Citation Nr: 18148283 Decision Date: 11/07/18 Archive Date: 11/07/18 DOCKET NO. 10-43 099 DATE: November 7, 2018 REMANDED Entitlement to service connection for a left knee disorder, to include as secondary to a service-connected left hip disability, is remanded. Entitlement to service connection for a right leg disorder, to include as secondary to a service-connected left hip disability, is remanded. REASONS AND BASES FOR REMAND The Veteran served in the United States Navy from June 1980 to June 1986. This case comes before the Board of Veterans’ Appeals (Board) on appeal from a March 2008 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Baltimore, Maryland. The Veteran testified at a hearing before the undersigned Veterans Law Judge in April 2016. A transcript of that proceeding is associated with the record. The Board remanded the case for further development in August 2016 and July 2017. The case has since been returned to the Board for appellate review. The Board had previously remanded the case, in pertinent part, to obtain a VA medical opinion addressing the aggravation prong of secondary service connection. Following the most recent remand, a January 2017 VA examiner opined that it was less likely than not that a current left knee disorder and right leg disorder were proximately due to or the result of his service-connected left knee disability. However, she still did not discuss whether the claimed disorders may have been aggravated by the service-connected left hip disability. See Stegall v. West, 11 Vet. App. 268, 271 (1998); see also 38 C.F.R. § 3.310; Allen v. Brown, 7 Vet. App. 439, 448 (1995); Atencio v. O'Rourke, No. 16-1561 (Vet. App. July 6, 2018), slip op. at 18-19 (finding a medical opinion inadequate because it was not clear from the opinion whether secondary aggravation as well as causation was addressed). Therefore, in order to ensure compliance with the prior remand, the Board finds that an additional medical opinion is needed. Accordingly, the case is REMANDED for the following action: 1. The Agency of Original Jurisdiction (AOJ) should request that the Veteran provide the names and addresses of any and all health care providers who have provided treatment for his left knee and right leg disorder. A specific request should be made for the private doctor seen by the Veteran in the 1990's. See April 2016 Board hearing. After acquiring this information and obtaining any necessary authorization, the AOJ should obtain and associated these records with the claims file. The AOJ should also obtain any outstanding VA treatment records. 2. After the above development has been completed, a VA medical opinion should be obtained to determine the nature and etiology of any left knee disorder that may be present. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran's service treatment records, post-service medical records, and lay assertions. The Veteran has asserted that his service-connected left hip disability has caused an altered gait and pressure on other joints, leading to long-term pain of his leg joints. He has also stated that he sprained his knee during a motorcycle accident in service. See November 2007 VA Form 21-526. In addition, he testified that he felt pain in in his left knee after the pins in his hip were removed while he was in service. The examiner should note that the Veteran is competent to attest to matters of which he has first-hand knowledge, including observable symptomatology. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. The examiner should identify any current left knee disorders that have been present at any point since the Veteran filed his claim in November 2007 or within close proximity thereto. If the Veteran does not have a current diagnosis, the examiner should state whether there is any functional impairment caused by left knee pain (evidence of pain alone that causes functional impairment, even without a specific diagnosis or identifiable disease, may constitute a disability for VA purposes). For each diagnosis identified or any functional impairment caused by left knee pain, the examiner should opine as to whether it is at least as likely as not that the disorder is causally or etiologically related to his military service, to include any injury or symptomatology therein. In so doing, the examiner should address the Veteran's assertions that he sprained his knee during a motorcycle accident in service and that he felt pain in his left knee after the pins in his hip were removed while he was in service. There is documentation of left knee complaints in his service treatment records. The examiner should also state whether it is at least as likely as not that the disorder is either caused by or aggravated by the Veteran's service-connected left hip disability. In rendering his or her opinion, the examiner should address both the causation and aggravation questions in his or her rationale. In other words, even if the Veteran's left hip disability did not cause his current left knee disorder, the examiner should still address whether his left hip disability worsened his left knee disorder. (The term "at least as likely as not" does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of conclusion as it is to find against it.) A clear rationale for all opinions must be provided and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. Because it is important "that each disability be viewed in relation to its history [,]" 38 C.F.R. § 4.1, copies of all pertinent records in the Veteran's claims file, or in the alternative, the claims file, must be made available to the examiner for review. 3. After obtaining any outstanding records, a VA medical opinion should be obtained to determine the nature and etiology of any right leg disorder that may be present. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran’s service treatment records, post-service medical records, and lay assertions. The Veteran has asserted that his right leg has pain from his knee up to his hip and that he first experienced problems with his right leg after he got off crutches while he was still in service. Additionally, the Veteran has asserted that he strained his right leg because he favored that leg over his left leg due to his service-connected left hip disability. The examiner should note that the Veteran is competent to attest to matters of which he has first-hand knowledge, including observable symptomatology. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. The examiner should identify any current right leg disorder that has been present at any point since the Veteran filed his claim in November 2007 or within close proximity thereto. If the Veteran does not have a current diagnosis, the examiner should state whether there is any functional impairment caused by right leg pain (evidence of pain alone that causes functional impairment, even without a specific diagnosis or identifiable disease, may constitute a disability for VA purposes). For each diagnosis identified or any functional impairment caused by right leg pain, the examiner should opine as to whether it is at least as likely as not that the disorder is causally or etiologically related to his military service, to include any injury or symptomatology therein. The examiner should also address whether it is at least as likely as not that the disorder is either caused by or aggravated by the Veteran’s service-connected left hip disability. In rendering his or her opinion, the examiner should address both the causation and aggravation questions in his or her rationale. In other words, even if the Veteran’s left hip disability did not cause his current right leg disorder, the examiner should still address whether his left hip disability worsened his right leg disorder. (The term "at least as likely as not" does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of conclusion as it is to find against it.) A clear rationale for all opinions must be provided and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. Because it is important "that each disability be viewed in relation to its history [,]" 38 C.F.R. § 4.1, copies of all pertinent records in the Veteran's claims file, or in the alternative, the claims file, must be made available to the examiner for review. 4. The AOJ should review the examination reports to ensure compliance with this remand. If the reports are deficient in any manner, the AOJ should implement corrective procedures. 5. After completing the above actions, the AOJ should conduct any other indicated development. J.W. ZISSIMOS Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD K.M. Walker, Associate Counsel