Citation Nr: 18153347 Decision Date: 11/27/18 Archive Date: 11/27/18 DOCKET NO. 16-32 412 DATE: November 27, 2018 REMANDED The issue of entitlement to service connection for a left knee disability is remanded. The issue of entitlement to service connection for an acquired psychiatric disorder, to include PTSD and a psychiatric disorder manifested by insomnia, is remanded. REASONS FOR REMAND 1. Entitlement to service connection for a left knee disability The Veteran asserts that he has a left knee disability that is related to service. Service treatment records reflect that in October 1999, the Veteran reported left knee pain. The assessment was left lateral collateral/medial ligament strain. In October 2010, internal derangement of the left knee and patellar tendinosis were assessed. In January 2011, the Veteran reported knee pain for several years. The impression was left knee patellar tendinosis. The provider indicated that he issued a permanent profile. A July 2011 problem list includes internal derangement of the left knee, discoid meniscus, and patellar tendonitis. On VA general medical examination in October 2013, the Veteran reported left knee pain since 2000 during Marine Corps training. The examiner noted an October 2010 service treatment record indicating internal derangement of the knee. Following examination, he concluded that there was no diagnosis related to the left knee. He did, however, indicate that there was functional loss and/or impairment of the knee and lower leg. In December 2013, he stated that there was a history of a very mild functional disturbance, for which no specific diagnosis was possible. Unfortunately, this examiner did not address the history of pathology and findings during service, as recited above, nor did he adequately describe the functional limitation identified on examination. The Board concludes that an additional examination is necessary to address the entirety of the pathology identified during service, as well as to fully describe any currently existing functional limitation referable to the Veteran’s left knee. 2. Entitlement to service connection for an acquired psychiatric disorder The Veteran has claimed entitlement to service connection for insomnia. In an October 2018 brief, his representative clarified that this claim should be expanded to include any diagnosed psychiatric disorder pursuant to Clemons v. Shinseki, 23 Vet. App. 1 (2009). The Board has accordingly characterized the issue as stated above. Service treatment records indicate that the Veteran was assessed with PTSD in November 2009, and that a provisional diagnosis of depression was also made at that time. Insomnia due to stress was assessed in February 2010. In November 2010, an assessment of adjustment disorder with depressed mood was made. The Veteran complained of problems with sleep in July 2011, and reported work stress. Treatment notes dating to January 2012 indicate insomnia due to stress and an assessment of PTSD. An October 2013 VA treatment record indicates that the Veteran was only recently separated from service. He endorsed significant emotional distress related to his father’s death and the loss of his daughter through divorce. On VA examination in November 2013, the examiner concluded that the Veteran’s symptoms did not adequately support a diagnosis of PTSD. She also concluded that a mental disorder other than PTSD was not present. While she discussed the underlying basis for her conclusion regarding PTSD, she did not do so regarding any other psychiatric disorder. In that regard, she noted only that PTSD symptoms were described in October 2011, when the Veteran sought treatment during service. Because service treatment records indicate a history including diagnoses of insomnia, adjustment disorder, and possible depression, the Board concludes that an additional examination is necessary, to include a complete review of the service records and a discussion of the various diagnoses therein. The matters are REMANDED for the following action: 1. Schedule the Veteran for a VA psychiatric examination to determine the nature and etiology of any diagnosed acquired psychiatric disorder, to include any psychiatric disability manifested by insomnia. The claims file must be made available to the examiner. All necessary tests and studies should be accomplished, and all clinical findings should be reported in detail. Following review of the record and examination of the Veteran, the examiner should provide an opinion with respect to whether it is at least as likely as not (50 percent or more probability) that any diagnosed acquired psychiatric disorder had its onset in service or is related to any event of service. If PTSD is diagnosed, the examiner should identify the specific stressors that led to the condition. The examiner is also asked to provide an opinion regarding whether insomnia constitutes a separate and distinct diagnosis, or whether it is a symptom of any diagnosed psychiatric disability. Review of the entire claims file is required; however, the examiner’s attention is specifically directed to the various psychiatric diagnoses rendered during service. The examiner is asked to explain the reasons behind any opinions expressed and conclusions reached. The examiner is reminded that the term “as likely as not” does not mean “within the realm of medical possibility,” but rather that the evidence of record is so evenly divided that, in the examiner’s expert opinion, it is as medically sound to find in favor of the proposition as it is to find against it. If the examiner is unable to offer any of the requested opinions, a rationale for the conclusion that an opinion cannot be provided without resort to speculation should be provided, together with a statement as to whether there is additional evidence that might enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. 2. Schedule the Veteran for a VA orthopedic examination to determine the nature and etiology of his claimed left knee disability. The claims file must be made available to the examiner. All necessary tests and studies should be accomplished, and all clinical findings should be reported in detail. Following review of the record and examination of the Veteran, the examiner should provide an opinion with respect to whether it is at least as likely as not (50 percent or more probability) that any diagnosed left knee disability is related to any event of service. If functional impairment due to pain is identified, the examiner should fully describe the nature of such impairment. Review of the entire claims file is required; however, the examiner’s attention is specifically directed to the various diagnoses ascribed to the Veteran’s knee pain during service. The examiner is asked to explain the reasons behind any opinions expressed and conclusions reached. The examiner is reminded that the term “as likely as not” does not mean “within the realm of medical possibility,” but rather that the evidence of record is so evenly divided that, in the examiner’s expert opinion, it is as medically sound to find in favor of the proposition as it is to find against it. (Continued on the next page)   If the examiner is unable to offer any of the requested opinions, a rationale for the conclusion that an opinion cannot be provided without resort to speculation should be provided, together with a statement as to whether there is additional evidence that might enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. DONNIE R. HACHEY Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD J. Barone, Counsel