indicated that the Veteran had left knee pain with stairs, long walks, and running. Range of motion testing indicated flexion to
, redness, heat, or guarding of movement. Also, there were no signs of drainage, subluxation, instability, or weakness. Both the drawer and McMurray tests were negative. On range of motion testing the left knee had flexion to 90 degrees and extension to 0 degrees. Additional functional loss with repetitive movement was not found. X-rays show an old fracture site with internal screws and sutures in place.

An April 2011 VA consult indicated that the Veteran had left knee pain and locking in the knee. An April 2011 VA orthopedic consult indicated that the Veteran had left knee pain with stairs, long walks, and running. Range of motion testing indicated flexion to 130 degrees and extension to 0 degrees. However, there was no discussion regarding instability, laxity, subluxation, or falls. A May 2011 physical therapy evaluation indicates the Veteran had left knee pain that started in 2009 due to an accident in service. Range of motion testing was within normal limits, but there was a note that left leg extension was to -10 degrees. There was no mention of instability, subluxation, or falls.

An August 2012 VA emergency room treatment note indicated that the Veteran had a history of falls, but without explanation as to whether these were related to the left knee disability.

An October 2014 VA treatment note indicated left knee pain with normal range of motion. Ankylosis was not noted.

In October 2015 the Veteran underwent a VA knee and lower leg examination which found a history of slight recurrent subluxation and slight lateral instability of the left knee. The Veteran complained of pain on walking or standing, and it was difficult to traverse up and down stairs. On range of motion testing flexion was to 120 degrees with extension to 5 degrees with pain. There was tenderness of the patellar region and the knee joint. Upon repetitive use, flexion was diminished by 10 degrees, to 110. X-ray films showed that there was traumatic arthritis of the left knee. The examiner further noted that there was weakened movement, swelling, pain on movement, and fatigability. Muscle strength was reduced and decreased in the left quadriceps. Frequent episodes of joint locking, joint pain, and joint effusion were reported, and the examiner indicated that the Veteran regularly used a knee brace.

In January 2016 the Veteran underwent a VA knee and lower leg examination. Degenerative arthritis was diagnosed. The Veteran complained of constant pain and locking of the left knee. He also stated that he had functional loss, in that it "hurt" going up and down stairs, the pain caused him to lose sleep, and standing/walking for long distances caused pain. On range of motion testing flexion was to 90 degrees with extension to 0 degrees. Muscle strength was diminished but ankylosis was not diagnosed. A meniscus cartilage condition was not diagnosed, and a meniscectomy was not recommended or diagnosed. The functional impact affected the Veteran's ability to climb stairs, walk, and stand for prolonged periods of time. It was noted that assistive devices and/or braces were used occasionally.

A January 2016 private consultation by Dr. Y., for multiple conditions, noted that the Veteran's knee gave out at unpredictable random times causing him to stumble and fall. Examination revealed lateral instability. Flexion was limited to 45 degrees by pain. The Veteran endorsed pain with standing, sitting, and use of stairs.

In November 2016, the Veteran was fitted for an elastic left knee sleeve during a prosthetic consultation. In November 2018 the Veteran was fitted for a hinged knee brace for both knees, to include for instability, edema, and pain.

VA treatment records include a December 2018 addendum which shows that on examination range of motion testing of the left knee showed maximum flexion to 22 degrees with extension to 130 degrees. In other words, left knee range of motion was 130 degrees flexion and 22 degrees extension. Atrophy was noted as to the left quad.

In February 2019 the Veteran underwent a VA knee and lower leg examination. Once again it was noted that the functional loss or impairment of the knee caused limited walking, standing, and squatting. Flare-ups of the knee were described as pain and stiffness. On range of motion testing flexion was to 60 degrees with extension to 0 degrees. The examiner indicated that the Veteran used a brace, and the functional impact of the injury residuals was listed as limitations on the Veteran's ability to walk, stand, run, and squat. There was objective evidence of pain on passive range of motion of
was 130 degrees flexion and 22 degrees extension. Atrophy was noted as to the left quad.

In February 2019 the Veteran underwent a VA knee and lower leg examination. Once again it was noted that the functional loss or impairment of the knee caused limited walking, standing, and squatting. Flare-ups of the knee were described as pain and stiffness. On range of motion testing flexion was to 60 degrees with extension to 0 degrees. The examiner indicated that the Veteran used a brace, and the functional impact of the injury residuals was listed as limitations on the Veteran's ability to walk, stand, run, and squat. There was objective evidence of pain on passive range of motion of the left knee and objective evidence pain on non-weight bearing testing on the left knee. The examiner further estimated that range of motion was reduced from 0 to 45 degrees during flare-ups or on repetitive use.

At the time of a November 2019 examination, there was no notation of instability, falls, ankylosis, and no range of motion testing. A March 2021 VA treatment note indicates that the Veteran had left knee pain, with normal range of motion, no ankylosis, no instability, and no falls, but was positive for crepitus.

In July 2021 the Veteran underwent a VA knee and lower leg examination of the left knee. The Veteran complained and said that the knee was "getting worse," it swelled, and it was restricted in its movement. He further indicated that he was undergoing physical therapy to help. The Veteran stated that when he had flare-ups, he had restrictions in standing, walking, jogging, running, jumping, hiking, squatting, and kneeling. He did not complain of instability or subluxation. On range of motion testing flexion was to 130 degrees with extension to 0 degrees. Fatigability, pain, and lack of endurance were chronicled. Nevertheless, ankylosis was not reported or found on examination. The examiner noted that the Veteran was not being examined during flare-up, but estimated that pain, fatigability, and lack of endurance significantly limited functional ability with flare-ups with range of motion from 110 degrees flexion to 0 degrees extension. The examiner indicated that the Veteran was being examined after repeated used, and that range of motion was from 120 degrees flexion to 0 degrees extension, further limited by pain and lack of endurance. The examiner further found no indication of instability.

A December 2021 VA Primary Care Nursing note indicated left knee pain and unsteadiness, but instability, falls, and ankylosis were not noted.

During a January 2022 VA physical therapy consult the Veteran stated that he engaged in biking, walking, and stretching to stay in shape. Range of motion of the left knee indicated flexion to 88 degrees. However, the VA medical professional noted that an individual must have 100 degrees of flexion to bike, and that the "Discrepancy on function and RO measurement with patient stopping the (sic) motion." Veteran was negative for Lachman's and Valgus and there was no indication of falls or instability. The medical provider indicated a normal range of motion and strength.

An August 2022 VA treatment note indicated reports of knee pain, but did not discuss range of motion, ankylosis, subluxation/instability, or falls. While the Veteran's knee brace was mentioned it was noted he used it when the weather was bad, or he was engaged in uncomfortable movement like walking stairs. In a December 2022 VA treatment note, the Veteran indicated that he had had no falls in the last 12 months. Similarly, July 2023 VA treatment notes also indicated that he had no falls in the last 12 months. Neither note contained any mention of instability, subluxation, or ankylosis. However, in an August 2023 VA Mental Health "Initial Assessment," the Veteran stated that he could not "do anything" because of his back and knee pain, when talking about physical activity and exercise.

In September 2024 the Veteran underwent another VA knee and lower leg examination. He indicated that his left knee disability had stayed the same since onset. Flare-ups of the left knee disability occurred weekly and varied in duration. They were described as knee pain and stiffness with mild severity. Functional loss or impairment was described as limited walking and standing. There was no history of instability or recurrent subluxation or history of frequent effusion.

On range of motion testing of the left knee indicated flexion to 85 degrees and extension to 20 degrees with pain. There was evidence of pain with weight-bearing and nonweight-bearing, active and passive motion, rest/non-movement, and pain caused functional loss. The Veteran had difficulties with squatting and climbing stairs due to pain. There was no objective evidence of crepitus or localized tenderness or pain on palpation of the left knee joint. On repetitive use testing there was additional loss of function or range of motion with flexion to 75 degrees and extension to 20 degrees. Pain and a lack of endurance caused functional loss.

The examiner indicated that based on the procured evidence (statements from the Veteran), pain and lack of endurance significantly limited functional ability with repeated use over time. Estimated range of motion immediately after repeated use over time indicated flexion to 65 degrees and 20 degrees extension. Procured evidence suggested that pain and lack of endurance limited functional ability with flare-ups and resulted in an estimated range of motion of flexion to 55 degrees and extension to 20 degrees. There was no evidence of muscle atrophy or ankylosis. Nor was there evidence of recurrent subluxation or persistent instability, a ligament tear (sprain), recurrent patellar instability, or meniscal condition.

The examiner opined that the left knee disability impacted the Veteran's ability to perform any type of occupational task due to difficulties with squatting and climbing stairs due to pain.

1. Entitlement to a rating in excess of 10 prior to September 4, 2024, and a rating in excess of 30 percent since September 4, 2024, for a left patellar fracture disability.

The Veteran seeks a higher rating his current 10 percent rating prior to September 4, 2024, and a rating higher than 30 percent since September 4, 2024, for service-connected left knee disability, which is currently rated pursuant to Diagnostic Code (DC) 5261-5024. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the specific basis for the evaluation assigned. 38 C.F.R. § 4.27. Here, the hyphenated diagnostic code 5261-5024 indicates that the Veteran's left patellar fracture disability is rated pursuant to DC 5261, which contemplates limitation of extension, and DC 5024, which contemplates tendonitis and rates the disability "based on limitation of motion of affected parts."

The parties to the second JMPR agreed that the Board had failed to provide an adequate statement of reasons or bases in addressing whether the Veteran was entitled to a rating higher than 10 percent for residuals of left patellar fracture under DC 5261. In this regard, the Board finds that the parties' reference to "DC 5161" in the JMPR is a typographical error with the intent that the Board determine whether a higher rating is warranted under "DC 5261." The parties asked the Board to consider and address whether a staged rating is warranted based on the favorable evidence from a December 2018 addendum medical opinion which shows that the Veteran's flexion of the left knee was, at a maximum, to 22 degrees.

In this regard, the normal range of knee motion is 140 degrees of flexion and zero degrees of extension. 38 C.F.R. § 4.71, Plate II. In December 2018, range of motion of the Veteran's left knee indicated 130 degrees flexion and 22 degrees extension.

Following review of the record, resolving reasonable doubt in favor of the Veteran, the Board finds that the evidence supports the assignment of a 30 percent rating for residuals of left patellar fraction prior to September 4, 2024, pursuant to DC 5261. As noted, the evidence shows that the Veteran had extension of the left knee limited to 22 degrees in December 2018. Therefore, a 30 percent rating is warranted pursuant to DC 5261. However, at no point during the rating period on appeal does the evidence support the assignment of a higher rating of 40 percent since the evidence does not show that the Veteran
Veteran's left knee indicated 130 degrees flexion and 22 degrees extension.

Following review of the record, resolving reasonable doubt in favor of the Veteran, the Board finds that the evidence supports the assignment of a 30 percent rating for residuals of left patellar fraction prior to September 4, 2024, pursuant to DC 5261. As noted, the evidence shows that the Veteran had extension of the left knee limited to 22 degrees in December 2018. Therefore, a 30 percent rating is warranted pursuant to DC 5261. However, at no point during the rating period on appeal does the evidence support the assignment of a higher rating of 40 percent since the evidence does not show that the Veteran's left knee extension was limited to 30 degrees, even when considering additional limitation of function due to factors such as pain with repeat motion or during flare-ups.

2. Entitlement to a rating in excess of 10 percent for left knee instability is denied.

The Veteran seeks a higher rating than his current 10 percent rating for left knee instability, which is currently rated pursuant to DC 5257.

The parties to the second JMPR agreed that the Board failed to provide an adequate explanation of how it evaluated the subjective terms "mild," "moderate," and "severe." They stated that the Board noted what symptoms the Veteran did not experience when finding that he did not have "moderate" instability. However, the Board did not explain what symptoms would be necessary to meet the definition of "moderate."

Following review of the evidence of record, both lay and medical, the Board finds that a rating higher than 10 percent for left knee instability is not warranted under the pre-amendment or amended rating criteria under Diagnostic Code 5257.

Regarding the pre-amended criteria, the evidence includes an August 2012 VA emergency room treatment note which indicates a history of falls, without noting whether these were related to the left knee disability. The evidence also shows that the Veteran regularly wore a knee brace in October 2015 and on January 2016 VA knee examination it was noted that he occasionally used an assistive device/brace. In November 2016, he used a hinged knee brace for instability. However, a November 2019 VA examination showed no evidence of instability. During a July 2021 VA examination there was no complaint of instability from the Veteran or indication of the same by the examiner. In January 2022 he used indicated that he used a knee brace during inclement weather. However, during a September 2024 VA examination the examiner indicated that the Veteran did not have a history of instability.

Considering the symptoms that would meet the definition of a "moderate" left knee disability, the Board finds that the Veteran's symptoms were more limited in scope than "tending toward the mean or average amount." See Merriam-Webster Dictionary Online, "Moderate." The definition of "moderate" contemplates a medium degree of knee instability or subluxation symptoms in size, degree or amount on a symptom spectrum between a nonexistent extreme and greatly symptomatic extreme. However, his symptoms do not rise to the level of "moderate" severity. While the October 2015 VA examination noted regular use of a knee brace, subsequent examination in 2016 described the frequency of use as only occasional. Moreover, the lack of any complaints of falls solely due to a left knee instability, and the lack of objective findings of joint instability during testing on VA examination in October 2015, January 2016, February 2019, July 2021, and September 2024 all lead to the conclusion that the instability here did not rise to the level of "tending toward the mean or average amount." Nor do these findings rise to the level of a "medium degree of knee instability or subluxation symptoms in size, degree or amount on a symptom spectrum between a nonexistent extreme and greatly symptomatic extreme." The persuasive evidence of record shows that throughout the period on appeal the Veteran's left knee disability has been manifested by no more than slight instability, which warrants the currently assigned 10 percent rating under DC 5257. Accordingly, the Veteran's left knee symptoms do not more nearly approximate the assignment of a 20 percent rating under the pre-amendment criteria for DC 5257. 38 C.F.R. §§ 4.6, 4.71a, Diagnostic Code 5257.

Regarding the post-amendment rating criteria, there is no evidence recurrent subluxation or instability arising from: (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. Moreover, there is no evidence of any diagnosis of patellar instability with recurrent instability after surgical repair that requires a prescription by a medical provider for one of the following: a brace, cane, or walker. Therefore, the Veteran's left knee symptoms do not more nearly approximate the criteria for a 20 percent rating under the revised criteria pursuant to DC 5257. 38 C.F.R. § 4.71a.

The Board has also considered the other diagnostic codes pertaining to the left knee. Other disability ratings may be assigned only if the symptomatology for a disability is not duplicative or overlapping with the symptomatology of any other disability. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994); Lyles v. Shulkin, 29 Vet. App. 107 (2017) (holding that 38 C.F.R. § 4.14 prohibits paying compensation twice for the same symptoms or functional impairment).

As to the other criteria under DCs 5256, 5258 and 5259, the Board does not find evidence supportive of a higher rating, as the Veteran has not had any meniscal issues or ankylosis. Although there were some entries of locking with effusion in there was no indication that the Veteran's semilunar cartilage was dislocated.

For all of the foregoing reasons, the Board finds that the Veteran is entitled to a 30 percent rating for left knee limitation of extension prior to September 4, 2024; however, he is not entitled to a rating higher than 30 percent prior to or since September 4, 2024. As to left knee instability he is not entitled to a rating higher than 10 percent. In reaching these determinations, the Board has considered and applied the benefit of the doubt doctrine. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7.

The Veteran has not raised any other issues, nor have any other issues been reasonably raised by the record, with respect to his claims. See Doucette v. Shulkin, 28 Vet. App. 366, 369-70 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record).

Service Connection

Service connection is warranted where the evidence of record establishes that a particular injury or disease resulting in disability was incurred in the line of duty in the active military service or, if pre-existing such service, was aggravated thereby. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a).

Generally, in order to prove service connection, there must be competent, credible evidence of (1) a current disability, (2) in-service incurrence or aggravation of an injury or disease, and (3) a nexus, or link, between the current disability and the in-service disease or injury. See, e.g., Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Pond v. West, 12 Vet. App. 341 (1999).

A layperson is generally incapable of opining on matters requiring medical knowledge. However, lay evidence can be competent and sufficient to establish a diagnosis of a condition when: (1) a layperson is competent to identify the medical condition; (2) the layperson is reporting a contemporaneous medical diagnosis; or, (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007
ki, 581 F.3d 1313 (Fed. Cir. 2009); Pond v. West, 12 Vet. App. 341 (1999).

In essence, lay testimony is competent when it pertains to the readily observable features or symptoms of injury or illness and "may provide sufficient support for a claim of service connection." Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also 38 C.F.R. § 3.159(a)(2). A determination as to whether medical evidence is needed to demonstrate that a Veteran presently has the same condition he or she had in service or during a presumptive period, or whether lay evidence will suffice, depends on the nature of the Veteran's present condition (e.g., whether the Veteran's present condition is of a type that requires medical expertise to identify it as the same condition as that in service or during a presumption period, or whether it can be so identified by lay observation). See Barr v. Nicholson, 21 Vet. App. 303, 310 (2007).

Thus, medical evidence is not always or categorically required when the determinative issue involves either medical diagnosis or etiology, but rather such may, depending on the facts of the particular case, be established by competent and credible lay evidence under 38 U.S.C. § 1154(a). See Davidson, supra.

When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. An approximate balance of the evidence includes, but is not limited to, equipoise. Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021). Evidence is not in "approximate balance" or "nearly equal" when the evidence persuasively favors one side or the other. Id.

The Veteran seeks to establish entitlement to service connection for a left foot disability diagnosed as Morton's neuroma.

The service treatment records are void of any diagnosis of a left foot disability, including Morton's neuroma.

In January 2016 the Veteran underwent a VA peripheral nerves examination, at which time he stated that he had noticed sharp tingling pain in between the toes since 2009. After an examination the examiner stated that the Veteran did not have a peripheral nerve condition or peripheral neuropathy.

In January 2016 the Veteran also underwent a VA foot conditions examination, at which time the examiner stated that the Veteran did not have a current diagnosis associated with any claimed condition, including Morton's neuroma.

In a January 2016 VA medical opinion the examiner opined that the claimed condition was less likely than not incurred in or caused by the claimed in-service injury, event or illness. In the rationale, the examiner stated that there was no indication that the Veteran was diagnosed or treated for a chronic foot condition during service. The examiner also noted that the Veteran had not been diagnosed with a peripheral nerve condition of the feet, i.e., interdigital neuroma of the foot.

However, a January 2016 private medical evaluation report from Dr. P.J.Y. states that the Veteran had been previously treated for and diagnosed with a left foot neuroma. The doctor noted that the neuroma caused pain with walking and was present when examined and that it was palpable to digital examination. The doctor opined that the disorder began in service and persisted to the date of the examination.

In February 2019 the Veteran underwent another VA foot conditions examination, at which time he stated that the disability began with spontaneous onset in 2011 and had worsened since that time. The examiner diagnosed radicular neuropathy of the lower extremities.

In May 2023, the Board remanded the Veteran's claim due to conflicting evidence for an addendum opinion to assess whether the Veteran has a current disability, and whether any such disability is associated with his service.

Pursuant to the Board's May 2023 remand, in November 2023 the Veteran underwent a VA foot conditions examination, at which time he stated that he underwent
that the disorder began in service and persisted to the date of the examination.

Pursuant to the Board's May 2023 remand, in November 2023 the Veteran underwent a VA foot conditions examination, at which time he stated that he underwent surgery for a patellar fracture and developed pain in the left foot (amongst others). The examiner opined that the Veteran's claimed symptoms are not consistent with a specific foot condition. He stated that the symptoms described are more consistent with referred pain from pathology outside the foot. He concluded that the signs/symptoms are not consistent with Morton's neuroma and there is no objective evidence in the file of this diagnosis.

However, in a July 2024 remand the Board found that the examiner did not discuss any of the conflicting evidence. The Board also found that the examiner noted the Veteran's subjective expression of symptoms but vaguely stated that those symptoms were "referred pain from pathology outside the foot." However, the examiner did not explain what that meant or provide any further discussion regarding the pathology of the Veteran's foot pain, leaving the Board unable to adjudicate the matter of whether the Veteran has a current disability. Third, the examiner stated that the symptoms experienced by the Veteran were not consistent with Morton's syndrome, but failed to explain why this is so. The Board concluded that the VA examination was inadequate and remanded the claim for a new examination and opinion. The examiner was asked to reference the complete claims folders and any inconsistent past diagnoses given, specifically the past diagnoses of left foot neuroma.

Pursuant to the Board's July 2024 remand, in September 2024 the Veteran was afforded another VA foot examination, at which time the examiner diagnosed plantar fasciitis and Morton's neuroma of the left foot. The Veteran stated that his left foot disability "started as a result of physical training." The examiner opined that the claimed condition was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. In the rationale, the examiner stated:

"After review [of] medical records 1/07/2016, 10/29/2016, 04/05/2018, 10/25/2018, 12/13/2018 and physical exam, the Veteran's left foot plantar fasciitis, is/are less likely than not incurred in or caused by ...service during service. Records do not show claimant having left foot problems during service or 1 year post-service. There are no treatment evidence within 4 years after separation to show a possible connection. Earliest records of the neuroma is in 2015, claimant separated in 2011. Therefore, no nexus has been established."

In response to the AOJ's finding that the September 2024 opinion pertained to the Veteran's plantar fasciitis, in an addendum submitted to VA in February 2025, the September 2024 VA examiner opined that the Veteran's Morton's neuroma was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. In the rationale, the examiner stated that the records did not show that the Veteran had left foot problems or one year post-service. There were no treatment records within 4 years after separation that showed a possible connection. The examiner further stated that the earliest records of the neuroma were dated in 2015. Therefore, no nexus was established.

The AOJ then asked for yet another addendum opinion. The AOJ noted that in the earlier addendum the examiner relied heavily upon the lack formal treatment during and after service. The examiner was asked to address the Veteran's reports and statements and discuss them in their rationale. The examiner was also advised that the Veteran was competent to report symptoms and treatment and that his reports, including his reports as to the onset and nature of his symptoms, must be taken into account, along with the other evidence of record, in formulating the requested opinions.

In an August 2025 addendum the examiner opined that the Veteran's left Morton's neuroma was related to the Veteran's service. He stated that the Veteran was competent to recall first-hand when the left foot problems began, which he stated was during service. He noted that the Veteran separated from
heavily upon the lack formal treatment during and after service. The examiner was asked to address the Veteran's reports and statements and discuss them in their rationale. The examiner was also advised that the Veteran was competent to report symptoms and treatment and that his reports, including his reports as to the onset and nature of his symptoms, must be taken into account, along with the other evidence of record, in formulating the requested opinions.

Based on the above, the evidence is at least in equipoise as to whether the claimed left foot Morton's neuroma had its onset in service. Accordingly, the claim is granted.

REASONS FOR REMAND

Entitlement to service connection for an acquired psychiatric disorder, to include PTSD, is remanded.

The Veteran seeks to service connection for an acquired psychiatric disorder, to include PTSD. He contends that he has PTSD related to fracturing his left knee during service. See July 2015 Statement in Support of Claim for Service Connection for PTSD. He also contends that he has PTSD related to attempting to help a Marine down from a rope in which he attempted to hang himself and a soldier's attempted jump from a balcony. See September 2024 VA examination.

In July 2024 the Board remanded the Veteran's claim for further development. At that time, the May 2023 Board decision was referenced, in which it had been found that the cornerstone criterion of a current disability had not been shown. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). The Veteran appealed that decision to the CAVC. In the subsequent December 2023 JMR before the CAVC, the parties agreed that the Board erred by not discussing various evidence of record that indicated that the Veteran did have a current psychiatric disability.

In January 2019 the Veteran underwent VA PTSD examination. The examiner reviewed the Veteran's file and undertook an in-person examination. Upon conclusion to the examination, the examiner found that the Veteran's symptoms did not meet the diagnostic criteria for PTSD pursuant to DSM-5 criteria. However, the examiner did not discuss the various conflicting evidence of record, including VA treatment records and a March 2016 private record noting diagnosis of PTSD.

In addition, while the examiner did note depression and anxiety, the examiner failed to provide an opinion as to whether the claimed disability onset in or was otherwise related to service.

A January 2016 private examiner provided a diagnosis of PTSD, and related that diagnosis to service, however, that examiner noted that further testing and examination would be needed to confirm the diagnosis, and did not review service treatment records or post-service treatment records. Although a March 2016 private provider also provided a diagnosis of PTSD related to service, the Veteran's significant post-service history was not discussed, nor were the Veteran's service records and post-service records reviewed.

Finally, the Board acknowledges the recently received 2023 report from Dr. H. submitted after the JMR; however, the Board also found this opinion in adequate to adjudicate the claim. Dr. H. concluded that the Veteran had PTSD caused by his suicide watches he was ordered to take part in during basic training, and also has persistent depressive disorder caused by his current service-connected physical disabilities (Specifically, his left knee). However, her analysis of the criteria for both PTSD and a depressive disorder failed to list, discuss, or tie any specific evidence regarding the symptoms to the specific criteria.

Second, regarding PTSD, Dr. H. notes the Veteran's contracting security work in the Mideast post separation, and she further notes how other psychological reviews have tied any psychiatric disorder to those engagements. For her part, Dr. H. opined that it was more likely the Veteran's suicide watches that caused it, rather than his private security work. However, Dr. H. fails to explain why this is so, and therefore lacks adequate rationale.

Given the inadequacies of the foregoing examination and opinion reports, the Board in July 2024 found that remand was warranted to afford the Veteran additional examination with medical opinion based on full consideration of the Veteran's documented medical history and assertions and supported by clearly-stated rationale.

Pursuant to the Board's remand, in September 2024 the Veteran underwent a VA PTSD examination, at which time PTSD was diagnosed. PTSD stressors included
psychiatric disorder to those engagements. For her part, Dr. H. opined that it was more likely the Veteran's suicide watches that caused it, rather than his private security work. However, Dr. H. fails to explain why this is so, and therefore lacks adequate rationale.

Pursuant to the Board's remand, in September 2024 the Veteran underwent a VA PTSD examination, at which time PTSD was diagnosed. PTSD stressors included attempting to help a Marine down from a rope in which he attempted to hang himself and during boot camp someone attempted to jump from the balcony. In a September 2024 opinion the examiner opined that the Veteran's PTSD was at least as likely as not incurred in or caused by the claimed in-service injury, event, or illness. The rationale, in part, was as follows:

"Veteran submitted a personal statement, and his sister provided detailed account of the various PTSD symptoms Veteran displays and how they impact his quality of life. Veteran's current symptoms are consistent with that of an individual that experienced the exposure to chronic combat. PTSD is a condition resulting from a trauma event that leads to chronic symptoms of anxiety, worry, sleep disturbance and interpersonal relationship difficulties similar to Veteran's current presentation."

In December 2024 the AOJ requested an addendum that addressed what verified combat stressors were related to his PTSD. In a December 2024 addendum the examiner essentially restated her earlier opinion.

In an April 2025 Records Research Response, the U.S. Department of Army, Records Management and Declassification Agency (RMDA) (formerly the Joint Services Records Research Center (JSRRC) concluded that no evidence was located to support documentation of the claimed stressor. Accordingly, the Board cannot find the opinion relating PTSD to unverified stressors report adequate for resolution of the Veteran's claim.

In May 2025 the Veteran underwent another VA PTSD examination, at which time the examiner opined that "The [V]eteran did not present a stressor related to claim for PTSD and does not meet criteria for a mental health diagnosis based on report of symptoms and the DSM-5."

In June 2025 the AOJ requested an addendum to "Consider the conflicting evidence regarding the Veteran's diagnosis and provided statements to support a diagnosis of PTSD or oppose the diagnosis of PTSD."

In a July 2025 Exam Scheduling Request Contention Cancellation, the AOJ stated that the Veteran was a "No Show." The addendum was not obtained.

Once VA has provided an examination, it is required to provide an adequate one, regardless of whether it was legally obligated to provide an examination in the first place. Barr v. Nicholson, 21 Vet. App. 303 (2007). In light of the foregoing, the Board finds that an addendum medical opinion is required to ensure that the matter of secondary service connection is addressed under the correct legal standard. See Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991) (When the medical evidence of record is insufficient, in the opinion of the Board, or of doubtful weight or credibility, the Board must supplement the record by seeking an advisory opinion, ordering a medical examination, or citing recognized medical treatises that clearly support its ultimate conclusions.).

The matter is REMANDED for the following action:

Arrange to provide the record on appeal to a qualified VA examiner for purposes of assessing the etiology of the Veteran's psychiatric disorder. The examiner should review the record. The need for another in-person examination, or video or telephone interview of the Veteran is left to the discretion of the examiner.

The examiner should opine whether it is at least as likely as not (i.e., whether the likelihood is at least approximately balanced or nearly equal, if not higher) that the Veteran has a current psychiatric disorder that had its onset in, or is otherwise attributable to, the Veteran's period of active service, to include the incident involving his left knee injury.

If it is deemed unlikely that the Veteran's psychiatric disorder had its onset in, or is otherwise attributable to, service, the examiner should offer a further opinion as to whether it is at least as likely as not (i.e., whether the likelihood is at least approximately balanced or nearly equal, if not higher) that the Veteran's psychiatric disorder (a) was caused or (b) has been aggravated by the service-connected left knee disability.

In so doing, the examiner should take care to provide a complete rationale as to both the causation and aggravation prongs of secondary service connection,
psychiatric disorder that had its onset in, or is otherwise attributable to, the Veteran's period of active service, to include the incident involving his left knee injury.

In so doing, the examiner should take care to provide a complete rationale as to both the causation and aggravation prongs of secondary service connection, and should consider and address each of those prongs separately, addressing the matter of whether it is at least as likely as not that the Veteran's service-connected left knee disability was a contributory cause of the psychiatric disorder.

In this regard, the examiner is advised that proximate cause is not required. Rather, the examiner's opinion should address whether the psychiatric disorder would have been less severe but-for the service-connected disability, either because there is an etiological link (to include worsening of functionality) between the two, or because the service-connected disability resulted in the inability to treat the non-service-connected disability.

A complete medical rationale for all opinions expressed must be provided.

ERIC S. LEBOFF

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board T. Adams, 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.

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