Citation Nr: 23040134 Decision Date: 07/21/23 Archive Date: 07/21/23 DOCKET NO. 15-04 457 DATE: July 21, 2023 REMANDED A rating in excess of 10 percent for osteoarthritis of the left knee is remanded. REASONS FOR REMAND The Veteran served on active duty from July 1972 to October 1984. The Veteran testified before the Board in August 2018. A transcript of that hearing is of record. This issue was last remanded in May 2022. While the Board sincerely regrets additional delay, the development requested in the May 2022 remand was not completed and additional development is still necessary prior to adjudication. A rating in excess of 10 percent for osteoarthritis of the left knee is remanded. As background, and as noted in the May 2022 remand, in February 2021, the Board denied the Veteran's claim for an increased rating for his left knee osteoarthritis. The Veteran appealed the Board's decision and, in January 2022, the Court of granted a Joint Motion for Remand (JMR) of the February 2021 denial. The Board remanded the appeal following the JMR's finding that a July 2020 examination included inconsistencies in range of motion findings and its September 2020 addendum opinion was inadequate. The May 2022 remand also discussed the JMR's finding that the Board erroneously found that there was no effusion of the left knee despite the examination's noting of small left knee joint effusion in an April 2014 and October 2019 x-ray. Finally, the JMR noted that the Board found that the Veteran did not have left knee instability but failed to adequately discuss the Veteran's use of a knee brace, or cane. With the above in consideration, the Board remanded the appeal for a new examination. Among other instructions, the Board specified that the examiner discuss left knee effusion specifically discussing April 2014 and October 2019 x-ray findings of effusion. The examiner was additionally requested to address the Veteran's use of a brace or cane and whether these were used in the treatment of or prevention of instability. Following remand, a new examination was conducted in December 2022. The examiner conducted a physical examination of the Veteran and stated that she reviewed the electronic claims file. However, while the examiner noted that April 2014 findings of effusion, the examiner neglected to discuss the October 2019 x-rays. Further, the examiner noted use of a cane and knee brace for ambulation and stated that instability was not found, but the examiner did not discuss why the Veteran used a cane and knee brace for ambulation and whether such was in treatment for or prevention of instability. Finally, while the examiner stated that the Veteran did not currently have effusion of the left knee, the examiner also found that the Veteran's left knee circumference was four centimeters greater than his right knee circumference without stating the cause of such. In an addendum from the examiner dated in May 2023, the examiner was asked again to discuss x-ray findings from 2014 and 2019. The examiner stated that the x-ray findings of effusion were presumed resolved, the examiner stated that the October 2019 x-ray stated "Impression: See Vista Imaging for Scanned Document." Finally, the examiner stated that there was no physical finding of effusion evidenced by joint appearance and that an intra-articular effusion was not visible and would be assessed via imaging. No imaging was requested by the examiner. The Board truly regrets the delay, however, as the examiner failed to address the medical evidence as requested, the Board finds the examination inadequate, and a new examination is required. Barr v. Nicholson, 21 Vet. App. 303, 311-12 (2007) (Once VA undertakes the effort to provide a medical examination or opinion, it must provide an adequate one). Stegall v. West, 11 Vet. App. 268, 271 (1998). Here, the examiner failed to address the significance of prior findings of left knee effusion. Significantly, too, it appears that records were available in VISTA imaging, but the examiner did not seek them out, and thus was unable or unwilling to complete the mandates of the May 2022 remand. Further, where additional testing, such as imaging, is necessary to make a determination, such testing must be completed. On remand, a new examination should be scheduled, the examiner must indicate that a copy of this remand was provided and reviewed. The examiner is asked to 1) review and discuss the April 2014 and October 2019 x-ray findings, 2) discuss the use of a cane and brace, or any other assistive devices to include the reason the Veteran uses such 3) determine what, if any further tests must be conducted to determine whether the Veteran has left knee effusion, state why or why not such a test is indicated and if such is indicated, complete such testing and address the significance, if any in the difference in size of the Veteran's right and left knee. The matters are REMANDED for the following action: 1. Schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his service-connected left knee disorder. 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. In so doing, the examiner must test the Veteran's active motion, passive motion, and pain with weight-bearing and without weight-bearing. 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). 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 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. 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). Further, the examiner must discuss whether the Veteran has left knee effusion on examination or prior to examination, specifically discussing the April 2014 and October 2019 x-ray findings of such. Additionally, the examiner is asked to specifically address instability and the Veteran's use of assistive devices to include a knee brace and cane and whether such is used in the treatment of or for prevention of instability shown on examination. Finally, the examiner is asked to discuss the difference in circumference in the Veteran's right and left knee and discuss the cause of the difference. If any necessary information or testing is necessary to make a complete analysis of the Veteran's left knee disability, records must be sought and considered and tests, to include imaging must be conducted. 2. Then readjudicate any claim remaining on appeal. If any of the benefits sought are not granted in full, furnish the Veteran and his representative with a supplemental statement of the case and an opportunity to respond, and return the case to the Board. KELLI A. KORDICH Veterans Law Judge Board of Veterans' Appeals Attorney for the Board G. Slovick, 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.