Citation Nr: 18141961 Decision Date: 10/12/18 Archive Date: 10/12/18 DOCKET NO. 16-19 456 DATE: October 12, 2018 REMANDED Entitlement to an initial compensable rating for right knee patellofemoral syndrome is remanded. Entitlement to an initial compensable rating for left knee patellofemoral syndrome is remanded. Entitlement to service connection for right hip condition is remanded. Entitlement to service connection for left hip condition is remanded. Entitlement to service connection for low back condition as secondary to service-connected knee conditions is remanded. REASONS FOR REMAND The Veteran had active duty in the Army from May 1997 to May 2000. This matter is on appeal to the Board of Veterans’ Appeals (Board) from an April 2014 rating decision of a regional office of the Department of Veterans Affairs (VA). Knee Conditions With respect to the Veteran’s service-connected knee conditions, the Veteran contends that the initial noncompensable ratings are not reflective of his present level of severity and do not account for functional loss due to pain in both legs. See Notice of Disagreement dated April 2015; Appellant Briefs dated July 2015 and August 2016. The Veteran was afforded a VA examination in February 2014, which the Board finds too remote in time to address the current severity of the Veteran’s service-connected lower leg conditions. See Caffrey v. Brown, 6 Vet. App. 377, 381 (1994). Moreover, the Board notes that since the Veteran’s last examination in February 2014, the United States Court of Appeals for Veterans Claims (Court), in Correia v. McDonald, 28 Vet. App. 158 (2016), issued a decision finding that VA examinations for musculoskeletal conditions must include joint testing for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint. See 38 C.F.R. § 4.59 (2018). Thus, the Court’s holding in Correia establishes additional requirements that must be met prior to finding that a VA examination is adequate. Critically, this type of joint testing was not accomplished during the Veteran’s February 2014 VA examination. As the previous examination report does not fully satisfy the requirements of Correia and 38 C.F.R. § 4.59, a new examination is necessary to decide the increased rating claim. Accordingly, an additional VA examination must be provided. Hips and Lower Back Conditions The Veteran contends that his hips and lower back conditions are caused or aggravated by his service-connected knee conditions. He also asserts that the February 2014 VA examinations provided in conjunction with his service connection claims are inadequate as the examiner rendered an opinion based solely on the absence of documentation and did not take into consideration the Veteran’s lay statements regarding continuity of symptomatology. See Dalton v. Peake, 21 Vet. App. 23 (2007). Further, the Veteran asserts that the examiner failed to adequately address his secondary service connection theory of entitlement, and the persistent and recurrent hip and back symptoms associated with his service-connected knee conditions. In order to ensure that the Veteran’s claims are afforded full consideration, the Board concludes that reexaminations are necessary. The matters are REMANDED for the following action: 1. Obtain any outstanding pertinent VA treatment records not evidenced by the current record and associate with the claims file. 2. Schedule the Veteran for a VA examination to determine the current nature, extent and severity of his patellofemoral syndrome of the left knee and right knee. All required tests should be performed. The claims file, including this remand, should be reviewed by the examiner to become familiar with the Veteran’s pertinent medical history and such review should be noted in the examination report. 3. Schedule the Veteran for a VA examination with an appropriate medical professional to determine the nature and etiology of the claimed right and left hip conditions. The Veteran’s claims file, to include a copy of the remand, must be made available to the examiner in conjunction with the examination along with any other information the medical professional deems pertinent. A note that it was reviewed should be included in the opinion. After examining the Veteran, the examiner is asked to provide the following: a) Does the Veteran have a current diagnosed hip disability? If so, please identify. For each diagnosis, is it at least as likely as not (a 50 percent or greater probability) that the Veteran’s current diagnosed condition is etiologically related to his active duty service? b) The examiner is also asked to specifically address whether the Veteran’s diagnosed hip disability is at least as likely as not (a 50 percent or greater probability) proximately due to or the result of the Veteran’s service-connected knee conditions. c) The examiner is also asked to specifically address whether the Veteran’s diagnosed hip disability is at least as likely as not (a 50 percent or greater probability) aggravated, beyond the natural progress of the disease, by the Veteran’s service-connected knee conditions. The provided examination opinions must reflect consideration of both the medical and lay evidence of record, setting forth a complete rationale for all findings and conclusions. All tests deemed necessary by the examiner must be performed. The examiner is advised that the Veteran is competent to report his symptoms and history, and such reports must be specifically acknowledged and considered in formulating any opinions. 4. Schedule the Veteran for a VA examination with an appropriate medical professional to determine the nature and etiology of the claimed lower back condition. The Veteran’s claims file, to include a copy of the remand, must be made available to the examiner in conjunction with the examination along with any other information the medical professional deems pertinent. A note that it was reviewed should be included in the opinion. After examining the Veteran, the examiner is asked to provide the following: a) Does the Veteran have a current diagnosed back disability? If so, please identify. For each diagnosis, is it at least as likely as not (a 50 percent or greater probability) that the Veteran’s current diagnosed condition is etiologically related to his active duty service? b) The examiner is also asked to specifically address whether the Veteran’s diagnosed back disability is at least as likely as not (a 50 percent or greater probability) proximately due to or the result of the Veteran’s service-connected knee conditions. c) The examiner is also asked to specifically address whether the Veteran’s diagnosed back disability is at least as likely as not (a 50 percent or greater probability) aggravated, beyond the natural progress of the disease, by the Veteran’s service-connected knee conditions. The provided examination opinions must reflect consideration of both the medical and lay evidence of record, setting forth a complete rationale for all findings and conclusions. All tests deemed necessary by the examiner must be performed. The examiner is advised that the Veteran is competent to report his symptoms and history, and such reports must be specifically acknowledged and considered in formulating any opinions. 5. After completing the above actions and any other development deemed necessary, the claims must be readjudicated. If the claims remain denied, a supplemental statement of the case must be provided to the Veteran and his representative. After the Veteran and his representative have had an adequate opportunity to respond, the appeal must be returned to the Board for appellate review. KELLI A. KORDICH Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD S. An, Associate Counsel