Citation Nr: 21025500 Decision Date: 04/28/21 Archive Date: 04/28/21 DOCKET NO. 18-10 527 DATE: April 28, 2021 REMANDED Entitlement to a compensable rating for post-traumatic brain injury headaches. Entitlement to a rating in excess of 10 percent for right knee patellofemoral pain syndrome and right shin splints. Entitlement to a rating in excess of 10 percent for left knee patellofemoral pain syndrome and left shin splints. Entitlement to a rating in excess of 10 percent for traumatic brain injury (TBI) (claimed as memory loss). Entitlement to a rating in excess of 10 percent for cervical strain and degenerative joint disease. Entitlement to a rating in excess of 10 percent for lumbar spine degenerative joint disease. REASONS FOR REMAND The Veteran served on active duty from February 2012 to June 2015, from October 2017 to September 2018, and from October 2018 to September 2019. This matter comes before the Board of Veterans Appeals (Board) on appeal from an October 2015 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). A Board hearing was held in April 2012. This decision is being made under the “one-touch” program. The hearing transcript will still be processed and associated with the claims file in the ordinary course of business. The Veteran seeks higher ratings for the service-connected disabilities on appeal. The Veteran last underwent VA examinations for the disabilities on appeal in July 2015 and August 2015 and has asserted that the disabilities on appeal have increased in severity since those examinations. In particular, at the April 2021 Board hearing the Veteran indicated that he had headaches every other day and was noticing increased memory loss. He reported that his knees had increased limitation of motion and were giving him difficulty in walking up and down stairs. His low back had increased limitation of motion and was productive of pain on prolonged sitting and standing. He also reported increased pain, locking, and increased limitation of motion of his neck. When there is evidence that there has been a material change in the Veteran’s disability, the current rating may be incorrect, or where the Veteran asserts that the disability has undergone an increase in severity since the last examination, a new examination must be provided. See Caffery v. Brown, 6 Vet. App. 377 (1994); Snuffer v. Gober, 10 Vet. App. 400 (1997). Accordingly, new VA examinations should be obtained on remand to determine the current severity of the Veteran’s disabilities on appeal. The matters are REMANDED for the following action: 1. Contact the appropriate VA Medical Center and obtain and associate with the claims file all outstanding records of treatment on and after November 2015. 2. Contact the Veteran and afford him the opportunity to identify by name, address and dates of treatment or examination any relevant non-VA medical records, including reports from Kaiser Permanente. Subsequently, and after securing the proper authorizations where necessary, make arrangements to obtain all the records of treatment or examination from all the sources listed by the Veteran which are not already on file. 3. After any additional records are associated with the claims file, provide the Veteran with the appropriate examination(s) to determine the current severity of the headaches and TBI claims. The entire claims file must be made available to and be reviewed by the examiner. Any indicated tests and studies must be accomplished, and all clinical findings must be reported in detail and correlated to a specific diagnosis. An explanation for all opinions expressed must be provided. The examiner must utilize the appropriate Disability Benefits Questionnaire. 4. After any additional records are associated with the claims file, provide the Veteran with the appropriate examination(s) to determine the current severity of the left and right knee claims and the low back and cervical spine claims. The entire claims file must be made available to and be reviewed by the examiner. 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. The examiner must utilize the appropriate Disability Benefits Questionnaire. In doing so, the examiner must test the Veteran’s active motion, passive motion, and pain with weight-bearing and without weight-bearing. Specific measurements must be provided, where appropriate. The examiner must also attempt to elicit information regarding the severity, frequency, and duration of any flare-ups, and the degree of functional loss during flare-ups. If it is not possible to provide a specific measurement based on direct observation, the examiner should provide an estimate, if at all possible, of the additional impairment due to flare-ups based on the other evidence of record and the Veteran’s statements. For the above, an explanation for all opinions expressed must be provided. 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). C. CRAWFORD Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board David Nelson 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.