Citation Nr: 18143089 Decision Date: 10/18/18 Archive Date: 10/17/18 DOCKET NO. 14-34 605A DATE: October 18, 2018 REMANDED The claim of entitlement to service connection for a low back disorder, to include as secondary to a service connected bilateral knee disorder is remanded. The claim of entitlement to service connection for a psychiatric disorder, to include as secondary to a service-connected bilateral knee disorder is remanded. Entitlement to a disability rating in excess of 10 percent for left knee patella alta with patellofemoral pain syndrome is remanded. Entitlement to a disability rating in excess of 10 percent for right knee patella alta with patellofemoral pain syndrome is remanded. REASONS FOR REMAND The Veteran served on active duty from February 1999 to August 1999. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a June 2010 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO).   1. Entitlement to service connection for a low back disorder, to include as secondary to a service connected bilateral knee disorder. 2. Entitlement to service connection for a psychiatric disorder, to include as secondary to a service-connected bilateral knee disorder. Remand is required to provide adequate examinations for the Veteran’s service connection claims. Where VA provides the veteran with an examination in a service connection claim, the examination must be adequate. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). The Veteran claims she has a low back disorder as a result of her service connected bilateral knee disorder. She further claims her depression is related to her back and knee conditions. See February 2010 claim. VA provided a low back examination in September 2014. The examiner diagnosed a lumbosacral strain and degenerative disc disease status post discectomy. The examiner noted that the Veteran had suffered a fall in 2010, sustaining a strain. The examiner opined that the Veteran’s back condition was less likely than not related to her knees and more likely related to her employment and aging. The examiner indicated that there was insufficient evidence of a knee condition severe enough to cause a back condition and more evidence of the Veteran’s prior history of a back strain, her weight, and her employment. This opinion is inadequate because the examiner did not address whether the Veteran’s bilateral knee disorder aggravates her low back disorder. Remand is thus required for an adequate opinion. Regarding the Veteran’s claimed psychiatric disorder, there are distinct diagnoses of record. In a March 2010 VA examination, the Veteran was diagnosed with depression. Then, the examiner did not find sufficient evidence to warrant the diagnosis of a depressive disorder secondary to pain in the Veteran’s right knee. In a September 2014 VA examination, the examiner diagnosed bipolar I disorder. The examiner opined that the Veteran’s condition was less likely than not related to military service or her service-connected knee conditions. For both opinions rendered in March 2010 and September 2014, neither examiner opined as to whether the Veteran’s service-connected knee disorders aggravate her psychiatric diagnoses. The March 2010 VA examiner also only discussed the right knee. VA recently provided an examination in December 2017. Then, a diagnosis of major depressive disorder was rendered. The examiner opined that it was less likely than not that the Veteran’s depressive disorder was related to military service or a service-connected condition. The examiner noted that the Veteran’s service treatment records showed a diagnosis of personality disorder and situational stress. However, there was a significant break between the Veteran’s discharge from service and her current complaints and treatment. Additionally, the Veteran’s treatment notes show post-partum depression and do not support a continuation of the condition noted in active duty. The examiner also explained that the Veteran’s treatment records do not support her depression being linked to the service-connected bursitis in her knees. Like the March 2010 and September 2014 opinions, the examiner’s opinion is inadequate because the examiner failed to address whether her diagnosed psychiatric disorder is aggravated by her service-connected bilateral knee disorder. As such, an adequate opinion should be obtained on remand. The Board notes that the opinion sought on remand should address the various psychiatric diagnoses of record. In the 2010, 2014, and 2017 VA examinations, the Veteran received diagnoses of major depressive disorder and bipolar disorder. VA treatment records show similar findings. The examination on remand should clarify what diagnosis is present and reconcile this finding with the evidence of record.   3. Entitlement to a disability rating in excess of 10 percent for left knee patella alta with patellofemoral pain syndrome. 4. Entitlement to a disability rating in excess of 10 percent for a right knee patella alta with patellofemoral pain syndrome. Remand is required for adequate VA examinations. In increased evaluation claims, a VA examination report is not adequate without an explanation for an examiner’s failure to evaluate the functional effects of a flare-up. Sharp v. Shulkin, 29 Vet. App. 26 (2017). The Board may accept a VA examiner’s statement that he or she cannot offer an opinion in that regard without resorting to speculation, but only after determining that this is not based on the absence of procurable information or on a particular examiner’s shortcomings or general aversion to offering an opinion on issues not directly observed. Although not binding on VA examiners, the VA Clinician’s Guide instructs examiners when evaluating certain musculoskeletal conditions to obtain information about the severity, frequency, duration, precipitating and alleviating factors, and extent of functional impairment of flares from the veterans themselves. Sharp, 29 Vet. App. at 34-35, citing VA CLINICIAN’S GUIDE, ch. 11. For example, a VA examination report is not adequate when the VA examiner failed to elicit relevant information as to the veteran’s flares or ask him to describe the additional functional loss, if any, he suffered during flares and then estimate the veteran’s functional loss due to flares based on all the evidence of record- including the veteran’s lay information-or explain why she or he could not do so. Sharp, 29 Vet. App. at 34-35. Also, 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. 38 C.F.R. § 4.59 (2018); Correia v. McDonald, 28 Vet. App. 158 (2016). The most recent knee VA examination was conducted in April 2017. The Veteran reported having flare-ups in her knees that occurred 15 days per month, lasting all day. While flaring, her knees limited to walking initially only a few feet and then walking a total of 50 feet before having to sit. She could also stand for 15 minutes before needing to sit, though the examiner noted that she also had back and hip symptoms that contributed to this limitation. However, when asked whether pain, weakness, fatigability, or incoordination significantly limited functional ability with flare-ups, the examiner was unable to say without resorting to mere speculation because the history provided by the Veteran was not specific enough to determine this. This examination is inadequate because the examiner failed to elicit relevant information from the Veteran regarding her flares or ask her to describe the additional functional loss she suffers during flares. The Veteran did describe some loss, but her description is not sufficient for rating purposes. In addition, the range of motion findings for the knee examination indicate that there was pain but did not specify where the pain had onset during motion. Not only is this inconsistent with the Court’s holding in Correia, it further is inadequate for rating purposes because the Board is unable to ascertain the extent of functional limitation attributable to pain in the Veteran’s knees. The matters are REMANDED for the following action: 1. Contact the appropriate VA Medical Center and obtain and associate with the claims file all outstanding records of treatment. If any requested records are not available, or the search for any such records otherwise yields negative results, that fact must clearly be documented in the claims file. Efforts to obtain these records must continue until it is determined that they do not exist or that further attempts to obtain them would be futile. The non-existence or unavailability of such records must be verified and this should be documented for the record. Required notice must be provided to the Veteran and his or her representative. 2. After any additional records are associated with the claims file, provide the Veteran with an appropriate examination to determine the etiology of her low back disorder. The entire claims file must be made available to and be reviewed by the examiner. Any indicated tests and studies must be accomplished and all clinical findings must be reported in detail and correlated to a specific diagnosis. An explanation for all opinions expressed must be provided. The examiner must provide an opinion regarding whether it is at least as likely as not (50 percent or greater probability) that the Veteran’s back disorder had onset in, or is otherwise related to, active military service. The examiner must also provide an opinion whether it is at least as likely as not (50 percent or greater probability) that the back disorder is caused or aggravated by the service-connected bilateral knee disorder. The examiner must address the lay statements of record and the prior VA examinations of record. 3. After any additional records are associated with the claims file, provide the Veteran with an appropriate examination to determine the etiology of her psychiatric disorder. The entire claims file must be made available to and be reviewed by the examiner. Any indicated tests and studies must be accomplished and all clinical findings must be reported in detail and correlated to a specific diagnosis. An explanation for all opinions expressed must be provided. The examiner should determine what psychiatric disorders are present. Any diagnosis should be reconciled with the previous diagnoses of bipolar disorder and major depressive disorder of record. The examiner must provide an opinion regarding whether it is at least as likely as not (50 percent or greater probability) that each psychiatric disorder had onset in, or is otherwise related to, active military service. The examiner must also provide an opinion whether it is at least as likely as not (50 percent or greater probability) that each psychiatric disorder is caused or aggravated by the service-connected bilateral knee disorder. The examiner must address the lay statements of record and the prior opinions of record. 4. After any additional records are associated with the claims file, provide the Veteran with an appropriate examination to determine the severity of the service-connected bilateral knee disorder. The entire claims file must be made available to and be reviewed by the examiner. Any indicated tests and studies must be accomplished and all clinical findings must be reported in detail and correlated to a specific diagnosis. An explanation for all opinions expressed must be provided. The relevant Disability Benefits Questionnaire must be utilized. The examiner is also asked to indicate the point during range of motion testing that motion is limited by pain. The examiner must test the range of motion and pain of the right and left knees in active motion, passive motion, weight-bearing, and non-weight-bearing. If the examiner is unable to conduct the required testing or concludes that the required testing is not necessary, he or she should clearly explain why that is so. In addition, describe any functional limitation due to pain, weakened movement, excess fatigability, pain with use, or incoordination. Additional limitation of motion during flare-ups and following repetitive use due to limited motion, excess motion, fatigability, weakened motion, incoordination, or painful motion must also be noted. If the Veteran describes flare-ups of pain, the examiner must offer an opinion as to whether there would be additional limits on functional ability during flare-ups. All losses of function due to problems such as pain should be equated to additional degrees of limitation of flexion and extension beyond that shown clinically. Should the examiner state that he or she is unable to offer such an opinion without resorting to speculation based on the fact that the examination was not performed during a flare, the examiner is directed to do all that reasonably can be done to become informed before such a conclusion, to include ascertaining adequate information-i.e. frequency, duration, characteristics, severity, or functional loss-regarding her flares by alternative means. 5. Notify the Veteran that it is his responsibility to report for any scheduled examination and to cooperate in the development of the claims, and that the consequences for failure to report for a VA examination without good cause may include denial of the claims. 38 C.F.R. §§ 3.158, 3.655 (2017). In the event that the Veteran does not report for any scheduled examination, documentation must be obtained which shows that notice scheduling the examination was sent to the last known address. It must also be indicated whether any notice that was sent was returned as undeliverable.   6. Ensure compliance with the directives of this remand. If the report is deficient in any manner, the AOJ must implement corrective procedures. Stegall v. West, 11 Vet. App. 268, 271 (1998). K. MILLIKAN Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Steve Ginski, Associate Counsel