Citation Nr: 20002372 Decision Date: 01/14/20 Archive Date: 01/10/20 DOCKET NO. 18-36 315 DATE: January 14, 2020 REMANDED Entitlement to service connection for a left knee disability is remanded. REASONS FOR REMAND The Veteran served on active duty from June 2005 to June 2006, and from May 2010 to June 2017. This matter comes before the Board of Veterans’ Appeals (Board) from an August 2017 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). Generally, a veteran is presumed to be in sound condition, except for defects, infirmities or disorders noted when examined, accepted, and enrolled for service. 38 U.S.C. §§ 1111, 1137; 38 C.F.R. § 3.304(b). Such conditions are considered to be pre-existing. When a pre-existing disorder is noted on entry, a veteran has the burden of showing that it is at least as likely as not that the disorder increased in severity during service. 38 U.S.C. § 1153; 38 C.F.R. § 3.306(a). If a veteran meets that burden and shows that an increase in severity occurred, the burden then shifts to VA to show whether such increase is clearly and unmistakably due to the natural progression of the pre-existing disability rather than due to service. Wagner v. Principi, 370 F.3d 1089, 1096 (Fed. Cir. 2004); Horn v. Shinseki, 25 Vet. App. 231, 235 (2012); C.F.R. § 3.306(a). Aggravation may not be conceded where the disability underwent no increase in severity during service on the basis of all the evidence of record pertaining to the manifestations of the disability prior to, during, and subsequent to service. 38 U.S.C. § 1153; 38 C.F.R. § 3.306(b). The Veteran’s service treatment records note that he suffered from a pre-existing left knee anterior cruciate ligament (ACL) reconstruction in 2004. As such, this injury clearly and unmistakably pre-existed his service and the Veteran has not argued otherwise. Service treatment records show that in December 2013 the Veteran sought treatment as he was suffering from left knee pain for the past three months. A Lachman test demonstrated one plane anterior instability. An x-ray from this time showed an old disruption of the ACL. The physician stated that it was suspected that there was ACL deficiency. The Veteran continued to seek treatment in January 2014 for his left knee pain. A follow-up x-ray noted a small contusion in the anterior patella as well as blunting of the free edges of the menisci. During a November 2014 examination, the Veteran continued to note knee trouble. The Veteran underwent a VA examination in July 2017. The examiner stated that the claimed condition, which clearly and unmistakable existed prior to service, was clearly and unmistakably not aggravated beyond its natural progression by an in-service injury, event, or illness. Based on the record reviewed, there is no documentation found in the active service record to support injury, illness, or event which suggests that active service caused aggravation of the claimant’s pre-existing left knee condition beyond its natural progression. A second VA opinion was requested in May 2018. This examiner also stated that there is no record of any particular incident in the records that could have led to aggravation beyond its natural progression. The Board finds the two opinions of record to be inadequate. Specifically, both examiners state that the Veteran’s service treatment records do not include any documentation of an incident which could imply or cause worsening. However, the Veteran’s service treatment records, which are voluminous, include multiple complaints of knee symptoms and treatment, to include a specific citation of an old disruption of the ACL in 2013 following three months of acute pain with sudden onset in the left knee, and a notation of anterior instability. Neither opinion acknowledged or discussed these incidents and records. Upon remand, the examiner should specifically comment on whether the Veteran’s in-service complaints and injury aggravated his pre-existing injury beyond its normal progression or whether this was due to the natural progression of the pre-existing disability rather than due to service. The matters are REMANDED for the following action: 1. Invite the Veteran to submit any additional evidence in support of his claim. (Continued on the next page)   2. Return the claims file to the examiner who provided the May 2018 VA examination, or if that examiner is not available, to another appropriate medical professional to obtain an addendum opinion as to whether the Veteran’s left knee ACL reconstruction, which pre-existed service, clearly and unmistakably (undebatable) was not aggravated (meaning that the condition was not permanently worsened beyond the natural progression of the disability) by the Veteran’s military service, to include as a result of the Veteran’s December 2013 left knee complaints and suspected disruptions of the ACL. The opinion requested should include a complete rationale and discussion, to include application of known medical principles to the specific facts of this case. M. Pryce Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. Shuster, Attorney Advisor 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.