Citation Nr: 21040003
Decision Date: 07/02/21	Archive Date: 07/02/21

DOCKET NO. 10-02 035
DATE: July 2, 2021

REMANDED

Entitlement to an initial rating in excess of 10 percent for minimal patellar spur of the left knee (claimed as arthritis) is remanded.

REASONS FOR REMAND

The Veteran served on active duty from March 1979 to March 1982.

This matter is before the Board of Veterans' Appeals (Board) on appeal from a March 2009 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO).

This matter was previously before the Board in May 2018 and April 2020 when it was remanded for further development.

Entitlement to an initial rating in excess of 10 percent for minimal patellar spur of the left knee (claimed as arthritis) is remanded.

Although the additional delay is regrettable, the Board finds an additional remand is required before a decision can be made on the Veteran's claim.

In accordance with the April 2020 Board remand order, the Veteran underwent a VA examination in January 2021 to assess the severity of his service-connected left knee condition. However, after a review of the examination report, the Board finds the examination inadequate for rating purposes as the examiner failed to adequately report the examination findings. For example, the examination report reflects that the Veteran reported severe flare ups of his left knee condition. When prompted to provide information regarding the extent of functional impairment the Veteran experiences during a flare up of symptoms, the examiner reported, "bilateral knee weakness and decreased when walking." The examiner used the same language when documenting the Veteran's description of functional loss. It is is unclear what exactly is decreased when the Veteran walks. 

The Board also notes that the examiner's findings regarding range of motion testing are unclear. Specifically, the examiner initially indicates that there is no evidence of pain on passive range of motion testing. However, when asked again whether there was evidence of pain, the examiner did not check the box indicating there was pain, but checked the boxes indicating there was pain on weight-bearing and nonweight-bearing, active and passive motion, and on rest. Furthermore, the examiner did not provide a response as to whether the pain caused functional loss. 

Lastly, it is unclear from the report whether the Veteran has shin splints. The examiner noted a diagnosis of shin splints and indicated that the condition was directly due to or related to the Veteran's service-connected diagnosis, but also reported that the Veteran did not have shin splints when asked for further information, including treatment and symptoms of the shin splints.

In light of the inconsistencies and unclear findings noted on the examination report, the Board finds remand for a new VA examination is necessary.

The matters are REMANDED for the following action:

Schedule the Veteran for a VA examination with an appropriate clinician to determine the nature and severity of his minimal patellar spur of the left knee. The entire claims file should be made available to the examiner in conjunction with this request. All testing deemed necessary to rate the Veteran's condition under the criteria of the rating schedule must be conducted and the results reported in detail. The examiner should describe all manifestations of the disability, to include whether assessment of shin splits is appropriate.

The examiner must provide a complete rationale for all the findings and opinions.

 

 

G. E. Wilkerson

Acting Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	S. Jiggetts

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.