Citation Nr: 18155466 Decision Date: 12/04/18 Archive Date: 12/04/18 DOCKET NO. 15-38 326 DATE: December 4, 2018 REMANDED Entitlement to an initial compensable evaluation for service-connected left knee iliotibial band syndrome. REASONS FOR REMAND The Veteran served honorably on active duty in the U.S. Air Force from September 1993 until September 2013. This matter comes to the Board of Veterans’ Appeals (Board) on appeal from an April 2014 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in April 2014. 1. Entitlement to an initial compensable evaluation for service-connected left knee iliotibial band syndrome. The matter is remanded to undertake efforts to obtain outstanding relevant medical records and another VA examination and opinion. First, VA has a duty to assist claimants to obtain evidence needed to substantiate a claim. 38 U.S.C. § 5103A (2012); 38 C.F.R. § 3.159(c) (2017). This includes making reasonable efforts to obtain relevant private medical records. 38 C.F.R. § 3.159(c)(1). At the June 2018 VA examination, the examiner reported the Veteran had undergone left knee arthroscopic surgery, but there are no operative reports of record. On remand, reasonable efforts must be undertaken to identify and obtain the outstanding treatment records. Second, remand is required for a VA examination that clarifies the scope and severity of the Veteran’s service-connected iliotibial band syndrome. By way of background, the April 2014 rating decision granted service connection for left knee iliotibial band syndrome. Review of the service treatment records (STRs) shows that the Veteran was diagnosed with right knee iliotibial band syndrome, but there is no record showing that left knee iliotibial band syndrome was diagnosed. Instead, an August 2004 STR documented the Veteran had bilateral knee pain and the assessment was posttraumatic arthritis, although no imaging studies were done. February 2013 STRs document the Veteran had progressing left knee pain, although x-rays did not show any arthritic process. The assessment in February 2013 was left knee soft tissue strain, and the treatment provider was not able to rule out a small meniscal derangement. The Veteran received a VA examination in October 2013, and no imaging studies were performed. That examiner reported there was no objective evidence to support a diagnosis of the claimed left knee condition. In an April 2014 addendum, the VA examiner reported there were no findings on clinical examination of a condition, and that the slightly decreased left knee range of motion was normal for Veteran’s age and habitus. Nevertheless, because the Veteran still complained of pain with squatting, the examiner reported that the diagnosis of iliotibial band syndrome could be added based on history and treatment. No imaging studies were obtained. A January 2015 VA MRI report of the left knee showed an osteochondral defect with underlying bone marrow edema. February 2016 VA MRI studies of the left knee document a subchondral cyst, degenerative osteochondral change, bone contusion or marrow edema of the medial femoral condyle, sprain but no definite tear of the medial collateral ligament, and slight sprain of the proximal portion of the fibular collateral ligament. Most recently, a June 2018 VA examiner reported the Veteran had active diagnoses of left knee strain, subchondral cyst, and arthritis. That examiner concluded that the service-connected iliotibial band syndrome had resolved, and that the currently diagnosed knee conditions were not related to the service-connected condition. No explanation was provided for this conclusion. Additionally, the examiner indicated that there was no knee instability or recurrent subluxation, however the examiner did not address the Veteran’s lay testimony that his knee buckles and causes him to fall. Thus, a new examination is warranted. The matter is REMANDED for the following action: 1. Contact the appropriate VA Medical Center and obtain and associate with the claims file all outstanding records of treatment. If any requested records are not available, or the search for any such records otherwise yields negative results, that fact must clearly be documented in the claims file. Efforts to obtain these records must continue until it is determined that they do not exist or that further attempts to obtain them would be futile. The non-existence or unavailability of such records must be verified and this should be documented for the record. Required notice must be provided to the Veteran and his or her representative. 2. Contact the Veteran and afford him the opportunity to identify by name, address and dates of treatment or examination any relevant medical records, to include all records related to his left knee surgery. Subsequently, and after securing the proper authorizations where necessary, make arrangements to obtain all the records of treatment or examination from all the sources listed by the Veteran which are not already on file. All information obtained must be made part of the file. All attempts to secure this evidence must be documented in the claims file, and if, after making reasonable efforts to obtain named records, they are not able to be secured, provide the required notice and opportunity to respond to the Veteran and his representative. 3. After any additional records are associated with the claims file, provide the Veteran with an appropriate examination to determine the severity of the service-connected left knee disability. The entire claims file must be made available to and be reviewed by the examiner. Any indicated tests and studies must be accomplished and all clinical findings must be reported in detail and correlated to a specific diagnosis. An explanation for all opinions expressed must be provided. The relevant Disability Benefits Questionnaire must be utilized. (a.) The examiner must clarify each diagnosed left knee disorder. With regard to iliotibial band syndrome, the examiner is requested to clarify whether another diagnosis would more accurately represent the service-connected left knee disorder. (b.) For each diagnosed left knee disorder, is it at least as likely as not (a 50 or greater percent probability) that the diagnosed condition is part of, a continuation of, or progression of, the service-connected left knee disability? (c.) Is it at least as likely as not (a 50 percent or greater probability) that degenerative arthritis of the left knee developed within one year of separation from service? (d.) Regarding recurrent subluxation or instability, the examiner is requested to specifically address the Veteran’s report of left knee buckling and falls. (e.) The examiner’s attention is directed to the STRs dated August 2004 and February 2013 that included findings of left knee posttraumatic arthritis, unremarkable x-rays, soft tissue strain, and cannot rule out small meniscal derangement. K. MILLIKAN Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD C. Smith, Associate Counsel