Citation Nr: 19190867 Decision Date: 12/03/19 Archive Date: 12/03/19 DOCKET NO. 17-40 396 DATE: December 3, 2019 REMANDED Entitlement to service connection for a left knee disorder is remanded. REASONS FOR REMAND The Veteran served on active duty from February 1990 to October 1993. This matter comes before the Board of Veterans Appeals (Board) on appeal from an October 2015 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). The issue on appeal was previously reopened and remanded by the Board in April 2019. The record reflects that the Veteran was diagnosed with left knee pre-patellar bursitis and patellofemoral pain syndrome in July 1993 (during active duty service). At that time, he reported that his knee symptoms had been present for almost a year. The Veteran also reported left knee symptoms at service separation. See September 1993 Report of Medical History (Veteran reported having a trick knee periodically). A VA medical opinion was most recently obtained in September 2019. The examiner diagnosed left knee patellar enthesopathy and opined that such disorder was less likely as not related to the Veteran’s military service. The examiner recognized the November 2014 left knee injury, as reflected on a February 2015 private treatment record. This 2015 record showed that the Veteran had a significant contusion on the left knee and an MRI showed evidence of bone contusion as well. However, the examiner stated that a contusion indicates that the Veteran suffered an acute injury with the inference that it does not represent a chronic disability stemming from service. The examiner also stated that the Veteran’s complaints of excessive generalized tenderness on palpation of the knees during the 2019 examination was not consistent with his previous complaints. Ultimately, the examiner concluded that the Veteran’s November 2014 /2015 left knee injury and treatment was due to an acute injury and not an ongoing one. The examiner noted that records of any previous encounters were not available for review. The Board has reviewed the September 2019 VA opinion and finds it inadequate to decide the claim. The examiner’s reasoning appears to have focused on the left knee contusion that was shown on the February 2015 private examination, which he referred to as an acute injury, not related to service. However, in addition to the contusion shown during that private examination, the Veteran was also shown to have bursitis of the pes anserinus and this diagnosis was not addressed by the examiner. This is potentially significant because as indicated, bursitis, albeit in the pre-patellar region, was diagnosed in service. Any relationship between the two should be addressed by the examiner. Additionally, although a diagnosis of left knee patellofemoral pain syndrome was not shown on the September 2019 VA examination report, it was shown on a July 2015 VA examination report, and as such, patellofemoral pain syndrome is considered a “current” diagnosis. On remand, an examiner must address the etiology of the patellofemoral pain syndrome to include whether it is related to the patellofemoral pain syndrome diagnosed in service. Moreover, any additional treatment records from the Comprehensive Spine Center of Dallas may provide further details regarding the history of the Veteran’s left knee disorder; no other treatment records from this facility are of record. Although the Veteran previously did not provide a completed VA Form 21-4142a, General Release for Medical Provider Information to VA (see notice letter dated in June 2019), the Board finds that he should be given another opportunity to complete such form, given the potential relevance of these private treatment records. The Veteran is advised that the duty to assist is a two-way street. See Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). Failure to cooperate with VA and provide the necessary information and evidence to support his claim may result in a denial of the benefits sought. The matters are REMANDED for the following actions: 1. Provide the Veteran with an additional opportunity to release potentially relevant private medical records from the Comprehensive Spine Center of Dallas and any other private facility where he has been assessed or treated for his left knee disorder. In doing so, furnish the Veteran with an additional “Authorization and Consent to Release Information” form (VA Form 21-4142) and ask that it be completed and returned to the AOJ. Then, make two requests for any authorized records, unless it is clear after the first request that a second request would be futile. 2. If, after making reasonable efforts to obtain private records the AOJ is unable to secure same, the AOJ must notify the Veteran and (a) identify the specific records the AOJ is unable to obtain; (b) briefly explain the efforts that the AOJ made to obtain those records; (c) describe any further action to be taken by the AOJ with respect to the claim; and (d) inform the Veteran that he is ultimately responsible for providing the evidence. The Veteran must then be given an opportunity to respond. 3. Regardless of whether additional relevant evidence is received, obtain an addendum from the VA examiner who provided the September 2019 VA left knee medical opinion, or if not available, from another appropriate VA clinician. If the designated examiner determines that an additional examination is needed, one should be provided to the Veteran. After reviewing the record, the examiner is asked to: For each left knee disorder diagnosed since the date of claim, including bursitis and patellofemoral pain syndrome, provide another opinion as to whether it is at least as likely as not related to his military service. *In doing so, please address: (a) the in-service diagnosis of pre-patellar bursitis of the left knee and the February 2015 diagnosis of pes anserinus bursitis; indicate any relationship between the two. (b) the in-service diagnosis of patellofemoral pain syndrome and the July 2015 VA examination diagnosis of such; indicate any relationship between the two. A complete rationale should be provided. 4. Then, readjudicate the claim on appeal. S. B. MAYS Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board R. Casadei, Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential, and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.