Citation Nr: 18142566 Decision Date: 10/17/18 Archive Date: 10/16/18 DOCKET NO. 05-36 023 DATE: October 17, 2018 REMANDED Entitlement to service connection for a back disability, to include as secondary to service-connected left knee disability, is remanded. Entitlement to service connection for a right knee disability, to include as secondary to service-connected left knee disability, is remanded. REASONS FOR REMAND After review of the record, the Board finds that further development is necessary before the Board can adjudicate the Veteran’s claims. Procedural background shows that the Veteran’s claim originated in July 2004 and was denied by the Board in February 2009. After appealing the Board’s decision to the Court of Appeals for Veterans Claims (Court), the parties agreed to a Joint Motion for Remand. The Board subsequently remanded the matters in November 2010 to obtain medical opinions to determine the etiology of the Veteran’s right knee and low back disabilities. In particular, the Board requested opinions to determine whether the Veteran’s right knee and low back disorders were caused by the Veteran’s antalgic gait stemming from his service-connected left knee. The Board notes that since remanding the matter, several examinations and medical opinions have been obtained for clarification. However, the opinions have all been inadequate for adjudicating the Veteran’s claims. For example, in a March 2013 addendum opinion, the examiner found that the Veteran’s right knee and low back disabilities were not caused by his service-connected left knee, but the examiner failed to opine whether the conditions were aggravated by the left knee, or whether the Veteran’s antalgic gait caused the Veteran’s right knee and low back disabilities. Additionally, in an August 2014 medical opinion,, the examiner did not discuss any antalgic gait; and, in a November 2015 medical opinion, the examiner found that the Veteran did not have an antalgic gait, which is contrary to the evidence of record. In December 2017, the Board sought a Veteran’s Health Administration ( VHA ) opinion in which the examiner found a negative nexus for the Veteran’s right knee and low back; however, this examiner also based her opinion on the absence of an altered gait. The Board requested an addendum opinion and asked the examiner to specifically consider medical treatment records from June 2005, and VA examinations from January 2006 and December 2012 which all note that the Veteran presented with an antalgic gait and/or altered gait. In response to the Board’s request, the examiner provided an addendum opinion in March 2018, and continued to find a negative nexus with consideration of the recommended medical evidence; however, the examiner noted that the June 2005 medical treatment records showed no evidence of altered gait or antalgia. In reviewing the Veteran’s June 2005 medical treatment records, the Board finds the examiner is incorrect in this regard. The Board notes that in a June 15, 2005 primary care note, it was noted that the Veteran had mobility changes in the past three months, to include an altered gait. In reviewing the record, the Board cannot determine whether the notation was made from an examination of the Veteran, or whether the response of “altered gait” was provided by the Veteran in response to the question concerning mobility changes. Nonetheless, the Board agrees with the Veteran’s contentions that the omission of this fact suggest that the examiner may not have reviewed the medical treatment records thoroughly, and also raises the question as to whether the examiner’s opinion would have changed to favorably support the Veteran’s claims for service connection. Considering the above, the Board finds a new examination and opinion is warranted. The Board notes that when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303 (2007). Therefore, while the Board regrets further delay of the Veteran’s case, a remand is warranted to obtain a new examination and medical opinion. Accordingly, the matters are REMANDED for the following action: 1. Obtain all of the Veteran’s outstanding VA treatment records from November 2015 to present. All efforts to obtain these records must be documented in the Veteran’s claim file. 2. Schedule the Veteran for a VA examination with an orthopedic physician to determine the nature and etiology of the Veteran’s back disability. The claims file, including a copy of this Remand, must be made available to, and reviewed by the examiner. 3. Based on an examination of the Veteran and a review of the complete record, the examiner should provide an opinion as to the following: a) Whether it is at least as likely as not (50 percent probability or greater) that any current right knee disorder is proximately caused or aggravated (chronically worsened) by the Veteran’s service-connected left knee, or from any antalgic and/or altered gait stemming from his left knee. b) Whether it is at least as likely as not (50 percent probability or greater) that any current low back disability is proximately caused or aggravated by the Veteran’s service-connected left knee, or from any antalgic and/or altered gait stemming from his left knee. The examiner must specifically consider medical records from June 2005, VA examinations from January 2006 and December 2012, and all other medical records that indicate the Veteran may or may not have an antalgic and/or altered gait. If the examiner finds that the Veteran does not have an antalgic gait, he or she must explain why or why not. A clear explanation for all opinions based on specific facts for the case as well as relevant medical principles is needed. If the examiner determines that he or she is unable to provide the requested opinion without resort to speculation, the examiner must provide a reasoned explanation for such conclusion. 4. Thereafter, the AOJ should review the examination and report to ensure that they are compliance with remand directives; and if not, the AOJ should implement corrective procedures. See Stegall v. West, 11 Vet. App. 268 (1998). 5. Then, readjudicate the claims. If any benefit sought remains denied, the AOJ should issue an appropriate supplemental statement of the case and afford the Veteran and his representative the opportunity to respond. The case should then be returned to the Board for further review. Gayle E. Strommen Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD K. Laffitte, Associate Counsel