Citation Nr: 21027166
Decision Date: 05/04/21	Archive Date: 05/04/21

DOCKET NO. 17-52 685
DATE: May 4, 2021

REMANDED

A disability rating in excess of 10 percent for the right knee patellofemoral syndrome (right knee disability) from March 2016 is remanded.

Service connection for a lumbar spine disorder, as secondary to the service-connected right knee disability, is remanded.

REASONS FOR REMAND

1. Increased rating for right knee patellofemoral syndrome

The Veteran was initially rated 10 percent for patellofemoral syndrome of the right knee from 2007. In March 2016, filed a claim for increased rating for the right knee disability. See March 2016 Fully Developed Claim. This Board decision addresses the 2016 claim for increase.

In a hearing before the Board in April 2020, the Veteran asserted that the pain and limitation of motion of the right knee patellofemoral syndrome had worsened since the last VA examination in 2016. The Veteran's representative contends that the worsening triggers the duty to assist by providing a new VA examination. As a result, the Board will remand the issue for a new examination to help determine the current level of severity of the right knee disability. 

Whether Separate Rating for Instability of the Right Knee

During the April 2020 Board hearing, the Veteran described episodes of weakness of the right knee, and that the right knee will suddenly give way. The Veteran reported being prone to falling, and having difficulty getting back up, and that these symptoms require use of a brace and occasionally a cane.

A VA examination performed in May 2008 noted instability of the right knee. The most recent VA examination in May 2016 included joint stability testing, and indicated joint stability testing was normal. As the Veteran has competently and credibly reported experiencing symptoms of instability, the Board finds that the right knee should also be tested for instability and recurrent subluxation in order to help determine whether a separate compensable rating for any knee instability or subluxation is warranted under DC 5257.

2. Secondary service connection for lumbar spine disorder

At the April 2020 Board hearing, the Veteran reported that, because of the pain and weakness in the right knee, he walks with a limp favoring the left leg. The Veteran reported using a cane, with the result being a shifting of balance from the center of his body towards the left side. The Veteran contends that this altered gait due to the right leg disability is aggravating the lumbar spine condition, raising a claim for secondary service connection (38 C.F.R. § 3.310).

The only VA examination addressing the lumbar spine was performed in October 2008. While the examiner opined that the lumbar spine condition is less likely as not caused by or a result of the right knee disability, the opinion did not address the question of whether an altered gait from the right knee disability is aggravating the lumbar spine condition. For this reason, the Board will remand this issue for a secondary aggravation opinion.

The matters are REMANDED for the following action:

Schedule an examination of the right knee and low back. In addition to ranges of motion testing and all other findings and opinions, the examination testing should specifically note whether the Veteran walks with an altered gait due to the right knee disability, and should include testing of the right knee for instability and subluxation.

The VA examiner should offer the following opinions:

1. Does the Veteran walk with an altered gait due to the right knee disability? 

2. If so, has the altered gait (that caused by the right knee disability) worsened in severity a back disorder? 

 

 

J. PARKER

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	Charles Plambeck

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.