Citation Nr: 21009268 Decision Date: 02/22/21 Archive Date: 02/22/21 DOCKET NO. 15-27 631A DATE: February 22, 2021 REMAND Entitlement to an evaluation in excess of 30 percent for posttraumatic stress disorder (PTSD) prior to January 28, 2014, is remanded. Entitlement to an evaluation in excess of 50 percent for PTSD from January 28, 2014, is remanded. Entitlement to an evaluation in excess of 10 percent for left knee patellofemoral pain syndrome (left knee disability) is remanded. Entitlement to an evaluation in excess of 10 percent for right knee patellofemoral pain syndrome (right knee disability) is remanded. Entitlement to an evaluation in excess of 20 percent for right shoulder chronic musculoligamentous strain (right shoulder disability) is remanded. REASONS FOR REMAND The Veteran served on active duty from September 2003 to September 2011. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a January 2012 rating decision by the Department of Veterans Affairs (VA) that granted service connection for PTSD, rated 30 percent, and left knee, right knee, and right shoulder disabilities, rated noncompensable each, effective September 17, 2011. In a July 2015 rating decision, the Agency of Original Jurisdiction (AOJ) increased the Veteran’s rating for PTSD to 50 percent, effective January 28, 2014, and for bilateral knees to 10 percent each, effective June 8, 2015. In an April 2018 rating decision, the AOJ increased the Veteran’s rating for a right shoulder disability to 20 percent, effective September 17, 2011; the AOJ also assigned an effective date of September 17, 2011, for the 10 percent ratings for right and left knee disabilities. This case was remanded in February 2020 for further development; it has since been re-assigned to the undersigned. In February 2020, the Board also remanded the issue of entitlement to service connection for a gastrointestinal order. In an August 2020 rating decision, the AOJ granted service connection for this disability; this issue is therefore no longer on appeal before the Board. In November 2018, the Veteran withdrew his request for a videoconference hearing. The issues of entitlement to increased ratings for osteoarthritis and degenerative disc disease of lumbar spine, as well as radiculopathy of the right and left lower extremities, were opted in to the Appeals Modernization Act (AMA) legal framework pursuant to an AMA notice of disagreement (VA Form 10182) received in December 2019. As a result, those issues will be the subject of a future Board decision, if otherwise in order. 1. Entitlement to an evaluation in excess of 30 percent for PTSD prior to January 28, 2014, is remanded. 2. Entitlement to an evaluation in excess of 50 percent for PSD from January 28, 2014, is remanded. In January 2015 correspondence, the Veteran’s attorney submitted medical evidence from a private facility in support of the Veteran’s claim. See September 2014 treatment from Lee-Davis Medical Associates. An October 2014 VA treatment record notes that the medical provider named in the September 2014 private treatment record, Dr. R.L.O., is the Veteran’s primary care physician. It is unclear if the Veteran sought more treatment from this facility. Additionally, a March 2016 VA treatment record notes a scanned document from Patient First in Mechanicsville, dated in September 2015. The Board does not have access to this scanned record. Accordingly, on remand, attempts to obtain these records should be made. 3. Entitlement to an evaluation in excess of 20 percent for a right shoulder disability is remanded. 4. Entitlement to an evaluation in excess of 10 percent for a left knee disability is remanded. 5. Entitlement to an evaluation in excess of 10 percent for a right knee disability is remanded. VA examinations must include joint testing for active and passive motion in both weight-bearing and non-weight-bearing circumstances. Correia v. McDonald, 28 Vet. App. 158 (2016). Additionally, estimated ranges of motion should be provided during flare-ups, if feasible, even if the Veteran is not experiencing one during the examination. See Sharp v. Shulkin, 29 Vet. App. 26 (2017). In this case, the VA shoulder and knee examinations of record do not fully comport with the requirements of Correia or Sharp. Thus, remand is necessary for new VA shoulder and knee examinations. The matters are REMANDED for the following action: 1. The AOJ should obtain, if possible, records of relevant private evaluations and treatment the Veteran has received for the disabilities on appeal. The Veteran must assist in the matter by identifying his private healthcare providers and by submitting releases for VA to obtain any private records identified. 2. The AOJ should obtain VA scanned documents. See March 22, 2016, VA treatment record. If such scanned documents cannot be associated with the claim file, the AOJ should provide a memorandum of actions taken attempting to obtain such records. 3. After the above development is completed, the AOJ should arrange for an orthopedic examination of the Veteran (to include telehealth interview, review of the record, etc., if an in-person examination is not feasible) to assess the current severity of his service-connected right and left knee and right shoulder disabilities. The examiner must review the entire record in conjunction with the examination and note such review was conducted. Pathology, symptoms (frequency and severity), and any associated impairment of function should be described in detail. All indicated tests or studies should be completed. (a.) Range of motion measurements should be included for active and passive motion in both weight-bearing and non-weight-bearing circumstances, including for the opposite undamaged joint, if applicable. If pain is noted, the point in the range of motion at which pain starts should be clearly noted. (b.) If feasible, the examiner must assess the additional functional impairment on repeated use or during flare-ups in terms of the degree of additional range of motion loss, using lay observations specifically elicited from the Veteran. If not feasible, the examiner must provide a detailed explanation and rationale for why such could not be accomplished. Specifically, if the medical professional cannot provide an opinion without resorting to mere speculation, he or she must provide a complete explanation for why an opinion cannot be rendered; a rationale based on the fact that the Veteran is not having a flare-up at the time of the examination will not be deemed adequate. Specifically with respect to the increased rating claims for right and left knee disabilities: The examiner should address whether the Veteran has patellar instability (a diagnosed condition involving the patellofemoral complex) and, if so, whether the Veteran requires a prescription by a medical provider for a brace, cane, and/or walker. The examiner should address whether the Veteran has recurrent subluxation or instability consisting of either a sprain or ligament tear that causes persistent instability, and whether the Veteran requires the use of an assistive device or bracing for ambulation. If the Veteran has a ligament tear, identify whether it is incomplete, or complete (to include repaired, unrepaired, or failed repair). 4. If upon completion of the above action the issues remain denied, the case should be returned to the Board after compliance with appellate procedures. E. I. VELEZ Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board T. Matta, 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.