Citation Nr: 18151338 Decision Date: 11/16/18 Archive Date: 11/16/18 DOCKET NO. 16-43 189 DATE: November 16, 2018 REMANDED Entitlement to an increased rating for chondromalacia of the left knee is remanded. Entitlement to an increased rating for chondromalacia of the right knee is remanded. REASONS FOR REMAND The Veteran served on active duty from February 1975 through February 1979 and from May 1979 to May 1995. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a September 2015 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). 1. Entitlement to an increased rating for chondromalacia of the left knee. Remand is required regarding this appeal for a new examination. First, in increased evaluation claims, 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 (2017); Correia v. McDonald, 28 Vet. App. 158 (2016). In this case, the VA examiner’s report does not provide range of motion testing for pain on active and passive motion. The Board thus finds that the dictates of Correia have not been fully satisfied in the present case. Accordingly remand for a new VA examination is required. Second, when a claimant asserts, or the evidence shows, that the severity of a disability has increased since the most recent rating examination, an additional examination is appropriate. VAOPGCPREC 11-95 (April 7, 1995); Snuffer v. Gober, 10 Vet. App. 400 (1997). At the September 2015 VA examination, the Veteran reported no pain or flares in her knees and good range of motion. However, since this time the Veteran stated that she lives in constant pain twenty-four hours a day, can barely walk, and cannot go places because of her limitations. See August 2016 substantive appeal. In addition, evidence associated with the claims file after September 2015 suggest a potential worsening of both knees and need for additional surgical intervention. See September 2017 private treatment record. Accordingly, remand for a new VA examination is required. 2. Entitlement to an increased rating for chondromalacia of the right knee. Remand is required regarding this issue for a new examination. First, remand is required for an adequate examination. The September 2015 VA examination did not include joint testing for pain on both active and passive motion, weight-bearing and nonweight-bearing or, if possible, with range of motion measurements of the opposite undamaged joint. 38 C.F.R. § 4.59; Correia, 28 Vet. App. at 158. Second, remand is required for a current examination. Since the September 2015 VA examination, the Veteran asserts, and the evidence shows, the severity of her bilateral knee disorders has increased. See Snuffer, 10 Vet. App. at 400; August 2016 substantive appeal; September 2017 private treatment record. Accordingly, remand for a new VA examination is required. 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. Obtain the Veteran’s service treatment records. 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. Contact the Veteran and afford her the opportunity to identify by name, address and dates of treatment or examination any relevant medical records, including Dr. KM mentioned as the September 2017 surgeon. Subsequently, and after securing the proper authorizations where necessary, make arrangements to obtain all the records of treatment or examination from all the sources listed by the Veteran which are not already on file. All information obtained must be made part of the file. All attempts to secure this evidence must be documented in the claims file, and if, after making reasonable efforts to obtain named records, they are not able to be secured, provide the required notice and opportunity to respond to the Veteran and his representative. 3. 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 knee disabilities. The entire claims file must be made available to and be reviewed by the examiner, including the Veteran’s private treatment records, post-service VA medical records, and assertions. 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 utilize the appropriate Disability Benefits Questionnaire. 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 bilateral 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. The examiner must 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 his flares by alternative means. 4. Notify the Veteran that it is her 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. K. MILLIKAN Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD S. Martinez, Associate Counsel