Citation Nr: 18159693 Decision Date: 12/19/18 Archive Date: 12/19/18 DOCKET NO. 16-48 771 DATE: December 19, 2018 ORDER New and material evidence has been received, and the request to reopen the claim for entitlement to service connection for a low back disability, to include as secondary to service-connected degenerative joint disease post-operative residuals of right ankle injury, is granted. New and material evidence has been received, and the request to reopen the claim for entitlement to service connection for a left knee disability, to include as secondary to service-connected degenerative joint disease post-operative residuals of right ankle injury, is granted. New and material evidence has been received, and the request to reopen the claim for entitlement to service connection for bilateral foot calluses, to include as secondary to service-connected degenerative joint disease post-operative residuals of right ankle injury, is granted. Entitlement to service connection for a right knee disability to include as secondary to service-connected degenerative joint disease post-operative residuals of right ankle injury is denied. Entitlement to service connection for a low back disability, to include as secondary to service-connected degenerative joint disease post-operative residuals of right ankle injury is granted. REMANDED Entitlement to service connection for a neck disability to include as secondary to service-connected degenerative joint disease post-operative residuals of right ankle injury is remanded. Entitlement to service connection for a left knee disability to include as secondary to service-connected degenerative joint disease post-operative residuals of right ankle injury is remanded. Entitlement to service connection for bilateral foot calluses to include as secondary to service-connected degenerative joint disease post-operative residuals of right ankle injury is remanded. Entitlement to a rating greater than 20 percent for degenerative joint disease post-operative residuals of right ankle injury is remanded. FINDINGS OF FACT 1. An unappealed August 2011 Board decision denied the Veteran service connection for a low back disability and is final. 2. An unappealed August 2011 Board decision denied the Veteran service connection for a left knee disability and is final. 3. An unappealed August 2011 Board decision denied the Veteran service connection for bilateral foot calluses and is final. 4. The Veteran does not have a current right knee disability. 5. The Veteran’s low back disability is secondary to the Veteran’s service-connected right ankle disability. CONCLUSIONS OF LAW 1. The August 2011 rating decision is final; new and material evidence has been received to reopen the claim of service connection for a low back disability. 38 U.S.C. §§ 5108, 7104; 38 C.F.R. §§ 3.104, 3.156, 20.1103. 2. The August 2011 rating decision is final; new and material evidence has been received to reopen the claim of service connection for a left knee disability. 38 U.S.C. §§ 5108, 7104; 38 C.F.R. §§ 3.104, 3.156, 20.1103. 3. The August 2011 rating decision is final; new and material evidence has been received to reopen the claim of service connection for bilateral foot calluses. 38 U.S.C. §§ 5108, 7104; 38 C.F.R. §§ 3.104, 3.156, 20.1103. 4. The criteria for service connection for a right knee disability are not met. 38 U.S.C. § 1131; 38 C.F.R. § 3.303. 5. The criteria for service connection for a low back disability are met. 38 U.S.C. § 1131; 38 C.F.R. § 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from October 1981 to October 1984. These matters come before the Board of Veterans' Appeals (Board) on appeal from a December 2014 rating decision. The Board notes that the Veteran is awaiting a hearing on the issue of entitlement to service connection for a right shoulder disability that he perfected in a July 2018 substantive appeal (via a VA form 9). That issue will be decided in a separate decision following the requested hearing. 1. Whether new and material evidence has been submitted to reopen the claim for service connection for a low back disability, to include as secondary to service-connected degenerative joint disease post-operative residuals of right ankle injury To reopen a claim following a final decision, new and material evidence must be submitted. 38 U.S.C. § 5108. New evidence means existing evidence not previously submitted to agency decisionmakers. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). Unless the Chairman orders reconsideration, or one of the other exceptions to finality apply, all Board decisions are final on the date stamped on the face of the decision and are not subject to revision on the same factual basis. 38 U.S.C. § 7104; 38 C.F.R. §§ 20.1100, 20.1104. By an August 2011 Board decision, the Board denied service connection for a low back disability, based on findings that the Veteran’s back pain began prior to the Veteran’s abnormal gait and that the Veteran’s abnormal gait was caused by the Veteran’s bilateral calluses. The Veteran did not appeal this decision and it is final. 38 U.S.C. § 7104; 38 C.F.R. § 3.156(b). Evidence submitted subsequent to the August 2011 Board decision includes VA treatment records, a VA examination report, and a private medical opinion from Dr. J.C. In a private medical report dated November 23, 2016, Dr. J.C. opined that it is more likely than not that the Veteran’s lower back disability is secondary to the Veteran’s right ankle injury and subsequent treatment and arthritis of the right ankle. The Board finds that these records are new and material evidence which directly relate to an unestablished fact necessary to substantiate the Veteran’s claim. The claim of entitlement to service connection for a low back disability is therefore reopened. 38 U.S.C. § 5108; 38 C.F.R. § 3.156(a). 2. Whether new and material evidence has been submitted to reopen the claim for service connection for a left knee disability, to include as secondary to service-connected degenerative joint disease post-operative residuals of right ankle injury By an August 2011 Board decision, the Board denied service connection for a left knee disability, based on findings that the Veteran’s left knee disability was not etiologically related to or aggravated by the Veteran’s right ankle disability. The Veteran did not appeal this decision and it is final. 38 U.S.C. § 7104; 38 C.F.R. § 3.156(b). Evidence submitted subsequent to the August 2011 Board decision includes VA treatment records, a VA examination report, and a private medical opinion from Dr. J.C. The Board finds that these records are new and material evidence which directly relate to an unestablished fact necessary to substantiate the Veteran’s claim. The claim of entitlement to service connection for a left knee disability is therefore reopened. 38 U.S.C. § 5108; 38 C.F.R. § 3.156(a). 3. Whether new and material evidence has been submitted to reopen the claim for service connection for bilateral foot calluses, to include as secondary to service-connected degenerative joint disease post-operative residuals of right ankle injury By an August 2011 Board decision, the Board denied service connection for bilateral foot calluses, based on findings that there the Veteran’s bilateral foot calluses were not directly related to service and that there is no indication that the Veteran’s right ankle disability aggravated the Veteran’s bilateral foot calluses. The Veteran did not appeal this decision and it is final. 38 U.S.C. § 7104; 38 C.F.R. § 3.156(b). Evidence submitted subsequent to the August 2011 Board decision includes VA treatment records, a VA examination report, and a private medical opinion from Dr. J.C. In a private medical report dated November 23, 2016, Dr. J.C. opined that it is likely that the Veteran’s calluses on the right foot, is a result of the ankle injury and the loss of motion of the right ankle. The Board finds that these records are new and material evidence which directly relate to an unestablished fact necessary to substantiate the Veteran’s claim. The claim of entitlement to service connection for bilateral foot calluses is therefore reopened. 38 U.S.C. § 5108; 38 C.F.R. § 3.156(a). 4. Entitlement to service connection for a right knee disability to include as secondary to service-connected degenerative joint disease post-operative residuals of right ankle injury Service connection may be granted for disability due to disease or injury incurred in or aggravated by service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. Service connection may be granted for any disease initially diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. § 3.303(d). To substantiate a claim of service connection, there must be evidence of: a current claimed disability; incurrence or aggravation of a disease or injury in service; and a nexus between the disease or injury in service and the claimed disability. See Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Further, service connection may be warranted for disability that is proximately due to or the result of a service-connected disability. 38 C.F.R. § 3.310 (a). Secondary service connection requires (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) medical nexus evidence establishing a connection between the service-connected disability and the current disability. Wallin v. West, 11 Vet. App. 509, 512 (1998). The Veteran was afforded a VA examination in July 2014. The examiner indicated that there was no diagnosis of the right knee. In addition, in a private medical opinion from Dr. J.C., dated November 2016, Dr. J.C. expressed that it does not appear that the Veteran has any “definite diagnostic abnormality of his right knee.” After a thorough review of the evidentiary record, the Board finds the Veteran is not entitled to service connection for his claimed right knee disability. The Board notes that the Veteran has not been diagnosed with a right knee disability. As there is no current diagnosis of a right knee disability, the criteria for service connection have not been met. The existence of a current disability is the cornerstone of a claim for VA disability compensation. 38 U.S.C. §§ 1110, 1131; Degmetich v. Brown, 104 F.3d 1328 (1997). The current disability requirement is satisfied when a claimant “has a disability at the time a claim for VA disability compensation is filed or during the pendency of that claim,” McClain v. Nicholson, 21 Vet. App. 319, 321 (2007), or “when the record contains a recent diagnosis of disability prior to... filing a claim for benefits based on that disability.” Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013). In the absence of proof of a current disability, there can be no valid claim. Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). The mere fact of a Veteran reporting subjective symptoms, whether knee pain, stiffness or otherwise, does not necessarily warrant a finding that he has met the current disability due to disease or injury requirement. Rather, in order for a Veteran to qualify for basic entitlement to compensation under 38 U.S.C. § 1110 or § 1131, the Veteran must prove existence of a disability, and one that has resulted from a disease or injury that occurred in the line of duty. See Sanchez-Benitez v. Principi, 259 F.3d 1356, 1361 (2001). As the preponderance of the evidence is against the claim, there is no reasonable doubt to be resolved in the Veteran’s favor, and the claim must be denied. 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1991). 5. Entitlement to service connection for a low back disability, to include as secondary to service-connected degenerative joint disease post-operative residuals of right ankle injury The Veteran contends that his low back disability is secondary to his service- connected right ankle disability. Specifically, the Veteran alleges that his low back disability is related to his abnormal gait caused by his service-connected right ankle disability. The Veteran also expressed that when he broke his ankle overseas, he had a leg length discrepancy and developed back pain due to walking uneven. For secondary service connection, it must be shown that the disability for which the claim is made is proximately due to or the result of service-connected disease or injury, or that service-connected disease or injury has aggravated the nonservice-connected disability for which service connection is sought. See 38 C.F.R. § 3.310. In a December 1984 VA ankle examination, the Veteran was noted to walk with a mild, but very definite right ankle stiff antalgic limp. In an January 1987 VA examination, the Veteran complained of back pains, however, the examination focused on his right ankle. The Veteran was noted to walk easily and well “without obvious limp.” In a July 1988 VA examination, the Veteran was noted to have “somewhat” of a “right stiff ankle gait.” In an October 1997 VA ankle examination, the Veteran was noted to walk with a limp on the right leg. In a March 2003 VA emergency room treatment note, the Veteran complained of back pain, left mid side with deep inspiration. The Veteran’s assessment was pleurisy. In July 2007, the Veteran was noted to walk with an antalgic gate, favoring the left side. In August 2007, the Veteran complained of low back pain following a camping trip and sleeping on a different mattress. The Veteran had muscles spasms on examination and was noted to have mild arthritis in his right ankle upon x-ray. A lumbar MRI from May 2009 revealed minimal disc bulge at several levels, and facet arthropathy with annular tear at L3-L4 and L4-L5. In an April 2009 VA treatment note, the Veteran reported a one-year history of low back pain. The Veteran denied any injury. In an August 2011 VA treatment note, the Veteran complained about back pain. The Veteran denied any trauma or injury. In an October 2012 VA podiatry note, the examiner noted that the Veteran now has left ankle and knee problems, and right knee and lower back problems due to change in gait secondary to an old right ankle fracture. The examiner noted that the Veteran has a shorter right lower leg by one-fourth of an inch to one-half of an inch secondary to right ankle disability. The Veteran was afforded a VA examination in October 2014. The Veteran was diagnosed with degenerative disc disease of the lumbar spine. The examiner opined that the Veteran’s low back disability was less likely than not proximately due or the result of the Veteran’s service-connected right ankle disability. The examiner expressed that she is unaware of any literature that supports a nexus between a previous right ankle fracture/right ankle post-traumatic arthritis and lumbar degenerative disc disease. The examiner stated that the “Veteran does not have a leg length inequality from his fractured ankle causing an abnormal gait.” In addition, the examiner noted that the Veteran has stated that his antalgic gait is secondary to the Veteran’s calluses and not his right ankle pain. Therefore, the examiner opined that the Veteran’s low back disability is less likely as not proximately due to or a result of the Veteran’s service-connected right ankle disability. In a November 2016 private medical opinion, Dr. J.C. evaluated the Veteran and reviewed the Veteran’s history and treatment over the years. The Veteran expressed that his right ankle condition has thrown off the Veteran’s back and he developed low back pain in the lumber spine over the years. The Veteran expressed that because of his altered gait, he shifts his weight and puts more stress on his lower back. The examiner noted that the Veteran’s right leg is shorter than the left. With regard to the Veteran’s lower back, the examiner noted that the Veteran has an altered gait. The examiner noted that the Veteran also has a stiff heel cord and a loss of motion of the right ankle. The examiner opined that the Veteran’s conditions has thrown off his back and upset the balance of the back. Even though the Veteran has some underlying degenerative change of the lumbar spine that everyone develops with old age, the examiner opined that it is more likely than not that the Veteran’s lower back condition is service-connected secondary to the right ankle injury and the subsequent treatment of the right ankle. Here, the lay evidence and the medical evidence are in relative equipoise. Under the benefit-of-the-doubt standard, when a claimant seeks benefits and the evidence is in relative equipoise, the claimant prevails. See Gilbert v. Derwinski, 1 Vet. App. 4 (1990). Therefore, the Board finds the Veteran’s low back disability is secondary to the Veteran’s service-connected right ankle disability. As such, service connection is warranted for his low back disability. REASONS FOR REMAND 1. Entitlement to service connection for a neck disability to include as secondary to service-connected degenerative joint disease post-operative residuals of right ankle injury is remanded. The Veteran contends that his neck disability is secondary to his service-connected right ankle disability. In a May 2004 VA treatment note, the Veteran called for a neck appointment after developing some neck pain. The Veteran stated that he had a prior history of whiplash in 1985 but it has never been a continuous problem. The Veteran stated that he works as a car salesman and that he has to do a lot of standing and computer work. The Veteran was afforded a VA examination in July 2014. The Veteran was diagnosed with multilevel cervical degenerative disc disease. The Veteran expressed that he did not hurt his neck in the military but stated that his pain started when he was “given the lift” in the shoe. The examiner opined that the Veteran’s neck condition was less likely than not incurred in or caused by service. In addition, the examiner opined that the Veteran’s neck condition was less likely than not proximately due to or the result of the Veteran’s service connected condition. The examiner expressed that after careful review of the Veteran’s service treatment records, VA treatment records, MRI reports, and interview and examination of the Veteran, it is the examiner’s opinion that the Veteran’s neck diagnosis is less likely than not related to his right ankle of even secondary to the condition. The examiner expressed that there is very little evidence in the literature that a right ankle condition could cause a neck condition. The examiner noted that the Veteran’s neck scan was done 29 years after the Veteran’s discharge from the military. The Board finds that the July 2014 VA opinion is inadequate for decision-making purposes as the examiner did not address aggravation. The Board notes that secondary service connection may be granted for either causation (in whole or in part) or aggravation. Thus, although the examiner reasoned that the Veteran’s neck disability was not caused by his right ankle disability, an opinion is necessary as to whether the Veteran’s neck disability has been aggravated by his right ankle disability. The Board further notes that the term “aggravation” refers to a chronic or permanent worsening of the underlying condition above and beyond its natural progression. Accordingly, the claim must be remanded so that an adequate opinion may be obtained from a different examiner. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). 2. Entitlement to service connection for a left knee disability to include as secondary to service-connected degenerative joint disease post-operative residuals of right ankle injury The Veteran contends that his left knee disability is secondary to his service-connected right ankle disability. In a December 1984 VA ankle examination, the Veteran was noted to walk with a mild, but very definite right ankle stiff antalgic limp. In an January 1987 VA examination, the Veteran was noted to walk easily and well “without obvious limp.” In a July 1988 VA examination, the Veteran was noted to have “somewhat” of a “right stiff ankle gait.” In an October 1997 VA ankle examination, the Veteran was noted to walk with a limp on the right leg. June 2006 x-rays of the Veteran’s left knee noted chondrocalcinosis and minimal degenerative joint disease. In a November 2006 VA treatment note, the Veteran complained of pain the medial aspect of his left knee which began after a long drive to Georgia. The Veteran denied any trauma to the knee. In January 2007, the Veteran underwent arthroscopy of the left knee following a diagnosis of left knee medial meniscus tear, chondral flap left knee medial condyle. The Veteran was afforded a VA left knee examination in May 2007. On physical examination, the Veteran was noted to have an antalgic gait on the left without assistive device. The Veteran’s shoes were noted to be more worn laterally on the right which the examiner attributed to his recent left knee surgery. The examiner reported that the Veteran’s primary care provider noted that the Veteran “did not demonstrate an abnormal gait that would put undue stress on the left knee related to the ankle.” The examiner also reported that the Veteran’s shoe wear pattern showed that he had been walking on his right foot and toeing off on the left because of a painful heel callus. The examiner opined that there was no evidence that his left knee condition was related to his right ankle condition. In May 2007, the Veteran’s VA orthopedic surgeon provided a statement that the Veteran’s left knee arthritis “correlates with [his] service connected condition.” In June 2007, the Veteran complained of increased left knee pain subsequent to feeling a “pop” in his knee after slipping on ice. A June 2007 x-ray of his left knee revealed significant degenerative pathology with joint space narrowing of the medial compartment with chondrocalcinosis noted both medially and laterally. In July 2007, the Veteran was noted to walk with an antalgic gate, favoring the left side. In a psychiatric note in February 2009, the Veteran expressed that he first had an ankle injury which led to his left knee problems, gait difficulties, and overcompensation of the left leg, prompting him to have left knee problems as well. The Veteran was noted to have walked with a severe limp. In an October 2012 podiatry note, the Veteran complained of deep calluses, both feet. The examiner noted that the Veteran now has left ankle and knee problems, and right knee and lower back problems due to change in gait secondary to old right ankle fracture. The examiner noted that the Veteran has a shorter right lower leg by one-fourth of an inch to one-half of an inch secondary to right ankle disability. The Veteran was afforded a VA examination in October 2014. The examiner opined that the Veteran’s left knee disability is less likely as not proximately due to or a result of the Veteran’s service-connected right ankle disability. The examiner noted that the Veteran does not have a leg length inequality from his right ankle condition that would cause an abnormal gait. The examiner noted that the Veteran has told other providers that his abnormal gait was secondary to his painful calluses and not his right ankle. The examiner expressed that neither orthopedics or his primary care providers have linked his right ankle disability to his left knee. Therefore, the examiner opined that the Veteran’s left knee is less likely than not proximately due to or a result of the Veteran’s service-connected right ankle disability. In a November 2016 private medical opinion, Dr. J.C. indicated that the Veteran’s right leg is shorter than his left. Dr. J.C. opined that the Veteran’s left knee disability is less likely than not related to the right ankle disability and it is more likely related to generalized wear and tear that comes with age. As noted above, secondary service connection may be granted for either causation (in whole or in part) or aggravation. Thus, although the examiners reasoned that the Veteran’s left knee disability was not caused by his right ankle disability, an opinion is necessary as to whether the Veteran’s left knee disability has been aggravated by his right ankle disability. The Board further notes that the term “aggravation” refers to a chronic or permanent worsening of the underlying condition above and beyond its natural progression. Accordingly, the claim must be remanded so that an adequate opinion may be obtained from a different examiner. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). 3. Entitlement to service connection for bilateral foot calluses to include as secondary to service-connected degenerative joint disease post-operative residuals of right ankle injury The Veteran contends that he has developed foot calluses as a result of favoring his service-connected right ankle. As noted above, for secondary service connection, it must be shown that the disability for which the claim is made is proximately due to or the result of service-connected disease or injury, or that service-connected disease or injury has aggravated the nonservice-connected disability for which service connection is sought. See 38 C.F.R. § 3.310. Treatment records in the claims file show that the Veteran suffers from calluses on both feet. In a December 1984 VA ankle examination, the Veteran was noted to walk with a mild, but very definite right ankle stiff antalgic limp. In a July 1988 VA examination, the Veteran was noted to have “somewhat” of a “right stiff ankle gait.” In an October 1997 VA ankle examination, the Veteran was noted to walk with a limp on the right leg. The Veteran also expressed that he has bilateral foot calluses and that he feels that his left foot is developing calluses because he is favoring his right foot. The Veteran was noted to have a plantar wart on his right foot beneath the fourth metatarsal head. In a March 1998 VA treatment records, the Veteran complained of calluses on both feet which had developed over “the past few years.” In a September 1999 VA treatment note the Veteran complained of painful bilateral foot calluses. The Veteran was afforded a VA left knee examination in May 2007. The VA examination addressed the Veteran’s in-service history of blisters and subsequent development of calluses. The examiner stated that the presence of calluses on both feet was an indication that there was “not an abnormal weight bearing just on the left foot due to the right ankle.” On physical examination, the Veteran was noted to have an antalgic gait on the left without assistive device. The examiner also reported that the Veteran’s shoe wear pattern showed that he had been walking on his right foot and toeing off on the left because of a painful heel callus. In July 2007, the Veteran was noted to walk with an antalgic gate, favoring the left side. In May 2009, the Veteran was noted to have an independent gait to the clinic without assistive devise. The Veteran walked on the outer edge of his right shoe due to painful calluses. In an October 2012 podiatry note, the Veteran complained of deep calluses, both feet. The examiner noted that the Veteran now has left ankle and knee problems, and right knee and lower back problems due to change in gait secondary to old right ankle fracture. The examiner noted that the Veteran has a shorter right lower leg by one-fourth of an inch to one-half of an inch secondary to right ankle disability. The Veteran was afforded a VA examination in October 2014. The Veteran stated that he favors his right ankle and therefore walks on the ball of his right foot and the back of his left foot. The Veteran indicated that the calluses are painful. After review of the records, and interview and examination of the Veteran, the examiner opined that it is less likely than not that the Veteran’s bilateral foot calluses are proximately due to or the result of the Veteran’s right ankle disability. The examiner expressed that the Veteran has bilateral calluses and the calluses are small and nontender on examination. The examiner noted that the Veteran’s podiatry treatment note reported that the Veteran’s right leg was shorter than the left but the examiner stated that it was not noted whether the Veteran’s legs were actually measured. The examiner indicated that after measuring the Veteran, the Veteran’s legs were both 97 centimeters. Therefore, the examiner reported that the Veteran does not have a leg length inequality from his previous ankle fracture that would cause an abnormal gait. The examiner opined that because calluses were on both feet, there was not an abnormal gait just on the left foot due to the right ankle. As a result, the examiner opined that the bilateral foot calluses were not proximately due to or a result of the Veteran’s service connected right ankle. In a November 2016 private medical opinion, Dr. J.C. evaluated the Veteran and reported that the Veteran’s right leg was shorter. The examiner also reported that the Veteran has an abnormal gait. The examiner opined that it is more likely than not that the calluses on the right foot, based on the history and review of the treatment over the years of the calluses, is a result of the ankle injury and the loss of motion of the right ankle. The examiner opined that with respect to the left foot calluses, it is less likely than not that the Veteran’s calluses are related to the right ankle. The Board finds that a new VA examination is warranted in order to address the conflicting medical opinions regarding whether the Veteran’s bilateral foot calluses are caused or aggravated by the Veteran’s right ankle disability. The Board finds the October 2014 VA examination inadequate as the examiner did not address whether the Veteran’s bilateral foot calluses were aggravated by the Veteran’s right ankle disability. In addition, new leg measurements are needed in order to determine whether or not the Veteran has a shorter right leg. Although the October 2014 VA examiner indicated that there was no leg inequality, the VA treatment records and the Veteran’s private medical opinion from Dr. J.C., both note that the Veteran’s right leg is shorter than the Veteran’s left leg and that there is an abnormal gait. Accordingly, the claim must be remanded so that an adequate opinion may be obtained from a different examiner. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). 4. Entitlement to a rating greater than 20 percent for degenerative joint disease post-operative residuals of right ankle injury is remanded. The Veteran contends that his right ankle disability warrants a rating in excess of 20 percent. Once VA has provided a VA examination, it is required to provide an adequate one, regardless of whether it was legally obligated to provide an examination in the first place. Barr v. Nicholson, 21 Vet. App. 303 (2007). Evaluations of joint disabilities must include a consideration of functional loss due to the factors listed under 38 C.F.R. § 4.45. DeLuca v. Brown, 8 Vet. App. 202 (1995). An examination is inadequate when the examiner declines to offer an opinion as to additional functional loss during flare ups due to a lack of direct observation of functionality under those circumstances. Sharp v. Shulkin, 29 Vet. App. 26 (2017). Instead, the examiner is required to elicit relevant information as to the Veteran’s flare ups, ask the Veteran to describe additional functional loss and then estimate the functional loss due to flare ups based on all the evidence of record. Id. at 34-35 The Veteran was afforded a VA examination in July 2014. The Veteran expressed that since his last VA examination in February 2012, the Veteran’s right ankle symptoms are about the same. The Veteran expressed that his right ankle bothers him when he walks on it for long periods. The Veteran denied pain on his right ankle on the date of this examination. The Veteran denied flare-ups that impact the function of his ankle. Range of motion in the right ankle was measured to 10 degrees plantar flexion and 10 degrees dorsiflexion with no objective evidence of painful motion. The examiner noted that the Veteran was able to perform repetitive-use testing with 3 repetitions. The Veteran’s right ankle post-test plantar flexion ended at 10 degrees. The Veteran’s right ankle post-test dorsiflexion ended at 10 degrees. The examiner noted that the Veteran did not have any additional limitation in range of motion for the ankle after repetitive-use testing. The examiner reported that the Veteran has functional loss and/or functional impairment of the ankle. The examiner noted that the Veteran had less movement than normal. The examiner noted that the Veteran does not have ankylosis of the ankle, subtalar and/or tarsal joint. The examiner reported that the Veteran does not have “shin splints,” stress fractures, achilles tendonitis, achilles tendon rupture, malunion of calcaneus (or calcis) or talus (astragalus). The examiner noted that the Veteran has not had a talectomy (astragalectomy). The examiner expressed that the examination was conducted during a period of quiescent symptoms. The examiner indicated that the symptoms elicited from the Veteran are compatible with the diagnoses. The examiner noted that during a flare-up of symptoms, which can occur with varying frequency, the physical findings of this examination could be different. The examiner noted that quantification of such changes would require an examination during a flare-up. The examiner stated that based upon the interview and examination of the Veteran, it would not be feasible to render an opinion, and therefore it would be mere speculation on the part of the examiner to attempt to detail additional limitation due to pain, weakness, fatigability, or incoordination during flare-ups or when the joint is used repeatedly over time. The Veteran was afforded a VA examination in August 2016. The Veteran reported flare-ups of the ankle. The Veteran expressed that his right ankle will ache with increased activity. The Veteran reported having functional loss or functional impairment. The Veteran expressed that his right ankle limits the ability to go up and down stairs and walking for more than 50 feet. Range of motion in the right ankle was measured to 20 degrees plantar flexion and 20 degrees dorsiflexion with pain noted on examination that caused functional loss. There was no evidence of pain with weight bearing and no evidence of crepitus. The examiner noted that the Veteran was able to perform repetitive-use testing with 3 repetitions. There was no additional loss of function or range of motion after three repetitions. The examiner was unable to state without mere speculation whether pain, weakness, fatigability or incoordination significantly limit functional ability with repeated use over a period of time. The examiner expressed that as a nurse practitioner, such a speculation/guess without sufficient objective evidence-based medical facts or direct observations is contrary to evidence based practice and outside the examiner’s scope of professional comportment and expertise. The examiner was also unable to state without mere speculation whether pain, weakness, fatigability or incoordination significantly limit functional ability with flare-ups due to the same reasoning as above. With regard to ankylosis, no response was provided. As the July 2014 and August 2016 examiners declined to offer an opinion as to functional loss during flare ups due to lack of direct observation, it is inadequate. Sharp, 29 Vet. App. 26. As both the July 2014 and August 2016 VA examinations did not fully satisfy the requirements of Sharp and 38 C.F.R. § 4.59, a new examination must therefore be provided upon remand. The matters are REMANDED for the following action: 1. Obtain updated VA treatment records. 2. Thereafter, forward the Veteran’s claims file to an appropriate examiner to obtain an addendum opinion as to the nature and etiology of the Veteran’s neck disability. The need for another examination is left to the discretion of the medical professional offering the addendum opinion. The claims file and a copy of this remand must be made available to the reviewing examiner, and the examiner should indicate in the report that the claims file was reviewed. Based on a review of the record the examiner is requested to provide an opinion as to the following: Whether it is at least as likely as not (a probability of 50 percent or greater) that the Veteran’s neck disability was caused by the Veteran’s service-connected right ankle disability. Whether it is at least as likely as not (a probability of 50 percent or greater) that the Veteran’s neck disability was aggravated (permanently worsened beyond the natural progression) by the Veteran’s service-connected right ankle disability. The examination report must include a complete rationale for all opinions expressed. The examiner is also advised that the Veteran is competent to report symptoms and treatment, and that his reports must be taken into account, along with the other evidence of record, in formulating the requested opinion. 3. After completing directive #1, schedule the Veteran for a VA examination in order to determine the nature and etiology of the Veteran’s left knee disability. The claims file and a copy of this remand must be made available to the reviewing examiner, and the examiner should indicate in the report that the claims file was reviewed. Based on a review of the record the examiner is requested to provide an opinion as to the following: Whether it is at least as likely as not (a probability of 50 percent or greater) that the Veteran’s left knee disability was caused by the Veteran’s service-connected right ankle disability. Whether it is at least as likely as not (a probability of 50 percent or greater) that the Veteran’s left knee disability was aggravated (permanently worsened beyond the natural progression) by the Veteran’s service-connected right ankle disability. The examination report must include a complete rationale for all opinions expressed. The examiner is also advised that the Veteran is competent to report symptoms and treatment, and that his reports must be taken into account, along with the other evidence of record, in formulating the requested opinion. 4. After completing directive #1, schedule the Veteran for a VA examination to determine the nature and etiology of the Veteran’s bilateral foot calluses disability. The claims file and a copy of this remand must be made available to the reviewing examiner, and the examiner should indicate in the report that the claims file was reviewed. Based on a review of the record the examiner is requested to provide an opinion as to the following: Whether it is at least as likely as not (a probability of 50 percent or greater) that the Veteran’s bilateral foot calluses was caused by the Veteran’s service-connected right ankle disability. Whether it is at least as likely as not (a probability of 50 percent or greater) that the Veteran’s bilateral foot calluses was aggravated (permanently worsened beyond the natural progression) by the Veteran’s service-connected right ankle disability. The examination report must include a complete rationale for all opinions expressed. The examiner is also advised that the Veteran is competent to report symptoms and treatment, and that his reports must be taken into account, along with the other evidence of record, in formulating the requested opinion. 5. After completing directive #1, schedule the Veteran for a VA examination with a medical doctor of appropriate expertise to determine the current level of severity of his right ankle disability. The examiner should review the file and provide a complete rationale for all opinions expressed. Range of motion should be reported, including whether and the extent to which such motion is affected by pain, weakness, fatigue, lack of endurance, incoordination or other symptoms resulting in functional loss. The examiner should also test the range of motion 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 why that is so. If the examination does not take place during a flare-up, the examiner should elicit relevant information as to the Veteran’s flare ups, ask the Veteran to describe additional functional loss and then estimate the functional loss due to flare ups based on all the evidence of record. (Continued on the next page)   The examiner should indicate whether or not the Veteran’s right ankle is ankylosed. The examination report must include a complete rationale for all opinions expressed. The examiner is also advised that the Veteran is competent to report symptoms and treatment, and that his reports must be taken into account, along with the other evidence of record, in formulating the requested opinion. LESLEY A. REIN Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD M.D.