Citation Nr: 21007280 Decision Date: 02/09/21 Archive Date: 02/09/21 DOCKET NO. 17-16 632 DATE: February 9, 2021 REMANDED Entitlement to service connection for a right knee disorder, to include as secondary to a service-connected right ankle disorder, is remanded. Entitlement to service connection for a left knee disorder, to include as secondary to a service-connected right ankle disorder, is remanded. Entitlement to a cervical spine disorder, to include as secondary to a service-connected thoracolumbar spine disorder, is remanded. Entitlement to a rating in excess of 10 percent for a thoracolumbar spine disorder is remanded. REASONS FOR REMAND The Veteran served on active duty from April 2008 to June 2010. In a September 2019 decision, the Board declined to grant entitlement to service connection for right knee, left knee, and cervical spine disorders and entitlement to an increased rating for a thoracolumbar spine disorder. An August 2020 Court of Appeals for Veterans Claims (CAVC) order vacated the Board’s decision regarding these issues and adopted a Joint Motion for Remand (JMR) for reconsideration of the Veteran’s claim. These issues are once again before the Board. 1. Entitlement to service connection for a right knee disorder, to include as secondary to a service-connected right ankle disorder, is remanded. 2. Entitlement to service connection for a left knee disorder, to include as secondary to a service-connected right ankle disorder, is remanded. As noted by the JMR, during a July 2016 VA examination, the examiner noted that knee pain caused no functional impact, but also noted the knee pain’s impact on the Veteran’s ability to perform occupational tasks. As these notes appear to be at odds, the VA examination is inadequate for rating purposes. Additionally, in a September 2019 brief, the Veteran’s representative indicated that his knees had worsened. A remand is needed to obtain an additional VA examination to determine whether there are any current diagnosable right and left knee disorders; whether right and/or left knee pain that causes any functional loss; and whether any diagnoses or pain is etiologically related to the Veteran’s service or his service-connected right ankle disorder. Additionally, an August 2015 VA radiological note indicates there may be an outstanding radiological record uploaded to VISTA relevant to the Veteran’s knees that must be associated with the claims file. 3. Entitlement to a cervical spine disorder, to include as secondary to a service-connected thoracolumbar spine disorder, is remanded. 4. Entitlement to a rating in excess of 10 percent for a thoracolumbar spine disorder is remanded. As noted by the JMR, the Veteran provided a March 2017 statement regarding in-service trauma to the veteran’s neck. The July 2016 VA examiner, however, determined that there was no trauma associated with the Veteran’s cervical spine. This VA examination is inadequate for rating purposes. Additionally, during a June 2016 VA examination, the examiner noted flare-ups of the thoracolumbar spine, but did not comply with the requirements in Correia v. McDonald, 28 Vet. App. 158 (2016) or Sharp v. Shulkin, 29 Vet. App. 26, 34-36 (2017). The examiner did not attempt to provide required measurements or elicit relevant information regarding the description of the Veteran’s flare-ups and any additional functional loss suffered during flare-ups. A remand is needed to obtain an adequate VA examination regarding the nature and etiology of the veteran’s cervical spine disorder and the current severity of the Veteran’s right disorders that complies with Correia and Sharp. The matters are REMANDED for the following action: 1. Obtain VA treatment records since January 2017 and associate them with the claims file. Specifically, the Agency of Original Jurisdiction should upload to the claims file the documents scanned into VISTA on August 5, 2016. See, August 2015 VA Radiology Scanned Report, with “VistA (sp) Imaging – Scanned Document.” 2. Schedule the Veteran for an examination by an appropriate examiner for an opinion regarding the nature and etiology of any diagnosed right and/or left knee disorders. The examiner must answer the following questions: (a) Does the Veteran have right and/or left knee pain, and does any such pain cause any functional limitations? (b) Is it at least as likely as not (i.e., probability of 50 percent or greater) that any diagnosed right knee disorder began in service, was caused by service, or is otherwise etiologically related to active duty service? (c) Is it at least as likely as not (i.e., probability of 50 percent or greater) that any diagnosed left knee disorder began in service, was caused by service, or is otherwise etiologically related to active duty service? (d) Is it at least as likely as not (i.e., probability of 50 percent or greater) that the Veteran’s service-connected right ankle disorder caused a functional increase in the severity of any diagnosed right and/or left knee disorder or any right and/or left knee pain at any time during the course of the appeal? In answering these questions, the examiner is requested to explain whether there is any medical reason to accept or reject the Veteran’s belief that his current right and left knee pain is related to his service-connected right ankle disorder. A complete medical rationale for all opinions expressed must be provided. 3. Schedule the Veteran for an examination by an appropriate examiner to determine the nature and etiology of any diagnosed cervical spine disorder and the current severity of the service-connected thoracolumbar spine disorder. The examiner must answer the following questions: (a) Is it at least as likely as not (i.e., probability of 50 percent or greater) that any diagnosed cervical spine disorder is etiologically related to active duty service? The examiner should address the Veteran’s March 2017 substantive appeal describing in-service trauma to his neck, and discuss whether there is any medical reason to accept or reject the Veteran’s contention that any cervical spine disability results from this injury. (b) Is it at least as likely as not (i.e., probability of 50 percent or greater) that the Veteran’s service-connected thoracolumbar spine disorder caused a functional increase in the severity of any diagnosed cervical spine disorder at any time during the course of the appeal? The examiner must also determine the current severity of the Veteran’s thoracolumbar spine disorder. The examiner should identify and evaluate any chronic neurologic manifestations of his thoracolumbar spine disorder. In order to comply with Sharp v. Shulkin, 29 Vet. App. 26, 33 (2017), the examiner is asked to 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. 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. Also, in order to comply with the Court’s decision in Correia v. McDonald, 28 Vet. App. 158 (2016), the VA examination must include range of motion testing in the following areas: active motion; passive motion; weight-bearing; and nonweight-bearing. A complete medical rationale for all opinions expressed must be provided. T. MAINELLI Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board C. Howell, 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.