Citation Nr: 21004072 Decision Date: 01/25/21 Archive Date: 01/25/21 DOCKET NO. 15-42 844 DATE: January 25, 2021 REMANDED Entitlement to an initial disability rating in excess of 10 percent, for degenerative changes of the right knee, is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from May 1998 to November 1998 and from October 2003 to July 2004. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from an October 2014 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO) in Guaynabo, Puerto Rico. Although the Veteran initially requested on his November 2015 substantive appeal to appear at a hearing before the Board, he later withdrew his request in a May 2017 correspondence. In June 2018, the Veteran submitted a Rapid Appeals Modernization Program (RAMP) Opt-in Election and elected to have his appeal reviewed in the Supplemental claim process. However, as his appeal for the right knee claim was certified to the Board for appellate review and was remanded for additional development, the right knee claim was not eligible for the RAMP program. Entitlement to an initial disability rating in excess of 10 percent, for degenerative changes of the right knee, is remanded. The matter last appeared before the Board in August 2018 at which time the issue was remanded to obtain a VA examination in compliance with Correia v. McDonald, 28 Vet. App. 158 (2016) and Sharp v. Shulkin, 29 Vet. App. 26 (2017). Specifically, the Board directed that the examiner must include range of motion (ROM) test results for active, passive, weightbearing and nonweight-bearing and any additional functional loss due to flareups. The Veteran underwent a new VA examination in September 2019. Although the examiner found that there is evidence of pain on passive ROM and on non-weight bearing, the examiner did not include the complete ROM test results as directed by the Board in August 2018 and in compliance with Correia and Sharp. It is critical that an examination on which a disability rating is based adequately portray the anatomical damage and functional loss occurring as a result of an inability to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. Correia, 28 Vet. App. at 169. 38 C.F.R. § 4.45 clarifies that the factors of joint disability reside in reductions of their normal excursion of movements in different planes, and provides that an adjudicator will consider factors including less or more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. Id. As the results of the complete ROM testing have not been included, the examination is inadequate, and remand is warranted to obtain an adequate examination. Id. The matter is REMANDED for the following actions: 1. Obtain any outstanding VA treatment records and private medical records and associate those records with the claims file. 2. Schedule the Veteran for an appropriate VA examination to assess the nature and current level of severity of his service-connected right knee disability. The Veteran’s claims file, including a copy of this REMAND, must be made available to and reviewed by the examiner in conjunction with the examination. An in-person examination may be conducted via telehealth or similar service during the social distancing restrictions of the COVID-19 pandemic. The examiner must note in the examination report that the evidence in the claims file has been reviewed. In the examination report, the examiner must include all the following: (a) Active range of motion testing results. (b) Passive range of motion testing results. (c) Weightbearing range of motion testing results. (d) Nonweight-bearing range of motion testing results. If the examiner is unable to conduct one or more of the above tests or finds that itis unnecessary, the examiner must provide an explanation. In any event, the type of test performed (i.e. active or passive, weightbearing or non-weightbearing), must be specified. The examiner must elicit as much information as possible from the Veteran regarding the severity, frequency, and duration of flare-ups, their effect on functioning, and precipitating and alleviating factors. If the examination is not performed during a flare-up, the examiner must provide an estimate of additional loss of range of motion during a flare-up. If the examiner is unable to provide an estimate of additional loss of motion during a flare-up, the examiner must provide a specific explanation as to why the available information, including the Veteran’s own statements, is not sufficient to make such an estimate. The examiner must provide a comprehensive report including complete rationales for all opinions and conclusions reached. DELYVONNE M. WHITEHEAD Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Q. Alli, 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.