Citation Nr: 18140205 Decision Date: 10/02/18 Archive Date: 10/02/18 DOCKET NO. 15-04 710 DATE: October 2, 2018 REMANDED Entitlement to an increased rating for traumatic arthritis of the left knee status post rupture of the left patella tendon, currently evaluated as 10 percent disabling, is remanded. REASONS FOR REMAND The Veteran had active duty service from January 1974 to January 1977. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a July 2013 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. The Board notes that the Veteran’s appeal had originally included the issues of entitlement to service connection for bilateral hearing loss and tinnitus. However, the Veteran did not submit a substantive appeal for those particular issues following the issuance of the December 2014 statement of the case. Instead, he limited his appeal to the issue of entitlement to an increased rating for his service-connected left knee disability. See January 2015 VA Form 9. Therefore, those issues no longer remain in appellate status, and no further consideration is required. The Veteran testified at a hearing in July 2018 before the undersigned Veterans Law Judge. A transcript of the hearing is associated with the claims file. The Veteran was afforded a VA examination in April 2013 in connection with his claim for an increased evaluation for his service-connected left knee disability. However, in light of a decision issued by the United States Court of Appeals for Veterans Claims (Court), Correia v. McDonald, 28 Vet. App. 158 (2016), a remand is required. In Correia, the Court concluded that 38 C.F.R. § 4.59 requires VA examinations to include joint testing for pain on both active and passive range of motion, as well as with weight-bearing and nonweight-bearing. The Court further found that, if possible, the VA examiner should also include range of motion measurements of the opposite undamaged joint. The April 2013 VA examination does not satisfy the requirements under Correia. Furthermore, the record suggests that the Veteran’s disability may have worsened since the April 2013 VA examination. VA’s General Counsel has indicated that, when a claimant asserts that the severity of a disability has increased since the most recent rating examination, an additional examination is appropriate. VAOPGCPREC 11-95 (April 7, 1995); see also Snuffer v. Gober, 10 Vet. App. 400 (1997); Caffrey v. Brown, 6 Vet. App. 377 (1994). Therefore, the Board finds that a VA examination is needed to ascertain the current severity and manifestations of the Veteran’s service-connected left knee disability. The matter is REMANDED for the following action: 1. The Agency of Original Jurisdiction (AOJ) should request that the Veteran provide the names and addresses of any and all health care providers who have provided treatment for his left knee. After acquiring this information and obtaining any necessary authorization, the AOJ should obtain and associate these records with the claims file. The AOJ should also obtain any outstanding VA medical records. 2. After completing the foregoing development, the AOJ should schedule the Veteran for a VA examination to ascertain the severity and manifestations of his service-connected left knee disability. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner is requested to review all pertinent records associated with the claims file. The examiner should note that the Veteran is competent to attest to factual matters of which he has first-hand knowledge, including observable symptomatology. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. The examiner should report all signs and symptoms necessary for rating the left knee disability under the rating criteria. In particular, the examiner should provide the range of motion in degrees of the right and left knees. In so doing, the examiner should test the Veteran’s range of motion in active motion, passive motion, weight-bearing, and nonweight-bearing. If the examiner is unable to conduct the required testing or concludes that the required testing is not necessary in this case, he or she should clearly explain so in the report. The examiner should also comment on whether there is any ankylosis; dislocated semilunar cartilage with frequent episodes of locking, pain, and effusion into the joint; or, the symptomatic removal of semilunar cartilage. He or she should also address whether the Veteran has recurrent subluxation or lateral instability, and if so, comment as to whether such symptomatology is slight, moderate, or severe. The examiner should further state whether there is any malunion or nonunion of the tibia and fibula. The presence of objective evidence of pain, excess fatigability, incoordination and weakness should also be noted, as should any additional disability (including additional limitation of motion) due to these factors. The examiner should also discuss any additional functional impairment that occurs during flare-ups, including any additional limitation of motion. Further, the VA examiner should comment as to whether range of motion measurements for active motion, passive motion, weight-bearing, and nonweight-bearing can be estimated for the April 2013 VA examination. See Chotta v. Peake, 22 Vet. App. 80 (2008) (when there is an absence of medical evidence during a certain period of time, a retroactive medical evaluation may be warranted). If the examiner is unable to provide a retrospective opinion as to these specific range of motion findings, he or she should clearly explain so in the report. A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. Because it is important “that each disability be viewed in relation to its history[,]” 38 C.F.R. § 4.1, copies of all pertinent records in the appellant’s claims file, or in the alternative, the claims file, must be made available to the examiner for review. 3. The AOJ should review the examination report to ensure that it is in compliance with this remand. If the report is deficient in any manner, the AOJ should implement corrective procedures. 4. After completing these actions, the AOJ should conduct any other development as may be indicated by a response received as a consequence of the actions taken in the preceding paragraphs. When the development requested has been completed, the case should be reviewed by the AOJ on the basis of additional evidence. J.W. ZISSIMOS Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD D.S. Chilcote, Associate Counsel