Citation Nr: 18156571 Decision Date: 12/10/18 Archive Date: 12/10/18 DOCKET NO. 15-41 755 DATE: December 10, 2018 ORDER Entitlement to service connection for a left knee disorder is remanded. Entitlement to service connection for a right knee disorder is remanded. REASONS FOR REMAND 1. Entitlement to service connection for a left knee disorder is remanded. 2. Entitlement to service connection for a right knee disorder is remanded. The Veteran served on active duty from October 1984 to October 1987 and from December 1996 to June 1999. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a September 2015 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. Service connection for right and left knee disorders was initially denied in an unappealed September 1988 rating decision. At the time of that decision, it does not appear that the Veteran’s complete service treatment records from his first period of service had been obtained, to include a copy of his July 1987 separation examination which has since been obtained. Accordingly, the claims will be reconsidered. See 38 C.F.R. § 3.156(c) (2017). Initially, the Board notes that private treatment records appear to be missing from the claims file. In this regard, the Veteran has been noted as being diagnosed with knee osteoarthritis. See May 2013 General Progress Note (reflecting a confirmed diagnosis of knee osteoarthritis); September 2015 Private Knee and Lower Legs Conditions Disability Benefits Questionnaire (DBQ). The x-ray reports confirming the Veteran’s bilateral knee osteoarthritis have not been associated with the claims file. On remand, efforts must be made to obtain these records. The Veteran was afforded a VA examination in December 2014, during which the examiner opined that the Veteran’s left knee Osgood Schlatter’s disease was less likely than not related to his active duty service. See December 2014 Knee and Lower Legs Conditions DBQ. The examiner found that the Veteran did not have a right knee diagnosis. Id. The Board notes that during the appellate period, the Veteran has been diagnosed with bilateral knee strain; bilateral knee tendonitis; patellofemoral pain syndrome; and possible bilateral knee osteoarthritis. See May 2013 General Progress Note; September 2015 Private Knee and Lower Legs Conditions DBQ; October 2018 Private Knee and Lower Legs Conditions DBQ. Therefore, the Veteran must be provided an additional VA examination to address his claims of entitlement to service connection for a left knee disorder and for a right knee disorder, as set forth below. See McClain v. Nicholson, 21 Vet. App. 319 (2007) (noting that the requirement of a current disability is satisfied when the claimant has a disability at the time a claim for VA disability compensation is filed or during the pendency of that claim). Additionally, it appears the Veteran has applied for disability benefits from the Social Security Administration. On remand, all records associated with the Veteran’s Social Security claim should be obtained. Finally, as this matter is being remanded, the Veteran’s updated VA treatment records should be obtained. The matters are REMANDED for the following action: 1. Make arrangements to obtain the Veteran’s complete VA treatment records, dated from October 1987 to December 1996 (to include any archived records) and dated from October 2018, forward. 2. Make arrangements to obtain the Veteran’s complete private treatment records, to include all x-ray imaging reports. 3. Contact the Social Security Administration and request the Veteran’s Social Security disability benefits records, including all medical documents and decisional documents. All attempts to obtain the records should be documented in the claims file. If no records are found and additional requested for Social Security records would be futile, notify the Veteran in accordance with 38 C.F.R. § 3.159(e). 4. Thereafter, schedule the Veteran for an appropriate VA examination to address the nature and etiology of his claimed knee disorder(s). The entire claims file must be reviewed by the examiner in conjunction with the opinion. The examiner should confirm in the examination report that he or she has reviewed the folder. The examiner should provide the following: a) Identify all left and right knee disorders that have been present since October 1987, to include knee strain, knee tendonitis, knee osteoarthritis, patellofemoral pain syndrome, etc. b) As to EACH diagnosed knee disorder, the examiner should provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that it had its clinical onset in, or is related to any other incident of, the Veteran’s active duty service. In providing this opinion, the examiner should acknowledge and consider the following: • Service treatment records including a February 7, 1986 x-ray of the left knee showing a separate bony density off the tibial tuberosity which may represent an old avulsion injury or nonunion; • Service treatment records including a note showing right knee pain after slipping/tripping over barbed wire on January 25, 1985; • Service treatment records showing treatment for the knees on November 28, December 8 and December 11, 1985; January 7, January 8, January 21, February 25, March 24, May 15, August 7, and September 8, 1986; and on March 16, 1987 (with diagnoses including left knee strain/sprain, possible sprained/strained ligaments, rule out chondromalacia, iliotibial band syndrome, Osgood Schlatter’s, and inflammation of knee ligaments); • Separation examination dated in July 1987 showing a notation of left knee strained ligaments, intermittently painful; and • A post-service VA examination report and left knee x-ray dated in May 1988 showing soft tissue calcification and ossification just above the anterior tibial tubercle at the inferior aspect of the patellar tendon. A supporting rationale for all opinions expressed must be provided. If the examiner is unable to provide any opinion as requested, the examiner should fully explain the reason why such opinion could not be rendered. P.M. DILORENZO Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD S. M. Stedman, Associate Counsel