Citation Nr: 20046880 Decision Date: 07/13/20 Archive Date: 07/13/20 DOCKET NO. 16-24 065 DATE: July 13, 2020 REMANDED Entitlement to service connection for a left knee disability, including residuals of a torn anterior crucial ligament (ACL), is remanded. . REASONS FOR REMAND The Veteran served on active duty from September 2000 to July 2004. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a May 2015 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). The Board remanded the matter for further development in September 2018. Service connection for a left knee disability is remanded. The Board remanded the claim, in part, to obtain a new VA medical opinion. The opinion was provided in December 2019, and a VA examination was subsequently performed in January 2020. The Board finds that the December 2019 opinion is not adequate to make an informed decision. The examiner opined that the Veteran’s left knee disability is less likely than not related to his in-service injuries because there was an interval of seven years between his period of service and the diagnosis of the ACL tear, and during that time he had engaged in sports “well known for their propensity to damage the ACL: snowboarding, hockey and soccer.” Further, the Veteran’s ligaments were examined and found to be stable during service, with no evidence that he had instability at the time. The opinion also notes that a July 2009 physical examination that was performed when he initially established care with VA was normal, and he denied any problems at the time. The examiner concluded that the Veteran’s instability is less likely than not a result of the injuries sustained in service, as the Veteran’s ligaments were examined and found to be normal in service. The medical opinion disregards the fact that while the Veteran engaged in snowboarding, hockey, and soccer after service, he did not sustain a known injury during these activities. However, he did sustain two known injuries during service. He twisted his left knee playing basketball in November 2003. After two weeks of rest, his knee was much improved, but he still had residual pain with walking and running. He then reinjured his knee in January 2004 in a parachute jump landing. At that time, he reported having left knee pain for the past three months, that is, since his November 2003 injury. He was placed on a physical profile for 30 days. It is true that the Veteran did not report knee pain in July 2009 when he came to VA to establish patient care. An examination of the lower extremities conducted as part of the initial physical examination at that time was normal. However, he was not being seen for treatment for any specific condition. When he sought emergency treatment in August 2010 for his left knee, he reported the in-service injury, and stated it improved on its own after a month; however, his knee would be sore off and on since that time if he sat or moved a certain way. A September 2010 VA treatment record notes that after service the Veteran was able to do sports such as hockey and soccer, and had only occasional discomfort every three to six months. It did not “bother[] him enough to seek attention.” Given this history, the Board finds it plausible that the Veteran would not report left knee problems in July 2009, and yet still have occasional left knee pain with certain movements. After service, the Veteran first sought treatment for his left knee in August 2010. He stated he was at a concert, and was “pushed around a bit when he felt two pops in the left knee.” He went to the emergency room two days later with pain to the medial aspect of his knee. Based on a September 2010 magnetic resonance imaging study (MRI), he was diagnosed with an ACL tear. He underwent left knee ACL reconstruction surgery in March 2011. In a September 2010 VA surgical consultation record, an orthopedic surgeon observed that the Veteran may have had a chronic ACL deficiency that was adequately rehabbed—referring to his in-service injuries and treatment—and that he had been compensating for it. The May 2015 VA examination report reflects that the Veteran told the examiner that his surgeon felt that the prior in-service injuries must have caused a near complete tear that left him vulnerable, and therefore the completion of the tear years later did not require extreme trauma to occur. In light of the September 2010 surgical consultation record, the Board finds this reported history credible. To summarize, the evidence shows that the Veteran sustained two in-service left knee injuries, including one from a parachute jump, and that he had occasional minor left knee pain at times thereafter, but did not find his symptoms bothersome enough to seek treatment. As suggested in the September 2010 surgery consultation, the Veteran’s left knee had been adequately rehabilitated, but he may still have had a chronic ACL deficiency for which he simply compensated, meaning that the underlying pathology had not resolved, but he was nevertheless able to continue his activities without significant symptoms or functional compromise. This is borne out by the fact that the injury resulting in a complete ACL tear requiring surgery seemed to involve little external force: the Veteran was simply pushed around by the crowd at a concert. In short, the September 2010 VA surgical consultation and the history related by the Veteran at the May 2015 examination indicate that he may have been living with a chronic ACL deficiency resulting from the in-service injuries, and that this is why he sustained a complete tear of his ACL in August 2010 from the relatively minor impact of being pushed around at a concert. Even if engaging in activities such as snowboarding, hockey, and soccer may have further aggravated the underlying ACL condition, that would not preclude a finding that the Veteran’s chronic ACL condition ultimately stemmed from the in-service injuries, especially as he did not sustain a known acute injury from these post-service activities. The Board is aware that the x-ray study of the left knee performed during service in January 2004, when the Veteran re-injured his knee from a parachute jump, was normal. Moreover, on physical examination, there was no effusion or instability at the time. The December 2019 VA opinion emphasizes the fact that stability testing during service was normal. However, when the Veteran’s left knee was examined at VA in August and September 2010, an x-ray study was also normal, and on physical examination there was no effusion, laxity, or erythema. His left knee otherwise appeared normal on physical examination. There was minimal pain with palpation. These findings were made contemporaneous with the ACL tear diagnosed on MRI, which necessitated surgery. Given these findings, it is obvious that the normal x-ray study and stability testing during service do not necessarily rule out an ACL tear or injury at the time. Notably, an MRI study was not performed during service. The December 2019 VA medical opinion does not account for these facts. As the Board lacks the medical expertise to make its own determination on these issues, which require competent medical judgment, a new opinion must be obtained. The Board’s September 2018 remand also directed the agency of original jurisdiction to obtain any outstanding service treatment records, including any records of treatment at Womack Army Medical Center (AMC). The Board noted in this regard that there is no separation examination report in the file, and it was unclear whether one existed but was outstanding. Since the Board’s remand, VA requested and received additional service department records. The Veteran’s treatment at Womack AMC for his left knee injuries is already documented in the service treatment records originally received by VA, and the additional records provided by that facility following the Board’s remand do not suggest that there was any other treatment for his left knee. While there is no separation examination report, the Board strongly suspects that one never existed. His DD 214 states that he did not complete his first full term of service, and was unavailable to sign the form. Under these circumstances, and as the service treatment records otherwise appear complete, the Board finds it likely that a separation examination was not conducted. Based on this finding and the additional records obtained by VA following the Board’s September 2018 remand, the Board concludes that the Veteran’s complete service treatment records are in the file, as there is no indication that there are any missing records at this juncture. The matters are REMANDED for the following action: 1. Add to the file any outstanding VA treatment records pertaining to the Veteran dated since February 2015. 2. Obtain a new VA medical opinion as to whether it is at least as likely as not (50 percent probability or more) that the Veteran’s left knee disability, including residuals of an ACL tear, is related to his in-service injuries. The opinion must consider the fact that although an x-ray study and stability testing of the knee were normal during service, the same was true in August and September 2010 when the Veteran was diagnosed on MRI with an ACL tear. In other words, the September 2010 MRI detected the ACL tear that was not otherwise found on x-ray or physical examination. Notably, an MRI study was not performed during service. The opinion must also consider the seemingly minor impact of being jostled at a concert, which is what triggered the Veteran’s significant left knee pain that was diagnosed as an ACL tear requiring surgery. As suggested by a surgeon in the September 2010 VA surgery consultation, the Veteran may have had a chronic ACL deficiency preceding the August 2010 injury. While he did not seek treatment for left knee problems after service until August 2010, and did not report knee problems when he established care with VA in July 2009, he has related a history of occasional left knee soreness with certain movements or activities in the years following service separation, but did not find that symptom sufficiently bothersome to warrant medical attention. Finally, while the December 2019 VA medical opinion observes that the Veteran engaged in sports like snowboarding, hockey, and soccer, which are “known for their propensity to damage the ACL,” he did not sustain any known acute injury from these activities. Even if they may have potentially aggravated an underlying ACL condition, that would not preclude a relationship between the Veteran’s ACL tear and his in-service injuries, if they are found to have initially caused a chronic ACL condition that worsened over time (whether or not due to subsequent impacts on the knee). P.M. DILORENZO Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Rutkin, 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.