Citation Nr: 22015161 Decision Date: 03/16/22 Archive Date: 03/16/22 DOCKET NO. 17-54 297 DATE: March 16, 2022 REMANDED The issue of a rating greater than 40 percent for a disability of the left knee from May 2, 2014, to present, is remanded. The issue of a rating greater than 40 percent for radiculopathy of the right upper extremity from May 2, 2014, to present, is remanded. The issue of a rating greater than 30 percent for a disability of the cervical spine from May 2, 2014, to present, is remanded. The issue of a rating greater than 20 percent for radiculopathy of the left upper extremity from May 2, 2014, to present, is remanded. The issue of a rating greater than 20 percent for a disability of the left shoulder from May 2, 2014, to present, is remanded. The issue of entitlement to a total disability rating based on individual unemployability (TDIU) from May 2, 2014, to present, is remanded. REASONS FOR REMAND The Veteran served on active duty from March 1979 to August 1979; from February 2003 to October 2003; and from June 2005 to December 2006. This matter comes before the Board of Veterans' Appeals (Board) from a January 2015 rating decision from a Department of Veterans Affairs (VA) regional office (RO). 1. The issue of a rating greater than 40 percent for a disability of the left knee from May 2, 2014, to present, is remanded. 2. The issue of a rating greater than 40 percent for radiculopathy of the right upper extremity from May 2, 2014, to present, is remanded. 3. The issue of a rating greater than 30 percent for a disability of the cervical spine from May 2, 2014, to present, is remanded. 4. The issue of a rating greater than 20 percent for radiculopathy of the left upper extremity from May 2, 2014, to present, is remanded. 5. The issue of a rating greater than 20 percent for a disability of the left shoulder from May 2, 2014, to present, is remanded. 6. The issue of entitlement to a total disability rating based on individual unemployability (TDIU) from May 2, 2014, to present, is remanded. The matters are REMANDED for the following action: 1. BACKGROUND FOR THE ADJUDICATOR A remand is necessary to provide the Veteran with examinations to determine the current severity of his service-connected disabilities. Snuffer v. Gober, 10 Vet. App. 400, 403 (1997). The evidence indicates the Veteran's left knee disability has worsened since his most recent examination in December 2014. Since then, the Veteran has reported increased pain in this left knee and received multiple rounds of physical therapy, which suggest his knee has a decreased range of motion when compared to the December 2014 examination. Further, the December 2014 examination was incomplete in that it did not provide an estimate as to the effect of flareups. A new examination is warranted. The evidence indicates the Veteran's cervical spine disability may also have worsened since his most recent examination in December 2014. Since then, the Veteran has reported increased pain in this neck and received multiple rounds of physical therapy, which noted a decreased range of motion. A new examination is warranted. The evidence indicates the Veteran's left shoulder disability may have worsened since his most recent examination in December 2014. Since then, the Veteran has reported increased pain in this left shoulder and received physical therapy for shoulder pain. A new examination is warranted. The evidence indicates the Veteran's bilateral radiculopathy of the upper extremities may have worsened since his most recent examination in August 2011. Since then, the Veteran reported an injury to his bilateral upper extremities in October 2018. Further, the condition is linked to the cervical spine disability which appears to have worsened. A new examination is warranted. Additionally, the record may be missing relevant records. The Veteran reported in March 2016 that he has a private treating orthopedist. The record does not contain records from this treating physician. Efforts to assist the Veteran in obtaining these records should be made. Finally, the Veteran claimed TDIU is warranted based on the increase in the above service-connected disabilities. Therefore, these issues are inextricably intertwined and must be remanded together. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991). THE REMAND DIRECTIVES FOLLOW. 2. Ask the Veteran to complete a VA Form 21-4142 for the private orthopedist he reported seeing in March 2016. Make two requests for the authorized records from the provider identified unless it is clear after the first request that a second request would be futile. 3. Schedule the Veteran for an examination of his left knee disability to determine the severity of the disorder, by an appropriately qualified VA clinician. All appropriate tests, studies and consultations must be accomplished, including a new medical examination if necessary, and all clinical findings should be reported in detail in the narrative portion of the examination report. The examiner must test the Veteran's active motion, passive motion, and pain with weight-bearing and without weight-bearing. If unable to provide a specific measurement without speculation, the examiner must state whether the need is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a problem in the record (additional facts are required), or the examiner (does not have the knowledge or training). The examiner must attempt to elicit information regarding the severity, frequency, and duration of any flare-ups, and the degree of functional loss during flare-ups. If unable to provide a specific measurement based on direct observation, the examiner should provide an estimate, if possible, of the impairment due to flare-ups based on the other evidence of record and the Veteran's statements. If unable 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 (i.e., no one could respond given science and the known facts), a problem in the record (additional facts are required), or the examiner (does not have the knowledge or training). The examiner must review the record as found in VA treatment reports and the electronic file. However, the record in substance indicates the following: At the December 2014 examination, the Veteran reported he had flareups in this left knee that prevented him from doing anything around the house, from driving, and limited his ability to stand or walk for a prolonged time. The Veteran reported his private orthopedist recommended knee surgery in March 2016. His left knee active range of motion was measured as 120 degrees in March 2016. In September 2016, the Veteran was fitted for a knee sleeve. It was noted that it was medically necessary for reduction of pain, swelling, and stiffness. In December 2016, he began physical therapy for bilateral knee pain. His gait function was noted as impaired. In March 2017, the Veteran reported the pain in his knees was worse. In August 2019, he again reported worsening pain in his knees. In October 2019, he began five sessions of physical therapy related to knee pain. In November 2019, the Veteran's left knee active range of motion was measured as 83 degrees. 4. Schedule the Veteran for an examination of his cervical spine disability to determine the severity of the disorder, by an appropriately qualified VA clinician. All appropriate tests, studies and consultations must be accomplished, including a new medical examination if necessary, and all clinical findings should be reported in detail in the narrative portion of the examination report. The examiner must test the Veteran's active motion, passive motion, and pain with weight-bearing and without weight-bearing. If unable to provide a specific measurement without speculation, the examiner must state whether the need is due to a deficiency in the state of general medical knowledge (i.e., no one could respond given medical science and the known facts), a problem in the record (additional facts are required), or the examiner (does not have the knowledge or training). The examiner must attempt to elicit information regarding the severity, frequency, and duration of any flare-ups, and the degree of functional loss during flare-ups. If unable to provide a specific measurement based on direct observation, the examiner should provide an estimate, if possible, of the impairment due to flare-ups based on the other evidence of record and the Veteran's statements. If unable 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 (i.e., no one could respond given science and the known facts), a problem in the record (additional facts are required), or the examiner (does not have the knowledge or training). The examiner must review the record as found in VA treatment reports and the electronic file. However, the record in substance indicates the following: In December 2016, the Veteran reported increased neck pain at a physical therapy evaluation. The Veteran's cervical spine range of motion was noted as limited in January 2018. In August 2019, the Veteran reported increased pain in his upper back and right shoulder. In October 2019, the Veteran started five sessions of physical therapy related to increased pain in his spine. 5. Schedule the Veteran for an examination of his left shoulder disability to determine the severity of the disorder, by an appropriately qualified VA clinician. All appropriate tests, studies and consultations must be accomplished, including a new medical examination if necessary, and all clinical findings should be reported in detail in the narrative portion of the examination report. The examiner must test the Veteran's active motion, passive motion, and pain with weight-bearing and without weight-bearing. If unable to provide a specific measurement without speculation, the examiner must state whether the need is due to a deficiency in the state of general medical knowledge (i.e., no one could respond given medical science and the known facts), a problem in the record (additional facts are required), or the examiner (does not have the knowledge or training). The examiner must attempt to elicit information regarding the severity, frequency, and duration of any flare-ups, and the degree of functional loss during flare-ups. If unable to provide a specific measurement based on direct observation, the examiner should provide an estimate, if possible, of the impairment due to flare-ups based on the other evidence of record and the Veteran's statements. If unable 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 science and the known facts), a problem in the record (additional facts are required), or the examiner (does not have the knowledge or training). The examiner must review the record as found in VA treatment reports and the electronic file. However, the record in substance indicates the following: In September 2015, the Veteran reported new pain in his shoulder over the prior month. He had decreased range of motion to abduction and reported a clicking noise with movement. In October 2015, he received a corticosteroid shot in his left shoulder. In September 2018, the Veteran reported decreased ability to reach or lift. In October 2018, the Veteran reported increased pain in the left shoulder after an accident in his attic. In August 2019, the Veteran reported increased pain in his upper back. 6. Schedule the Veteran for an examination of his bilateral radiculopathy of the bilateral upper extremities to determine the severity of the disorder, by an appropriately qualified VA clinician. All appropriate tests, studies and consultations must be accomplished, including a new medical examination if necessary, and all clinical findings should be reported in detail in the narrative portion of the examination report. The examiner must attempt to elicit information regarding the severity, frequency, and duration of any flare-ups, and the degree of functional loss during flare-ups. If unable to observe, the examiner should provide an estimate, if possible, of the impairment due to flare-ups based on the other evidence of record and the Veteran's statements. If unable to provide a response without speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (i.e., no one could respond given science and the known facts), a problem in the record (additional facts are required), or the examiner (does not have the knowledge or training). The examiner must review the record as found in VA treatment reports and the electronic file. However, the record in substance indicates the following: In December 2016, the Veteran reported increased neck pain at a physical therapy evaluation. The Veteran's cervical spine range of motion was noted as limited in January 2018. In October 2018, the Veteran reported that he injured both arms from a fall in his attic. In August 2019, the Veteran reported increased pain in his upper back and right shoulder. In October 2019, the Veteran started five sessions of physical therapy related to increased pain in his spine. (CONTINUED ON THE NEXT PAGE) 7. Readjudicate the issues of entitlement to increased ratings for a left knee disability, a cervical spine disability, a left shoulder disability, bilateral radiculopathy of the upper extremities, and entitlement to a TDIU. Vito A. Clementi Veterans Law Judge Board of Veterans' Appeals Attorney for the Board S. Reed, Counsel The Board's decision is only binding on this case. This action is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.