Citation Nr: 21061357 Decision Date: 10/01/21 Archive Date: 10/01/21 DOCKET NO. 09-02 065 DATE: October 1, 2021 REMANDED Entitlement to a rating in excess of 10 percent for a right tibia stress fracture is remanded. Entitlement to a rating in excess of 10 percent for a left tibia stress fracture is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. REASONS FOR REMAND The Veteran served on active duty from December 1984 to May 1990, from August 1990 to November 1990, and from January 1991 to April 1991. These matters return to the Board of Veterans' Appeals (Board) following the issuance of a Joint Motion for Remand by the Court of Appeals for Veterans' Claims (CAVC) in January 2018, and a subsequent Board remand in June 2018 and July 2021 which directed the Regional Office (RO) to undertake additional development. The Board finds that there has not been substantial compliance with the Board's previous remand directive and another remand is required. Stegall v. West, 11 Vet. App. 268, 271 (1998). Although an examination was provided in July 2021, for the reasons provided below, it is inadequate. Where VA provides an examination or obtains an opinion, it must be adequate. Barr v. Nicholson, 21 Vet. App. 303 (2007). 1. Entitlement to a rating in excess of 10 percent for a right tibia stress fracture is remanded. 2. Entitlement to a rating in excess of 10 percent for a left tibia stress fracture is remanded. Issues 1 & 2: The Veteran reports pain in her lower legs, and pain, crepitus, instability, limitation of motion, and locking in her knees. The Veteran contends that her bilateral knee degenerative changes are caused by her bilateral stress fractures. See Form 9 (October 2016); Form 9 (January 2009). The Board finds that the July 2021 VA medical opinion is inadequate as it is inconsistent with the other medical evidence of record, and is supported by no reasoning. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008) (an adequate medical opinion must contain a clear conclusion with supporting data, and a reasoned medical explanation connecting the two). It is also noted that a medical opinion must support the conclusions reached with an analysis that is adequate for the Board to consider and weigh against other evidence of record. Stefl v. Nicholson, 21 Vet. App. 120, 124-25 The July 2021 report of VA examination shows that the examiner provided diagnoses of left knee patellofemoral pain syndrome and right knee degenerative arthritis, with date of onset on August 1, 2021. However, the evidence shows that left knee degenerative joint disease and chondromalacia patella were diagnosed in September 1995, and right knee degenerative joint disease was diagnosed in October 2006. The examiner provided no reasoning for the inconsistencies in the diagnosis dates, or why left knee degenerative joint disease was not included as a diagnosis. Additionally, the examiner opined that the service-connected diagnosis resolved, and reasoned that bone scans in 2008 indicated that the bilateral stress fractures resolved. The examiner further opined that the new diagnosis is a correction of the previous diagnosis. The examiner then stated that right knee degenerative arthritis and left knee patellofemoral pain syndrome were not caused by bilateral stress fractures as those had resolved. However, the examiner's rationale is insufficient as it included no analysis of the onset date of arthritis and patellofemoral pain syndrome in relation to the resolution of bilateral stress fractures. Notably, the rationale that arthritis and patellofemoral pain syndrome are not caused by stress fractures, as those resolved in 2008, indicates that it was based on the diagnosis date of August 2021 for arthritis and patellofemoral pain syndromewhich is inaccurate, as explained above. Further, the Board finds that the July 2021 VA examination is inadequate as the examination report shows that the examiner noted that pain was exhibited on flexion, but the examiner provided no indication of where pain began on motion. See Mitchell v. Shinseki, 25 Vet. App. 38, 44 (2011) (when pain is shown on motion, the examiner must indicate whether and at what point during the range of motion the appellant experienced any limitation of motion that was specifically attributable to pain). Therefore, to ensure that VA has met its duty to assist, remand is required. A remand by the Board imposes upon the Secretary of VA a concomitant duty to ensure compliance with the terms of the remand. Where remand orders of the Board are not complied with, the Board errs in failing to ensure compliance. Stegall, 11 Vet. App. at 271. 3. Entitlement to TDIU. The issue of TDIU is inextricably intertwined with the increased rating claims being remanded for additional development. The Veteran included her left tibia stress fracture with knee pain as one of the medical conditions which prevent her employment. See Statement In Support of Claim (March 2008). Therefore, the Board must defer consideration of that claim at this time. See Harris v. Derwinski, 1 Vet. App. 181 (1991) (two or more issues are inextricably intertwined if one claim could have significant impact on the other). (Continued on the next page) Accordingly, the matters are REMANDED for the following action: 1. Schedule the Veteran for an examination by an appropriate clinician to determine the current severity of her service-connected left and right tibia stress fractures, to include any residuals thereof. The examiner should review the Veteran's medical history with respect to his right and left tibiae as described in the prior pages of this remand. The examiner should then provide a full description of the disabilities and report all signs and symptoms necessary for evaluating the Veteran's disabilities 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 and record the range of motion (ROM) for each, to include the degree at which pain begins. The examiner must also 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 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). 2. Thereafter, conduct any indicated development regarding the claim for TDIU. (Continued on the next page) 3. Readjudicate the claims and issue a Supplemental Statement of the Case. David Gratz Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Thaddaeus J. Cox, 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.