Citation Nr: 21014804 Decision Date: 03/15/21 Archive Date: 03/15/21 DOCKET NO. 17-10 744 DATE: March 15, 2021 REMANDED Entitlement to an initial compensable evaluation for right knee patellofemoral syndrome is remanded. REASONS FOR REMAND The Veteran served on active duty for training in the U.S. Army from August 2004 to December 2004. This matter comes before the Board of Veteran’s Appeals (Board) on appeal from a January 2016 rating decision by the Regional Office (RO) that granted service connection for right knee patellofemoral syndrome and assigned a noncompensable rating. Entitlement to an initial compensable evaluation for right knee patellofemoral syndrome The Veteran’s right knee patellofemoral syndrome is currently assigned a noncompensable rating under Diagnostic Code 5260, effective September 17, 2015. The Veteran seeks a higher initial rating. See NOD, January 2016. The Veteran was last afforded a VA examination in November 2015. The focus of the examination appears to have been of the left knee. Likewise, the Veteran testified at the Board hearing that he had not reviewed the report but that the examiner seemed more focused on the left knee than the right. While the report shows diagnostic testing was performed, the underlying x-ray report shows it was for the left knee only. The examiner noted objective evidence of pain in weight-bearing, but did not provide the ranges of motion in both weight-bearing and nonweight-bearing, active and passive, as required by Correia v. McDonald, 28 Vet. App. 158 (2016). The examiner noted he could not describe functional loss due to pain during flare-ups in terms of ranges of motion without resorting to speculation, but did not provide any rationale as required by in Sharp v. Shulkin, 29 Vet. App. 26 (2017). Regardless, the Veteran testified at the Board hearing that his right knee had worsened since the last VA examination in 2015. Therefore, the Board finds this matter should be remanded so that the Veteran may be afforded a new VA examination to address the current severity of his right knee patellofemoral syndrome. In addition, there are no records of treatment in the claims file for the period on appeal. The Veteran testified at the Board hearing that he received treatment at the VA medical center after the 2015 VA examination. Therefore, all of the Veteran’s VA treatment records dated since November 2015 should be associated with the claims file. The matter is REMANDED for the following action: 1. Associate with the claims file all of the Veteran’s VA treatment records dated from November 2015 to present. 2. After the above development has been completed, provide the Veteran with a new VA examination to address the current severity of his right knee disability – to include ranges of motion in weight-bearing and nonweight-bearing, active and passive. The claims folder should be made available to the examiner and pertinent documents therein should be reviewed by the examiner. All necessary tests and studies should be accomplished, and all clinical findings should be reported in detail. Diagnostic imaging must be performed (e.g., x-rays). The examination must comply with the requirements of 38 C.F.R. § 4.59 involving measurements of passive and active range of motion - in both weight-bearing and nonweight-bearing. The examiner must explain why any of these clinical tests are not appropriate or could not be performed. A complete rationale for any opinions expressed should be provided. If flare-ups are noted, the examiner should note whether pain during flare-ups additionally limits functional ability. The examiner should note whether there are any additional degrees of loss of motion due to pain during flare-ups (if it is not feasible to quantify, please explain). Also, the examiner should ask the Veteran to describe in his own words whether there is any additional functional loss during flare-ups, and the examiner should note the frequency, duration, and severity of flare-ups. The examiner should also note whether weakened movement, excess fatigability, incoordination, or pain significantly limits functional ability with repeated use over time. If so, the examiner should note whether there are any additional degrees of loss of motion as a result (if it is not feasible to quantify, please explain). Regarding both flare-ups and repeated use over time, please note to the VA examiner that if additional functional loss cannot be described in terms of degrees of limitation of motion, it should be clear that an examiner has “considered all procurable and assembled data before stating that an opinion cannot be reached,” and “that the inability to provide an opinion without resorting to speculation reflects the limitation of knowledge in the medical community at large.” The Board may “accept a VA examiner’s statement that he or she cannot offer an opinion without resorting to speculation, but only after determining that this is not based on the absence of procurable information or on a particular examiner’s shortcomings or general aversion to offering an opinion on issues not directly observed.” See Sharp v. Shulkin, 29 Vet. App. 26, 33 (2017). The examiner should also address the effect of the Veteran’s right knee disability on his occupational functioning. J.W. FRANCIS Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Juliano, 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.