Citation Nr: 18147679 Decision Date: 11/06/18 Archive Date: 11/05/18 DOCKET NO. 16-34 486 DATE: November 6, 2018 REMANDED Entitlement to service connection for left knee disability is remanded. Entitlement to an increased rating in excess of 20 percent for the service-connected intervertebral disc disease of the lumbar spine is remanded. REASONS FOR REMAND The Veteran served on active duty from April 2002 to April 2006 and he served in Iraq from January 2003 to July 2003. This appeal to the Board of Veterans’ Appeals (Board) is from a January 2014 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. The Board finds that additional development is needed before the Veteran’s claim on appeal can be decided. VA’s duty to assist a claimant includes providing a medical examination or obtaining a medical opinion when an examination or opinion is necessary to make a decision on the claim. 38 U.S.C. § 5103A (d)(1) (2012). The Veteran underwent an examination of his service-connected lumbar spine disability in 2013. Evidence added to the record since the examination reflects a possible worsening. See the July 2016 VA Form 9 and statement by the Veteran. Thus, a new examination is needed to determine the current level of severity of the lumbar spine disability. The Board also finds that an additional medical examination is necessary to determine whether the Veteran currently has a left knee disability separate from the service-connected left lower extremity radiculopathy. The November 2013 VA examination report indicates that the Veteran did not have knee pathology. However, there is evidence that the Veteran continues to have knee pain. See the July 2016 statement and VA Form 9. The Board notes that upon the January 2006 separation examination, the Veteran reported having bilateral knee pain. A July 2006 VA treatment record notes that the Veteran had chronic mild bilateral knee pain and the assessment was probable patella femoral syndrome. The Board also notes that service connection for left lower extremity radiculopathy was granted in a May 2012 rating decision and that this disability is evaluated as 10 percent disabling. The agency of original jurisdiction (AOJ) should obtain copies of any outstanding VA treatment records showing treatment of the service-connected lumbar spine disability and the claimed left knee disability dated from November 2014 to present. 38 U.S.C. § 5103A (b)(1). The matters are REMANDED for the following action: 1. Obtain copies of any relevant and outstanding VA treatment records pertaining to the Veteran’s low back and left knee dated from November 2014 to present. 2. Then, schedule the Veteran for an examination by an appropriate clinician to determine the current severity of the service-connected lumbar spine disability, and to determine the nature and etiology of the claimed left knee disability. a. With regard to the Veteran’s service-connected low back disability, the examiner is asked to: (1) test the range of motion of the Veteran’s lumbar spine in active motion, passive motion, and (where appropriate) weight-bearing and nonweight-bearing settings. 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 why that is so. The examiner must report the presence (including degree) or absence of painful motion, weakened movement, excess fatigability, or incoordination in the lumbar spine. These determinations should be expressed in terms of the degree of additional range-of-motion loss due to any painful motion, weakened movement, excess fatigability, or incoordination. (2) report whether there is favorable or unfavorable ankylosis of the thoracolumbar spine and the total duration of any incapacitating episodes caused by the service-connected lumbar spine disability during the past 12 months. (3) provide a detailed assessment of the severity of the lower extremity radiculopathy. The level of nerve impairment for each such nerve must be described as “mild,” “moderate,” “moderately severe,” or “severe” disability. b. With regard to the Veteran’s left knee, the examiner should: (1) specify whether the Veteran has a current left knee diagnosis separate from his left lower extremity radiculopathy. (2) If the Veteran has a current left knee disability, the examiner should opine whether the left knee disability is at least as likely as not related to an in-service injury, event, or disease. The VA examiner should provide a complete rationale for each opinion rendered. If the VA examiner determines that he or she is unable to provide the requested medical opinion without resorting to speculation, the examiner should indicate this in the report. THERESA M. CATINO Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD C.L. Krasinski, Counsel