Citation Nr: 20048071 Decision Date: 07/17/20 Archive Date: 07/17/20 DOCKET NO. 13-03 633 DATE: July 17, 2020 REMANDED Entitlement to an evaluation in excess of 10 percent for residual arthritis of a left knee injury with anterior cruciate ligament (ACL) reconstruction is remanded. REASONS FOR REMAND The Veteran served on active duty from April 1988 to May 1991. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a February 2011 rating decision. The Veteran testified at a hearing before the undersigned Veterans Law Judge in December 2016. A transcript is of record. In August 2017 and August 2018, the Board remanded the case for further development. The case has since been returned to the Board for appellate review. The Board previously referred the issue of entitlement to service connection for a right wrist disorder, to include as secondary to the service-connected left knee disability, to the agency of original jurisdiction (AOJ). However, the record currently available to the Board still contains no indication that the AOJ has addressed this matter. Therefore, the Board does not have jurisdiction over the issue, and it is once again referred to the AOJ for appropriate action. Upon review, the Board finds that additional development is needed prior to adjudication of the claim. In an October 2019 VA medical opinion, the examiner stated that he was unable to estimate range of motion findings for the other VA examinations conducted during the appeal period without resorting to speculation because he did not examine the Veteran during the examinations at issue. However, the examiner did not address the lay and medical evidence of record. Moreover, it is unclear whether the examiner was unable to provide a retrospective opinion due to the limitations of his personal knowledge or that of the medical community at large. In addition, in April 2020, the Veteran stated that injections to treat pain in her knee no longer provided relief of her symptoms and that her knee disorder had progressively worsened. In addition, during a March 2020 consultation, a private orthopedist reportedly informed her that x-ray findings now showed “bone on bone” contact and that the only cure for her condition was a knee replacement surgery. Such statements suggest that the Veteran’s disability may have worsened since she was last examined. VAOPGCPREC 11-95 (April 7, 1995); see also Snuffer v. Gober, 10 Vet. App. 400 (1997); Caffrey v. Brown, 6 Vet. App. 377 (1994). For these reasons, a remand is necessary to obtain an additional VA examination to ascertain the current severity and manifestations of the Veteran’s service-connected left knee disability. Moreover, in a March 2020 supplemental statement of the case (SOC), the AOJ noted that the evidence of record included VA treatment records from the Biloxi VA Medical Center (VAMC) dated in February 2018. However, the VA treatment records currently associated with the claims file do not include records dated in February 2018. In addition, the Veteran submitted copies of VA treatment records dated in July 2017 and August 2019. However, there is no indication that the AOJ made efforts to associate any outstanding VA medical records with the claims file, as directed by the Board. Therefore, a remand is necessary to obtain any outstanding VA medical records. Lastly, as discussed above, the Veteran referenced private treatment records that reportedly suggested that her service-connected left knee disability had worsened in severity. However, the records identified by the Veteran are not currently associated with the claims file. Therefore, on remand, the AOJ should attempt to obtain any outstanding private medical records. The matters are REMANDED for the following action: 1. The AOJ should request that the Veteran provide the names and addresses of any and all health care providers who have provided treatment for her service-connected left knee disability that are not already of record. A specific request should be made for authorization to obtain the additional private orthopedic records from Dr. S. (initial used to protect privacy) identified by the Veteran in her April 2020 correspondence. 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 obtain any outstanding VA medical records, to include any records dated from January 2017 to the present. Any additional records should be associated with the claims file. 2. After completing the foregoing development, the Veteran should be afforded a VA examination to ascertain the current severity and manifestations of her service-connected left 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. It should be noted that the Veteran is competent to attest to factual matters of which she 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 state this with a fully reasoned explanation. The examiner should report all signs and symptoms necessary for evaluating the Veteran’s disability under the rating criteria. In particular, the examiner should provide the range of motion of the left and right knee in degrees on 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 provide an explanation for this determination in the report. 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. The examiner should also discuss any additional functional impairment that occurs during flare-ups, including any additional limitation of motion. Further, the examiner should comment as to whether ranges 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. See, e.g., January 2011, October 2012, November 2013, and August 2016 VA examinations. If the examiner is unable to provide a retrospective opinion as to these specific range of motion findings, he or she should provide an explanation for this determination 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. 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 3. After completing the above actions, the AOJ should conduct any other development as may be indicated. J.W. ZISSIMOS Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. Wulff, Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.