Citation Nr: 20049913 Decision Date: 07/27/20 Archive Date: 07/27/20 DOCKET NO. 17-35 577 DATE: July 27, 2020 REMANDED The issue of entitlement to an evaluation in excess 10 percent for right knee patellofemoral pain syndrome is remanded. The issue of entitlement to service connection for a low back disorder is remanded. REASONS FOR REMAND The Veteran served on active duty from July 2000 to July 2004. The Veteran testified before the undersigned Veterans Law Judge during a May 2020 virtual hearing; a transcript is of record. 1. The issue of entitlement to an evaluation in excess 10 percent for right knee patellofemoral pain syndrome is remanded. A remand is required because the VA examination of record is inadequate for rating purpose. During a December 2016 VA examination, the Veteran reported that during a flareup, he had difficulty walking due to the pain in the right knee. He further reported that he had more pain in the knee after inspecting student housing for his job. The examiner was not able to say without mere speculation what functional limitation was after repeated use over a period of time. The examiner also stated that there was no functional limitation with flareups. In a June 2017 VA Form 9, the Veteran stated that he had issues with climbing stairs, which was frequently required for his job. He stated that when his knee gave issues, he was unable to bend or flex his knee and as a result, he had trouble walking. At a May 2020 Board hearing, the Veteran testified that when he was on his knee for a long period of time, he could not flex his leg backwards or forwards and his knee became painful when he put any pressure. He also reported stiffness in the knee. The Board finds that the December 2016 VA examination did not adequately report the extent of the Veteran’s right knee disability. Contrary to the examiner’s finding, the Veteran has consistently reported having limitation in range of motion in the right knee after a repeated use over a period of time and indicated that his difficulty with walking, in particular with flareups, was due to limitation in range of motion. As such, the Veteran must be afforded a new VA examination to ascertain the severity of his right knee disability. See Correia v. McDonald, 28 Vet. App. 158 (2016); Sharp v. Shulkin, 29 Vet. App. 26 (2017). 2. The issue of entitlement to service connection for degenerative disc disease of the lumbar spine, claimed as back injury, is remanded. The Veteran contends that he injured his back while in service and has a current disability as a result. He has a current diagnosis of degenerative disc disease of the lumbar spine, as found in a December 2016 VA examination. A September 2002 service treatment record indicates that the Veteran sought treatment for low back pain, which was lasing for three months after he dead-lifted heavy weights. The x ray taken at the time was negative. In a March 2004 report of medical history for separation examination, the Veteran reported recurrent back pain or back problem any time he ran or stood for a long time. A February 2017 medical opinion provided a negative nexus opinion. The rationale was that the Veteran’s report of recurrent back pain had no support in the evidence and that his back condition was likely accelerated due to his body habitus. The examiner noted no documented history of injury to the lumbar spine. In an April 2017 notice of disagreement, the Veteran reported that due to lack of insurance after discharge from the military, he was unable to get medical help until several years after discharge and that he did not feel that his weight was a factor in his back condition as he was injured while on active duty. In a June 2017 VA Form 9, the Veteran stated that he hurt his back several times while in service and his back had gotten worse each year and that he did not believe his back injury was treated seriously while in service and that was why he was having major issues now. At the May 2020 Board hearing, the Veteran reported that he couldn’t straighten his back and had a burning sensation down the thighs. He stated that he had had this symptom during service. Based on the above, the Board finds that the February 2017 medical opinion is inadequate for rating purposes for failing to consider the Veteran’s report of symptoms in the opinion. A layperson is competent to report on the onset and continuity of his current symptomatology. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a Veteran is competent to report on that of which he or she has personal knowledge). Therefore, a new medical opinion that properly considers the Veteran’s report of symptomatology must be obtained. The matters are REMANDED for the following action: 1. Ask the Veteran to complete a VA Form 21-4142 for private treatment he received for his right knee and lumbar spine disability. Make two requests for the authorized records from facilities identified by the Veteran, unless it is clear after the first request that a second request would be futile. If any VA treatment is indicated, those records should also be obtained to the extent they are not on file. The Veteran’s assistance in identifying and obtaining records should be requested as needed. All attempts to obtain records should be documented in the claims file. 2. Schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his service-connected right knee disability. The examiner must review the Veteran’s claims file and should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran’s disability under the rating criteria. In so doing, the examiner must test the Veteran’s active motion, passive motion, and pain with weight-bearing and without weight-bearing. If it is not possible to provide a specific measurement without speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). Moreover, the examiner must attempt to elicit information regarding the severity, frequency, and duration of any flare-ups, and the degree of functional loss during flare-ups. If it is not possible to provide a specific measurement based on direct observation, the examiner should provide an estimate, if at all possible, of the additional impairment due to flare-ups based on the other evidence of record and the Veteran’s statements. If it is not possible to provide a specific measurement without speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). 3. Obtain a medical opinion from an appropriate clinician to determine the nature and etiology of the Veteran’s lumbar spine disability. The examiner must review the Veteran’s claim file. Then, the examiner must opine whether it is at least as likely as not that any low back disorder found is related to an in-service injury, event, or disease, including the in-service occurrence of low back pain lasting for three months after heavy weight-lifting. The examiner is advised that a layperson is competent to report on the onset and continuity of his current symptomatology. A complete rationale for any opinions expressed must be provided. MICHAEL D. LYON Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Y. Taylor, Associate 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.