Citation Nr: 21021976 Decision Date: 04/14/21 Archive Date: 04/14/21 DOCKET NO. 13-27 904 DATE: April 14, 2021 REMANDED Entitlement to a rating in excess of 10 percent prior to September 26, 2019, and in excess of 30 percent from that date for service-connected right knee degenerative joint disease (DJD) with loss of extension is remanded. REASONS FOR REMAND The Veteran served on active duty in the U.S. Army from April 1981 to April 1984. In July 2018, the Veteran testified at a Travel Board hearing before the undersigned Veterans Law Judge. This case was most recently remanded in May 2020 for additional development. The Board notes that VA secured additional VA treatment records following the November 2020 Supplemental Statement of the Case (SSOC). If additional evidence is received after the Agency of Original Jurisdiction (AOJ) furnishes the SSOC, and that evidence is pertinent and not duplicative, the AOJ must furnish a Supplemental Statement of the Case (SSOC) as provided in 38 C.F.R. § 19.31. The AOJ has not issued a SSOC after receipt of this new evidence. See 38 C.F.R. §§ 19.31, 19.37. Nevertheless, as the AOJ will have an opportunity to review all of the new evidence on remand, there is no prejudice to the Veteran in proceeding with adjudication at this time. 1. Entitlement to a rating in excess of 10 percent prior to September 26, 2019, and in excess of 30 percent from that date for service-connected right knee DJD with loss of extension. In October 2020, the Veteran underwent a VA examination to evaluate the severity of his right knee condition. During the examination, the examiner diagnosed the Veteran with degenerative arthritis of the right knee. Upon examination, the Veteran reported that his condition had worsened and that he experienced constant sharp pain and swelling. The Veteran did not report flare-ups, but indicated that he suffered decreased range of motion, an inability to squat and bend, difficulty in climbing stairs, and a limited ability to drive long periods. Range of motion testing was performed and yielded results of 0 to 50 degrees for flexion and 50 to 0 degrees for extension. Additionally, pain was noted on both flexion and extension. Evidence of pain on weight bearing and objective evidence of crepitus was found. The Veteran was able to perform repetitive use testing, but no additional function or range of motion was noted after three repetitions. The examination was not conducted immediately after repetitive use over time; however, range of motion was described as 0 to 40 degrees for flexion and 40 to 0 degrees for extension. No ankylosis was found and no history of lateral instability, recurrent effusion, or recurrent subluxation was noted. Joint stability testing was performed and returned all normal results. Due to the condition, disturbance of locomotion and interference with standing was found, which required the use of a cane. Objective evidence of pain was noted when the right knee was not used in weight bearing. See October 2020 VA Examination. In conjunction with the examination, the examiner provided an opinion stating that the Veteran did not have knee instability. In reaching this conclusion, the examiner explained that during the examination the Veteran demonstrated the ability to ambulate without a right knee brace without any right knee instability. Thus, the examiner noted, the findings were consisted with the Veteran’s ability to ambulate and bear weight on the right knee to the extent that it would not cause frequent falls from it “giving way.” Finally, the examiner noted that the Veteran used a cane, without a rubber stopper to limit its slippage, on an extremely slippery surface. Ultimately, the examiner opined that the Veteran’s strength in the right leg/knee and balance were adequate enough to maintain stability. See October 2021 VA Medical Opinion. In spite of the above opinion, the Board finds the VA examiner’s opinion to be insufficient as it was not based on a complete understanding of the Veteran’s medical history. Notably, while the examiner indicated that the Veteran did not wear a right knee brace during the examination, numerous VA treatment records reveal that the Veteran has worn a right knee brace in the past. See, e.g., VA Treatment Record received September 2017; VA Treatment Record received September 2016. Additionally, VA examinations from September 2019 and October 2015 indicate that the Veteran used a knee brace for stability. See September 2019 VA Examination; October 2015 VA Examination. Additionally, the examiner did not reconcile his finding that the Veteran had sufficient strength and balance to maintain stability, with the Veteran’s consistent reports in his VA treatment records and during the Board hearing that his knee would “give way”, which sometimes caused him to fall. See July 2018 Board Hearing Transcript; VA Treatment Record Received January 2021; VA Treatment Record received August 2019; VA Treatment Record received February 2016; Private Treatment Record received September 2016. The evidence noted above does not appear to be considered or discussed by the October 2020 VA examiner and it may have a bearing on the Veteran’s claim. Accordingly, remand is warranted for a new VA medical opinion consistent with the directives herein. The matters are REMANDED for the following action: 1. Obtain a VA medical opinion from an appropriate examiner to opine whether now, or if at any point during the pendency of the appeal, the Veteran suffered from right knee instability (a physical examination may be conducted, if deemed necessary). The claims folder (including a copy of this remand) must be provided to and reviewed by the examiner as part of the examination. All clinical findings should be reported in detail. In rendering the above opinion, the VA examiner should consider and discuss the Veteran’s reports from the July 2018 Board Hearing, October 2020 VA treatment record, August 2019 VA treatment record, February 2016 VA treatment record, and August 2016 VA treatment record wherein the Veteran reports his right knee giving way, which at times has caused him to fall. Additionally, the examiner should consider and discuss the September 2019 and October 2015 VA examinations, August 2016 VA treatment record, March 2013 VA treatment record, and September 2013 VA treatment record, which indicate that the Veteran wore a brace on his right knee. A. ISHIZAWAR Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Talton, John H. 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.