Citation Nr: 21063160 Decision Date: 10/13/21 Archive Date: 10/13/21 DOCKET NO. 18-08 976 DATE: October 13, 2021 REMANDED Entitlement to a disability rating in excess of 70 percent for posttraumatic stress disorder (PTSD) is remanded. Entitlement to a disability rating in excess of 20 percent for status post (s/p) lumbosacral strain with low back pain syndrome is remanded. Entitlement to a disability rating in excess of 10 percent for s/p stress fracture, right lower extremity, with patella-femoral syndrome of the right knee is remanded. Entitlement to a disability rating in excess of 10 percent for s/p stress fracture, left lower extremity, with loss of motion of the left knee is remanded. Entitlement to a disability rating in excess of 10 percent for s/p right ankle strain is remanded. REASONS FOR REMAND The Veteran served on active duty from September 1999 to June 2005. This matter comes before the Board of Veterans' Appeals (Board) on appeal from May 2017 and October 2017 rating decisions issued by a Department of Veterans Affairs (VA) Regional Office (RO). In February 2021, the Veteran testified at a videoconference hearing before the undersigned Veterans Law Judge (VLJ). A transcript of that proceeding has been associated with the record. 1. Entitlement to a disability rating in excess of 70 percent PTSD is remanded. 2. Entitlement to a disability rating in excess of 20 percent for s/p lumbosacral strain with low back pain syndrome is remanded. 3. Entitlement to a disability rating in excess of 10 percent for s/p stress fracture, right lower extremity, with patella-femoral syndrome of the right knee is remanded. 4. Entitlement to a disability rating in excess of 10 percent for s/p stress fracture, left lower extremity, with loss of motion of the left knee is remanded. 5. Entitlement to a disability rating in excess of 10 percent for s/p right ankle strain is remanded. The Veteran is seeking increased disability ratings for his service-connected PTSD, back, knee, and right ankle disabilities. The Veteran contends his disabilities are more severe than reflected by his currently assigned disability ratings. Based on a review of the claims file, the Board finds that additional development is needed prior to adjudication of the claim. In the February 2021 Board hearing, the Veteran testified that his PTSD caused severe aggravation and depression at times. He noted nightmares, lack of sleep, and anxiety. He had flashbacks and difficulties as certain anniversaries approached. Regarding his musculoskeletal disabilities, the Veteran testified that he experienced uncomfortable pressure in his back that would require him to sit. Straightening his back was uncomfortable and caused issues with his sleep. He stated that when he sneezed, his body jerked and caused a rattling sensation in his back. The Veteran testified that he experienced cracking, rattling, pain, and pressure in both his knees. He noted a bone-on-bone sensation with movement. The Veteran's right ankle was painful with a severe burning sensation under the foot. He noted he wore braces for his knees, ankle, and back. The Veteran testified that the severity of his disabilities had increased since his last VA examinations. The Board finds that a remand is necessary to afford the Veteran contemporaneous examinations to determine the current severity of his psychiatric and musculoskeletal disabilities. See Allday v. Brown, 7 Vet. App. 517, 526 (1995) (indicating that, where the record does not adequately reveal the current state of the claimant's disability, fulfillment of the statutory duty to assist requires a contemporaneous medical examination, particularly if there is no additional medical evidence that adequately addresses the level of impairment of the disability since the previous examination). The evidence of record indicates a possible change in the severity of the Veteran's service-connected disabilities since his 2017 musculoskeletal VA examinations and 2019 psychiatric VA examination, and as such, the Veteran should be afforded examinations to determine the severity of current manifestations of his PTSD, s/p lumbosacral strain with low back pain syndrome, s/p stress fracture, right lower extremity, with patella-femoral syndrome of the right knee, s/p stress fracture, left lower extremity, with loss of motion of the left knee, and s/p right ankle strain. 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 his service-connected PTSD. The examiner 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. The examiner must attempt to elicit information regarding the severity, frequency, and duration of symptoms. To the extent possible, the examiner should identify any symptoms and social and occupational impairment due to PTSD alone. 2. Schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his service-connected s/p lumbosacral strain with low back pain syndrome. The examiner 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). Additionally, 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. Schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his service-connected s/p stress fracture, right lower extremity, with patella-femoral syndrome of the right knee and s/p stress fracture, left lower extremity, with loss of motion of the left knee. The examiner should 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. 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). Additionally, 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). 4. Schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his service-connected s/p right ankle strain. The examiner 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). Additionally, 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). 5. After completing the above, and any other development as may be indicated by any response received as a consequence of the actions taken in the preceding paragraphs, the Veteran's claims should be readjudicated based on the entirety of the evidence. If any benefit sought remains denied, furnish the Veteran and his attorney a supplemental statement of the case (SSOC) and return the case to the Board. KRISTI L. GUNN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board L. Silverblatt, 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.