Citation Nr: 18150239 Decision Date: 11/14/18 Archive Date: 11/14/18 DOCKET NO. 16-41 353 DATE: November 14, 2018 REMANDED Entitlement to an initial compensable rating from November 1, 2013, to December 13, 2016, and to a rating in excess of 10 percent from December 13, 2016, for left medial and lateral epicondylitis is remanded. Entitlement to an initial compensable rating from November 1, 2013, to December 13, 2016, and to a rating in excess of 10 percent from December 13, 2016, for right medial and lateral epicondylitis is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Navy from July 1986 to October 2000, and served in the United States Air Force from May 2002 to October 2013. The record reflects that the Veteran was afforded a VA examination in July 2013. An addendum opinion was obtained in July 2016, and another VA examination was conducted in December 2016. The Board finds that the examination findings of record are not sufficient to rate the Veteran’s service-connected elbow disabilities. In particular, the opinions do not provide an evaluation of the impairment the Veteran experiences during flare-ups and with repeated use over time. In evaluating joint disabilities, VA must consider granting a higher rating in cases in which functional loss due to pain, weakness, excess fatigability, or incoordination is demonstrated, and those factors are not contemplated in the relevant rating criteria. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202 (1995). The United States Court of Appeals for Veterans Claims (Court), in Correia v. McDonald, 28 Vet. App. 158 (2016), held 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. Further, in Sharp v. Shulkin, 29 Vet. App. 26 (2017), the Court also addressed the adequacy of VA orthopedic examinations. The Court held that when a VA examiner is asked to opine as to additional functional loss during flare-ups of a musculoskeletal disability, such opinion must be based on all procurable and assembled medical evidence, to include eliciting relevant information from the veteran as to the flare (i.e., the frequency, duration, characteristics, severity, or functional loss), and such opinion cannot be based on the insufficient knowledge of the specific examiner. The Court found the VA examination report in that case inadequate because the examiner merely indicated that an opinion could not be provided without resorting to speculation because the Veteran was not undergoing a flare-up at the time of the examination. In this case, the July 2016 and December 2016 VA clinicians found that they could not determine whether pain, weakness, fatigability, or incoordination significantly limited functional ability with repeated use over time or with flare-ups without resorting to speculation because the Veteran was not examined after repeated use over time or during a flare-up. However, the Veteran has provided information regarding his additional symptoms with repetitive use and during flare-ups, indicating further limitations on functional ability. As in Sharp, this finding does not adequately depict additional functional loss. Accordingly, a new VA examination and opinion are needed. The matter is REMANDED for the following action: 1. Obtain outstanding VA treatment records from July 2013. 2. Contact the Veteran and ask him to identify any relevant outstanding private treatment records and assist him in obtaining such records. 3. Schedule the Veteran for a VA examination with an appropriate professional to determine the extent and severity of his service-connected bilateral medial and lateral epicondylitis disabilities. (a.) All indicated tests should be performed, including range of motion findings expressed in degrees and in relation to normal range of motion. (b.) The examination should include testing results on both active and passive motion, and in weight-bearing, and nonweight-bearing. The examiner should assess where pain begins on the Veteran’s initial range of motion and upon repetitive testing. The examiner should also describe any pain, weakened movement, excess fatigability, and incoordination present. If the examiner is unable to conduct such testing or concludes that the required testing is not necessary in this case, he or she should clearly explain why that is so. (c.) The examiner should estimate any additional functional loss in terms of additional degrees of limited motion of the bilateral elbows experienced during flare-ups and repetitive use over time. If the examiner cannot provide the above-requested opinion without resorting to speculation, he or she should state whether all procurable medical evidence had been considered, to specifically include the Veteran’s descriptions as to the severity, frequency, and duration of the flare-ups and his description as to the extent of functional loss during a flare-up and after repetitive use over time; whether the inability is due to the limits of the medical community or the limits of the examiner’s medical knowledge; and whether there is additional evidence, which if obtained, would permit the opinion to be provided. (d.) Although review of the entire record is requested, the examiner’s attention is specifically directed towards the Veteran’s lay statements at the December 2016 VA examination and in a December 2016 letter regarding his symptoms and flare-ups. (e.) The examiner is further asked to discuss any occupational impact of the Veteran’s service-connected bilateral medial and lateral epicondylitis disabilities. (f.) All opinions expressed should be accompanied by supporting rationale. (Continued on the next page)   4. Thereafter, readjudicate the issues on appeal. If the benefits sought are not granted to the Veteran’s satisfaction, the Veteran and his representative should be furnished a Supplemental Statement of the Case and afforded a reasonable opportunity to respond before the record is returned to the Board for further review. L. M. BARNARD Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Rachel E. Jensen, Associate Counsel