Citation Nr: 1313476 Decision Date: 04/23/13 Archive Date: 05/03/13 DOCKET NO. 10-16 545 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Roanoke, Virginia THE ISSUES 1. Entitlement to service connection for a left knee disability. 2. Entitlement to service connection for a left hip disability, to include as secondary to a left knee disability. 3. Entitlement to service connection for a left leg disability, to include as secondary to left knee and left hip disabilities. ATTORNEY FOR THE BOARD T. Adams, Counsel INTRODUCTION The Veteran served on active duty from October 1979 to December 1981. This matter comes to the Board of Veterans' Appeals (Board) on appeal from an October 2009 rating decision of the Roanoke, Virginia, Regional Office (RO) of the Department of Veterans Affairs (VA). The Veteran was scheduled for a Board hearing to be held at the Roanoke, Virginia RO in March 2013, but failed to appear. Thus, his request for a Board hearing is deemed withdrawn. 38 C.F.R. § 20.704(d) (2012). The appeal is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. VA will notify the appellant if further action is required. REMAND Additional development is needed prior to the disposition of the Veteran's claims. VA has a duty to assist claimants in the development of facts pertinent to claims and VA must accomplish additional development of the evidence if the record before it is inadequate. 38 U.S.C.A. § 5103A (West 2002). The Board regrets the additional delay that will result from this remand. Nevertheless, the Board is constrained by the fact that proper adjudication of the claim requires additional development. Left knee The Board has reviewed July 2012 VA knee and lower leg and peripheral nerves conditions Disability Benefits Questionnaire (DBQ) examinations, each performed by the same examiner, undertaken to address the etiology of the Veteran's left knee disability. However, the Board finds that the medical examination does not contain sufficient detail to decide the claim on appeal. Hayes v. Brown, 9 Vet. App. 67, 73 (1996); see also Barr v. Nicholson, 21 Vet. App. 303, 311-12 (2007) (noting that once VA provides an examination to a Veteran, VA has a duty to ensure that the examination is adequate for evaluation purposes). Specifically, upon examination of the Veteran's left knee, the July 2012 VA examiner diagnosed the Veteran with chondromalacia patella of the left knee, an ununited fracture of the left patella, and arthritis (degenerative or traumatic). The examiner noted that the Veteran alleged that he injured his left knee in service after he fell from a tank onto some rocks, but that the Veteran's STRs did not indicate in-service knee trauma. He thereby opined that the Veteran's ununited fracture of the left patella was less likely than not incurred in or caused by his service. The examiner acknowledged that the left knee ununited patellar fracture was the result of prior trauma to the left knee, such as a fall directly onto the left knee, but there was no indication of any such injury in the STRs. In addition, the Veteran was involved in a motorcycle accident in 1981 during which such mechanism of injury could have resulted in a patellar fracture. He also commented that a high school football injury to the left knee that Veteran sustained prior to service did not preclude enlistment into service. With regard to the Veteran's in-service diagnosis of chondromalacia patella of the left knee, the examiner explained that this was a common occurrence and did not predispose nor cause patellar fracture. However, the examiner did not comment as to whether there was any relationship between chondromalacia patella of the left knee that was identified on examination and the chondromalacia patella that was diagnosed during service in March 1981. Therefore, while the examiner clearly articulated that the Veteran's ununited fracture of the left patella is not related to his service, it remains unclear as to whether he presents a current diagnosis of chondromalacia patella of the left knee (versus a diagnosis of chondromalacia patella by history) and it is related to the same condition he was diagnosed with during service. It is also unclear as to whether the Veteran's left knee arthritis is related to the chondromalacia patella or the ununited patellar fracture. The Court has held that to have probative value, a medical examination submitted to the Board must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 300-1 (2008); see Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) (a medical opinion must support its conclusions with an analysis that can be considered and weighed against contrary opinions). Thus, on remand, an addendum should be obtained to properly address the issue of whether the Veteran's currently diagnosed chondromalacia patella of the left knee is related to his in-service diagnosis of the same condition or had its onset in service. Left hip The Board has reviewed a July 2012 VA hip and thigh DBQ examination undertaken to address the etiology of the Veteran's left hip disability. However, the Board finds that the medical examination does not contain sufficient detail to decide the claim on appeal. See Hayes v. Brown; see also Barr v. Nicholson. The July 2012 VA examiner diagnosed chronic left hip strain and opined that the Veteran had musculoskeletal pain referable to the left hip that was multifactorial in etiology, including the effects of chronic biomechanical stress from favoring the left knee and left ankle and the additional biomechanical stress of morbid obesity. However, the examiner did not comment as to whether the Veteran's change in gait and resulting left hip strain were related to the Veteran's left knee arthritis, chondromalacia patella, or ununited fracture of the patella. The Board acknowledges that it is precluded from differentiating between symptomatology attributed to a non-service-connected disability and a service-connected disability in the absence of medical evidence which does so. Mittleider v. West, 11 Vet. App. 181 (1998) (citing Mitchem v. Brown, 9 Vet. App. 136 (1996)). Here, however, is it unclear whether the Veteran's change in gait is related to the residuals of the fractured patella, arthritis, or chondromalacia patella of the left knee. A remand is necessary so that arrangements can be made for provision of the aforementioned clarification in this regard. Left leg The July 2012 DBQ examination attributed the Veteran's complaints of left leg pain to meralgia paresthetica. The examiner explained that this condition was a compressive mononeuropathy involving the left lateral femoral cutaneous nerve. He also indicated that the cause was most likely due to the Veteran's morbid obesity that resulted in compressive neuropraxia. Nevertheless, since the Veteran contends that his left leg disability is related to his left knee and hip disabilities, the claim for service connection for a left leg disability is inextricably intertwined with the left knee and hip claims being developed. See Parker v. Brown, 7 Vet. App. 116 (1994); Harris v. Derwinski, 1 Vet. App. 180, 183 (1991). As appellate consideration of the claim for service connection for a left leg disability would, thus, be premature at this juncture, remand of this matter also is warranted. Indeed, if service connection for a left knee and/or left hip disability be established, then an opinion would be needed to address whether there is aggravation of meralgia paresthetica, which was a medical question not discussed in the July 2012 examination. Accordingly, the case is REMANDED for the following actions: 1. Return the Veteran's claims file to the examiner who conducted his VA examination in July 2012, or to a qualified medical professional if the July 2012 VA examiner is unavailable. If the examiner determines that an examination is necessary, one should be scheduled. As regards the Veteran's left knee, the examiner is asked identify all present disabilities. If chondromalacia is present, or has been present at any time since 2009. The examiner should state whether it is at least as likely as not (a 50 percent probability or greater) that the chondromalacia of the left knee had its onset during the Veteran's active service or is otherwise causally related to his service, to include the March 1981 in-service diagnosis of chondromalacia patella of the left knee. The examiner is also asked to provide an opinion as to whether it is whether it is at least as likely as not (a 50 percent probability or greater) that any current left knee arthritis is causally related to the chondromalacia patella of the left knee or to the ununited patellar fracture. The examiner should also comment, to the extent possible, as to whether the symptoms attributable to the in-service left knee chondromalacia patella be differentiated from those attributable to the Veteran's other left knee diagnoses, including arthritis, chondromalacia patella, and an ununited patellar fracture. As regards the Veteran's left hip, to the extent possible, differentiate the symptoms and findings due to the Veteran's chronic left hip strain and resulting altered gait from those due to arthritis, chondromalacia patella, and a ununited patellar fracture of the left knee. As regards the Veteran's meralgia paresthetica of the left leg, if it is determined that a left knee or left hip disability is related to his active service (or a service related disability), is at least as likely as not that any such disorder has been caused or aggravated beyond natural progression by the left knee and/or hip disability(ies). Rationale for all requested opinions shall be provided. If the examiner cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation stating why this is so. In so doing, the examiner shall explain whether the inability to provide a more definitive opinion is the result of a need for additional information or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question(s). 2. The RO should then readjudicate the claims. If the benefits sought are not granted, the Veteran should be furnished a supplemental statement of the case and be afforded an opportunity to respond. The case should then be returned to the Board for appellate review. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). These claims must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). _________________________________________________ MICHAEL A. HERMAN Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 2002), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Appeals for Veterans Claims. 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) (2012).