Citation Nr: 21072126 Decision Date: 12/02/21 Archive Date: 12/02/21 DOCKET NO. 19-24 007 DATE: December 2, 2021 REMANDED The claim for an initial disability rating in excess of 10 percent for a right knee strain is remanded. The claim of service connection for a low back injury/pain is remanded REASONS FOR REMAND The Veteran served on active duty from November 1984 to January 1988. These matters come before the Board of Veterans' Appeals (Board) on appeal from a March 2017 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). In November 2021, the Veteran testified at a Board hearing before the undersigned Veterans Law Judge. This decision is being made under the "one-touch" program. The hearing transcript will still be processed and associated with the claims file in the ordinary course of business. The Veteran is seeking an increased rating for his service-connected right knee strain and service connection for his low back injury/pain. As stated above, the Veteran was afforded a Board hearing in November 2021. Upon the Veteran's testimony, the Board finds that VA examinations for his service-connected right knee disability and claimed low back injury/pain are warranted. Regarding the Veteran's claim of service connection for a low back disability, the VA examiner is asked to address whether the Veteran's low back disability is the result of his motor vehicle accident in service or secondary to an altered gait resulting from his service-connected right knee. Additionally, outstanding medical treatment records, specifically those from Dr. Copeland, should also be obtained. 38 U.S.C. § 5103A (c). The matters are REMANDED for the following action: 1. Copies of updated treatment records should be obtained and added to the claims file, including the outstanding private treatment records from Dr. Copeland. 2. Once all outstanding records, if any, have been associated with the claims file, schedule the Veteran for a VA orthopedic examination to evaluate the severity of his service-connected right knee strain. The VA examiner should provide an assessment of the current nature of the Veteran's right knee disability. Accordingly, the VA examiner is asked to describe the severity, frequency, and duration of all symptomatology associated with the condition. Also, all functional limitations present (a) after repetition over time and, separately, (b) during flare-ups should be reported. If for any reason the VA examiner is unable to conduct the required testing, he or she should clearly explain why that is so. If instability is found in the right knee, the VA examiner should note the revised changes of the criteria for rating musculoskeletal system and muscle injuries disabilities, effective February 7, 2021, to include the change in criteria for instability of the knee under Diagnostic Code 5257. With regard to Diagnostic Code 5257, the examiner should consider: a) the extent of any sprain or ligament tear (and repair thereof), b) the use of assistive devices (e.g., a cane, crutches, or a walker), c) the need for bracing for ambulation, and d) the extent and degree of any current instability. The VA examiner should also consider and address the relevant medical evidence and the lay statements by the Veteran regarding his symptomatology. 3. Once all outstanding records, if any, have been associated with the claims file, schedule the Veteran for an examination to assess the etiology of his lower back disability. The VA examiner should answer the following questions: a. Is it at least as likely as not that a low back disability began in or was otherwise caused by the Veteran's active military service? Why or why not? In so doing, the VA examiner should address the Veteran's contention that his low back disability was the result of his motor vehicle accident during service in 1985, as described at his Board hearing. b. Is it at least as likely as not that a low back disability is secondary to, or aggravated by (made worse by), his service-connected disabilities, to include a right knee disability (specifically, whether it was caused by an altered gait from his right knee sprain)? Why or why not? The VA examiner should also consider and address the relevant medical evidence and lay statements by the Veteran regarding the onset and continuity of his symptomatology. MATTHEW W. BLACKWELDER Veterans Law Judge Board of Veterans' Appeals Attorney for the Board H. Yoo, 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.