Citation Nr: 21024918 Decision Date: 04/27/21 Archive Date: 04/26/21 DOCKET NO. 14-31 537A DATE: April 27, 2021 REMANDED Entitlement to an increased rating for left knee chondromalacia patella, grade III with instability associated with left femur fracture with residual shortening of the femur, currently evaluated as noncompensable prior to August 29, 2016, as 10 percent disabling from August 29, 2016 to November 19, 2020, and 20 percent disabling thereafter, is remanded. REASONS FOR REMAND The Veteran had active service in the United States Army from July 1980 to July 1984. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a June 2012 rating decision of the Department of Veteran Affairs (VA) Regional Office (RO). In May 2017, the Veteran provided testimony before the undersigned Veterans Law Judge. A transcript of the record is associated with the claims file. This matter was previously remanded in March 2018, June 2020, and November 2020 to the Agency of Original Jurisdiction (AOJ) for further development. The matter now returns to the Board for appellate consideration. During the pendency of the appeal, in a January 2021 rating decision, the Agency of Original Jurisdiction (AOJ) increased the rating for the Veteran’s left knee chondromalacia patella, Grade III with instability, to 20 percent effective November 19, 2020. As the increase did not satisfy the appeal in full, the issue remains on appeal and has been characterized as shown above. See AB v. Brown, 6 Vet. App. 35 (1993). Entitlement to an increased rating for left knee chondromalacia patella, grade III with instability associated with left femur fracture with residual shortening of the femur, currently evaluated as noncompensable prior to August 29, 2016, as 10 percent disabling from August 29, 2016 to November 19, 2020, and 20 percent disabling thereafter, is remanded. The Veteran contends that his left knee disability is more severe than contemplated by the assigned disability rating. Although the Board regrets the delay, a remand is required before an appellate decision can be rendered. A November 2020 VA examination reflects abnormal ranges of motion in the left knee, with flexion limited to 120 degrees and extension to 0 degrees. The examination also reflects sharp pain within all ranges of motion in the left knee, evidence of pain with weight bearing, localized tenderness medially and posteriorly, moderate subluxation, and joint instability but no evidence of ankylosis or meniscal condition. The examiner also indicated that there was pain on passive range of motion testing but none on non-weight bearing and noted that, during flare ups, his flexion would decline from 0-90 degrees whenever his left knee gives out/subluxations. The Board finds the November 2020 examination is inadequate. Passive range of motion measurements upon weight bearing and non-weight bearing testing were not documented. Correia v. McDonald, 28 Vet. App. 158 (2016). The examiner noted a decline in flexion from 0-90 degrees upon flare-ups but did not indicate measurements upon passive range of motion testing. It is unclear to the Board whether the documented flare ups are specific to the pain noted during passive range of motion testing. As such, an addendum opinion is needed to address the Veteran’s passive range of motion measurements, as the examiner has also indicated objective evidence of pain on passive range of motion testing. The Board notes that a revised criterion for rating musculoskeletal claims pursuant to 38 C.F.R. § 4.71a came into effect February 7, 2021. As the Veteran’s claim for his left knee condition is rated under Diagnostic Codes (DC) 5257, which in part has been revised, the current severity of the left knee should be evaluated under these revised regulations. The matters are REMANDED for the following actions: 1. Obtain an addendum opinion from the examiner who conducted the November 2020 VA examination or another appropriate clinician. The examiner providing the opinions must be provided access to the electronic claims file and indicate review of the file in the examination report. The claims folder and a copy of this remand in its entirety must be provided to the examiner in conjunction with the addendum opinion. The examiner is requested to review all pertinent records associated with the claims file, and the examiner must indicate on the examination report that such review was undertaken. If examination of the Veteran is necessary, such should be arranged. To comply with Correia v. McDonald, the examiner must test and record the range of motion in active motion, passive motion, weight-bearing, and non-weight-bearing of the both knees. If the examiner is unable to conduct the required testing or concludes that the required testing is not necessary in this case, he or she should clearly explain why that is so. The examiner must ensure that the revised rating criteria of Diagnostic Code 5257 (effective from February 7, 2021) are amply addressed, whether or not the revised criteria are reflected in the provided Disability Benefits Questionnaire. This discussion should include a full description of the whether this disability is manifested by a ligament tear (incomplete, complete), a diagnosed condition involving the quadriceps tendon, the patella, or the patellar tendon, whether or not such has been repaired, and whether assistive devices such as crutches, a walker, and/or a brace have been prescribed by a medical professional. 2. Readjudicate the Veteran’s claim on appeal. If the benefit sought on appeal remains denied, provide the Veteran and his representative a supplemental statement of the case and allow an appropriate period for response. L. CHU Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Y. Asfaw, 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.