Citation Nr: 18155233 Decision Date: 12/03/18 Archive Date: 12/03/18 DOCKET NO. 16-46 995 DATE: December 3, 2018 REMANDED Service connection for low back pain, claimed as lumbar spine degenerative arthritis and muscle spasms, is remanded. Service connection for left knee condition is remanded. Service connection for right knee condition is remanded. Service connection for left ankle condition is remanded. Service connection for right ankle condition is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from February 1977 to July 1989. When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. For an opinion to be adequate, it must include consideration of the Veteran’s statements, be based on accurate factual premises, and contain a rationale sufficient to support its conclusions. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007); see also Kowalski v. Nicholson, 19 Vet. App. 171, 179 (2005) (a VA examination must be based on an accurate factual premise). If an examiner does not consider the Veteran’s history, complaints, and lay statements, as well as document in-service events, diseases, and/or injuries in the service treatment records (STR) any negative opinion is inadequate for rating purposes. See Dalton v. Nicholson, 21 Vet. App. 23 (2007); Nieves-Rodriguez v. Nicholson, 22 Vet. App. 295 (2008). Under McLendon v. Nicholson, 20 Vet. App. 79 (2006), a medical examination or medical opinion is necessary in a claim for service connection when there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability, (2) evidence establishing that an event, injury, or disease occurred in service or establishing certain diseases manifesting during an applicable presumptive period for which the claimant qualifies, and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the Veteran’s service or with another service-connected disability, but (4) insufficient competent medical evidence on file for the Secretary to make a decision on the claim. See also 38 U.S.C. § 5103A (d)(2) (2012); 38 C.F.R. § 3.159 (c)(4)(i). 1. Service connection for low back pain, claimed as lumbar spine degenerative arthritis and muscle spasms is remanded. The Veteran credibly stated in her Substantive Appeal that she injured her lower back in vehicle accident while in Egypt on a field exercise. She also submitted private treatment records showing a history of back problems since 1982 from the same vehicle incident when she was thrown back in a car when it stopped suddenly, and that she has had back pain off and on since then. The Veteran was afforded a VA Back examination in April 2015. The examiner initially noted no diagnosis, but then in remarks, wrote, “mild degenerative arthritis of lumbar spine with minimal loss of function.” The examiner did not address the STR entry in April 1985 of low back pain for 3 days. Nor did the examiner address the VA treatment records describing the Veteran’s low back pain, muscle spasms, and the assignment of a TENS unit for pain relief. The examiner stated in his medical opinion that the Veteran had received no medical attention for her back since 1983, which is not factually accurate. Based on the foregoing, the Board finds this VA examination inadequate for adjudication purposes. 2. Service connection for left knee condition is remanded. 3. Service connection for right knee condition is remanded. The Veteran asserts in her Notice of Disagreement and her Substantive Appeal that she injured her knees from the “constant trauma from jumping off of the truck/other equipment…” The Board notes that she has been diagnosed with bilateral knee arthritis and has received steroid injections in both knees to treat her pain. To date, she has not been afforded a VA examination. McLendon v. Nicholson, 20 Vet. App. 79 (2006). Moreover, she originally filed a claim for service connection for her knees in August 2012, prior to the current February 2015 claim, and no development or assistance or adjudication was completed on the August 2012 bilateral knee service connection claim. The Board observes that the August 2012 claim is the date of the claim for her bilateral knees now on appeal. 4. Service connection for left ankle condition is remanded. 5. Service connection for right ankle condition is remanded. The Veteran asserts in her Notice of Disagreement that her ankles were injured when she was in service as a result of road marches on cobblestone. The Board notes many entries in her STR for ankle strains and sprains requiring rest, crutches, and/or profiles for up to 4 weeks. In the April 2015 VA Examination and medical opinion, the examiner stated that her ankles were “normal” and that there was “no specific injury to either ankle while in service, and no documented disorder or condition of either ankle…” Based on a thorough review of the Veteran’s file, this is factually incorrect. Furthermore, in September 2016, the Veteran’s left ankle required Brostrum-Gould modified lateral ankle stabilization surgery. For all these reasons, the Board finds this examination and opinion wholly inadequate for adjudication purposes. The matters are REMANDED for the following action: 1. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any low back disability, to include chronic low back pain, arthritis, and muscle spasms. The examiner must opine whether it is at least as likely as not related to an in-service injury, event, or disease, including her back injury in 1982 from a car accident, documented in her private treatment record as back problems off and on ever since then, as well as the April 1985 STR entry for low back pain. 2. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any bilateral knee disability, to include arthritis. The examiner must opine whether it is at least as likely as not related to an in-service injury, event, or disease, including her repeated jumping off of large trucks and road marching while in service. 3. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any bilateral ankle disability, to include any lateral instability or arthritis. The examiner must opine whether it is at least as likely as not related to an in-service injury, event, or disease, including the STR documentation of repeated injuries to her ankles while in service. 4. Then, the record should again be reviewed. If any benefit sought on appeal remains denied, the Veteran and her representative should be furnished with a supplemental statement of the case and be given the opportunity to respond. T. REYNOLDS Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD L. Nelson, Associate Counsel