Citation Nr: 18160548
Decision Date: 12/27/18	Archive Date: 12/27/18

DOCKET NO. 16-51 379
DATE:	December 27, 2018
ORDER
1. Entitlement to service connection for chronic fatigue syndrome, to include as due to Gulf War illness, and as secondary to service connected constochondritis and bilateral knee patellofemoral syndrome disabilities is denied.
2. Entitlement to service connection for headaches, to include as due to Gulf War illness, and as secondary to service connected constochondritis and bilateral knee patellofemoral syndrome disabilities is denied.
3. Entitlement to restoration of a 10 percent disability rating for a left knee patellofemoral syndrome since August 1, 2016 is granted.
4. Entitlement to restoration of a 10 percent disability rating for a right knee patellofemoral syndrome since August 1, 2016 is granted.
REMANDED
Entitlement to an increased disability rating for bilateral knee patellofemoral syndrome in excess of 10 percent after October 12, 2014 is remanded.
FINDINGS OF FACT
1. The Veteran is not diagnosed with chronic fatigue syndrome and does not have a disability manifested by chronic fatigue that is related to service, to include as an unexplained chronic multisymptom illness, or as secondary to service connected constochondritis and bilateral knee patellofemoral syndrome disabilities.
2. The Veteran does not have a headache disability that is related to service, to include as an undiagnosed illness or an unexplained chronic multisymptom illness, or as secondary to service connected constochondritis and bilateral knee patellofemoral syndrome disabilities.
3. The evidence does not show an improvement in the Veteran’s ability to function under the ordinary conditions of life and work with respect to his service-connected left knee patellofemoral syndrome disability since August 1, 2016.
4. The evidence does not show an improvement in the Veteran’s ability to function under the ordinary conditions of life and work with respect to his service-connected right knee patellofemoral syndrome disability since August 1, 2016.
CONCLUSIONS OF LAW
1. The criteria for service connection for chronic fatigue syndrome have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.303, 3.317.
2. The criteria for service connection for a headache disability have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.317.
3. The criteria for entitlement to restoration of a 10 percent disability rating for the service-connected left knee patellofemoral syndrome was met; the reduction to 0 percent, effective August 1, 2016, was not proper. 38 U.S.C. §§1155, 5107; 38 C.F.R. §§ 3.102, 3.105(e), 3.159, 4.1, 4.2, 4.10, 4.71a, Diagnostic Codes 5257, 5261, 5260, 5024.
4. The criteria for entitlement to restoration of a 10 percent disability rating for the service-connected right knee patellofemoral syndrome was met; the reduction to 0 percent, effective August 1, 2016, was not proper. 38 U.S.C. §§1155, 5107; 38 C.F.R. §§ 3.102, 3.105(e), 3.159, 4.1, 4.2, 4.10, 4.71a, Diagnostic Codes 5257, 5261, 5260, 5024.

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS
The Veteran served on active duty from February 2000 to July 2006. This case is before the Board of Veterans’ Appeals (Board) on appeal from May 2016 and November 2015 rating decisions by a Department of Veterans Affairs (VA) Regional Office (RO). 
In the May 2016 rating decision, the RO reduced the previously assigned rating disability for the service-connected bilateral knee patellofemoral syndrome from 10 percent to 0 percent, effective from August 1, 2016. The Veteran timely appealed the reduction and asserted that full restoration to 10 percent for her bilateral knee patellofemoral syndrome was warranted. Thus, the issue is characterized as an entitlement to restoration of the 10 percent rating, to include whether the reduction to 0 percent for the bilateral knee patellofemoral syndrome was proper.
In the November 2015 rating decision, the RO denied the claims of service connection for chronic fatigue syndrome and headaches for lack of a current diagnosis and a lack of nexus, respectively. 
Service Connection
Establishing service connection generally requires evidence of (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); 38 C.F.R. § 3.303.
Certain chronic disabilities, including some types of headaches (as organic disease of the nervous system), will be considered incurred in service if manifest to a degree of ten percent within one year of service. 38 C.F.R. §§ 3.307, 3.309(a); see also VBA Adj. Manual M21-1, III.iv.4.G.1.d (classifying migraine headaches as an organic disease of the nervous system under 38 C.F.R. § 3.309 (a)).
Under 38 C.F.R. § 3.303 (b), an alternative method of establishing the second and third Shedden element is through a demonstration of continuity of symptomatology; however, this method may be used only for the chronic disabilities noted in 38 C.F.R. § 3.309, which includes migraine headaches. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013).
Service connection may be awarded on a presumptive basis to a Persian Gulf veteran who (1) exhibits objective indications; (2) of a chronic disability such as those listed in 38 C.F.R. § 3.317 (b) (including fatigue and headaches); (3) which became manifest either during active military, naval, or air service in the Southwest Asia theater of operations during the Persian Gulf War, or to a degree of 10 percent or more not later than December 31, 2021; and (4) such symptomatology by history, physical examination, and laboratory tests cannot be attributed to any known clinical diagnosis. Gutierrez v. Principi, 19 Vet. App. 1, 7 (2004); 38 U.S.C. § 1117; 38 C.F.R. § 3.317; 76 Fed. Reg. 81834 -81836 (Dec. 29, 2011).
A “Persian Gulf veteran” is one who served in the Southwest Asia Theater of operations during the Persian Gulf War. 38 C.F.R. § 3.317 (e)(1). The Southwest Asia Theater of operations includes Iraq, Kuwait, Saudi Arabia, the neutral zone between Iraq and Saudi Arabia, Bahrain, Qatar, the United Arab Emirates, Oman, the Gulf of Aden, the Gulf of Oman, the Persian Gulf, the Arabian Sea, the Red Sea, and the airspace above these locations. 38 C.F.R. § 3.317 (e)(2). The United States Congress has defined the Persian Gulf War as beginning on August 2, 1990, the date that Iraq invaded the country of Kuwait, through a date to be prescribed by Presidential proclamation of law. 38 C.F.R. § 3.2 (i).
The Veteran’s Form DD 214 indicates that among his awards he received the Global War on Terrorism Expeditionary Medal and the Global War on Terrorism Service Medal. The Veteran’s Form DD 214 also confirms that he was deployed to Iraq from January 2005 to January 2006. Therefore, the Veteran had active service in the Southwest Asia Theater of operations during the Persian Gulf War.
The term “qualifying chronic disability” means a chronic disability resulting from an undiagnosed illness or a medically unexplained chronic multisymptom illness that is defined by a cluster of signs or symptoms, such as chronic fatigue syndrome, fibromyalgia, or functional gastrointestinal disorders (excluding structural gastrointestinal disease). 38 C.F.R. § 3.317 (a)(2)(i).
For secondary service connection, it must be shown that the disability for which the claim is made is proximately due to or the result of service-connected disease or injury, or that service-connected disease or injury has aggravated the nonservice-connected disability for which service connection is sought. See 38 C.F.R. § 3.310 (2015).
With disability compensation claims, VA adjudicators are directed to assess both medical and lay evidence. As a general matter, a layperson is not capable of opining on matters requiring medical knowledge. See 38 C.F.R. § 3.159 (a)(2); see also Routen v. Brown, 10 Vet. App. 183, 186 (1997) (“a layperson is generally not capable of opining on matters requiring medical knowledge”). In certain circumstances, however, lay evidence may be sufficient to establish a medical diagnosis or nexus. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). In addressing lay evidence and determining its probative value, if any, attention is directed to both competency (“a legal concept determining whether testimony may be heard and considered”) and credibility (“a factual determination going to the probative value of the evidence to be made after the evidence has been admitted”). See Layno v. Brown, 6 Vet. App. 465, 469 (1994).
In terms of competency, lay evidence has been found to be competent with regard to a disease with “unique and readily identifiable features” that is “capable of lay observation.” See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). That notwithstanding, a Veteran is not competent to provide evidence as to more complex medical questions and, specifically, is not competent to provide an opinion as to etiology in such cases. 
In weighing credibility, VA may consider interest, bias, inconsistent statements, bad character, internal inconsistency, facial plausibility, self-interest, consistency with other evidence of record, malingering, desire for monetary gain, and demeanor of the witness. See generally Caluza v. Brown, 7 Vet. App. 498 (1995). The Board may weigh the absence of contemporaneous medical evidence against the lay evidence in determining credibility, but the Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence. See Buchanan v. Nicholson, 451 F.3d 1331, 1335 (Fed. Cir. 2006); but see Maxson v. Gober, 230 F.3d 1330 (Fed. Cir. 2000) (evidence of a prolonged period without medical complaint after service can be considered along with other factors in the analysis of a service connection claim). 
In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination, the benefit of the doubt is afforded the claimant. 
1. Entitlement to service connection for chronic fatigue syndrome, to include as due to Gulf War illness and as secondary to service connected constochondritis and bilateral knee disabilities
The Veteran seeks service connection for fatigue, to include chronic fatigue syndrome (CFS), which he claims is warranted under the Gulf War illness presumption, or secondary to service connected constochondritis and bilateral knee disabilities.
The Veteran was provided with a VA examination for Chronic Fatigue Syndrome (CFS) in June 2016. The examiner determined that the Veteran does not have and has never been diagnosed with CFS. During the examination, the Veteran reported that his fatigue symptoms had their onset in 2011. He indicated that “I was always tired, no matter how much sleep I got.” The Veteran stated that when he moved to Dallas, Texas, he started seeing a doctor for his fatigue symptoms. The Veteran indicated that at that time “I had a hard time sleeping and I was constantly tired.” At the time of the examination, the Veteran indicated that he still felt constantly drained, and even if he slept 14 hours, he felt tired. The Veteran also reported that his fatigue had made it difficult for him to concentrate, and had caused him to forget his name, pass his children’s daycare, enter the wrong building and forget where he parked the car. He stated that he narrowly averted several accidents due to fatigue. The Veteran stated that he has never been told the cause of his fatigue and that “he thinks the initial assumption was that his fatigue problems are due to his sleep problems.” The Veteran reported that he has not been required to take medication for his fatigue symptoms.
The examiner reported that the Veteran has a history of “diagnoses of mental health issues, which can cause symptoms of fatigue.  (The Veteran's diagnosis was changed from Depression to a somatic disorder). Also states that he has trouble with sleep, to include diagnosed sleep apnea (OSA) and PLMD. The examiner classified the Veteran’s condition, as it relates to his fatigue symptoms, as a “diagnosable chronic multisymptom illness with a partially explained etiology.” The examiner opined that the Veteran’s chronic fatigue was less likely than not due to a specific exposure event in Southwest Asia, because there is not available lay or medical evidence that the Veteran had an exposure that would be at least as likely as not to have caused/aggravated fatigue. The examiner added the following rationale: exposure to insect-treated uniforms, vehicle or truck exhaust fumes, sand/dust and standard immunizations for deployment has been reported by the Veteran, but there are no medical associations that rise to the level of causality between any of the above exposures and chronic fatigue.
The examiner also opined that the Veteran’s chronic fatigue symptoms are less likely than not secondary to his service connected costochondritis, bilateral knee patellofemoral syndrome, or somatic symptom disorder (previously diagnosed as depression) because the Veteran does not meet the criteria for CFS, costochondritis is not a etiologic agent of CGS, the Veteran does not carry the diagnosis of depression based on the most recent C &P examination and his new diagnosis of somatic symptom is not an etiologic agent of CFS, and bilateral knee patellofemoral syndrome is not an etiologic agent of CFS.
There is no evidence that the examiner was not competent or credible, and as his opinions were based on the medical evidence and physician evaluations of the Veteran, the Board finds they are entitled to significant probative weight as to the severity of the Veteran’s headache disability at the time of the examinations. Nieves-Rodriguez, 22 Vet. App. 295.
The Veteran is competent to report on observable symptomatology of his chronic fatigue condition, including the impact of his fatigue on his daily activities. Barr v. Nicholson, 21 Vet. App. 303, 307-08 (2007). Therefore, the Board finds the Veteran’s testimony regarding his symptoms credible. 
The Board has reviewed all of the evidence but finds that service connection for a headache disorder is not warranted on any theory of entitlement. First, service connection is not warranted on a direct basis, to include as due to an in-service event or injury, as there is no diagnosed disability. VA does not generally grant service connection for symptoms alone, such as fatigue, without an identified basis for those symptoms. Sanchez-Benitez v. West, 13 Vet. App. 282 (1999). Accordingly, the Board finds that CFS has not been diagnosed. Additionally, the Veteran’s service treatment records do not show complaints of fatigue in service. As noted by the Veteran, his fatigue symptoms only manifested in 2011, approximately five years after his separation from service.
Regarding service connection based on the Gulf War illness presumption, the June 2016 VA examiner determined that the Veteran had a diagnosable chronic multisymptom illness with a partially explained etiology. Without a determination of an undiagnosed illness or a medically unexplained chronic multisymptom illness, this theory of entitlement does not apply.
With regards to secondary service connection, the June 2016 VA examination confirmed that the Veteran’s chronic fatigue symptoms are less likely than not secondary to his service connected costochondritis, bilateral knee patellofemoral syndrome or somatic symptom disorder because a review of the medical records and the Veteran’s statements do not provide support for a medically reasonable connection between the Veteran’s aforementioned service-connected disabilities and chronic fatigue syndrome. Moreover, the Veteran does not have a current diagnosis for CFS, which is required to establish secondary service connection. 
Although the medical evidence shows that the Veteran was diagnosed with sleep apnea and suggests that the Veteran’s symptoms of fatigue could be related to his sleep problems, the Veteran is not service connected for sleep apnea. As such, secondary service connection for fatigue symptoms cannot be established on the basis of the Veteran’s sleep apnea disability.
Based on the foregoing, the Board cannot grant service connection for a disability manifesting as fatigue. Because the preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine is not applicable. See 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. Therefore, service connection for chronic fatigue syndrome is not warranted. 
2. Entitlement to service connection for headaches, to include as due to Gulf War illness and as secondary to service connected constochondritis and bilateral knee disabilities
The Veteran seeks service connection for headaches, which he claims which he claims is warranted under the Gulf War illness presumption. He also claims that his headaches could be secondary to his service connected constochondritis and bilateral knee disabilities.
In this case, the Veteran’s service treatment records (STRs) do not show a diagnosis of a chronic headache or complaints of headaches. In fact, the Veteran’s STRs show that he denied experiencing headaches. Following his deployment, the Veteran noted on his post-deployment health assessment form that he did not have headaches, memory issues, dizziness, fainting or lightheadedness on deployment. The Veteran’s service treatment records show no reporting of a head injury in service, but the Veteran reported that while on deployment in Iraq, he tripped and hit his head on rocks. He denied losing consciousness after the fall and stated that he returned to his room and laid down for 4-5 hours. Upon wakening, he felt fine, but later that day, he felt that he had trouble reading and retaining information. He stated that he has had memory problems ever since the event. He remained in Iraq for a few months following the incident, but did not report his symptoms. He reported that he had no difficulty performing his duties of computer network maintenance following the incident. He denied any other neurological symptoms, such as seizures, head injuries or loss of consciousness in the military. The Veteran’s separation examination was negative for dizziness, fainting, frequent or severe headaches, head injury, memory loss, amnesia, a period of unconsciousness or concussion, and frequent trouble sleeping.
Although Veteran was first diagnosed with headaches during a February 2015 Traumatic Brain Injury (TBI)VA examination. he reported in a 2007 VA examination that he started experiencing headaches sometime between his separation from the military in July 2006 and his 2007 VA examination. In November 2007, a private physician at Ohio Health characterized the Veteran’s headaches as tension headaches related to muscle strain from a motor vehicle accident.  Similarly, during a January 2009 re-check for a neck injury following a car accident, the examiner noted that while the Veteran’s major complaint was local discomfort in the neck, he did get some headaches. 
 Since separation, he attended college. He received his bachelor’s degree in 2010 in Management in Computer Systems, and his master’s degree in Administrative Leadership. During his masters degree, the Veteran reported that he had trouble with sleep, headaches, and retaining information and had to drop classes in 2012 and then again in 2014. He was seen at the VA for these symptoms. He has since been dealing with daily headaches. As of August 2016, his headaches occur daily upon wakening with one migraine a week. His daily headaches last all day an occur in the occipital area and are throbbing. His migraine pain occurs in the posterior occipital and frontal areas of the head. His migraines are associated with nausea and require him to lie in a dark room. He takes sumatriptan for this pain, but the pain still lasts overnight. . 
The Veteran was provided with a VA examination for headaches in June 2016. During the examination, the Veteran reported that there had been a few times when he has had constant headaches for several months. The first time this happened was in August/September 2014 and the headaches lasted until January/February 2015. It happened a second time in June 2015 and his headaches lasted through September. The Veteran reported that his headaches might last a few hours on good days. The Veteran reported that the VA in Dallas thought that his headaches were tied to his sleeping issues. It was also noted in the examination that the Veteran was evaluated by a PMR specialist at the VA in Dallas in 2014 and it was determined that the Veteran had tension headaches. The VA examiner classified the Veteran’s headache as a diagnosable chronic multisymptom illness with a partially explained etiology. 
The examiner opined that the Veteran’s headache condition was less likely than not related to a specific exposure event during service in Southwest Asia because there was no evidence of an exposure event during service in Southeast Asia and the Veteran’s exposure to insect-treated uniforms, vehicle or truck exhaust fumes, and sand/dust and standard immunizations for deployment, as reported by the Veteran, are not known to cause chronic headaches. The examiner also opined that the Veteran's headaches/migraines are less likely than not secondary to his service connected costochondritis, bilateral knee patellofemoral syndrome or somatic symptom disorder because a review of the medical records and the Veteran's statements do not provide support for a medically reasonable connection between chronic costochondritis and headaches, based on generally accepted medical knowledge. Notably, during the June 2016 VA examination, the Veteran initially stated that he did not think that his headaches were due to his costochondritis disability, but rather contemplated whether his headaches were caused by poor sleep due to his pain. 
During a December 2014 examination, the Veteran reported that he had daily headaches for the last three weeks with steady pain and prior to this, had headaches once a week or every other week. The Veteran noted that the headaches improved when taking motrin. The examiner described the headaches as tension headaches. In November 2014, the Veteran complained of headaches with lack of sleep and denied dizziness, blurred vision and focal weakness. During a February 2015 clinic visit, the Veteran complained of headaches but again stated that he that they were secondary to poor sleep.
The Veteran was provided a Gulf War Medical Examination in June 2016. The examiner noted that the Veteran had a history of headaches (including migraine headaches), peripheral nerves, and TBI. The examiner also noted that the Veteran had not shown additional signs and/or symptoms that may represent an "undiagnosed illness" or "diagnosed medically unexplained chronic multisymptom illness.” The examiner indicated that the Veteran did not have any diagnosed illnesses for which no etiology was established. The Veteran reported that he was exposed to insect-treated uniforms, vehicle or truck exhaust fumes, and sand/dust and standard immunizations for deployment during his deployment in Iraq. 
The Veteran was provided with a TBI VA examination in August 2016. During the examination, he reported that he had missed 100 hours of work in 2016 due to his headaches and being tired. The examiner reviewed the Veteran’s medical history and noted that a September 2011 CT of the head, an October 2015 MRI and a February 2016 EEG showed normal brain activity. The examiner also noted the results of a May 2016 neuropsychological test, which showed that the “Veteran's cognitive profile is less likely as not consistent with a cognitive disorder. The cognitive profile is considered intact with no consistent deficits within any cognitive domain and variable effort.” The examiner referenced a February 2015 TBI clinic evaluation which determined that the Veteran’s symptoms were not caused by TBI. The examiner opined that, based on the examination, imaging and neuropsychological testing results, the Veteran is negative for current residuals of a TBI secondary to a fall that the Veteran sustained while on active duty in 2005. The examiner further noted the following: “per the Veteran’s history, he may have sustained a mild TBI in 2005, but the injury did not result in any long-term residual symptoms. The Veteran remained on active duty for up to one year following the event, without any record of symptoms related to his fall. He was seen by medical providers multiple time during that year, but failed to report symptoms of headaches or cognitive symptoms. The Veteran denied symptoms that would be consistent with residuals of a TBI on both his PHDA in December of 2005 as well as his separation exam in April of 2006. He currently reports that his headaches did not begin until after his separation, making them unlikely attributable to an injury that reportedly occurred greater than 6 months prior. The Veteran has been seen by TBI providers through the VA system, who have reported no residual symptoms secondary to a TBI.”
There is no evidence that the examiners were not competent or credible, and as their opinions were based on the medical evidence and physician evaluations of the Veteran, the Board finds they are entitled to significant probative weight as to the severity of the Veteran’s headache disability at the time of the examinations. Nieves-Rodriguez, 22 Vet. App. 295.
The Veteran is competent to report on observable symptomatology of his headache disability, including pain associated with his headaches, and the frequency and duration of his headaches. Barr v. Nicholson, 21 Vet. App. 303, 307-08 (2007). Therefore, the Board finds the Veteran’s testimony regarding his symptoms credible. 
The Board has reviewed all of the evidence but finds that service connection for a headache disorder is not warranted on any theory of entitlement. First, regarding direct service connection based on various exposures during the Veteran’s deployment in Iraq, the June 2016 VA examiner provided a negative nexus opinion on the basis that the Veteran’s exposure to insect-treated uniforms, vehicle or truck exhaust fumes, and sand/dust and standard immunizations for deployment are not medically known to cause chronic headaches. The examiner also noted that the Veteran denied headaches in service, including after his deployment in Iraq, and at the time of his separation examination.  
The Board also considered whether there is a causal relationship between the Veteran’s headaches and his head injury in service. According to the August 2016 VA examination, the examiner concluded that the Veteran did not currently have TBI nor did he have long-term residual symptoms of TBI. In doing so, the examiner determined that the Veteran’s headaches were not residual symptoms of his head injury in service. The objective medical testing also confirms that the Veteran does not have any brain abnormalities that could be described as residual symptoms of a brain injury. Moreover, the record contains evidence, including the Veteran’s own statements, that the Veteran’s headaches could be caused by intervening factors, such as a motor vehicle accident in 2007 and poor sleep due to pain in his body. As such, service connection for headaches based on various exposures during his deployment in Iraq and an in-service head injury is denied. 
The Board has also considered whether service connection is warranted under the Gulf War illness presumption. Both the June 2016 VA examiners found that the Veteran did not have an undiagnosed illness or medically unexplained chronic multisymptom illness or symptoms. Therefore, this theory of entitlement does not apply. 
Finally, regarding service connection based on chronicity and continuity of symptomatology under 38 C.F.R. § 3.303 (b), the Veteran does not have a diagnosis of migraine headaches. In fact, the Veteran’s headaches have been characterized by multiple medical examiners as tension headaches. The Veteran’s diagnosis, according to the June 2016 VA examination for headaches, is “mixed headaches”, meaning a mix of migraines and tension headaches. As such, without a diagnosis for a chronic disability as defined under 38 C.F.R. § 3.309 (a), the criteria for service connection based on this theory of entitlement does not apply. 
Even if the Board were to take the position that the Veteran’s mixed headaches diagnosis qualified as a diagnosis of migraine headaches, the Veteran’s migraines must have manifested to a degree of 10 percent within one year of separation. The Veteran’s medical records do not reflect that he had migraine headaches within one year of separation from service. Also, during the June 2016 VA examination for headaches, the examiner determined that the Veteran experienced prostrating attacks of migraines with less frequent attacks. Therefore, not only did the Veteran’s migraine headaches not manifest within one year of separation, but the frequency of the migraines is associated with a non-compensable rating. 
With regards to secondary service connection, the June 2016 VA examination confirmed that the Veteran’s headaches/migraines are less likely than not secondary to his service connected costochondritis, bilateral knee patellofemoral syndrome or somatic symptom disorder because a review of the medical records and the Veteran’s statements do not provide support for a medically reasonable connection between chronic costochondritis and headaches, based on generally accepted medical knowledge. Additionally, the record contains statements by the Veteran denying that his headaches are due to his costochondritis disability.
In conclusion, the weight of the most competent and credible evidence establishes that the current headache condition is not due to service. Because the preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine is not applicable. See 38 U.S.C.A. § 5107 (b); 38 C.F.R. § 3.102. Therefore, service connection for a headache disorder is not warranted. The appeal is denied.
3. Entitlement to restoration of a 10 percent disability rating for a left knee patellofemoral syndrome since August 1, 2016 
In a rating reduction, not only must it be determined that an improvement in a disability has actually occurred, but also that the improvement actually reflects an improvement in a Veteran’s ability to function under the ordinary conditions of life and work. Brown v. Brown, 5 Vet. App. 413, 420-21 (1993); Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). 
The provisions of 38 C.F.R. §§ 4.1, 4.2, and 4.10 require that a reduction in rating be based upon review of the entire history of a veteran’s disability. VA must then ascertain whether the evidence reflects an actual change in the disability and whether the examination reports reflecting such change are based on thorough examinations. Faust v. West, 13 Vet. App. 342 (2000). VA is not limited, however, to medical indicators of improvement. Rather, VA may rely on non-medical indicators of improvement to show that a Veteran is capable of more than marginal employment. Id. The examination reports on which the reduction is based must be adequate. See Tucker v. Derwinski, 2 Vet. App. 201 (1992) (holding that the failure of the examiner in that case to review the claims file rendered the reduction decision void ab initio). 
In addressing whether improvement is shown, the comparison point generally is the last examination on which the rating at issue was assigned or continued. See Hohol v. Derwinski, 2 Vet. App. 169 (1992). Where, however, the rating was continued in order to see if improvement was in fact shown, the comparison point could include prior examinations as well. Collier v. Derwinski, 2 Vet. App. 247 (1992). 
Specific requirements must be met in order for VA to reduce certain ratings assigned for service-connected disabilities. See 38 C.F.R. § 3.344; see also Dofflemyer v. Derwinski, 2 Vet. App. 277 (1992). The requirements for reduction of ratings in effect for five years or more are set forth at 38 C.F.R. § 3.344 (a) and (b), prescribe that only evidence of sustained material improvement under the ordinary conditions of life, as shown by full and complete examinations, can justify a reduction; these provisions prohibit a reduction on the basis of a single examination. See Brown, 5 Vet. App. at 417-18. Where a rating reduction was made without observance of law, the reduction must be vacated and the prior rating restored. Schafrath, 1 Vet. App. at 595. 
In this case, the 10 percent rating for the bilateral knee patellofemoral syndrome disability was in effect for more than five years at the time of the reduction. Accordingly, the provisions of 38 C.F.R. § 3.344 (a) and (b) apply to this rating. 
When reducing a disability rating based on the severity of a Veteran’s condition, the burden falls on VA to show “material improvement” in the Veteran’s condition from the time of the previous rating examination that assigned the Veteran’s rating. Ternus v. Brown, 6 Vet. App. 370, 376 (1994). 
In determining whether the reduction was proper in this case, the Board must focus upon the evidence available to the RO at the time the reduction was effectuated, although post-reduction medical evidence may be considered in the context of evaluating whether the disability had actually improved. Cf. Dofflemyer v. Derwinski, 2 Vet. App. 277, 281-282. Such after-the-fact evidence may not be used to justify an improper reduction.
Disability ratings are determined by the application of a schedule of ratings which is based on average impairment of earning capacity. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities. 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. 38 C.F.R. §§ 4.3, 4.7. 
In specific regard to rating disabilities of the knee, precedent opinions of VA’s General Counsel have held that dual ratings may be given for a knee disorder, with one rating for instability (Diagnostic Code 5257) and one rating for arthritis with limitation of motion (Diagnostic Codes 5003 and 5010). VAOPGCPREC 9-98 (63 Fed. Reg. 56,704 (1998)) and 23-97 (62 Fed. Reg. 63,604 (1997)). Another such opinion held that separate ratings under Diagnostic Code 5260 (leg, limitation of flexion) and Diagnostic Code 5261 (leg, limitation of extension) may be assigned for disability of the same joint. VAOPGCPREC 9-2004 (69 Fed. Reg. 59988 (2004)).
Diagnostic code 5024, under which the Veteran received disability ratings for bilateral knee patellofemoral syndrome, is rated on limitation of motion of affected parts. The diagnostic codes for limitation of motion, to include limitation of flexion and extension, are 5260 and 5261, respectively. Diagnostic code 5261 provides ratings for limitation of extension with the following ratings assigned: 0 percent for extension limited to 5 degrees, 10 percent for extension limited to 10 degrees, 20 percent for extension limited to 15 degrees, 30 percent for extension limited to 20 degrees, 40 percent for extension limited to 30 degrees, and 50 percent for extension limited to 45 degrees. 38 C.F.R. § 4.71a.
Under diagnostic code 5260, a noncompensable rating will be assigned for limitation of flexion of the leg to 60 degrees; a 10 percent rating will be assigned for limitation of flexion of the leg to 45 degrees; a 20 percent rating will be assigned for limitation of flexion of the leg to 30 degrees; and a 30 percent rating will be assigned for limitation of flexion of the leg to 15 degrees.  38 C.F.R. § 4.71a.
For rating purposes, normal range of motion of the knee is to zero degrees extension and to 140 degrees flexion. See 38 C.F.R. § 4.71a, Plate II.
Knee disabilities can also be rated under diagnostic code 5257, which covers other impairments of the knee as a result of recurrent subluxation or lateral instability. A 10 percent rating will be assigned for slight recurrent subluxation or lateral instability; a 20 percent rating will be assigned for moderate recurrent subluxation or lateral instability; and a 30 percent rating will be assigned for severe recurrent subluxation or lateral instability. 38 C.F.R. § 4.71a.
In evaluating joint disabilities, VA must consider higher ratings in cases in which functional loss due to pain, weakness, excess fatigability, or incoordination is demonstrated, and those factors are not contemplated in the relevant rating criteria. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202 (1995). Although pain may be a cause or manifestation of functional loss, limitation of motion due to pain is not necessarily rated at the same level as functional loss where motion is impeded. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011). Instead, pursuant to 38 C.F.R. §§ 4.40 and 4.45, the possible manifestations of functional loss include decreased or abnormal excursion, strength, speed, coordination, or endurance, as well as less or more movement than is normal, weakened movement, excess fatigability, and pain on movement (as well as swelling, deformity, and atrophy) that affects stability, standing, and weight-bearing. See 38 C.F.R. §§ 4.40, 4.45. Thus, functional loss caused by pain must be rated at the same level as if the functional loss were caused by any of the other factors cited above. In evaluating the severity of a joint disability, VA must determine the overall functional impairment due to these factors.
In this case, the Veteran was originally granted service connection for left knee patellofemoral syndrome disability in a March 2011 rating decision. A noncompensable disability rating was assigned under Diagnostic Code 5024, effective from August 2006. In a June 2011 rating decision, the disability rating for the Veteran’s bilateral knee patellofemoral syndrome was increased to 10 percent, effective from April 2011. In a May 2016 rating decision, the RO decreased the disability rating for the Veteran’s left knee patellofemoral syndrome to 0 percent, effective from August 2016.
Therefore, the Board is only deciding the issue of whether the reduction of the left knee rating for patellofemoral syndrome disability was warranted. As such, the Board’s sole concern is whether there was evidence of sustained material improvement in the left knee patellofemoral syndrome under the ordinary conditions of life, as shown by full and complete examinations. In making this determination, the Board will have to consider all painful limitation of motion, to include both flexion and extension, as well as whether there was functional impairment beyond the level of actual limitation of flexion and/or extension. 
At the time of the June 2011 rating decision that increased the Veteran’s disability rating for left knee patellofemoral syndrome to 10 percent, the RO relied on findings from an April 2011 VA examination, which indicated that the Veteran had endorsed pain weakness, swelling stiffness, instability and fatigability of the left knee. The Veteran also reported that he experienced pain around the knee cap on both sides, and that walking worsened the pain. The Veteran did not report that his knee disability had a functional impact on his occupation as an IT specialist. He did report, however, that he was able to perform routine daily activities, although at times it was painful to do so. The Veteran also reported that he had flare ups, which consisted of increased pain and occurred during increases in physical activity and cold or moist weather. On examination, active range of motion for the left knee was limited to 92 degrees. The examiner reported that there was no objective evidence of pain with motion, and there was no additional limitation of motion on exam with three repetitions. Knee x-rays did not show degenerative changes, but rather, showed preservation of the joint spaces with no fractures or effusions. The examiner also reported no warmth, crepitus, tenderness or effusion upon examination. 
Essentially, the RO increased the Veteran’s disability rating from 0 percent to 10 percent because the VA examination showed “some limitation of motion”, so the RO “resolved reasonable doubt in [the Veteran’s] favor.” 
In a May 2016 rating decision, the RO reduced the Veteran’s disability rating from 10 percent to 0 percent for the service-connected bilateral knee patellofemoral syndrome, effective August 2016. The RO based the reduction on the reasons provided in the November 2015 proposal to reduce the Veteran’s disability rating. In its proposal, the RO referenced the November 2015 VA examination and the examiner’s conclusion that the Veteran had “a diagnosed disability with no compensable symptoms.”  The May 2016 rating decision also noted that, based on the most recent April 2016 VA examination, the Veteran’s symptoms do not warrant a compensable disability rating.
As noted above, before the Veteran’s disability rating was reduced to 0 percent, he was provided with two VA examinations.  The November 2015 VA examination showed flexion and extension of the left knee limited to 135 degrees. The examiner did not note pain in the left knee during the range of motion examination and with weight bearing. There was also no objective evidence of localized tenderness or pain on palpation of the joint in the left knee. There was no reporting of additional functional loss or range of motion after three repetitions for the left knee. With regards to functional loss due to pain, weakness fatigability or incoordination, the examiner reported that “[a]lthough the Veteran complained of an intermittent soreness pain that occurs with rest and increased activity, there were no complaints of or objective signs of pain, fatigue, weakness, incoordination or further decreases in range of motion demonstrated with the DeLuca measurement. Therefore, it would require mere speculation to attempt to quantify any additional limitation that may or may not occur with repetitive motion or a flare.” Muscle strength was normal, there was no indication of ankylosis, recurrent subluxation, lateral instability, effusion, joint instability, or swelling. X-rays of the knees were normal and showed no fractures or effusions. With regards to the functional impact of the Veteran’s disability on his ability to perform occupational tasks, the Veteran reported that his left knee become sore with ambulation at times.
During the April 2016 VA examination, the Veteran reported that he had pain on movement in the anterior left knee area. He said that he got sharp shooting pain in his left knee when going up and down stairs or driving. He reported that he is constantly sore and can only walk short distances before requiring a break. He also reported weakness in the knees and stated that “if I misstep, I get sharp pain in my knees and I’ll be limping. I wake up and they are sore.” The Veteran reported having daily flare-ups which cause sharp/shooting pain. The Veteran reported experiencing functional loss or impairment due to the pain in his knees while going up and down stairs, pushing the pedals of a car while driving, and standing or walking for prolonged periods of times. With regards to the functional impact of the Veteran’s disability on his ability to perform occupational tasks, the Veteran reported that as an IT Specialist, his supervisor requires him to walk the one mile long complex to speak with the IT customers, which hurts his knees and causes him extreme pain. The Veteran also stated that sitting and standing for prolonged periods of times also hurts his knees. The examination showed flexion and extension of the left knee limited to 125 degrees. The examiner noted that the Veteran did not report pain during the range of motion examination or with weight bearing. However, the examiner did report localized tenderness on palpation around the anterior patella area and over the patella tendon. There was objective evidence of crepitus in the left knee. There was no reporting of additional functional loss or range of motion after three repetitions for either of the knees. The examiner reported that there was no evidence that pain, weakness, fatigability or incoordination significantly limited functional ability with repeated use over a period of time. Muscle strength was normal, there was no indication of ankylosis, recurrent subluxation, lateral instability, effusion, or joint instability. X-rays of the left knee showed no osseous or articular abnormalities. 
In June 2016, the Veteran had an MRI of his knees. The MRI results were normal for the left knee. There were no significant bony abnormalities, other significant inflammatory or arthritic changes. There was also no evidence of fractures or joint effusions.
The Veteran claims that his November 2015 VA examination was inadequate because it was rushed and the examiner did not make notations of everything that the Veteran reported. Specifically, the Veteran stated that on examination, the examiner noted pain on motion and his knees made loud popping noises during the range of motion tests. However, the examiner did not note these observations in the VA examination. 
During a May 2016 primary care examination, the examiner noted pain to palpation of the knees, medial and lateral. He also stated that his pain had recently increased.
There is no evidence that the examiners were not competent or credible, and as their opinions were based on the medical evidence and physician evaluations of the Veteran, the Board finds they are entitled to significant probative weight as to the severity of the Veteran’s left knee patellofemoral syndrome at the time of the examination. Nieves-Rodriguez, 22 Vet. App. 295.
In May 2015, Veteran also reported that his hobbies were severely hampered by his knee pain/soreness. He is no longer able to walk with his wife and kids, teach his kids how to ride their bikes, or play outside with them. He indicated that he has had to use his daughter as a walker to get around the house because of his knee pain. In an August 2016 VA examination relating to his headaches, the Veteran reported that he is engaged in very little recreational activities, whereas in the past he liked to golf, go to football games and take his daughters to the park. He also stated that his knee pain has had an impact on his job, causing him to take time off from work.
The Veteran is competent to report on observable symptomatology of his knee disability, including pain in his left knee and its impact on his ability to function on a day-to-day basis. Barr v. Nicholson, 21 Vet. App. 303, 307-08 (2007). Therefore, the Board finds the Veteran’s testimony credible.
A review of the medical and lay evidence in the record since the February 2011 rating decision, that granted the Veteran a 10 percent disability rating, shows that the Veteran’s symptoms have been consistent. Although the Veteran’s limitations of flexion and extension in the left knee have not amounted to a compensable rating from April 2011 to May 2016, the Veteran has shown functional impairment beyond the level of actual limitation of flexion and extension. The Veteran has consistently complained of pain in his left knee when he is moving. He has described that this pain has caused him to miss days at work, created difficulty in completing job duties, specifically sitting or standing for long periods of time, and walking long distances to meet with his IT customers. The Veteran has also consistently reported that his knee pain on motion is exacerbated when he climbs or descends stairs and when he walks for long periods of time. As reported by the Veteran, this has prevented him from taking walks with his family, playing with his children and moving around the house. The Veteran has also reported that the pain in his left knee has weakened his knee, causing instability. Although the VA examinations do not report objective evidence of pain on motion, the Veteran’s credible lay statements provide evidence of painful motion resulting in functional loss.  Given the Veteran’s reporting of continuous pain in his left knee that has limited his daily activities, the Board finds that there is insufficient evidence of sustained material improvement under the ordinary conditions of life, as shown by full and complete examinations, to justify a reduction.
A claimant is entitled to the benefit of the doubt when there is an approximate balance of positive and negative evidence on any issue material to the claim. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102 (providing, in pertinent part, that reasonable doubt will be resolved in favor of the claimant). When the evidence supports the claim or is in relative equipoise, the claim will be granted. See Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990).
In the instant case, as the weight of the evidence is at least in relative equipoise regarding the disposition of the Veteran’s claim, the benefit-of-the-doubt rule does apply, and the Veteran is entitled to the restoration of his 10 percent disability rating for left knee patellofemoral syndrome disability effective August 1, 2016.

4. Entitlement to restoration of a 10 percent disability rating for a right knee patellofemoral syndrome since August 1, 2016 
The procedural history for the Veteran’s restoration claim for his right knee patellofemoral syndrome is the same as the one described in the above analysis for the Veteran’s right knee patellofemoral syndrome. Here, the Board is only deciding the issue of whether the reduction of the right knee rating for patellofemoral syndrome disability was warranted. As such, the Board’s sole concern is whether there was evidence of sustained material improvement in the right knee patellofemoral syndrome under the ordinary conditions of life, as shown by full and complete examinations. In making this determination, the Board will have to consider all painful limitation of motion, to include both flexion and extension, as well as whether there was functional impairment beyond the level of actual limitation of flexion and/or extension. 
The April 2011 VA examination, which led to the increase to 10 percent in the Veteran’s right knee disability rating, indicated that the Veteran had endorsed pain weakness, swelling stiffness, instability and fatigability of the right knee. The Veteran also reported that he experienced pain around the knee cap on both sides, and that walking worsened the pain. The Veteran did not report that his knee disability had a functional impact on his occupation as an IT specialist. He did report, however, that he was able to perform routine daily activities, although at times it was painful to do so. The Veteran also reported that he had flare ups, which consisted of an increase in pain and occurred with increase in activity and cold or moist weather. On examination, active range of motion was limited to 95 degrees in the right knee. The examiner reported that there was no objective evidence of pain with motion, and there was no additional limitation of motion on exam with three repetitions. Knee x-rays did not show degenerative changes, but rather, showed preservation of the joint spaces with no fractures or effusions. The examiner also reported no warmth, crepitus, tenderness or effusion upon examination. 
Essentially, the RO increased the Veteran’s disability rating from 0 percent to 10 percent because the VA examination showed “some limitation of motion”, so the RO “resolved reasonable doubt in [the Veteran’s] favor.” 
In a May 2016 rating decision, the RO reduced the Veteran’s disability rating from 10 percent to 0 percent for the service-connected right knee patellofemoral syndrome, effective August 2016. The RO based the reduction on the November 2015 and April 2016 VA examinations.
The November 2015 VA examination showed flexion and extension of the right knee limited to 125 degrees. The examiner did not note pain in the right knee during the range of motion examination and with weight bearing. There was also no objective evidence of localized tenderness or pain on palpation of the joint in either of the knees. There was no reporting of additional functional loss or range of motion after three repetitions for either of the knees. With regards to functional loss due to pain, weakness fatigability or incoordination, the examiner reported that “Although the Veteran complained of an intermittent soreness pain that occurs with rest and increased activity, there were no complaints of or objective signs of pain, fatigue, weakness, incoordination or further decreases in range of motion demonstrated with the DeLuca measurement. Therefore, it would require mere speculation to attempt to quantify any additional limitation that may or may not occur with repetitive motion or a flare.” Muscle strength was normal, there was no indication of ankylosis, recurrent subluxation, lateral instability, effusion, joint instability, or swelling. X-rays of the knees were normal and showed no fractures or effusions. With regards to the functional impact of the Veteran’s disability on his ability to perform occupational tasks, the Veteran reported that his knees become sore with ambulation at times.
During the April 2016 VA examination, the Veteran reported that he had pain on movement in the anterior area of the right knee. He said that he got sharp shooting pain in his knee when going up and down stairs or driving. He reported that he is constantly sore and can only walk short distances before requiring a break. He also reported weakness in the knees and stated that “if I misstep, I get sharp pain in my knees and I’ll be limping. I wake up and they are sore.” The Veteran reported having daily flare-ups which cause sharp/shooting pain. He reported experiencing functional loss or impairment due to the pain in his knees while going up and down stairs, pushing the pedals of a car while driving, and standing or walking for prolonged periods of times. With regards to the functional impact of the Veteran’s disability on his ability to perform occupational tasks, the Veteran reported that as an IT Specialist, his supervisor requires him to walk the one mile long complex to speak with the IT customers, which hurts his knees and causes him extreme pain. The Veteran also stated that sitting and standing for prolonged periods of times also hurts his knees. The examination showed flexion and extension of the right knee limited to 125 degrees. The examiner noted that the Veteran did not report pain during the range of motion examination or with weight bearing. However, the examiner did report localized tenderness on palpation around the anterior patella area and over the patella tendon. There was objective evidence of crepitus in the right knee. There was no reporting of additional functional loss or range of motion after three repetitions for the right knee. The examiner reported that there was no evidence that pain, weakness, fatigability or incoordination significantly limited functional ability with repeated use over a period of time. Muscle strength was normal, there was no indication of ankylosis, recurrent subluxation, lateral instability, effusion, or joint instability. X-rays of both knees showed no osseous or articular abnormalities. 
In June 2016, the Veteran had an MRI of his knees. The MRI results for the right knee were unremarkable. There were no significant bony abnormalities, other significant inflammatory or arthritic changes. There was also no evidence of fractures or joint effusions.
The Veteran claims that his November 2015 VA examination was inadequate because it was rushed and the examiner did not make notations of everything that the Veteran reported. Specifically, the Veteran stated that on examination, the examiner noted pain on motion and his knee made loud popping noises during the range of motion tests. However, the examiner did not note these observations in the VA examination. 
During a May 2016 primary care examination, the examiner noted pain to palpation of the knees, medial and lateral. He also stated that his pain had recently increased.
There is no evidence that the examiners were not competent or credible, and as their opinions were based on the medical evidence and physician evaluations of the Veteran, the Board finds they are entitled to significant probative weight as to the severity of the Veteran’s left knee patellofemoral syndrome at the time of the examination. Nieves-Rodriguez, 22 Vet. App. 295.
In May 2015, Veteran also reported that his hobbies were severely hampered by his knee pain/soreness. He is no longer able to walk with his wife and kids, teach his kids how to ride their bikes, or play outside with them. He indicated that he has had to use his daughter as a walker to get around the house because of his knee pain. In an August 2016 VA examination relating to his headaches, the Veteran reported that he is engaged in very little recreational activities, whereas in the past he liked to golf, go to football games and take his daughters to the park. He also stated that his knee pain has had an impact on his job, causing him to take time off from work.
The Veteran is competent to report on observable symptomatology of his knee disability, including pain in his knee and its impact on his ability to function on a day-to-day basis. Barr v. Nicholson, 21 Vet. App. 303, 307-08 (2007). Therefore, the Board finds the Veteran’s testimony credible.
A review of the medical and lay evidence in the record since the February 2011 rating decision, that granted the Veteran a 10 percent disability rating, shows that the Veteran’s symptoms have been consistent. Although the Veteran’s limitations of flexion and extension in the right knee have not amounted to a compensable rating from April 2011 to May 2016, the Veteran has shown functional impairment beyond the level of actual limitation of flexion and extension. The Veteran has consistently complained of pain in his right knee when he is moving. He has described that this pain has caused him to miss days at work, created difficulty in completing job duties, specifically sitting or standing for long periods of time, and walking long distances to meet with his IT customers. The Veteran has also consistently reported that his knee pain on motion is exacerbated when he climbs or descends stairs and when he walks for long periods of time. As reported by the Veteran, this has prevented him from taking walks with his family, playing with his children and moving around the house. The Veteran has also reported that the pain in his right knee has weakened his knees, causing instability. Although the VA examinations do not report objective evidence of pain on motion, the Veteran’s credible lay statements provide evidence of painful motion resulting in functional loss.  Given the Veteran’s reporting of continuous pain in his right knee that has limited his daily activities, the Board finds that there is insufficient evidence of sustained material improvement under the ordinary conditions of life, as shown by full and complete examinations, to justify a reduction.
A claimant is entitled to the benefit of the doubt when there is an approximate balance of positive and negative evidence on any issue material to the claim. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102 (providing, in pertinent part, that reasonable doubt will be resolved in favor of the claimant). When the evidence supports the claim or is in relative equipoise, the claim will be granted. See Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990).
In the instant case, as the weight of the evidence is at least in relative equipoise regarding the disposition of the Veteran’s claim, the benefit-of-the-doubt rule does apply, and the Veteran is entitled to the restoration of his 10 percent disability rating for a right knee patellofemoral syndrome disability effective August 1, 2016.

REASONS FOR REMAND
Entitlement to a non-initial increased rating for bilateral knee patellofemoral syndrome disability in excess of 10 percent after October 12, 2014 is remanded.
While the record contains a contemporaneous VA examination, dated April 2016, regarding the Veteran’s bilateral knee patellofemoral syndrome disability, the examination does not comply with the requirements in Correia, 28 Vet. App. 158, 168 (2016).  The examination does not contain testing for pain on active and passive range of motion, and non-weight bearing. 
Therefore, a new VA examination is required so that the Board can conduct further development into the Veteran’s claim for an increased rating for a bilateral patellofemoral syndrome disability.
The matter is REMANDED for the following action:
1. Obtain any outstanding VA and private treatment records since October 12, 2014 to be associated with the Veteran’s claims file.
2. Schedule the Veteran for an examination of the current severity of his service-connected bilateral knee patellofemoral syndrome. The examiner must test the Veteran’s active motion, passive motion, and pain with weight-bearing and without weight-bearing.  The examiner must also attempt to elicit information regarding the severity, frequency, and duration of any flare-ups, and the degree of functional loss during flare-ups.  To the extent possible, the examiner should identify any symptoms and functional impairments due to service-connected bilateral knee patellofemoral syndrome disability alone and discuss the effect of the Veteran’s service-connected bilateral knee patellofemoral syndrome on any occupational functioning and activities of daily living.  
3. If it is not possible to provide a specific measurement, or an opinion regarding flare-ups, symptoms, or functional impairment without speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training).
4. Thereafter, complete any other development deemed necessary and then readjudicate the Veteran’s increased rating claim. If a complete grant of the benefits requested is not awarded, issue a supplemental statement of the case to the Veteran and his representative, and provide them an opportunity to respond before returning the case to the Board.

 
Michael Pappas
Veterans Law Judge
Board of Veterans’ Appeals
ATTORNEY FOR THE BOARD	A. White, Associate Counsel  

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