Citation Nr: 18149678 Decision Date: 11/13/18 Archive Date: 11/13/18 DOCKET NO. 17-57 535 DATE: November 13, 2018 REMANDED Entitlement to an evaluation in excess of 10 percent for degenerative joint disease (DJD) of the lumbar spine is remanded. Entitlement to an evaluation in excess of 10 percent for radiculopathy of the right lower extremity associated with DJD of the lumbar spine is remanded. Entitlement to an evaluation in excess of 10 percent for radiculopathy of the left lower extremity associated with DJD of the lumbar spine is remanded. Entitlement to service connection for left shoulder disorder is remanded. Entitlement to service connection for right knee disorder is remanded. Entitlement to service connection for left knee disorder is remanded. REASONS FOR REMAND The Veteran served on active duty from March 1979 to March 1999. These matters come before the Board of Veterans’ Appeals (Board) on appeal from a September 2016 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Winston-Salem, North Carolina. During the course of the appeal, in September 2016 and October 2018 rating decisions, the RO granted service connection and assigned separate, initial ratings for radiculopathy of the right and left lower extremities, both evaluated as 10 percent disabling, effective June 16, 2016 for the right extremity and July 30, 2018 for the left extremity. The Board notes that the September 2017 statement of the case (SOC) did not include all issues identified in the Veteran’s November 2016 VA Form 21-0958 (NOD), namely entitlement to service connection for a left hip disorder. However, the Board finds no error in this omission and concludes that the matters as stated on the title page are the only issues properly before the Board. Specifically, the November 2016 NOD addressed the September 2016 Rating Decision which deferred, but did not issue any final adjudication with respect to the issue of entitlement to service connection for a left hip disorder. This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900 (c). 38 U.S.C. § 7107 (a)(2). 1. Entitlement to an increased evaluation for degenerative joint disease (DJD) lumbar spine is remanded. 2. Entitlement to an increased evaluation of radiculopathy left lower extremity associated with DJD lumbar spine is remanded. 3. Entitlement to an increased evaluation of radiculopathy right lower extremity associated with DJD lumbar spine is remanded. The Court of Appeals for Veterans Claims (Court) held in Correia v. McDonald, 28 Vet. App. 158 (2016), that the final sentence of 38 C.F.R. § 4.59 requires that VA examinations 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. 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 claim. An additional relevant opinion pertaining to flare-ups was also issued by the Court in Sharp v. Shulkin, 29 Vet. App. 26 (2017). 4. Entitlement to service connection for left shoulder disorder is remanded. 5. Entitlement to service connection for right knee disorder is remanded. 6. Entitlement to service connection for left knee disorder is remanded. Regarding entitlement to service connection for a left shoulder disorder, to date, the Veteran has not been afforded an examination. The Board notes that upon VA examination in June 2016 for his service-connected right shoulder disability, the examiner identified that the left shoulder is “symptomatic and abnormal on exam,” however he was not authorized to render a conclusion about the extremity and thus, no diagnosis was reported, despite the claims file reflecting left shoulder maladies including osteoarthritis. The Board finds that the existence of a current disability, coupled with an April 1992 in-service report of “(L) shoulder pain” meets the low threshold for requiring an examination to determine etiology of the claimed disorder. See McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006). Regarding the Veteran’s claims for entitlement to service connection for bilateral knee disorders, the Board finds that evidence currently of record is insufficient to rely upon for a proper adjudication of these claims. Specifically, an addendum VA medical opinion is necessary to clarify the lack of any identified diagnosis during the August 2017 VA examination despite the Veteran’s reports of ongoing pain stemming from the in-service documented treatment for knee problems and the VA examiner’s own finding of “minor” bilateral crepitus of “no clinical significance.” This clarifying addendum opinion should additionally account for the identified diagnoses of bilateral knee disorders in the record, including an April 2016 VAMC Primary Care note documenting “osteoarthritis of both knees.” The matters are 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 an appropriate VA examination to evaluate the service-connected low back disability. The Veteran’s claims folder must be reviewed by the examiner. (a) In reporting the results of range of motion testing, the examiner should identify any objective evidence of pain, and the degree at which pain begins. (b) Pursuant to Correia v. McDonald, the examination should record the results of range of motion testing for pain on BOTH active and passive motion AND in weight-bearing and nonweight-bearing. If the back cannot be tested on “weight-bearing,” then the examiner must specifically indicate that such testing cannot be done. (c) The examiner should also express an opinion concerning whether there would be additional functional impairment on repeated use or during flare-ups assessed in terms of the degree of additional range of motion loss. In regard to flare-ups (pursuant to Sharp v. Shulkin, 29 Vet. App. 26 (2017)) if the Veteran is not currently experiencing a flare-up, based on relevant information elicited from the Veteran, review of the file, and the current examination results regarding the frequency, duration, characteristics, severity, and functional loss regarding his flares, the examiner is requested to provide an estimate of the Veteran’s functional loss due to flares expressed in terms of the degree of additional range of motion lost, or explain why the examiner cannot do so. [The Board recognizes the difficulty in making such determinations but requests that the examiner provide his or her best estimate based on the examination findings and statements of the Veteran.] 2. Schedule the Veteran for a VA examination by an appropriate medical professional to determine the nature and etiology of his bilateral knee and left shoulder disabilities. All necessary tests and studies related to the claim should be conducted. The examiner is to provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that any current knee and left shoulder disabilities (including crepitus in the knees noted on the August 2017 VA examination and “osteoarthritis of both knees” noted in an April 2016 VAMC Primary Care record) had their onset during, or were otherwise related to an in-service disease or injury. A complete rationale should be provided for all opinions expressed. TANYA SMITH Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Marcus J. Colicelli, Associate Counsel