Citation Nr: 18158490 Decision Date: 12/17/18 Archive Date: 12/17/18 DOCKET NO. 16-53 504A DATE: December 17, 2018 REMANDED Entitlement to an initial compensable evaluation for the residuals of a right anterior cruciate ligament (ACL) tear and right knee sprain is remanded. REASONS FOR REMAND The Veteran served on active duty from November 2007 to November 2012. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a March 2013 rating decision. The Veteran was most recently afforded a VA knee examination in November 2012. However, in light of a decision issued by the United States Court of Appeals for Veterans Claims (Court), a remand is required. In Correia v. McDonald, 28 Vet. App. 158, 169 (2016), the Court held that § 4.59 creates a requirement that 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,” as well as the necessary findings to evaluate functional loss during flare-ups. See also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011); Deluca v. Brown, 8 Vet. App. 202, 206-07 (1995). In this case, the November 2012 VA examination report did not include these findings. Therefore, the Veteran should be afforded an additional VA examination to ascertain the severity and manifestations of his service-connected right knee disability in compliance with the requirements of Correia. In addition, in the Veteran’s November 2016 substantive appeal, he indicated that his private primary care physician had referred him to a private orthopedic specialist for treatment of his right knee disability. On remand, attempts should be made to obtain any outstanding private treatment records. The matter is REMANDED for the following action: 1. The Agency of Original Jurisdiction (AOJ) should request that the Veteran provide the names and addresses of any and all health care providers who have provided treatment for his service-connected right knee disability. A specific request should be made for any private treatment records from the Veteran’s private primary care physician and private orthopedic specialist, as identified in the November 2016 substantive appeal. After acquiring this information and obtaining any necessary authorization, the AOJ should obtain and associate these records with the claims file. The AOJ should also secure any outstanding VA medical records. 2. After obtaining any outstanding records, the Veteran should be afforded a VA examination to ascertain the severity and manifestations of his service-connected right knee disability. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner is requested to review all pertinent records associated with the claims file. The examiner should note that the Veteran is competent to attest to factual matters of which he has first-hand knowledge, including observable symptomatology. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. The examiner should report all signs and symptoms necessary for rating the right knee disability under the rating criteria. In particular, the examiner should provide the range of motion in degrees of the right and left knees. In so doing, the examiner should test the Veteran’s range of motion of both knees in active motion, passive motion, weight-bearing, and nonweight-bearing. 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 so in the report. The examiner should also indicate whether there is any ankylosis; dislocated semilunar cartilage with frequent episodes of locking, pain and effusion into the joint; or the symptomatic removal of semilunar cartilage. He or she should also address whether the Veteran has recurrent subluxation or lateral instability, and if so, comment as to whether such symptomatology is slight, moderate, or severe. The examiner should further state whether the Veteran has any impairment of the tibia and fibula. The presence of objective evidence of pain, excess fatigability, incoordination and weakness should also be noted, as should any additional disability (including additional limitation of motion) due to these factors. Further, the VA examiner should comment as to whether range of motion measurements for active motion, passive motion, weight-bearing, and/or nonweight-bearing can be estimated for the other VA examination conducted during the appeal period in November 2012. If the examiner is unable to provide a retrospective opinion as to these specific range of motion findings, he or she should clearly explain so in the report. A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. Because it is important “that each disability be viewed in relation to its history[,]” 38 C.F.R. § 4.1, copies of all pertinent records in the appellant’s claims file, or in the alternative, the claims file, must be made available to the examiner for review. J.W. ZISSIMOS Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD K. Osegueda, Counsel