Citation Nr: 20003207 Decision Date: 01/14/20 Archive Date: 01/14/20 DOCKET NO. 13-13 676 DATE: January 14, 2020 REMANDED Entitlement to service connection for left knee disorder, to include as secondary to service-connected right knee disability, is remanded. REASONS FOR REMAND The Veteran had active military service from September 1990 to September 1996. This matter comes before the Board of Veterans’ Appeals (Board) on appeal of a May 2012 rating decision by the Department of Veteran’s Affairs (VA) Regional office (RO), which denied, in part, service connection for a left knee injury. The Veteran initially requested a videoconference hearing before a Veterans Law Judge. See VA Form 9 (May 2013). However, in March 2014, the Veteran submitted a written cancellation request. Thus, the Veteran’s hearing request has been withdrawn. See 38 C.F.R. § 20.704(e). The claim was previously remanded in December 2016 and August 2018 for further development, to include obtaining a VA examination with addendum opinion. Entitlement to service connection for left knee disorder to include as secondary to service-connected right knee disability is remanded. The Veteran contends that his left knee disability is secondary to his service-connected right knee disability. He believes that he has compensated for right knee problems and over relied on his left leg, which caused him to fall down a flight of stairs, twisting the left knee and resulting in a left knee injury and disability. Pursuant to an August 2018 Board remand, VA obtained a new VA examination and medical opinion in this matter. However, the July 2019 VA medical opinion is inadequate. The examiner opined that Veteran’s left knee sprain, degenerative joint disease and anterior cruciate ligament (ACL) tear are less than likely as not “caused or aggravated permanently worsened beyond its natural progression by the service-connected right knee disorder.” The examiner noted that the Veteran’s records were reviewed and that the medical reports indicate that he had a fall down stairs and this led to his injury resulting in an ACL tear and he required surgery. The opinion is inadequate for the following reasons: First, as to aggravation, a permanent worsening is not required where service connection is sought on a secondary basis. See Ward v. Wilkie, 17-1204, 2019 U.S. App. Vet. Claims LEXIS 994 (June 14, 2019). Second, the medical opinion does not adequate address the clinical evidence of record and whether it suggests the development of a left knee disorder (prior to the fall) linked to the Veteran’s service-connected right knee. In this regard, the Board observes that October 2005 VA records reflect the Veteran was seeking treatment for his right knee condition when he complained that his left knee started to cause discomfort with no acute trauma or history of prior pain; as a result, he was diagnosed with left knee arthralgias. On objective examination, he had a healing abrasion and there was sign of some laxity. In May 2009, the Veteran sought follow up treatment for his service connected right knee, but complained that his left knee ached at times. He was taking ibuprofen four to five times per week for bilateral knee pain, which he reported was partially helpful. August 2010 VA records reflect the Veteran sought emergency room treatment for status post fall, where he heard popping in his left knee. September 2010 records reflect his left knee was positive for effusion, status post fall; Lachman’s test was inconclusive secondary to quadricep and hamstring spams along with guarding. MRI in in the same month showed complete ACL tear associated with bone contusions and mild impaction fracture of the lateral femoral condyle. The Veteran underwent left knee ACL reconstruction in December 2010. Lastly, although the Veteran’s service connected for right knee osteoarthritis with limitation of flexion, and not for subluxation or lateral instability, the VA medical opinion does not address whether there is objective evidence of right knee symptoms, such as muscle weakness or atrophy, that could cause the Veteran’s right knee to give way causing him to fall as he reports. It is noted that the Veteran is competent to state the series of events that led to his fall. Accordingly, to ensure that VA has met its duty to assist, remand is necessary for an addendum medical opinion. The matter is REMANDED for the following action: 1. Obtain the Veteran’s VA treatment records for the period from February 2019 to present. 2. Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran’s left knee disability is at least as likely as not proximately due to his service-connected right knee disability or aggravated beyond its natural progression by the service-connected right knee disability. Indicate whether there were objective findings or history consistent with right knee symptomatology, such as muscle weakness or atrophy, that could have caused his right knee to give way causing him to fall and injury his left knee as reported by the Veteran. Address the clinical evidence of record and whether it suggests the development of a left knee disorder (prior to the fall and/or after the fall) caused or aggravated by the Veteran’s service-connected right knee disability. Although the examiner must review the entire claim file, his/her attention is directed to the following evidence: (a.) October 2005 VA records reflect the Veteran sought treatment for his service-connected right knee when he complained his left knee was starting to cause discomfort with no acute trauma or history of prior pain. On objective examination, he had a healing abrasion and there was sign of some laxity. He was diagnosed with left knee arthralgias. (b.) May 2009 VA records reflect the Veteran sought follow up treatment for his service- connected right knee but complained that his left knee was starting to ache at times. He was taking ibuprofen four to five times per week, which he reported was partially helpful. (c.) August 2010 VA records reflect the Veteran sought emergency room treatment for status post fall, where he heard popping in his left knee. (d.) September 2010 records reflect his left knee was positive for effusion, status post fall; Lachman’s test was inconclusive secondary to quadricep and hamstring spams along with guarding. (e.) MRI in in the same month showed complete anterior cruciate ligament tear associated with bone contusions and mild impaction fracture of the lateral femoral condyle. (f.) The Veteran underwent a left knee ACL reconstruction in December 2010. (g.) At the June 2012 VA examination, the Veteran contended that his condition began when his[service-connected] right knee gave out and caused the fall, weakness in the left knee and subsequent ACL damage. 3. Ensure that the VA medical opinion obtained includes a complete rationale for the conclusions reached. The medical opinion must support the conclusions reached with an analysis that is adequate for the Board to consider and weigh against other evidence of record; medical opinions must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. If an opinion cannot be expressed without resort to speculation, ensure that the clinician so indicates and discusses why an opinion is not possible, to include whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. (CONTINUED ON NEXT PAGE) 4. Readjudicate. C.A. SKOW Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board N. Pendleton, Associate 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.