BVA9505050 DOCKET NO. 93-20 056 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUE Entitlement to an increased evaluation for osteochondritis of the right knee, currently evaluated as 10 percent disabling. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Rebecca A. Kelly, Associate Counsel REMAND The veteran served on active duty from February 1970 to January 1977. This appeal arises from a May 1992 rating decision of the St. Petersburg, Florida, Department of Veterans Affairs (VA), Regional Office (RO), which denied an increased evaluation greater than 10 percent for the service-connected osteochondritis of the right knee. The veteran contends that his service-connected osteochondritis of the right knee has increased in severity. He further contends that his post-operative right knee disability has caused him to limp due to a painful and loosened right knee joint and that his knee continues to grind, pop, creek, and give way. He argues that his service-connected disability for osteochondritis of the right knee impairs his ability to work and live life in a normal manner. He further argues that despite his severe discomfort and pain from his right knee, he continues to work the job he has held for the last 20 years because he does not have the financial means to be retrained. The veteran's representative argues that the veteran has not had the full benefit of the VA's duty to assist and requests that a remand would serve to fully comply with the precedents of the United States Court of Veterans' Appeal and VA regulations. The VA has a duty to provide a fully developed evidentiary record based upon the assertions made for his or her benefits claim so that a fair and sound decision can be made for every veteran. Schafrath v. Derwinski, 1 Vet.App. 589 (1991). The VA has the duty to assist the veteran in the development of all facts pertinent to his claim. 38 U.S.C.A. § 5107(a) (West 1991); 38 C.F.R. § 3.103(a) (1993). This includes the duty to obtain VA examinations which are an adequate basis upon which to determine entitlement to the benefit sought, as well as the duty to obtain all relevant records to which the veteran has referred. Littke v. Derwinski, 1 Vet.App. 90 (1991). Moreover, the veteran's disability must be interpreted in light of his or her whole medical and industrial history for a proper evaluation of that particular disability. Schafrath v. Derwinski, 1 Vet.App. 589 (1991). The medical examination reports must articulate the functional impairment caused by the veteran's disability in terms of a fully developed medical classification. The medical examination report must note the limitations and effects of that particular disability upon the veteran's capacity for employment and ability to perform ordinary activities. When the VA examination of record no longer reflects the current degree and severity of the veteran's disability then a VA re-examination must be ordered. Id. When a veteran has reasonably raised the issue of his inability to work in his or her pleadings, such an inference sufficiently raises the issue of unemployability and the matter must be remanded to the RO of original jurisdiction for readjudication. Caffrey v. Brown, 6 Vet.App. 377 (1994). It is appropriate for the RO to readjudicate the original claim and make a determination for an increased rating and the inferred claim for unemployability (TDIU) since they both have an overlapping evidentiary foundation. Holland v. Brown, 6 Vet.App. 443 (1994). Upon reviewing the entire record, the Board finds that the record, specifically the medical evidence, is incomplete. The veteran's most recent medical evidence shows the diagnosis of degenerative joint disease and therefore suggests a trend of increasing severity in the veteran's current disability. Moreover, the most recent VA examination of record is over three years old; therefore, current severity of the appellant's disability is not reflected in the current VA examination of record. Nor was the veteran's functional loss or his physical or industrial limitations resulting from the service-connected disability of osteochondritis of the right knee or its associated pain noted on the examination. The record reflects that on appeal the veteran raised the issue of his need for retraining due to his service-connected disability of osteochondritis in the right knee and it's related residual of severe pain. The examination does not include an opinion about the veteran's inability to work due to a related degree of impairment from his service-connected disability. Before the Board can render an opinion on the issue of whether an increased evaluation is warranted, the RO must fully develop the record. Under the circumstances of this case, it is the opinion of the undersigned that additional assistance is necessary, and this case is REMANDED to the RO for the following: 1. The RO should contact the VA Medical Centers in Pensacola, Florida and Biloxi, Mississippi and request that they provide copies of the veteran's outpatient treatment records for his right knee and to include reports of all x-ray studies from 1990 to the present. Any indicated records should be associated with the record. 2. The RO should afford the veteran a special orthopedic examination to evaluate his right knee. The examiner should evaluate the right knee and report active range of motion of the right knee to include but not limited to limitation of flexion and extension of the right leg, the degree and severity of pain with and without motion, the degree of muscle atrophy, the degree and severity of recurrent subluxation, the degree and severity of lateral instability, the degree and severity of weakness to include weight bearing and non-weight bearing findings, and the degree and severity of effusion. The examiner must render an opinion as to the degree and severity of the veteran's functional loss due to physical ability and pain to perform normal working movements of the body to include normal excursion, strength, speed, coordination and endurance. The examiner should render an opinion as to the effect of the veteran's service connected right knee upon his ability to maintain substantially gainful employment or whether re-training is necessary due to the degree of impairment from his service-connected disability of osteochondritis of the right knee. The factors upon which the opinion is based must be set forth. The physical capability and the effect of pain should be described separately and in sufficient detail. All necessary special studies should be accomplished. The claims folder must be made available to the examiner prior to the examination so that the veteran's entire history can be taken into consideration. The examiner should also review the VA's Physician's Guide for Disability Evaluation Examinations § § 1.4-1.7, 1.11-1.13, and 2.13-2.17 (1985). 3. Once the above requested evidence is received and associated with the record, the RO should review the evidence and re- adjudicate the issue of whether the veteran is entitled to an increased evaluation for his service-connected osteochondritis of the right knee and also determine whether the veteran is entitled to a total compensation rating based on his service-connected osteochondritis of the right knee and its associated residuals. In the event that the veteran's claim remains denied, in whole or in part, he and his representative should be provided with an appropriate supplemental statement of the case, and an opportunity to respond, and the case should be returned to the Board for further appellate consideration if otherwise in order. C.P. RUSSELL Member, Board of Veterans' Appeals The Board of Veterans' Appeals Administrative Procedures Improvement Act, Pub. L. No. 103-271, § 6, 108 Stat. 740, ___ (1994), permits a proceeding instituted before the Board to be assigned to an individual member of the Board for a determination. This proceeding has been assigned to an individual member of the Board. Under 38 U.S.C.A. § 7252 (West 1991), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Veterans Appeals. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (1994).