Citation Nr: 21064565 Decision Date: 10/20/21 Archive Date: 10/20/21 DOCKET NO. 18-38 287 DATE: October 20, 2021 REMANDED Entitlement to a rating in excess of 10 percent for degenerative arthrosis of the right knee is remanded. Entitlement to a rating in excess of 60 percent for left total knee replacement is remanded. Entitlement to a rating in excess of 10 percent for degenerative joint disease of the right ankle is remanded. Entitlement to service connection for left ankle condition secondary to service-connected knee conditions is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from December 1970 to December 1972. In May 2021, the Veteran testified at a Board hearing. The transcript is of record. Entitlement to increased ratings for degenerative arthrosis of the right knee, left total knee replacement, and degenerative joint disease of the right ankle The Veteran's April 2019 VA examination for the knees and January 2016 VA examinations for the knees and ankles do not comply with the requirements in Sharp v. Shulkin, 29 Vet. App. 26, 34-36 (2017). At each examination, the Veteran reported flare ups that cause pain and difficulty with ambulating, sitting, carrying, and standing. The examiners reported that an estimation of functional loss during flare-ups could not be determined without speculation. An examiner must do all that reasonably should be done to become informed before concluding that a requested opinion cannot be provided without resorting to speculation. However, the examiners did not attempt to ascertain adequate information from the Veteran such as frequency, duration, characteristics, and severity. An examiner must offer flare-ups estimates based on available information from all relevant sources, to include lay statements. Id. Additionally, the Board notes that the Veteran last underwent a VA examination for his ankles in January 2016. The VA has a duty to provide the Veteran with a thorough and contemporaneous medical examination. As such, a remand is also warranted so that Veteran may be afforded a new VA examination to determine the functional and occupational impact of his service-connected right ankle condition. See 38 U.S.C. § 5103A; 38 C.F.R. § 3.159; see also Green v. Derwinski, 1 Vet. App. 121, 124 (1991). Entitlement to service connection for left ankle condition The Veteran underwent a VA examination for his left ankle condition in October 2014. The VA examiner opined that the Veteran's left ankle condition is less likely than not proximately due to or the result of his service-connected lower leg conditions; however, the examiner did not provide an opinion as to whether the left ankle condition is aggravated by his service-connected bilateral knee conditions. Therefore, a remand is necessary to obtain an addendum opinion addressing aggravation. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) (Once VA undertakes the effort to provide an examination, it must provide an adequate one). The matters are REMANDED for the following action: 1. In remanding this case, the Board makes no credibility determination, expressed or implied, at this juncture. 2. Obtain updated VA and/or private treatment records. If such records are unavailable, the Veteran's claim file must be clearly documented to that effect and the Veteran notified in accordance with 38 C.F.R. § 3.159(e). 3. Schedule the Veteran for a VA medical examination to determine the current severity of his service-connected right ankle, right knee, and left knee. The electronic claims file must be reviewed in conjunction with the examination. All necessary testing must be conducted. In particular, the examination must include tests of all applicable ranges of motion in active motion, passive motion, weight-bearing, and non- weight-bearing in both knees and ankles. 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 clearly explain why that is so. The examiner must describe whether pain, weakness, fatigue and/or incoordination significantly limits functional ability during flares or repetitive use, and if so, the examiner must estimate range of motion during flares or repetitive use. If the examination does not take place during a flare or repetitive testing cannot be performed, the examiner should have the Veteran describe and/or demonstrate the extent of motion loss during flares or repetitive use and provide the extent of motion loss described in terms of degrees. If there is no pain and/or no limitation of function, such facts must be noted in the report. The examiner should comment as to whether there is any medical reason to accept or reject the Veteran's description of reduced range of motion during flares or repetitive use. The examiner must also provide an assessment of the Veteran's functional limitations due to his right ankle, left knee, and right knee condition as it may relate to his ability to function in a work setting and to perform work tasks. However, the examiner should refrain from commenting on the Veteran's employability. A complete rationale for all medical opinions is required. The examiner should identify and explain the relevance or significance, as appropriate, of any history, clinical findings, medical knowledge, or literature, etc., relied upon in reaching the conclusion(s). If the examiner feels that a requested opinion cannot be rendered without resorting to speculation, the examiner must state whether the need to speculate is caused by a deficiency in the state of general medical knowledge (i.e., no one could respond given medical science and the known facts) or by a deficiency in the record or the examiner (i.e., additional facts are required, or the examiner does not have the needed knowledge or training). 4. Obtain an addendum medical opinion from a medical professional with appropriate expertise. The examiner should review the Veteran's claims file. If the examiner determines that an opinion cannot be provided without an examination, the Veteran should be scheduled for one. Based on a review of the record, and a new examination if necessary, the examiner must address the following: (a.) Is it at least as likely as not (i.e., probability of 50 percent or higher) that the left ankle condition is proximately due to or the result of the Veteran's service-connected knee conditions? (b.) If the answer to (a) is negative, is it at least as likely as not that the left ankle condition is aggravated (i.e., permanently, or temporarily worsened) by the knee conditions? (c.) If aggravation is found, the examiner should address the following medical issues: 1) the baseline manifestations of the disorder found prior to aggravation; and 2) the increased manifestations which, in the examiner's opinion, are proximately due to the service-connected disorder. The term "at least as likely as not" does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a certain conclusion is so evenly divided that it is as medically sound to find in favor of such a conclusion as it is to find against it. In all opinions rendered, the examiner is advised that the Veteran is competent to report his symptoms and treatment history. A complete rationale containing clear conclusions with supporting data and a reasoned medical explanation connecting the two is required for all medical opinions. The examiner should also identify and explain the relevance or significance, as appropriate, of any history, clinical findings, medical knowledge, or literature, etc., relied upon in reaching the conclusion(s). If the medical professional cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation for why an opinion cannot be rendered. In so doing, the medical professional shall explain whether the inability to provide a more definitive opinion is the result of a need for additional information, or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question(s). 5. Finally, readjudicate the appeal. If the benefits sought on appeal remain denied, issue a supplemental statement of the case, and return the case to the Board. G. A. WASIK Veterans Law Judge Board of Veterans' Appeals Attorney for the Board S. A. Prinsen 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.