Citation Nr: 1803509 Decision Date: 01/18/18 Archive Date: 01/29/18 DOCKET NO. 15-28 849 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Seattle, Washington THE ISSUES 1. Entitlement to a disability rating in excess of 20 percent for left knee degenerative joint disease (DJD) based on a recurrent subluxation or lateral instability. 2. Entitlement to a separate compensable rating for left knee DJD based on limitation of motion. 3. Entitlement to service connection for a right eye disability. 4. Entitlement to service connection for a left ankle disability. 5. Entitlement to service connection, to include on a secondary basis, for a left leg disability. REPRESENTATION Veteran represented by: Disabled American Veterans ATTORNEY FOR THE BOARD D. Houle, Associate Counsel INTRODUCTION The Veteran served on active duty from May 1976 to September 1985, with additional service in the Washington Army National Guard from September 1985 to August 1996. These matters come before the Board of Veterans' Appeals (Board) on appeal from a January 2014 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Seattle, Washington. A July 2016 Board decision denied the Veteran's claim for a disability rating in excess of 20 percent for left knee DJD. The Veteran appealed the decision to the United States Court of Appeals for Veterans Claims (Court). In February 2017, the Court granted a Joint Motion for Partial Remand (JMPR), vacating the portion of the July 2016 Board decision that denied entitlement to an evaluation in excess of 20 percent for left knee DJD, and remanded the matter for action consistent with the terms of the JMPR. Thereafter, the Board remanded the appeal in May 2017 for a new VA examination, and again, in October 2017, for the issuance of a supplemental statement of the case (SSOC). Such development has been completed and this matter is returned to the Board for further consideration. Additionally, the Board notes that its July 2016 decision remanded the claims for entitlement to service connection for left ankle, left leg, and right eye disabilities for further development, to include VA examinations. These matters were remanded again October 2017 for the issuance of an SSOC. Stegall v. West, 11 Vet. App. 268 (1998). Such development has been completed and these matters are returned to the Board for further consideration. This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2017). 38 U.S.C. § 7107(a)(2) (2012). The issues of entitlement to a disability rating in excess of 20 percent for left knee degenerative DJD based on a recurrent subluxation or lateral instability and entitlement to a separate compensable rating for left knee DJD based on limitation of motion are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. The Veteran's right eye disability did not originate in service, was not manifest within one year of service, and is not otherwise etiologically related to the Veteran's active service. 2. The Veteran's left ankle disability did not originate in service, was not manifest within one year of service, and is not otherwise etiologically related to the Veteran's active service. 3. The Veteran does not have a current diagnosis of a left leg disability. CONCLUSIONS OF LAW 1. The criteria for service connection for a right eye disability have not been met. 38 U.S.C. §§ 1131, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2017). 2. The criteria for service connection for a left ankle disability have not been met. 38 U.S.C. §§ 1131, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2017). 3. The criteria for service connection, to include on a secondary basis, for a left leg disability have not been met. 38 U.S.C. §§ 1131, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist VA provided the Veteran with 38 U.S.C. § 5103(a)-compliant notice in September 2013. The record also shows that VA has fulfilled its obligation to assist the Veteran in developing the claim, including with respect to VA examinations of the Veteran. With respect to the right eye disability claim, the Veteran and her representative assert that the October 2016 VA examination is inadequate because the examination report contains an incorrect statement as to the onset of the Veteran's right eye symptoms and the examiner did not adequately assess the worsening of the Veteran's right eye disability. The Board finds the October 2016 VA examination report to be adequate, as the examiner reviewed the Veteran's claims file, examined the Veteran, and the examiner's opinion and rationale reflect consideration of the Veteran's reported history of right eye symptoms, dating back to the 1990's, which is the date of onset that the Veteran asserts that she received treatment for right eye symptoms. Further, the Board finds that the examination report adequately assesses a worsening in the Veteran's right eye symptoms, as the report contains an assessment as to loss of vision and functional impact. With respect to the left ankle disability claim, the Veteran and her representative assert that the October 2016 VA examination is inadequate because the examiner did not adequately address the Veteran's contentions that her left ankle symptoms had their onset during active duty and have continued since service to the present day. The Board finds the October 2016 VA examination report to be adequate, as the examiner reviewed the Veteran's claims file, examined the Veteran, and the examiner's opinion and rationale reflect consideration of the Veteran's reported history of left ankle symptoms, dating back to the 1980's, as well as the Veteran's report that left ankle pain and swelling have remained the same post-service. With respect to the left leg disability claim, the Veteran and her representative assert that the October 2016 VA examination is inadequate because the examiner did not adequately address the worsening of the Veteran's left leg symptoms. The Board finds that the October 2016 VA examination report to be adequate, as the examiner reviewed the Veteran's claims file, examined the Veteran, and the examiner's opinion and rationale reflect consideration of the Veteran's reported history of left leg pain and the examination report contains an assessment as to any severity in lower extremity nerves, to include the Veteran's left leg. Neither the Veteran nor her representative has raised any other issues with the duty to notify or duty to assist. In October 2017, the Board remanded the claims of entitlement to service connection for right eye, left ankle, and left leg disabilities for additional development. Pursuant to the Board's remand, the AOJ reajudicated the claims and issued an SSOC. Based on the foregoing actions, the Board finds that there has been substantial compliance with the Board's remand. Stegall v. West, 11 Vet. App. 268 (1998) (finding that a remand by the Board confers on the appellant the right to compliance with the remand orders). Therefore, in light of the foregoing, the Board will proceed to review and decide the claims based on the evidence that is of record. II. Entitlement to Service Connection A. Legal Principles Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. See 38 U.S.C. §§ 1131 (2012); 38 C.F.R. § 3.303(a) (2017). Generally, the evidence must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may also be granted for a disability that is proximately due to or the result of a service-connected disability. 38 C.F.R. § 3.310 (2017). Service connection is permitted not only for a disability caused by a service-connected disability, but also for the degree of disability resulting from aggravation to a nonservice-connected disability by a service-connected disability. 38 C.F.R. § 3.310; Allen v. Brown, 7 Vet. App. 439 (1995). B. Factual Background and Analysis Right Eye The Veteran contends that her right eye disability is related to service. A review of the Veteran's service treatment records (STRs) indicates that she wears glasses. During her time with the National Guard in May 1995, the Veteran reported redness and itching in both of her eyes and was diagnosed with conjunctivitis. Post-service VA treatment records show reports of pain and worsening vision in the Veteran's right eye, and a diagnosis of right eye retinal macroaneursym with edema and cataracts in connection with a diagnosis of diabetes. The treatment records also reflect the Veteran received Avastin injections in her right eye. Pursuant to the Board's July 2016 remand, the Veteran was afforded a VA examination in October 2016. The examiner noted a 2009 diagnosis of macroaneurysm of the right eye at macular. The Veteran reported a history of central vision loss in her right eye, beginning in 2009. She received laser treatment and Avastin shots. She complained of worsening vision in her right eye but indicated that she was not under any current treatment for the disability. The examiner opined that the Veteran's right eye disability was less likely than not (less than 50 percent probability) incurred in or caused by an in-service injury, event, or illness. The examiner stated that May 1995 episode of conjunctivitis during the Veteran's National Guard time was treated successfully and there is no relationship between that episode and changes in the Veteran's right eye macular area beginning in 2006. In an April 2017 addendum to the October 2016 VA examination report, the examiner stated that conjunctivitis is a superficial inflammation of the surface lining of the eye, which is usually viral in nature. The examiner opined that conjunctivitis could not in any way cause or change the health or vision of the interior of the eye. The examiner concluded that the Veteran's current right eye disability related to a vascular event in the back of the eye with loss of vision that was completely unrelated to her conjunctivitis diagnosis in May 1995, which had since resolved, producing no residual effects. In an April 2017 statement, the Veteran asserted that changes in her right eye macular area, to include eye pain, began prior to 2006. She asserted that her eye pain began during service and that she received treatment for this pain in the 1990's. She indicated that she currently receives injections in her eye, which affect her driving, and that her pain feels like pins are sticking her in her eye. She also contended that bright lights hurt her eye and that she experiences problems with night driving. After consideration of the entire record and the relevant law, the Board finds that service connection for a right eye disability is not warranted. Here, there is a present disability, as the Veteran was diagnosed with macroaneurysm right eye at macular during her October 2016 VA examination. Therefore, the Veteran meets the threshold criterion for service connection of a current disability. Boyer v. West, 210 F.3d 1351 (Fed. Cir. 2000). Thus, the remaining question is whether this disability manifested during service, within one year of service, or is otherwise related thereto. First, the Board finds that the Veteran's right eye disability did not manifest during service or within one year thereafter. While the Veteran's STRs contain reported right eye symptoms, to include pain, the Veteran was diagnosed with conjunctivitis. Her STRs are silent for diagnosis or treatment of a right eye macroaneurysm. Additionally, the evidence does not indicate right eye macroaneurysm manifested within one year of discharge. Post-service VA treatment records show changes in the Veteran's right eye macular beginning in 2006, approximately ten years following separation from service with the National Guard. Thus, the Board finds that the Veteran's right eye disability did not have its onset in active service or within one year thereafter. Additionally, there is no medical or other competent evidence of a nexus between the Veteran's right eye disability and service. As noted in the October 2016 VA examination report and the April 2017 addendum, the examiner opined that the Veteran's right eye disability was less likely than not caused by or a result of an event in military service, basing his opinion on a review of the Veteran's STRs and post-service treatment records, which do not show symptoms and treatment of right eye macroaneurysm until 2006. Further, in the April 2017 addendum to the October 2016 VA examination report, the examiner opined that the Veteran's current right eye disability was not related to her 1995 diagnosis of conjunctivitis. The examiner explained that conjunctivitis is viral in nature and does not change the vision of the interior of the eye. The examiner stated that the Veteran's conjunctivitis was treated successfully and resolved, and that her current diagnosis of right eye macroaneursym is related to the Veteran's diabetes, of which the Board notes the Veteran is not service-connected for. Thus, the Board finds that the Veteran's right eye disability is not related to active service. The Board finds the VA medical opinions from October 2016 and April 2017 to be probative, as they include the most thorough and factually supported opinions of record, given they are consistent with other evidence of record and included review of the Veteran's claims file as well as her lay statements. Specifically, the VA examiner considered the Veteran's treatment for conjunctivitis in 1995 and her reported history of eye pain. The VA examiner determined that there was no nexus between the Veteran's current right eye disability and her military service. The VA examiner has training, knowledge, and expertise on which he relied on to form his opinions, and he provided persuasive rationale for them. The Board acknowledges the Veteran's contentions that her current right eye disability is related to service. The Veteran is considered competent to report the observable manifestations of her claimed disability. See Charles v. Principi, 16 Vet. App. 370, 374-75 (2002); Layno v. Brown, 6 Vet. App. 465, 469-70 (1994). While the Veteran is competent to report observable symptoms, the Board finds that determining the etiology of a right eye disability requires more than a layperson can be expected to competently address. In this case, the etiology of a right eye disability is a complex medical question that is not within the competence of a lay person and requires medical expertise. As there is no indication that the Veteran has any medical training, education or expertise, the Board finds she is not competent to etiologically link any such symptoms to a current diagnosis. Therefore, the Board finds that the Veteran's statements as to the etiology of her right eye disability are not sufficient to satisfy the requisite nexus requirement. Taking into account all the relevant evidence of record, the Board finds that the weight of the evidence is against the Veteran's claim of service connection for a right eye disability. Although the Veteran is entitled to the benefit of the doubt where the evidence is in approximate balance, the benefit of the doubt doctrine is inapplicable where, as here, the preponderance of the evidence is against the claim. Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Left Ankle The Veteran contends her left ankle disability is related to service. Specifically, she asserts that she injured her left ankle in service performing her duties as a Material Storage and Handling Specialist. Review of the Veteran's STRs show a June 1980 left ankle sprain that occurred when the Veteran was bowling. Reported symptoms included swelling and tenderness in the Veteran's left ankle. The left ankle was treated with a bandage, ice, and elevation. A second incident pertaining to the Veteran's left foot occurred in July 1986. The Veteran injured her left heel performing her duties as a Material Storage and Handling Specialist. She was in charge of the off-loading and placement of equipment for a unit returning from two weeks of active duty. The wheel of a cart transporting equipment hit the Veteran's foot, and she received VA medical treatment for her injury soon after. In an October 2013 statement, the Veteran indicated she was informed that there is a lipoma in her left ankle and that her ankle was swollen. The Veteran underwent a VA examination for her left ankle in December 2014. The examiner noted the Veteran's left ankle sprain in 1980. The Veteran reported her left ankle disability began as a gradual onset of pain that worsened over time. She reported flare-ups and indicated that she was unable to wear shoes due to her ankle being swollen and that it was difficult for her to stand for an extended period of time. She reported pain in her left ankle upon movement and palpation. The Veteran indicated that she utilizes a cane. Post-service VA treatment records from 2016 show reported symptoms of left ankle swelling. Pursuant to the Board's July 2016 remand, the Veteran underwent another VA examination in October 2016 for her left ankle. The examiner noted a recent diagnosis of a left ankle strain in 2016. The Veteran reported that she sprained her left ankle in 1980 and asserted that the pain and swelling associated with the ankle sprain has remained the same following separation from service. She reported current symptoms of pain, especially with weight-bearing, as well as continuous swelling in her left ankle. She indicated she treats her ankle pain with Tylenol or Tramadol. She did not report flare-ups but indicated that she uses a cane and cannot stand or walk for an extended period of time. The examiner opined that it is less likely than not that the Veteran's current left ankle disability was incurred in or caused by an in-service injury, event, or illness. The examiner stated that while there is evidence of a left ankle sprain in service in 1980, it is less likely that this single and simple sprain would lead to any long-term disability. In an April 2017 addendum to the October 2016 VA examination report, the examiner stated that the Veteran's left ankle sprain incurred in 1980 was simple in nature and is unlikely to have produced chronic symptoms. The examiner stated that the Veteran's STRs following the 1980 sprain do not support evidence of chronic left ankle symptoms. While the Veteran sustained another injury in June 1986, this was a left heel injury, rather than an ankle injury, which was also an isolated event, as no further medical evidence in the Veteran's file shows ongoing heel problems. Left foot problems mentioned in later years were in reference to a left foot bunion. The examiner concluded that the Veteran's current left ankle disability was unrelated to her left ankle sprain in 1980 and her left heel injury in 1986. After consideration of the entire record and the relevant law, the Board finds that service connection for a left ankle disability is not warranted. Here, there is a present disability, as the Veteran was diagnosed with a left ankle strain in 2016. Therefore, the Veteran meets the threshold criterion for service connection of a current disability. Boyer v. West, 210 F.3d 1351 (Fed. Cir. 2000). Thus, the remaining question is whether this disorder manifested during service, within one year of service, or is otherwise related thereto. First, the Board finds that the Veteran's left ankle disability did not manifest during service or within one year thereafter. While the Veteran's STRs contain a 1980 report and treatment for a left ankle strain, as well as a 1986 report and treatment for a left heel injury, her STRs are silent thereafter for reports of chronic left ankle symptoms. Additionally, the evidence does not indicate a left ankle disability manifested within one year of discharge. While the Veteran asserts that her left ankle disability has been present since separation from service and has continued since service to the present day, a gap of approximately twenty years exists in the Veteran's treatment records from the Veteran's separation from service up until the first post-service medical record showing complaints and treatment for left ankle symptoms in 2016. This period without treatment for a left ankle disability is evidence that there has not been a continuity of symptoms and it weighs heavily against the claim on a direct basis. Maxson v. Gober, 230 F.3rd, 1330, 1333 (Fed. Circ. 2000). Thus, the Board finds that the Veteran's left ankle disability did not have its onset in active service or within one year thereafter. Additionally, there is no medical or other competent evidence of a nexus between the Veteran's left ankle disability and service. As noted in the October 2016 VA examination report and the April 2017 addendum, the examiner opined that the Veteran's left ankle disability was less likely than not caused by or a result of an event in military service. Further, in the April 2017 addendum to the October 2016 VA examination report, the examiner opined that the Veteran's current left ankle disability was not related to her 1980 left ankle sprain or 1986 left heel injury. The examiner explained that both injuries were simple in nature and resolved with treatment, as no further chronic left ankle symptoms were noted thereafter in the Veteran's STRs or post-service treatment records. Thus, the Board finds that the Veteran's left ankle disability is not related to active service. The Board finds the VA medical opinions from October 2016 and April 2017 to be probative, as they include the most thorough and factually supported opinions of record, given they are consistent with other evidence of record and included review of the Veteran's claims file as well as her lay statements. Specifically, the VA examiner considered the Veteran's treatment for a left ankle sprain in 1980 and a left heel injury in 1986, as well as her reported history of left ankle pain and swelling. The VA examiner determined that there was no nexus between the Veteran's current left ankle disability and her military service. The VA examiner has training, knowledge, and expertise on which he relied on to form his opinions, and he provided persuasive rationale for them. The Board acknowledges the Veteran's contentions that her current left ankle disability is related to service. The Veteran is considered competent to report the observable manifestations of her claimed disability. See Charles v. Principi, 16 Vet. App. 370, 374-75 (2002); Layno v. Brown, 6 Vet. App. 465, 469-70 (1994). While the Veteran is competent to report observable symptoms, the Board finds that determining the etiology of a left ankle disability requires more than a layperson can be expected to competently address. In this case, the etiology of a left ankle disability is a complex medical question that is not within the competence of a lay person and requires medical expertise. As there is no indication that the Veteran has any medical training, education or expertise, the Board finds she is not competent to etiologically link any such symptoms to a current diagnosis. Therefore, the Board finds that the Veteran's statements as to the etiology of her left ankle disability are not sufficient to satisfy the requisite nexus requirement. Taking into account all the relevant evidence of record, the Board finds that the weight of the evidence is against the Veteran's claim of service connection for a left ankle disability. Although the Veteran is entitled to the benefit of the doubt where the evidence is in approximate balance, the benefit of the doubt doctrine is inapplicable where, as here, the preponderance of the evidence is against the claim. Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Left Leg The Veteran contends her left leg disability is related to her service-connected lumbar spine disability. The Veteran's STRs are silent for complaints of, diagnosis of, or treatment for a left leg disability. Subsequent to service, within one year of separation, the Veteran's post-service treatment records are negative for signs and symptoms related to a left leg disability. Thereafter, post-service treatment records reflect complaints of left leg pain and swelling, but no diagnosis of a left leg disability. Tests conducted to assess whether lower extremity radiculopathy is present yielded normal results. The Veteran was afforded a VA examination in November 2014. The examiner noted a 1980 surgery to remove a lipoma from the Veteran's lower left thigh. The Veteran reported that her leg symptoms began following this surgery and have worsened over time. Upon examination, no current diagnosis of a left leg disability was found by the examiner. Pursuant to the Board's July 2016 remand, the Veteran was afforded an additional VA examination in October 2016. The Veteran reported complaints of left leg pain but asserted that she was unaware of any diagnosed peripheral nerve condition in her left leg. Testing conducted to assess the lower radicular group of nerves, revealed normal results in both the lower right and lower left extremities. The examiner opined that it was less likely than not (less than 50 percent probability) that any left leg disability was incurred in or caused by an in-service injury, event, or illness, as there is no current diagnosis of a left leg disability. The examiner concluded that there is no evidence of left lumbar radiculopathy to warrant service connection secondary to the Veteran's service-connected lumbar spine disability. In an April 2017 addendum to the October 2016 VA examination report, the examiner stated that despite a finding of left S-1 radiculitis during the Veteran's June 2000 VA examination, the October 2016 VA examination found no evidence of any radiculopathy in the Veteran's left leg. The examiner explained that radicular symptoms can resolve with or without surgery. As the Veteran's post-treatment records do not show radicular symptoms of the lower left extremity, and the Veteran reported pain in her left leg but did not provide a history of radicular symptoms in her lower left extremity, the examiner concluded that any S-1 radiculopathy found in 2000 had since resolved by 2016 and that there was no present left leg disability. After consideration of the entire record and the relevant law, the Board finds that service connection, to include on a secondary basis, for a left leg disability is not warranted. The Board has reviewed all of the evidence of record, to include in-service and post-service treatment records, which does not support the finding that a left leg disability was demonstrated during the Veteran's military service, that this claimed disability was compensably disabling within one year of separation from active duty, or that there is a nexus between the claimed disability and service or a service-connected disability, to include the Veteran's lumbar spine disability. A necessary element for establishing entitlement to service connection is the existence of a current disability; it is the cornerstone of a claim for VA disability compensation. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); Degmetich v. Brown, 104 F.3d 1328, 1332 (Fed. Cir. 1997). For VA purposes, a current disability exists when a claimant has a disability at the time a claim is filed or at some point during the pendency of that claim. McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). The Veteran's STRs and post-service treatment records are silent for a diagnosis of a left leg disability. While the Veteran's post-service treatment records reflect reports of left leg pain and swelling, on multiple instances, the Veteran has denied lower extremity radicular pain, and testing conducted to evaluate whether lower extremity radicular pain was present yielded normal results. Further, after review of the Veteran's medical history, consideration of her reported symptoms and onset of the claimed left leg disability, and examination of the Veteran, the October 2016 VA examiner found that the Veteran did not have a current diagnosis of a left leg disability based upon negative findings of left lower extremity radiculopathy. Although the June 2000 VA examiner noted left S-1 radiculitis, the October 2016 VA examiner opined that evidence in the Veteran's claims file does not support a diagnosis of radiculopathy of the lower left extremity, and if there was in fact lower left radiculopathy present at the time of the June 2000 VA examination, it has since resolved. Here, there is simply no indication in the record that the Veteran has a current diagnosis of a left leg disability, or that she has had any such diagnosis at any time during the appeal period. A threshold requirement for the granting of service connection is evidence of a current disability. In the absence of evidence of a current disability there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). In making this finding, the Board accords significant probative weight to the October 2016 VA examination report and its April 2017 addendum report. The Board finds this examination report and addendum include the most thorough and factually supported opinion of record as to whether the Veteran presently has a left leg disability. The opinions were provided based upon comprehensive review of the claims file, and collectively contained an adequate rationale for the conclusions reached. As such, these opinions are persuasive and entitled to great probative weight. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Taking into account all the relevant evidence of record, the Board finds that the weight of the evidence is against the Veteran's claim of service connection, to include on a secondary basis, for a left leg disability. Although the Veteran is entitled to the benefit of the doubt where the evidence is in approximate balance, the benefit of the doubt doctrine is inapplicable where, as here, the preponderance of the evidence is against the claim. Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). ORDER Entitlement to service connection for a right eye disability is denied. Entitlement to service connection for a left ankle disability is denied. Entitlement to service connection, to include on a secondary basis, for a left leg disability is denied. REMAND The Board finds that additional development is required prior to further disposition of the Veteran's claims. With respect to the Veteran's claims for entitlement to a disability rating in excess of 20 percent for left knee DJD based on a recurrent subluxation or lateral instability and entitlement to a separate compensable rating for left knee DJD based on limitation of motion, pursuant to the Board's May 2017 remand, the Veteran underwent a VA examination for her left knee in June 2017. During the examination, the Veteran reported a worsening in symptoms and that she experienced flare-ups which impacted her ability to walk or go up and down stairs. The examiner was unable to opine as to whether pain, weakness, fatigability or incoordination significantly limit functional ability with flare-ups, however, stating he could not do so without speculation. The examination stated that the Veteran was uncooperative during her examination and range of motion testing could not be performed, and the Veteran was not experiencing a flare-up on the day of the examination. Although the purpose of the examination was to assess the current severity of the Veteran's left ankle disability, the examiner provided a negative nexus opinion regarding direct service connection. The Court addressed the adequacy of a VA examiner's opinion as it pertains to additional functional loss during reported flare-ups of a musculoskeletal disability, pursuant to DeLuca v. Brown, 8 Vet. App. 202 (1995). The Court held that a new VA examination and opinion are necessary when the examiner does not obtain information from the Veteran regarding the severity, frequency, duration, or functional loss manifestations of any reported flare-ups, and that in declining to offer an opinion regarding additional functional loss as it relates to reported flare-ups, the examiner must provide adequate rationale for doing so. Sharp v. Shulkin, No. 16-1385 (September 6, 2017). In April 2017, the Veteran submitted a statement challenging the adequacy of the examination. The Veteran stated that she asked for help getting up on the examination table, the examiner and his assistant declined her request, and the examiner refused to examine her, stating that he would write the examination report based upon the evidence in her claims file. The Veteran stated that she also had difficulty understanding the examiner when he spoke, asking him to repeat himself numerous times, and thus causing her and the examiner to become frustrated. The Board finds the June 2017 examination for the Veteran's left knee to be inadequate for evaluation purposes because the examiner did not estimate range of motion loss based on the Veteran's reported flare-ups and their impact. Further, it appears that both the Veteran and the examiner encountered difficulty communicating with one another, thus contributing to inconclusive examination results. Based on the foregoing reasons, the Board finds that a remand is necessary for a new VA examination. Accordingly, the case is REMANDED for the following action: (Please note, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c). Expedited handling is requested.) 1. Schedule the Veteran for a VA examination to determine the nature and current severity of her service-connected left knee DJD. Given the inadequacy of the June 2017 VA examination opinion of record, the Veteran's examination should preferably be administered by a VA physician who has not previously examined her in connection with this appeal. The Veteran's electronic claims file must be accessible for review by the VA examiner in conjunction with the examination. A complete history from the Veteran should be obtained and recorded. All testing deemed necessary by the examiner should be performed and the results reported in detail. In particular, the examiner must test the range of motion in active motion, passive motion, weight-bearing, and non-weight-bearing. If possible, provide these tests for the opposite joint. If the examiner is unable to conduct any aspect of the required testing or concludes that it is not necessary, e.g., non-weight-bearing, the examiner should clearly explain why that is the case. The rationale for all opinions expressed should be provided. Following the review of the claims file and examination of the Veteran, the examiner is then requested to respond to the following: a) Describe any functional limitation due to pain, weakened movement, excess fatigability, pain with use, or incoordination. b) Indicate whether the examination is taking place during a period of flare-up, and if it is not, the examiner should ask the Veteran to describe the flare-ups, including: frequency, duration, severity, and functional impairment. c) Provide an opinion estimating any additional degrees of limited motion caused by functional loss during a flare-up. If the examiner cannot estimate the degrees of additional range of motion during flare-ups without resorting to speculation, the examiner should state whether the need to speculate is caused by a deficiency in the state of general medical knowledge or by a deficiency in the record or the examiner. The examiner should address how the Veteran's left knee DJD impacts her activities of daily living, including her ability to obtain and maintain employment. 2. Thereafter, readjudicate the issues on appeal. If the benefits sought on appeal remain denied, the Veteran should be furnished with a supplement statement of the case, given the opportunity to respond, and the case should be thereafter returned to the Board for further appellate review, if warranted. The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This case must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C. §§ 5109B, 7112 (2012). ______________________________________________ Thomas H. O'Shay Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs