Citation Nr: 18142494 Decision Date: 10/17/18 Archive Date: 10/16/18 DOCKET NO. 16-32 260 DATE: October 17, 2018 REMANDED Entitlement to service connection for a left knee disorder is remanded. REASONS FOR REMAND The Veteran has verified periods of active duty from July 1974 to July 1976, November 1990 to July 1991, February 2001 to October 2001, December 2004 to June 2006, March 2007 to July 2008, and March 2009 to April 2010. He served in the United States Army. Entitlement to service connection for a left knee disorder First, remand is required to attempt to verify the Veteran’s duty dates. VA has a duty to assist claimants to obtain evidence needed to substantiate a claim. 38 U.S.C.§ 5103A (2012); 38 C.F.R. § 3.159(c) (2018). This includes making as many requests as are necessary to obtain relevant records from a Federal department or agency, including, but not limited to, military records. 38 C.F.R. § 3.159(c)(2). The Veteran alleges that his left knee disorder is related to a left knee injury in 1988 while on active duty. The Veteran further reported that he continued to receive treatment for his knee since injuring it, and that he has also continued to have problems with it. The Veteran’s service personnel records (SPRs) show that the Veteran sustained injuries to his knees while performing training in July 1988. See September 1990 Army Memorandum. The Veteran’s status during this period is unclear as June 1988 State of Georgia Orders indicate the Veteran was ordered to full time training duty from June 17, 1988 to August 9, 1988. The Veteran’s SPRs also show that he injured his left knee in April 1991 while he was standing in line during in-processing and experienced severe pains which was determined to be an aggravation of a prior knee injury (1988). The April 1991 injury was deemed to be incurred during active duty. The Veteran’s service treatment records (STRs) indicated that he had been on a permanent profile since September 1990 for left knee pain, and that he had a possible diagnosis of chondromalacia. However, the record does not clearly document the exact dates of the Veteran’s period of active duty, ACDUTRA, and INACDUTRA. This must be verified prior to a determination of service connection. Second, remand is required to attempt to obtain any outstanding STRs and relevant VA treatment and medical records. In response to an April 2014 request for STRs, the VA Records Management Center (RMC), in May 2014, indicated that it had conducted several searches and were unable to locate the STRs for the Veteran. However, since this appeal is being remanded, the RO should attempt to locate STRs from other records repositories. Third, remand is required to obtain VA treatment records. VA’s duty to assist also includes making as many requests as are necessary to obtain relevant records from a Federal department or agency, including, but not limited to, VA medical records. 38 C.F.R. § 3.159(c)(2). In a December 2015 VA primary care follow up note, the Veteran reported that he had been to the Dublin VA for re-evaluation of his left knee complaints. These VA records are not part of the claims file and it does not appear that any attempts have been made to obtain these records. Additionally, a February 2016 CAPRI record showed that the Veteran had also received treatment at the Austin Information Tech Center, the El Paso VA, and the Veterans ID Card System. The RO must obtain these VA treatment records on remand. Fourth, remand is required to attempt to obtain all relevant private medical records. VA has a duty to assist claimants to obtain evidence needed to substantiate a claim which includes making reasonable efforts to obtain relevant private medical records. 38 C.F.R. § 3.159(c)(1). In a December 1998 VA treatment note, the Veteran was recommended to get a re-evaluation of the ortho clinic at the Winn Army Hospital for is left knee pain. A May 2014 third party correspondence was received by the VA from a medical records technician at the Winn Army Community Hospital. However, the correspondence did not clearly identify whether or not the hospital had medical records pertaining to the Veteran’s claim. On remand, the RO should attempt to obtain any records available from the Winn Army Community Hospital. Finally, remand is required for a new VA examination. Where VA provides the Veteran with an examination in a service connection claim, the examination must be adequate. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). A medical opinion must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions. Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). A January 2015 VA examination was conducted. The Veteran was diagnosed with a knee meniscal tear with frequent episodes of joint locking, joint pain, and joint effusion. After examination and review of the available record, the examiner opined that the claimed condition, which clearly and unmistakably existed prior to service, was not aggravated beyond its natural progression by and in-service event, injury, or illness. The examiner reasoned that MRI of the left knee in 2000 was unremarkable, an MRI of the left knee in 2014 revealed a meniscus tear, and that there were no records to show ongoing chronic knee condition after 2000 with a normal MRI in 2000. The examiner also stated that it would be resorting to mere speculation to state that the current meniscus tear is related to knee injury in 1991 as the MRI was normal in 2000. However, the examiner did not address all diagnoses of record including findings from a May 2014 X-ray, which showed underlying chondromalacia and a small Baker cyst. The examination report also did not consider the full record including the Veteran’s SPRs showing a knee injury in July 1988 and ultimately being put on a permanent profile since September 1990, or medical treatment records indicating that there were ongoing complaints of and treatment for left knee pain and chondromalacia starting in 1998 and 2000. The examination report also failed to consider and address the Veteran’s lay statements that he hurt his left knee in 1988 during physical training, had been seen by various providers over the years for pain, and that his left knee had worsened since he injured it. Thus, a new VA examination is warranted. The matter is REMANDED for the following action: 1. Contact any and all sources necessary to confirm the Veteran’s active duty, National Guard, and Reserve service. The AOJ must attempt to contact the Veteran’s National Guard and/or Reserve units, if possible, the National Personnel Records Center (NPRC), any other appropriate repositories. The RO must provide a precise listing of the Veteran’s specific periods of active duty, active duty for training (ACDUTRA), and inactive duty for training (INACDUTRA). A retirement points summary will not suffice. If any requested records are not available, or the search for any such records otherwise yields negative results, that fact must clearly be documented in the claims file. Efforts to obtain these records must continue until it is determined that they do not exist or that further attempts to obtain them would be futile. The non-existence or unavailability of such records must be verified and this should be documented for the record. Required notice must be provided to the Veteran and his representative. 2. After the Veteran’s service dates are confirmed and documented for the file, contact the Veteran’s unit(s), NPRC, or any other appropriate entity to obtain all service personnel and treatment records from all periods of service. If any requested records are not available, or the search for any such records otherwise yields negative results, that fact must clearly be documented in the claims file. Efforts to obtain these records must continue until it is determined that they do not exist or that further attempts to obtain them would be futile. The non-existence or unavailability of such records must be verified and this should be documented for the record. Required notice must be provided to the Veteran and his representative. 3. Contact the appropriate VA Medical Centers and obtain and associate with the claims file all outstanding records of treatment, specifically those from including the Dublin and El Paso VA. Also obtain any records from the Austin Information Tech Center and the Veterans ID Card System, if appropriate and applicable. If any requested records are not available, or the search for any such records otherwise yields negative results, that fact must clearly be documented in the claims file. Efforts to obtain these records must continue until it is determined that they do not exist or that further attempts to obtain them would be futile. The non-existence or unavailability of such records must be verified and this should be documented for the record. Required notice must be provided to the Veteran and his representative. 4. Contact the Veteran and afford him the opportunity to identify by name, address, and dates of treatment or examination any relevant medical records, to include the Winn Army Community Hospital. Subsequently, and after securing the proper authorizations where necessary, make arrangements to obtain all the records of treatment or examination from all the sources listed by the Veteran which are not already on file. All information obtained must be made part of the file. All attempts to secure this evidence must be documented in the claims file. If, after making reasonable efforts, the records cannot be obtained, notify the Veteran and his representative and (a) identify the specific records that cannot be obtained; (b) briefly explain the efforts made to obtain those records; and (c) describe any further action to be taken with respect to the claim. The Veteran must then be given an opportunity to respond. 5. After any additional records are associated with the claims file and verification of the Veteran’s service dates is completed, provide the Veteran with an appropriate examination to determine the etiology of any left knee disorder. The entire claims file must be made available to and be reviewed by the examiner. Any indicated tests and studies must be accomplished and all clinical findings must be reported in detail and correlated to a specific diagnosis. An explanation for all opinions expressed must be provided. The examiner must elicit from the Veteran a full history and/or description his service. (a.) The examiner must identify all left knee disorders. If no left knee disorder is diagnosed, the examiner must address all prior diagnoses of record, including a meniscal tear, chondromalacia, and a small Baker cyst, and explain why such diagnoses are not warranted. (b.) For each diagnosed left knee disorder, the examiner must provide an opinion regarding whether the left knee disorder clearly and unmistakably preexisted active duty service from 1990 to 1991. If so, the examiner must state whether it was clearly and unmistakably not aggravated during service from 1990 to 1991. (c.) If the answer to either question is no, the examiner must provide an opinion regarding whether it is at least as likely as not (50 percent or greater probability) that the left knee disorder had onset in, or is otherwise related to, active military service. 6. Notify the Veteran that it is his responsibility to report for any scheduled examination and to cooperate in the development of the claim, and that the consequences for failure to report for a VA examination without good cause may include denial of the claim. 38 C.F.R. §§ 3.158, 3.655 (2018). In the event that the Veteran does not report for any scheduled examination, documentation must be obtained which shows that notice scheduling the examination was sent to the last known address. It must also be indicated whether any notice that was sent was returned as undeliverable. K. MILLIKAN Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD P. Nguyen, Associate Counsel