Citation Nr: 18158076 Decision Date: 12/14/18 Archive Date: 12/14/18 DOCKET NO. 17-49 976 DATE: December 14, 2018 REMANDED Entitlement to an increased rating in excess of 30 percent for left knee limitation of extension, previously rated as internal derangement, is remanded. REASONS FOR REMAND The Veteran served in the United States Marines from August 1958 to August 1962. Left Knee Although the Board sincerely regrets further delay, additional development is required prior to adjudication of the Veteran’s claim. In October 2015, the Veteran received a VA examination. The examiner noted that the examination was for the Veteran’s left knee condition and noted the claimed condition was traumatic arthritis. However, upon examination, the examiner noted that it was the Veteran’s right knee that had abnormal range of motion (ROM) with flexion limited to 100 degrees and extension limited to 20 degrees, while the left knee was marked as normal. The examiner then provided that the Veteran suffered from pain, fatigue, weakness, and lack of endurance that significantly limited functional ability in his right knee, with no mention of the Veteran’s left knee. The examiner also provided that the Veteran’s right knee had decreased muscle strength, while his left knee had full strength, and stated the reduction in strength of the right knee was entirely due to the claimed condition in the diagnosis section; however, the Board again notes that claimed condition in the diagnosis section was traumatic arthritis of the left knee. The examiner then provided that there was slight recurrent subluxation and lateral instability in the left knee. In December 2015, the Veteran was provided another VA examination with the same VA examiner. The examiner again noted that the examination was for the Veteran’s left knee condition and noted the claimed condition was traumatic arthritis. Upon examination, the examiner provided that the Veteran’s range of motion (ROM) for his left knee was outside of normal range and normal for his right knee. The Veteran’s left knee flexion was to 100 degrees and his extension was to 0 degrees. The examiner noted the Veteran’s ROM itself contributed to functional loss due to decreased flexion with pain and weakness that required use of a walker. The Veteran was able to perform repetitive testing and there was additional functional loss of ROM after three repetitions in his left knee. The examination was not being conducted during a flare-up, however, the examiner noted the examination was medically consistent with the Veteran’s statements describing functional loss. The examiner noted that pain, weakness, fatigue, and lack of endurance significantly limited functional ability during flare-ups in his left knee. The Veteran also had slight recurrent subluxation and slight lateral instability in his left knee only. The Board finds the October 2015 and December 2015 VA examinations inadequate to fairly adjudicate the Veteran’s increased rating claim. To begin, it appears the examiner in the October 2015 examination inaccurately put the ROM readings and other mentions of pain, flare-ups, and functional loss, that was meant for the left knee under the right knee. However, as there was no clarification provided, the Board cannot affirmatively assume that the limitation of extension and flexion noted on the right knee in the October 2015 examination was meant for the left knee. Secondly, in the December 2015 examination, the examiner noted that the Veteran’s right knee was normal and that there was no limitation of extension in the Veteran’s left knee. If in the October 2015 examination the examiner meant the Veteran’s left knee suffered from the limitation of extension to 20 degrees, it is conflicting that only two months later the Veteran’s left knee would have absolutely no limitation in extension. Therefore, clarification of the Veteran’s October 2015 and December 2015 examinations is required. Further, in an October 2015 rating decision, the Regional Office (RO), based off the October 2015 examination, changed the Veteran’s left knee designation from Internal Derangement under Diagnostic Code 5257 (now referred to as Recurrent Subluxation or Lateral Instability) to Diagnostic Code 5261 for Limitation of Extension. However, the October 2015 examination noted the limitation of extension as the Veteran’s right knee, and thus, the RO should have gotten clarification. Given all of the above, a remand is required in order to get clarification on the conflicting October 2015 and December 2015 VA examinations, and proper consideration of left knee limitation of extension and lateral instability or recurrent subluxation separately for rating purposes. The matter is REMANDED for the following action: 1. Obtain and associate with the Veteran’s electronic claims file any outstanding VA treatment records and private medical records relevant to the Veteran’s claim. 2. After all outstanding records have been associated with the claims file, send the claims file to the examiner that performed the October 2015 and December 2015 VA examinations. The record and a copy of this Remand must be made available to the examiner. If the examiner determines that an examination of the Veteran is necessary to provide the requested opinion with rationale, then such examination should be scheduled. Further, if the October 2015/December 2015 examiner is not available, then a new examination should be scheduled. (a) If the October 2015/December 2015 VA examiner is available, then, following a review of the entire record, the examiner should clarify whether his descriptions under the right knee in the October 2015 examination were in fact meant to be listed under the Veteran’s left knee, to include the limitation of extension to 20 degrees that was noted under the right knee. If the readings were in fact meant for the Veteran’s left knee, is it accurate that only two months later in the December 2015 examination the Veteran did not suffer from any limitation of extension? (b) If a new examination is scheduled, whether with the October 2015/December 2015 examiner or a new examiner, then, following a review of the entire record, to include the Veteran’s lay statements regarding his current symptoms, the examiner should identify any findings related to the Veteran’s left knee condition and fully describe the current extent and severity of those symptoms. M. Tenner Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD J. Negron, Associate Counsel