Citation Nr: 18157522 Decision Date: 12/13/18 Archive Date: 12/12/18 DOCKET NO. 11-33 019 DATE: December 13, 2018 REMANDED Service connection for a left knee disability is remanded. Service connection for a right knee disability is remanded. REASONS FOR REMAND The Veteran served honorably on active duty in the United States Army from February 1971 to February 17, 1974, with a subsequent period of dishonorable service from February 18, 1974 to February 1979. The issues are on appeal from a March 2009 rating decision. Service connections for a left knee disability and a right knee disability are remanded. In its May 2018 remand, the Board of Veterans’ Appeals (Board) instructed the regional office (RO) to obtain an addendum opinion on the etiology of the Veteran’s knee disabilities. In June 2018, the Veteran was afforded a new VA examination for his bilateral knee disability. However, the examiner did not adequately address the questions included in the May 2018 remand directives, and therefore, the issues must be remanded again. Stegall v. West, 11 Vet. App. 268 (1998). In the May 2018 remand, the examiner was instructed to answer whether the Veteran’s genu varum was a congenital defect or disease, and if so, whether it was at least as likely as not that the Veteran’s congenital disease was aggravated by his period of honorable service. The June 2018 examiner did not answer whether the Veteran’s genu varum was a congenital defect or disease, and then opined that the genu varum was at least as likely as not aggravated beyond its natural progression by a service-connected disability. At the time of the examination, the Veteran was service-connected for post-traumatic stress disorder (PTSD) and tinnitus. The examiner did not address which of these service-connected disabilities was the aggravating disability. On remand, clarification is needed on whether the genu varum was a congenital disease or defect; and if so, whether the genu varum was aggravated beyond its natural progression by his service; and whether the examiner’s opinion that the genu varum was aggravated beyond its natural progression by the Veteran’s service-connected PTSD and/or tinnitus was done in error. If not done in error, the examiner should opine on which service-connected disability caused the aggravation of the genu varum. Further, if the genu varum was not found to be a congenital defect or disease, the examiner was asked to opine on whether it was at least as likely as not incurred in or caused by an in-service injury, event, or illness, for potential direct service connection. Again, the examiner did not state whether the genu varum was a congenital disease or defect. The examiner also provided two opposing medical opinions, stating on one form that the genu varum was at least as likely as not related to service, and then, opining that it was less likely than not related to service on another form. On remand, clarification for potential direct service connection is needed. Finally, the examiner opined that the Veteran’s bilateral patellofemoral syndrome was less likely than not incurred in or caused by service because the Veteran enlisted in 1971, and he had complained of knee pain for the past seven years in 1974. Therefore, the knee condition would have begun prior to his 1971 enlistment. On remand, an etiology opinion on the bilateral patellofemoral syndrome as a pre-existing condition should be addressed. The matters are REMANDED for the following action: 1. Obtain an addendum opinion from the same June 2018 VA examiner. If the same VA examiner is unavailable, obtain an addendum opinion from another appropriate clinician. Whether a physical examination is required is left to the examiner’s discretion. The examiner is requested to address the following: (a) Is the Veteran’s genu varum a congenital defect or disease? (For VA purposes, a defect differs from a disease in that the former is more or less stationary in nature while the latter is capable of improving or deteriorating). (i) If the Veteran’s genu varum is considered a congenital or developmental disease, opine as to whether it is at least as likely as not (50 percent or greater probability) that such disease was aggravated (worsened beyond natural progression) by the Veteran’s honorable period of service. In addressing this question, consider the May 1974 service treatment record in which the Veteran reports painful knees for the past seven years, coincident with his honorable period of service. (ii) If the June 2018 examiner’s opinion that the genu varum is a secondary to a service-connected disability of PTSD and/or tinnitus was not done in error, opine as to whether it is at least as likely as not (50 percent or greater probability) that the genu varum was aggravated (worsened beyond natural progression) by the service-connected PTSD and/or tinnitus. If aggravation is found, the examiner should attempt to quantify the degree of additional disability resulting from the aggravation. (b) If the Veteran’s genu varum does not have a congenital origin, opine as to whether it is at least as likely as not (50 percent or greater probability) that such disability had its onset during the Veteran’s honorable period of service or is otherwise related to his honorable period of service. In addressing this question, consider the May 1974 service treatment record in which the Veteran reports painful knees for the past seven years, coincident with his honorable period of service. (c) If the Veteran’s bilateral patellofemoral syndrome clearly and unmistakably pre-existed the Veteran’s entrance into service. (i) If there is clear and unmistakable evidence that the disability pre-existed service, opine as to whether or not there is clear and unmistakable evidence that the pre-existing disability did not undergo an increase in the underlying pathology during service (i.e., was not aggravated during service). In other words, is it clear and unmistakable that any worsening of the disability was due to the natural progression of the disability? If the examiner is unable to provide an opinion without resorting to speculation, he or she should explain why this is so and what, if any, additional evidence would be necessary before an opinion could be rendered. The examiner must provide a rationale for each opinion given that is consistent with the evidence of record. All examination findings, along with complete, clearly-stated rationale for the conclusions reached, must be provided. 2. Readjudicate the appeals L. M. BARNARD Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD J. Lee, Associate Counsel