Citation Nr: 21024603 Decision Date: 04/23/21 Archive Date: 04/23/21 DOCKET NO. 17-52 531 DATE: April 23, 2021 REMANDED Entitlement to an initial rating in excess of 10 percent for left knee degenerative arthritis is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army National Guard from November 2002 to May 2003 and in the United States Army from May 2003 to April 2004 and May 2004 to June 2012. At a February 2020 hearing, the Veteran testified before the undersigned Veterans Law Judge. A transcript of the proceeding has been associated with the claims file. 1. Entitlement to an initial rating in excess of 10 percent for left knee degenerative arthritis is remanded. The Veteran’s left knee disability was evaluated at March 2016 and December 2017 VA examinations. The United States Court of Appeals for Veterans Claims (Court) in Correia v. McDonald, 28 Vet. App. 158 (2016), held that the final sentence of 38 C.F.R. § 4.59 requires that VA examinations include joint testing for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with range-of-motion measurements of the opposite undamaged joint. Thus, the Court’s holding in Correia establishes additional requirements that must be met prior to finding that a VA examination is adequate. Additionally, the Court has stated that flare-ups must be factored into an examiner’s assessment of functional loss. See Sharp v. Shulkin, 29 Vet. App. 26, 32 (2017). Neither of the VA examinations of record fully satisfies the requirements of Correia, Sharp, and 38 C.F.R. § 4.59. Further, the March 2016 examination did not demonstrate instability in the left knee and the December 2017 examination did not evaluate instability. At the February 2020 hearing, the Veteran described symptomology of instability in the left knee. Based on the foregoing, the Board finds that a new VA examination is necessary to determine the current extent and severity of the Veteran’s left knee disability and to ensure all manifestations of the disability are addressed. The Board notes that the December 2017 examiner did not evaluate many of the aspects that are requested on a VA examination report for a knee disability. As such, upon remand, the examiner conducting the evaluation is specifically asked to complete the forms provided for this purpose. It may be assumed the findings are those caused by service connected disability, but if in the judgement of the examiner they are a result of a disability that is not service connected, that disability should be identified. If some symptoms and findings are a result of service connected disability, and some from a non-service connected disability, that distinction should be recorded. The matters are REMANDED for the following action: 1. Obtain all outstanding VA treatment records, specifically to include records since December 2017, and associate them with the claims file. 2. Schedule the Veteran for a VA examination to determine the current nature and severity of his left knee disability. The examiner should be willing to complete the forms provided for this purpose. It may be assumed the findings are those caused by service connected disability, but if in the judgement of the examiner they are a result of a disability that is not service connected, that disability should be identified. If some symptoms and findings are a result of service connected disability, and some from a non-service connected disability, that distinction should be recorded. The entire claims file should be made available to and reviewed by the examiner. All indicated tests should be conducted and all findings reported in detail. (a.) The examination should include testing results on both active and passive motion, and in weight-bearing, and nonweight-bearing. The examiner should assess where pain begins on the Veteran’s initial range of motion and upon repetitive testing. The examiner should also describe any pain, weakened movement, excess fatigability, and incoordination present. If the examiner is unable to conduct such testing or concludes that the required testing is not necessary in this case, he or she should clearly explain why that is so. (b.) The examiner should estimate any additional functional loss in terms of additional degrees of limited motion of the left knee experienced during flare-ups and repetitive use over time. If the examiner cannot provide the above-requested opinion without resorting to speculation, he or she should state whether all procurable medical evidence had been considered, to specifically include the Veteran’s descriptions as to the severity, frequency, and duration of the flare-ups and his description as to the extent of functional loss during a flare-up and after repetitive use over time; whether the inability is due to the limits of the medical community or the limits of the examiner’s medical knowledge; and whether there is additional evidence, which if obtained, would permit the opinion to be provided. Noting that the Veteran was not examined during a flare-up will not suffice. (c.) The examiner is asked to consider the Veteran’s lay statements of record regarding the functional impact of his left knee disability, particularly to include his February 2020 hearing testimony regarding instability in the knee. 3. After the above development and any additionally indicated development has been completed, readjudicate the issue on appeal. MICHAEL E. KILCOYNE Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Rachel E. Jensen, 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.