Citation Nr: 21012506 Decision Date: 03/04/21 Archive Date: 03/04/21 DOCKET NO. 20-04 555 DATE: March 4, 2021 REMANDED Entitlement to a rating in excess of 10 percent for carpal tunnel syndrome, median nerve, of the left upper extremity (hereinafter left arm disability) is remanded. Entitlement to a rating in excess of 10 percent for carpal tunnel syndrome, median nerve, of the right upper extremity (hereinafter right arm disability) is remanded. Entitlement to a rating in excess of 10 percent for right knee patellofemoral syndrome (hereinafter right knee disability) is remanded. Entitlement to a compensable rating for bilateral foot tinea pedis is remanded. REASONS FOR REMAND The Veteran served on active duty from May 1998 to May 2004, and from October 2007 to July 2009. This appeal comes before the Board of Veterans’ Appeals (Board) from a November 2018 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). In February 2021, the Veteran testified before the undersigned Veterans Law Judge (VLJ). The hearing transcript is not presently of record; however, the transcript will be associated with the file in the ordinary course of business. 1. Entitlement to a rating in excess of 10 percent for left arm disability is remanded. 2. Entitlement to a rating in excess of 10 percent for right arm disability is remanded. 3. Entitlement to a rating in excess of 10 percent for right knee disability is remanded. 4. Entitlement to a compensable rating for bilateral foot tinea pedis is remanded. Issues 1-4. The Veteran, and his representative, contends that a higher evaluation is warranted for his service-connected disabilities. At the February 2021 Board hearing, the Veteran competently and credibly testified as to a material worsening of his disabilities since his last VA examinations. In this regard, for his bilateral arm disabilities, he stated that his grip has worsened to the point that objects now slip from his hands; he additionally provided testimony as to experiencing increased numbness, weakness, and pain. For his right knee, the Veteran reported, among other things, experiencing instability, and gradual loss of range of motion (ROM). For his foot tinea pedis, the Veteran reported using medication, twice a week on average, and increased symptomology, which he described as comparable to poison ivy. While the mere passage of time is not grounds for a new examination, a new examination is appropriate when there is an assertion (and indication) of an increase in severity since the last examination. See 38 C.F.R. § 3.159; see also Palczewski v. Nicholson, 21 Vet. App. 174, 181 (2007); Snuffer v. Gober, 10 Vet. App. 400, 403 (1997). Here, the Veteran testified to an increased severity of symptoms associated with his disabilities since his last VA examinations. Given the competent, credible evidence of worsened symptoms since the last VA examinations, a remand is necessary to adequately evaluate the current severity of the Veteran’s service-connected disabilities. Caffrey v. Brown, 6 Vet. App. 377, 381 (1995) (VA must provide a new examination where a veteran claims the disability is worse than when originally rated and the available evidence is too old to adequately evaluate the current severity). Therefore, new VA examinations are needed to assist in determining the current severity of the Veteran’s service-connected disabilities. Snuffer, 10 Vet. App. at 400. Moreover, the October 2018 examination report, for the right knee disability, is inadequate for rating purposes because it is not shown to be in compliance with the Court’s ruling in Correia v. McDonald, 28 Vet. App. 158 (2016). While the October 2018 examiner did answer questions as to pain with weightbearing and non-weightbearing and passive ROM, the examiner did not provide adequate explanations or rationale for her answers and she did not provide specific values for active or passive ROM testing, weight-bearing or non-weight-bearing. As the examiner provided deficient explanations and failed to give adequate findings in regard to the Correia standards, on remand the new examination should include Correia compliant testing along with thorough explanations of the examiner’s findings. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). The new examination should include specific findings regarding the Veteran’s ROM for his right knee, in active motion, passive motion, weightbearing, and non-weightbearing. It is noted that for the October 2018 examination, the Veteran did not report experiencing flares. See Sharp v. Shulkin, 29 Vet. App. 26 (2017). Therefore, given the above, remand for a new VA examination to adequately address the Correia standards is required. See Barr, 21 Vet. App. at 311. Further, retrospective supplemental findings should be requested from the examiner on remand. See Chotta v. Peake, 22 Vet. App. 80, 85-86 (2008) (discussing situations when it may be necessary to obtain a “retrospective” medical opinion to determine the date of onset or severity of a condition in years past); see also Vigil v. Peake, 22 Vet. App. 63 (2008) (holding that the duty to assist may include development of medical evidence through a retrospective medical evaluation where there is a lack of medical evidence for the time period being rated). Aside from the above explicit findings, in remanding these matters, the Board makes no further finding, implicit or otherwise, as to the credibility of the Veteran’s assertions. Neither the Veteran’s credibility nor any lack thereof should be presumed in this remand. The matters are REMANDED for the following actions: 1. Obtain all VA treatment records dated from October 2019 to the Present. 2. Schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his service-connected (1) left arm carpal tunnel syndrome, (2) right arm carpal tunnel syndrome, and (3) bilateral foot tinea pedis. The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran’s disability under the rating criteria. 3. Schedule the Veteran for a VA examination by an appropriate clinician to determine the current severity of his service-connected right knee disability. The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran’s disability under the rating criteria. As to the below, if it is not possible to provide a specific measurement without speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). (a) Test the Veteran’s active motion, and passive motion, with weight-bearing and without weight-bearing. Note: The examiner should determine the effective ROM for the disability and present the results of ROM tests in a written report which complies with 38 C.F.R. § 4.59 by recording separate sets of the ROM test results for both active and passive motion, and in weightbearing and non-weightbearing. The examiner’s report should describe objective evidence of painful motion, if any, during each test. IT IS NOT SUFFICIENT MERELY TO INDICATE WHETHER OR NOT PAIN WAS PRESENT DURING ONE OF THE REQUIRED ROM TESTS. If any of these findings are not possible, please provide an explanation. (b) Attempt to elicit information regarding the severity, frequency, and duration of any flare-ups, and the degree of functional loss during flare-ups. Note: 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 ROM during flares or repetitive use. Retrospective Findings Following a review of the record, the clinician should provide retrospective findings for the below identified past examination. If it is not possible to provide a specific measurement without speculation, the clinician must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the clinician (does not have the knowledge or training). (c) Provide an addendum retrospective opinion for the Veteran’s service-connected right knee disability to supplement the October 2018 VA Examination Report that: (i) Estimates the amount in degrees of ROM lost due to pain in both weightbearing and non-weight bearing positions, and on both active and passive motion based on the evidence of record and the Veteran’s statements. 4. Readjudicate. C.A. SKOW Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board A. Griffey, Associate 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.