Citation Nr: 18155444 Decision Date: 12/04/18 Archive Date: 12/04/18 DOCKET NO. 16-58 886 DATE: December 4, 2018 REMANDED The claim of entitlement to service connection for a left knee strain is remanded. The claim of entitlement to service connection for a right knee strain, also claimed as knee pain is remanded. The claim of entitlement to an evaluation in excess of 10 percent disabling for a service-connected lumbar strain is remanded. REASONS FOR REMAND The Veteran served on active duty with the United States Army from July 1991 to April 2000. Regrettably, a remand is necessary in this case to ensure that due process is followed and that there is a complete record upon which to decide the appellant’s claim so that he is afforded every possible consideration. 38 U.S.C. § 5103A (West 2014); 38 C.F.R. § 3.159 (2018). 1. The issues of entitlement to service connection for left knee strain and entitlement to service connection for a right knee strain, also claimed as knee pain, are remanded. Although the further delay entailed by remand is regrettable, current adjudication of the Veteran’s claims would be premature. Undertaking additional development prior to a Board decision is the only way to ensure compliance with the duty to assist, as required. 38 U.S.C. § 5103A (West 2014); 38 C.F.R. § 3.159 (2018). The Veteran contends that his left knee strain and right knee strain, also claimed as knee pain, are causally related to active service. He further asserts a causal linkage between his current symptoms and in-service treatment for a bilateral knee condition. Review of service treatment records indicate that the Veteran was treated for knee pain. At enlistment, normal physical findings were indicated in September 1990. A subsequent examination in February 1995 showed that the Veteran was deemed qualified for airborne training school. In May 1995, an acute medical note shows that the Veteran was treated for left knee pain following an airborne jump. He described chronic and worsening anterior knee pain over a 2-month period. A physical evaluation revealed tenderness and swelling to the left knee. Pain was reported with running, bending and physical activity, in general. Full range of motion was noted. Mild tenderness over the joint line and interior patellar tendon was indicated; however, there was no evidence of a meniscal tear. In May 1996, the Veteran was evaluated at a VA hospital. He complained of chronic knee pain following a parachute jump injury. The treatment record noted left infra patella and supra-medial patella knee pain for 3 months. On physical examination, the Veteran reported pain with running, squatting, bending, and prolonged walking. Reportedly, the pain improved at rest or limited exercise. Sensitivity to cold weather was also reported. He denied any locking sensation. Some instability was noted in the lateral left knee “cutting to the right” with stress to the knee. An increase in crepitus was also reported. The examination report noted “rule-out meniscus tear.” In July 1997, the Veteran described dull aching pain in the bilateral knees, to include after running. During the clinical evaluation, the Veteran reported pain for one year and suggested that his pain was likely related to a knee injury sustained in airborne training school in 1995. He also reported a prior history of physical therapy. X-ray films were taken. The listed diagnoses included bilateral capsular ligament and patella tendonitis synovitis, and ligament strain. The Veteran was placed on profile for 2 weeks. Motrin was prescribed for pain. Additional complaints of chronic bilateral knee pain were reported in April 1998. An MRI (magnetic resonance image) was ordered; however, the evaluation report has not been associated with the claims file. Post-service treatment records show frequent complaints of bilateral knee pain. The Veteran was evaluated for knee pain in April 2010, and July 2011. In October 2015, he reported chronic bilateral knee and shoulder pain. He endorsed decreased range of motion in both knees, with worsening symptoms on the right side. A prior history of arthritis was noted. X-ray films in November 2015 revealed degenerative changes in the Veteran’s back and right knee. In April 2016, the Veteran underwent a VA examination. During the clinical evaluation, he described an onset of his bilateral knee pain as 1995 or 1996 during airborne training. The Veteran reported one jump after which he experienced an abrupt onset of knee and heel pain upon landing. He sought immediate treatment and was placed on profile. Worsening knee pain persisted after separation, with more severe symptoms in the right knee. The Veteran described right knee pain as a constant ache, localized to the medial joint line. Left knee pain was localized to the sub patellar region. Cold or wet weather exacerbates his pain. At times, the Veteran described his pain as throbbing. He denied swelling, locking, or instability of the knee. X-ray films of the bilateral knees, dated October 2015, were described as unremarkable. On examination, range of motion testing revealed normal findings. There was no evidence of decreased muscle strength, ankylosis, or instability. Following the clinical evaluation, the examiner opined that it is less likely than not that the Veteran’s left or right knee conditions were casually related to active service, to include the in-service diagnosis of bilateral patellar tendonitis. In support of the stated conclusion, the examiner indicated that “patellar tendonitis” is self-limiting. The Veteran’s vague/non-specific knee symptoms were inconsistent with patellar tendonitis. On review of the record, the Board finds the April 2016 VA examination inadequate. Specifically, the asserted opinion lacked adequate reasons and bases. Review of service treatment records indicates that the Veteran was treated for a chronic bilateral knee condition in service. His active symptoms included pain, reduced range of motion, difficulty with prolonged walking, standing, and bending. On examination in July 1997, several bilateral knee conditions were listed including bilateral capsular ligament and patella tendonitis synovitis, and ligament strain. The Board notes that patellar tendonitis is also called “jumper’s knee.” Although an MRI evaluation was ordered in April 1998, the examination report has not been associated with the claims file. That record should be obtained. In rendering the April 2016 VA opinion, the examiner noted a review of the record. Nevertheless, it was concluded that the Veteran did not suffer from any functional impairment due to his bilateral knee condition. This finding was reached despite multiple references to pain, limited motion and difficulty with prolonged walking, standing, and bending. Further, the examiner determined that the Veteran’s current bilateral knee conditions were not causally related to active service, to include in-service treatment for bilateral knee conditions. In support of the stated conclusion, the examiner noted that the Veteran was diagnosed with patellar tendonitis. Patellar tendonitis was described as “self-limiting,” with no further explanation of the asserted description. The Veteran’s current symptoms were described as vague or non-specific, and therefore, unrelated to his in-service diagnosis of patellar tendonitis. As the examiner’s opinion merely offers a “conclusory” finding, the Board finds that a more detailed rationale is required. When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. See 38 U.S.C. § 5103(d); Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). 2. Entitlement to an evaluation in excess of 10 percent disabling for a service-connected lumbar strain is remanded. The Veteran contends that the current severity of his lumbar spine condition warrants a higher evaluation. Review of the record indicates that the Veteran has been receiving ongoing treatment for his lumbar spine condition. In November 2016, he endorsed worsening low back pain and difficulty with prolonged sitting, walking, or standing. The Veteran also complained of radiating pain and tingling into his right leg. Similar symptoms were acknowledged in the left leg, with reduced frequency. In February and March of 2017, the Veteran complained of reduced range of motion and radiating pain to both lower extremities. Pain was described as dull, achy, and sharp at times. The pain was ranked between a 5 and 7 on a 10-point scale. Review of the record indicates that the Veteran’s lumbar spine condition was last evaluated in December 2016. His current diagnoses were listed as a lumbar strain and intervertebral disc syndrome. The Board recognizes that the Veteran is generally competent to report on his current symptoms and their worsening. Proscelle v. Derwinski, 2 Vet. App. 629 (1992). Where there is evidence that the condition has worsened since the last examination, a veteran is entitled to a new VA examination. Snzy’fer v. Gober, 10 Vet. App. 400 (1997). The matters are REMANDED for the following action: 1. Conduct an additional records search for the Veteran’s service treatment records. Specifically, a request should be forwarded to the appropriate custodian to obtain Magnetic Resonance Imaging (MRI) reports of the Veteran’s left and right knees which were reportedly conducted at Walter Reed Medical Center in 1997 or 1998. All correspondence related to the records request must be associated with the claim’s file. 2. Upon receipt of the above referenced records, schedule the Veteran for an appropriate VA examination to determine the nature and etiology of the Veteran’s left knee disability. The entire claims file and a copy of this remand should be made available to the examiner for review, and such review should be noted in the examination report. All necessary tests and studies should be conducted. (a) The examiner should identify a diagnosis for any left knee condition found and note the evidence in support thereof. (b) Then, the examiner should provide an opinion as to whether it is at least as likely as not (50 percent or greater probability), that a left knee disability was incurred in, caused by or is otherwise related to any in-service treatment for a chronic left knee pain. Consideration must be given to the possibility of aggravation. As a part of the examination and/or opinion, the examiner must consider all prior diagnoses in the record and nexus opinions and explain or distinguish any variations in findings and conclusions. 3. Any opinion offered must be accompanied by a complete rationale, which should reflect consideration of the STRs, medical evidence of record, and lay statements. If any requested opinion cannot be offered without resorting to speculation, the examiner should indicate such in the examination report and explain why a non-speculative opinion cannot be offered. The examiner should also identify what, if any, additional information or evidence would allow for a more definitive opinion. 4. Schedule the Veteran for an appropriate VA examination to determine the nature and etiology of the Veteran’s right knee disability. The entire claims file and a copy of this remand should be made available to the examiner for review, and such review should be noted in the examination report. All necessary tests and studies should be conducted. (a) The examiner should identify a diagnosis for any right knee condition found and note the evidence in support thereof. (b) Then, the examiner should provide an opinion as to whether it is at least as likely as not (50 percent or greater probability), that a right knee disability was incurred in, caused by or is otherwise related to any in-service treatment for a chronic right knee pain. Consideration must be given to the possibility of aggravation. As a part of the examination and/or opinion, the examiner must consider all prior diagnoses in the record and nexus opinions and explain or distinguish any variations in findings and conclusions. Any opinion offered must be accompanied by a complete rationale, which should reflect consideration of the STRs, medical evidence of record, and lay statements. If any requested opinion cannot be offered without resorting to speculation, the examiner should indicate such in the examination report and explain why a non-speculative opinion cannot be offered. The examiner should also identify what, if any, additional information or evidence would allow for a more definitive opinion. 5. Schedule the Veteran for an appropriate VA examination to determine the current severity of the Veteran’s lumbar strain. The entire claims file and a copy of this remand should be made available to the examiner for review, and such review should be noted in the examination report. All necessary tests and studies should be conducted. (a) In reporting the results of range of motion testing, the examiner should identify any objective evidence of pain, and the degree at which pain begins. (b) The extent of any weakened movement, excess fatigability, and incoordination on use should also be described by the examiner. The examiner should assess the additional functional impairment due to weakened movement, excess fatigability, or incoordination in terms of the degree of additional range of motion loss. If it is not feasible to do so to any degree of medical certainty without resorting to speculation, then the examiner must provide an explanation for why this is so. (c) The examiner should also express an opinion concerning whether there would be additional functional impairment on repeated use or during flare-ups. The examiner should assess the additional functional impairment on repeated use or during flare-ups in terms of the degree of additional range of motion loss. If it is not feasible to do so to any degree of medical certainty without resorting to speculation, then the examiner must provide an explanation for why this is so. (d) Range of motion of the Veteran’s lumbar spine should be tested actively and passively, in weight bearing and non-weight bearing, and after repetitive use. If the examiner is unable to conduct the required testing or concludes that the required testing is not necessary in this case, he or she should clearly explain why this is so. (e) The examiner is invited to consider and comment on the Veteran’s prior complaints of symptoms related to radiculopathy, to include tingling and numbness in the lower extremities. 6. Thereafter, re-adjudicate the Veteran’s claims. If any benefit sought remains denied, provide the Veteran with a supplemental statement of the case and an adequate opportunity to respond before returning the matter to the Board for further adjudication, if otherwise in order. The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans’ Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C. §§ 5109B, 7112 (2012). B. MULLINS Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD N. Whitaker, Associate Counsel