Citation Nr: 21067119 Decision Date: 11/03/21 Archive Date: 11/03/21 DOCKET NO. 16-58 504 DATE: November 3, 2021 REMANDED Service connection for diabetes mellitus, to include as secondary to service-connected kidney disability or hypertension, is remanded. Service connection for bilateral lower extremity peripheral neuropathy is remanded. An increased disability rating (more than 10 percent) for service-connected right knee patellofemoral syndrome (right knee disability) is remanded. An increased disability rating (more than 10 percent) for service-connected left knee patellofemoral syndrome (left knee disability) is remanded. REASONS FOR REMAND The appellant is a Veteran who served on active duty from July 1987 to April 1991. These matters are before the Board of Veterans' Appeals (Board) on appeal from October 1998 and May 2015 rating decisions. The Veteran testified at a September 2019 hearing before the undersigned and a transcript is of record. The Board remanded these matters in January 2020. 1. Service connection for diabetes mellitus, to include as secondary to service-connected kidney disability or hypertension is remanded. The May 2021 VA medical opinions obtained on remand are inadequate for rating purposes and require additional clarification. Specifically, the examiner at the time indicated that diabetes cannot be aggravated by hypertension or kidney disease because "it would have to pre-exist those conditions," but it is not immediately clear why this is the case and that rationale does not appear to make logical or even intuitive sense. 2. Service connection for bilateral lower extremity peripheral neuropathy is remanded. This claim is intertwined with the diabetes claim and an adjudication thereof must be deferred for now. 3. More than a 10 percent rating for service-connected right knee patellofemoral syndrome (right knee disability) is remanded. 4. More than a 10 percent rating for service-connected left knee patellofemoral syndrome (left knee disability) is remanded. The last Board remand specifically directed that the examiner record range of motion in active motion, passive motion, weight-bearing, and non-weight-bearing. However, while the May 2021 examiner did note that active squatting was tested (weight-bearing flexion), he did not indicate where extension ended, though he did note that the Veteran was apprehensive as to whether he could return to a standing position. Moreover, the examiner indicated that the Veteran did not report any functional loss or impairment of the knees despite earlier noting that the Veteran endorsed occasionally severe knee pain (9/10) brought on by twisting or moving the knee (like when walking), all of which certainly sounds consistent with functional impairment. He also does not reconcile that finding with the fact that the Veteran could only actively squat to 90 degrees of knee flexion (which is less than the full range of motion). Consequently, the Board finds a new examination is needed. The matters are REMANDED for the following action: 1. Obtain all updated records (i.e., those not already of record) of VA and adequately identified private treatment the Veteran has received for the disabilities remaining on appeal. 2. Schedule the Veteran for an in-person or telehealth (whichever is appropriate) examination by an endocrinologist or other appropriate physician to clarify the nature and cause of his diabetes. Based on a review of the record, examination of the Veteran (INCLUDING A COMPLETE SUBJECTIVE HISTORY AND REPORT DESCRIBING ONSET, COURSE, AND PROGRESSION OF HIS SYMPTOMS), and any tests or studies deemed necessary, the examiner must opine as to whether it is AT LEAST AS LIKELY AS NOT (A 50 PERCENT PROBABILITY OR GREATER) that the Veteran's diabetes is AGGRAVATED (WORSENED BEYOND ITS NATURAL PROGRESSION, REGARDLESS OF PERMANENCE) BY his hypertension or kidney disease. All opinions must include a detailed rationale. Providing an opinion or conclusion without enough explanation will delay processing of the claim and require further clarification. 3. Schedule the Veteran for an in-person or telehealth examination (whichever is more appropriate) by an orthopedist or other appropriate physician to determine the current severity of his service-connected right and left knee disabilities. Based on an examination (INCLUDING A COMPLETE SUBJECTIVE HISTORY AND REPORT DESCRIBING ONSET, COURSE, AND PROGRESSION OF HIS SYMPTOMS AND HOW FUNCTIONING AND LIMITATION OF MOTION VARY WITH FLARE-UPS, REPEATED USE OVER A PERIOD OF TIME, OR OTHER SUCH CIRCUMSTANCES), review of the record, and any tests or studies deemed necessary, the examiner should describe all pathology, symptoms (frequency and severity), and functional impairment associated with such disabilities in enough detail to allow for application of the pertinent rating criteria. Range of motion test results must be recorded in ACTIVE MOTION, PASSIVE MOTION, WEIGHT-BEARING, and NON-WEIGHT-BEARING and must include FLEXION AND EXTENSION UNDER ALL ABOVE CIRCUMSTANCES. If it is not feasible to perform range of motion testing in any of these circumstances, the examiner MUST EXPLAIN WHY. The examiner should also note any further functional limitations due to pain, weakness, fatigue, incoordination, or any other such factors. The examiner MUST ALSO comment on or describe, to the extent possible, the impact the Veteran's service-connected right and left knee disabilities have on his functioning during flare-ups or with repeated use over a period of time. In doing so, the examiner MUST elicit from the Veteran subjective reports of his functioning under such conditions and consider such reports along with all other pertinent evidence. If the examiner is still unable to provide such an opinion, he or she MUST explain why that is so in specificity. The examiner should note that the inability to directly observe functioning under such conditions IS NOT a valid reason to avoid providing an opinion in this matter per se. All opinions must include a detailed rationale. Providing an opinion without one will delay processing of the claim and may require clarification. VICTORIA MOSHIASHWILI Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Yuan, 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.