Citation Nr: 18147801 Decision Date: 11/06/18 Archive Date: 11/06/18 DOCKET NO. 16-41 098 DATE: November 6, 2018 REMANDED Entitlement to service connection for a left leg disorder, to include as secondary to service-connected back disability and/or an undiagnosed illness, is remanded. REASONS FOR REMAND The Veteran served on active duty from October 1978 to October 1981 and January 1991 to April 1991, including service in Southwest Asia. He had additional service in the Army Reserve, which included periods of active duty for training (ACDUTRA) and inactive duty for training (INACDUTRA), until May 2016. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from an April 2016 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). In July 2018, the Veteran revoked representation by Disabled American Veterans (DAV). 38 C.F.R. § 14.631(f)(1). As he has not selected another representative, he is unrepresented in the present matter before the Board. The Veteran’s claim of entitlement to service connection for a left knee disorder has been recharacterized, to include consideration of all left leg disabilities reasonably raised by the record. Clemons v. Shinseki, 23 Vet. App. 1 (2009). Further, as explained below, the Veteran’s claim has been expanded in scope to include secondary service connection. 1. Entitlement to service connection for a left leg disorder, to include as secondary to service-connected back disability and/or an undiagnosed illness, is remanded. The Veteran seeks service connection for a left leg disorder, to include his knee. He asserts that his leg and knee disorders are related to his ACDUTRA injury. The Veteran underwent VA leg and knee examinations in February 2016 to determine the nature and etiology of his condition. The examiner diagnosed left knee patellofemoral pain syndrome and opined that it was less likely than not incurred in or otherwise related to service as the Veteran’s April 1997 complaint of left knee pain occurred during Reserve duty, not active duty. The Board finds this etiology opinion to be inadequate, as service connection can be established as a result of a disease or injury incurred during ACDUTRA or an injury during or INACDUTRA. Barr v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006). It is undisputed that the Veteran suffered a right leg injury during a period of ACDUTRA in March 1987. During a follow-up visit two days later, he complained of left medial aspect tenderness on palpation. As the examiner failed to address this ACDUTRA injury, an addendum medical opinion is warranted. Furthermore, a June 2011 Reserve treatment record reveals a complaint of back pain radiating to the Veteran’s left knee. Based on the Veteran’s written statements, the Board finds that it is appropriate to expand the scope of the Veteran’s left leg claim to include entitlement to service connection on a secondary basis, as the Veteran is service-connected for a back disability. Furthermore, the February 2016 VA examiner found no diagnosis of a left leg disorder. However, the Veteran’s May 2016 Reserve separation examination includes a finding of tenderness on palpation to the left medial tibia. The Board notes that pain that results in functional impairment may be considered a disability for VA purposes. See Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018). As such, a remand is required to afford the Veteran a new examination to determine the functional impairment caused by the Veteran’s left medial tibia pain, and whether it is related to his ACDUTRA injury, or is caused by or aggravated by his back disability. An additional search for the Veteran’s complete service treatment records should also be conducted on remand. All active duty and Reserve treatment records should be obtained on remand. Moreover, the Veteran’s periods of ACDUTRA and INACDUTRA have not been verified, and this should be accomplished on remand. Finally, all updated VA and private treatment records should be secured. The matter is REMANDED for the following actions: 1. Verify the Veteran’s specific dates of ACDUTRA and INACDUTRA. Retirement points will not suffice. 2. Obtain a complete copy of the Veteran’s service treatment records pertaining to his active service and Reserve service. If any of these records are unavailable, notify the Veteran pursuant to 38 C.F.R. § 3.159(e). 3. Obtain any outstanding VA treatment records. 4. With any necessary assistance from the Veteran, obtain all outstanding private treatment records. If any records are unavailable, notify the Veteran pursuant to 38 C.F.R. § 3.159(e). 5. After obtaining the requested records (to the extent possible), schedule the Veteran for an appropriate VA examination to address the current nature and etiology of his left leg disorder, to include the knee. The claims file should be made available to and reviewed by the examiner and all necessary tests should be performed. All findings should be reported in detail. The examiner should address the following: (1) Identify each left leg disorder diagnosed during the appeal period, including but not limited to left knee patellofemoral pain syndrome, tenderness on palpation to the left medial tibia, and left patellar and small left tibial tubercole enthesophytes. See March 2017 VA X-ray. If no diagnosis is rendered and only pain is identified, the examiner must indicate whether the Veteran’s reported knee and leg pain causes any functional impairment. (2) For each left leg and knee disability so diagnosed, or any functional impairment identified, please opine whether it is at least as likely as not (50 percent probability or more) that such disability/impairment: (a) had its onset during service or a verified period of ACDUTRA, considering his April 1997 complaint of knee pain every three to four months; (b) is otherwise the result of a disease or injury incurred during active duty or a verified period of ACDUTRA, to include his March 1987 injury and associated complaint of left medial aspect tenderness; (c) is otherwise the result of an injury incurred during a verified period of INACDUTRA; (d) is proximately due to his service-connected back disability, considering the June 2011 Reserve treatment record complaint of back pain radiating to the Veteran’s left knee; (e) is aggravated (worsened beyond natural progression) by his service-connected back disability. A complete rationale must be provided for all opinions expressed. The rationale should reflect consideration of the pertinent evidence of record, to include the Veteran’s statements and numerous Reserve treatment record regarding complaints of knee pain, including the April 1997 complaint of knee pain every three to four months. If unable to opine without resorting to speculation, the examiner should provide a rationale for this conclusion. S. BUSH Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD K. Forde, Counsel