Citation Nr: 20048053 Decision Date: 07/17/20 Archive Date: 07/17/20 DOCKET NO. 14-38 588A DATE: July 17, 2020 ORDER Entitlement to an increased disability rating in excess of 20 percent for service-connected right patellofemoral syndrome is denied. Entitlement to a total disability rating based on individual employability due to service-connected disability (TDIU) is granted, effective May 1, 2011. REMANDED Entitlement to service connection for degenerative joint disease of the left knee is remanded. Entitlement to service connection for bilateral Achilles tendonitis is remanded. FINDINGS OF FACT 1. The Veteran’s right patellofemoral syndrome condition consistently presented with “normal” joint stability with no evidence of recurrent subluxation or lateral instability. 2. The Veteran’s service-connected disabilities alone have rendered him unable to secure and follow a substantially gainful occupation. CONCLUSIONS OF LAW 1. The criteria for entitlement to an increased disability rating in excess of 20 percent for service-connected right patellofemoral syndrome have not been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.71a, Diagnostic Code 5257. 2. The criteria for entitlement to a TDIU have been met effective May 1, 2011 (but excluding from August 21, 2018 to October 31, 2018). 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.340, 3.341, 4.15, 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active duty service in the United States Army from October 1995 to March 2000, with a prior period of active duty for training from October 1994 to June 1995. In May 2018, the Board remanded to obtain VA examinations/medical nexus opinions and any outstanding treatment records. To the extent that all of these records have been obtained, the Board finds substantial compliance with its prior remand directive. See Stegall v. West, 11 Vet. App. 268 (1998). However, because the obtained medical nexus opinions are inadequate, the Board finds that another remand is required for the service connection claims for degenerative joint disease of the left knee and bilateral Achilles tendonitis as discussed further in remand section below. While additional private medical records have been associated with the claims file since the issuance of the April 2020 Supplemental Statement of Case, the Board may proceed at this time as the Veteran himself submitted those records. Neither the Veteran nor his representative has raised any issues with the duty to notify or duty to assist. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that “the Board’s obligation to read filings in a liberal manner does not require the Board... to search the record and address procedural arguments when the veteran fails to raise them before the Board.”); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). The Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive and provide the reasons for its rejection of any material favorable to the claimant, when rendering a decision on appeal. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. See Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994). The Board has thoroughly reviewed all the evidence in the Veteran’s VA files. In every decision, the Board must provide a statement of the reasons or bases for its determination, adequate to enable the Veteran to understand the precise basis for the Board’s decision, as well as to facilitate review by the United States Court of Appeals for Veterans Claims (Court). 38 U.S.C. § 7104 (d)(1) (2012); see Allday v. Brown, 7 Vet. App. 517, 527 (1995). Although the entire record must be reviewed by the Board, the Court has repeatedly found that the Board is not required to discuss, in detail, every piece of evidence. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000); Dela Cruz v. Principi, 15 Vet. App. 143, 149 (2001) (rejecting the notion that the Veterans Claims Assistance Act mandates that the Board discuss all evidence). Rather, the law requires only that the Board address its reasons for rejecting evidence favorable to the Veteran. See Timberlake v. Gober, 14 Vet. App. 122 (2000). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claim. The Veteran must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake, supra. Increased Rating Disability ratings are determined by applying a schedule of ratings that is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R., Part 4. Each disability must be viewed in relation to its history and the limitation of activity imposed by the disabling condition should be emphasized. 38 C.F.R. § 4.1. Examination reports are to be interpreted in light of the whole recorded history, and each disability must be considered from the point of view of the appellant working or seeking work. 38 C.F.R. § 4.2. Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining will be resolved in favor of the Veteran. 38 C.F.R. § 4.3. The evaluation of the same disability under various diagnoses, known as pyramiding, is generally to be avoided. 38 C.F.R. § 4.14. The critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the disabilities is duplicative or overlapping with the symptomatology of the other disability. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance. 38 C.F.R. § 4.40. It is essential that the examination on which ratings are based adequately portray the anatomical damage and functional loss with respect to all these elements. The functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective innervations, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part which becomes painful on use must be regarded as seriously disabled. A little used part of the musculoskeletal system may be expected to show evidence of disuse, either through atrophy, the condition of the skin, absence of normal callosity, or the like. Id. With any form of arthritis, painful motion is an important factor of disability, the facial expression, wincing, etc., on pressure or manipulation, should be carefully noted and definitely related to affected joints. Muscle spasm will greatly assist the identification. The intent of the schedule is to recognize painful motion with joint or particular pathology as productive of disability. It is the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. Crepitation either in the soft tissues such as the tendons or ligaments, or crepitation within the joint structures should be noted carefully as points of contact which are diseased. Flexion elicits such manifestations. The joints involved should be tested for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with the range of the opposite undamaged joint. 38 C.F.R. § 4.59. When evaluating disabilities of the musculoskeletal system, 38 C.F.R. § 4.40 allows for consideration of functional loss due to pain and weakness causing additional disability beyond that reflected on range of motion measurements. DeLuca v. Brown, 8 Vet. App. 202 (1995). Further, 38 C.F.R. § 4.45 provides that consideration also be given to decreased movement, weakened movement, excess fatigability, incoordination, and pain on movement, swelling, and deformity or atrophy of disuse. Painful motion is considered limited motion at the point that the pain actually sets in. See VAOPGCPREC 9-98. While the Veteran’s entire history is reviewed when assigning a disability rating, 38 C.F.R. § 4.1, where service connection has already been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55 (1994). Additionally, the Court has held that in determining the present level of a disability for any increased evaluation claim, the Board must consider the application of staged ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007). In other words, where the evidence contains factual findings that demonstrate distinct time periods in which the service-connected disability exhibited diverse symptoms meeting the criteria for different ratings during the course of the appeal, the assignment of staged ratings would be necessary. A veteran is entitled to the benefit of the doubt when there is an approximate balance of positive and negative evidence. 38 C.F.R. § 3.102; see Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 1. Entitlement to an increased disability rating in excess of 20 percent for service-connected right patellofemoral syndrome is denied. The Veteran seeks a higher rating for his service-connected right patellofemoral syndrome. He has not made any specific contentions, but has made a general statement suggestive of worsening (which ultimately led to ordering a new VA examination pursuant to the May 2018 Board remand and him undergoing a new VA examination in June 2019). The Veteran’s right patellofemoral syndrome is currently rated as 20 percent under Diagnostic Code (DC) 5257 (excluding from March 10, 2011 to April 30, 2011, as temporary total ratings pursuant to 38 C.F.R. § 4.30 were assigned throughout this period). In this case, the Veteran filed his increased rating claim in September 2009. Pertinent regulations were provided to the Veteran in the September 2014 Statement of the Case and will not be repeated here. After reviewing all pertinent records, the Board finds that the Veteran is not warranted a rating in excess of 20 percent under DC 5257 throughout the appeal period. In this case, the Veteran was consistently found to have no history of recurrent subluxation/lateral instability/reduction of muscle strength (see June 2019 VA examination, July 2015 VA examination; see also July 2014 VA examination, no evidence or history of recurrent patellar subluxation/dislocation; see also September 2011 VA treatment records, no abnormal subluxation or tilting of patella; see also March 2010 VA examination, no instability), and he also consistently presented “normal” joint stability test/muscle strength (see June 2019 VA examination, July 2015 VA examination; see July 2014 VA examination), as well as “normal” anterior/posterior/medial/lateral instability. (see August 2015 VA examination, June 2019 VA examination). There was also only minimal or negative finding for muscle atrophy or reduction in muscle strength (see July 2015 VA examination, “during this examination, the Veteran demonstrated a lack of physical effort and pain out of proportion to physical findings”; June 2019 VA examination, although there was a reduction in muscle strength, the Veteran still presented 4/5 flexion and extension muscle strength, with no muscle atrophy). In fact, at no time during any of the VA examinations did the Veteran report or allege any symptoms of his knee giving out/being instable. Although the Board is cognizant of the Veteran’s reports of stiffness/locking/giving away documented in his treatment records (ie. April 2012 VA treatment records, June 2010 VA treatment records), the Board notes that the Veteran consistently reported the frequency of such symptoms as only intermittent/occasional at most (June 2010, April 2012 treatment records), warranting only the rating for moderate instability (which is what he is currently under), and even during those sessions that he reported any of those symptoms, the objective findings were that he either had only intermittent symptom (again, warranting only the current 20 percent rating) or did not manifest any instability. Thus, even considering these objective and subjective findings, the Board finds that his condition was limited to at most only moderate condition. The Board reiterates that there is consistently negative findings for any evidence suggestive of severe recurrent subluxation or lateral instability of the right knee (see June 2019 VA examination, July 2015 VA examination; see also July 2014 VA examination, no evidence or history of recurrent patellar subluxation/dislocation; see also September 2011 VA treatment records, no abnormal subluxation or tilting of patella; see also March 2010 VA examination, no instability), with normal or only minimal muscle atrophy or reduction in muscle strength. In light of above, the Board finds that he is not entitled to a rating in excess of 20 percent for his right patellofemoral syndrome. In evaluating the Veteran’s increased rating claim, the Board must consider all applicable diagnostic codes, with an eye towards assigning the most favorable code. See Schafrath v. Derwinski, 1 Vet. App. 589, 593 (1991). Disabilities of the knee joint, generally, are rated under Diagnostic Codes 5256 through 5263. 38 C.F.R. § 4.71a. Thus, the Board considered the aforementioned codes that could warrant a higher or an additional rating. Initially, the Board notes that DC 5259 is not applicable, as it contemplates meniscal disabilities after the semilunar cartilage is removed. The Veteran had not undergone such surgery on the right side. The Board has also considered whether the Veteran may be entitled to a separate compensable rating under DC 5258, since evaluation of a knee disability under DC 5257 or 5261, or both, as a matter of law, does not preclude separate evaluations of the same knee under DC 5258, if such symptoms are shown. See Lyles v. Shulkin, 2017 U.S. App. Vet. Claims LEXIS 1704. However, the Board finds that the Veteran is not entitled to a separate compensable rating under DC 5258. There is no clear evidence of semilunar cartilage dislocation or meniscal tears. In fact, he was consistently found to not have any dislocation/semilunar condition or crepitus. Thus, he is not warranted a separate compensable rating under DC 5258. The Board also considered all applicable diagnostic codes (DC 5256 through 5263) relating to knee condition that could warrant a higher or an additional rating, but finds them inapplicable, as there is no evidence of ankylosis, tibial or fibular impairments, limitation of extension or flexion compensable under DC 5261 or 5260, or genu recurvatum. The Board also considered whether he would be entitled to a separate 10 percent rating under DC 5003 for his right knee joint osteoarthritis established by x-ray finding, but finds he is not. Notably, this condition was noted to be a “new and separate non-service related condition” related to “normal aging and obesity,” not associated with his service-connected patellofemoral syndrome (see June 2019 VA examination, July 2015 VA examination). The Board also considered the assignment of schedular ratings in excess of those upheld or awarded herein based on consideration of any of the factors addressed in 38 C.F.R. §§ 4.40, 4.45 and DeLuca v. Brown, 8 Vet. App. 202, 204-7 (1995). To the extent that the Veteran has experienced functional loss due to pain, fatigability, incoordination, pain on movement (ie. difficulty sitting/standing up from his desk (March 2010 VA general examination)), these symptoms have been fully contemplated by the Veteran’s assigned schedular ratings. Furthermore, the Veteran was consistently able to perform repetitive use testing with at least three repetitions and noted no additional limitation in range of motion after repetitive use. Based on the foregoing, the preponderance of the evidence is against the Veteran’s claim for a rating in excess of 20 percent for the Veteran’s right patellofemoral pain disability throughout the appeal period. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 2. Entitlement to TDIU is granted effective May 1, 2011 (but excluding from August 21, 2018 to October 31, 2018). The Veteran claims entitlement to a TDIU. Although he initially filed a VA 21-8940 form in September 2009, alleging that his service-connected disabilities have precluded him from securing or following substantially gainful occupation effective October 2008, he subsequently limited his claim to entitlement to TDIU effective May 1, 2011. See March 2015 brief from his attorney (requesting VA grant “Entitlement to a TDIU rating, effective May 1, 2011”) and May 2020 correspondence (same). Since the Veteran’s attorney has consistently limited the TDIU appeal to a request for a grant of benefits effective May 2011, the Board will not consider the time period on appeal prior to that date. A claimant can limit his appeal to a specific rating or a specific time period, and that has clearly been done here. It is the established policy of VA that all veterans who are unable to secure and follow a substantially gainful occupation by reason of service-connected disabilities shall be rated totally disabled. 38 C.F.R. § 4.16. A TDIU may be assigned when the schedular rating for service-connected disabilities is less than 100 percent when it is found that the service-connected disabilities are sufficient to produce unemployability without regard to advancing age, provided that, if there is only one such disability, it is ratable at 60 percent or more, or, if there are two or more disabilities, there is at least one disability ratable at 40 percent or more and additional disabilities to bring the combined rating to 70 percent or more. 38 C.F.R. §§ 3.340, 3.341, 4.16. A finding of total disability is appropriate, “when there is present any impairment of mind or body which is sufficient to render it impossible for the average person to follow a substantially gainful occupation.” 38 C.F.R. §§ 3.340 (a)(1), 4.15. When determining whether the Veteran is unable to secure or follow a substantially gainful occupation due to his service-connected disabilities, consideration may be given to the Veteran’s level of education, special training, and previous work experience, but it may not be given to his or her age or to any impairment caused by nonservice-connected disabilities. 38 C.F.R. §§ 3.341, 4.16, 4.19. Before proceeding to discuss whether the Veteran is unable to secure or follow a substantially gainful occupation due to his service-connected disabilities, the Board first points out that the Veteran was awarded a temporary total 100 percent rating from August 21, 2018 to October 31, 2018, for surgical or other treatment necessitating convalescence for his service-connected left foot condition. As the Veteran was in receipt of the maximum benefit allowed under law, the claim of entitlement to TDIU is moot during this period. See, e.g., Bradley v. Peake, 22 Vet. App. 280, 294 (2008); see also Buie v. Shinseki, 24 Vet. App. 242, 248 (2010). The Board recognizes that it is not categorically true that assignment of a total schedular rating always renders a TDIU request moot, particularly as it relates to possible entitlement to special monthly compensation. See Bradley, 22 Vet. App. at 293. In Bradley, the Court held that a TDIU rating could be warranted in addition to a schedular 100 percent evaluation, where the TDIU could be granted for a disability other than the disability for which a 100 percent schedular rating was in effect, explaining that under such circumstances, there was no “duplicate counting of disabilities.” However, in this case, the Veteran was already granted special monthly compensation from August 21, 2018 to October 31, 2018 under 38 U.S.C. § 1114, subsection (s) and 38 C.F.R. § 3.350(i). Again, for the reasons given above, the Board finds the question of entitlement to TDIU is limited only to the time period effective May 1, 2011. Effective May 1, 2011, the Veteran met the schedular basis under 38 C.F.R.§ 4.16(a), as he has multiple service-connected disabilities, with at least one disability rated at 40 percent or more, with a combined rating of 70 percent or higher. Therefore, a TDIU is warranted if the evidence shows that he has been unable to secure or follow a substantially gainful occupation as a result of his service-connected disabilities, considering his specific educational and employment background, but without regard to age, non-service connected disabilities, or previous unemployability status. See 38 C.F.R. §§ 4.16(a), 4.19. After a full review of the record, the Board finds that this is the case here. Therefore, entitlement to a TDIU is granted effective May 1, 2011, but excluding from August 21, 2018 to October 31, 2018. The Veteran’s education history is through one year of college. His employment history consists primarily of years of security guard/driver work and a very brief period of nursing assistant work. Although he indicated that he last worked in 2008 in his September 2009 VA 21-8940 form (which he claims to have left due to pain in his feet/right knee), he actually continued to work thereafter until around 2009 (security officer/lab courier/van driver). In 2010, he took additional classes as a patient care technician. He indicated that he left his last job (driver) in 2009, due to his service-connected disabilities, to include right knee and feet conditions (see March 2010 VA examination). Thereafter, he did not work or take additional classes until much later - in 2016 – when he took six weeks of nursing classes, for which he received a certificate in May 2016. He then did a post-grad internship as a certified nursing assistant for 10 months, which he claims he quit due to his inability to cope with the physical demands of the position due to his service-connected disabilities. He was then unemployed for 2 years, after which he worked as a guard for 4 months in 2018 (confined to only light duty position), which he also quit due to his inability to stand for a prolonged period due to his service-connected right knee/left ankle/bilateral foot disabilities. Review of the evidence shows that the Veteran’s service-connected disabilities have affected his ability to work, such that the Board finds that he was precluded from securing or following substantially gainful employment by reason of his service-connected disabilities effective May 1, 2011. VA examinations suggest that the combined effect of his combined service-connected disabilities alone impact his ability to secure or follow a substantially gainful occupation: • January 2011 VA examination: although noted that “the combined limitation upon his ability to psychologically function in an occupational setting would be virtually impossible and be a matter of resorting to speculation,” the examiner indicated that his psychological symptoms caused clinically significant distress/impairment in social occupational or other important areas of functioning and that he manifested symptoms of pain disorder leading to his inability to concentrate and irritability due to pain) • July 2014 VA examination: indicating his patellofemoral syndrome and bilateral pes planus would only allow him to work in a light and sedentary capacity • November 2018 VA examination: unable to stand and/or walk for prolonged period of time due to bilateral feet condition • June 2019 VA examination: “work restrictions may include avoidance of prolonged exertion, no heavy lifting, no heavy carrying of excess poundage” The Veteran has also submitted February 2015 and May 2020 private vocational evaluations. Those evaluations concluded that his service-connected disabilities, to include his bilateral pes planus/plantar fasciitis, left ankle osteoarthritis, and right patellofemoral pain syndrome, impact his ability to walk/kneel/run/climb/stand or get up from a sedentary position, and that his service-connected pain disorder with mood disorder negatively interferes with his ability to focus/concentrate. With regards to his advanced degree/recently acquired nursing assistant certificate, the specialist pointed out that the nursing assistant work requires medium to heavy jobs lifting, which are the very activities that the Veteran is limited to perform due to his service-connected disabilities. He also found that due to pain from his service-connected plantar fascitis and plantar planus, and right patellofemoral syndrome, the Veteran quit his last driving/security guard job (ie. difficulty repetitively getting in and out of the delivery vehicle, pain causing difficulty concentrating, difficulty sitting/standing for a prolonged time). The Board is cognizant of a June 2019 VA examination, in which the examiner opined, “the combination the veteran’s service-connected conditions (ie. pes planus, right knee patellofemoral syndrome) would preclude heavy, but not light duty occupation, if work restrictions could be accommodated.” However, the VA examiner went on to state that “exactly what these occupations are is beyond the scope of this examiner without speculation.” As pointed out by the May 2020 private vocational opinion, it appears that the June 2019 VA examiner was not familiar with the Veteran’s occupational history, which involves only non-sedentary positions (driver, security guard, nursing assistant), requiring moderate to heavy duty work, as well as standing/walking/driving for a prolonged period, all of which are the very functions noted to have been limited by his service-connected disabilities and thus impact his ability to obtain gainful employment. Upon consideration and resolving reasonable doubt in favor of the Veteran, the Board grants entitlement to a TDIU effective May 1, 2011. While he has a relatively advanced educational degree/skills/experience (ie. certified nursing assistant), the Board notes that this position requires medium to physical heavy duty work, concentration/ability to carry out instructions accordingly (requiring lifting patients, prolonged walking/sitting/standing). Furthermore, his past work experience otherwise consists primarily of security guard and driver, both of which require prolonged walking/sitting/standing, which were noted to have been impacted by his service-connected disabilities, affecting his ability to obtain gainful employment. While the Board recognizes some of the earlier VA examinations that did not find functional impact as related to his service-connected condition (ie. July 2015 VA examination indicating no functional impact related to his service-connected disabilities, to include right patellofemoral syndrome), the Board finds that the evidence is otherwise at least in equipoise (and resolving the reasonable doubt in favor of the Veteran) that his service-connected disabilities affect his ability to maintain substantially gainful employment. The Board is also cognizant that the Veteran was either in school/working temporarily between 2016 and 2018 (ie. nurse assistant class in 2016 for 6 weeks; post-grad internship as a certified nursing assistant in 2016 for about 10 months, 4-month long job in 2018 as a security guard). While the Board has considered whether the grant of TDIU should be excluded from these periods, the Board finds these findings show that he was unable to sustain employment for more than a few months. Thus, the Board grants TDIU effective May 1, 2011, inclusive of this period. On balance, the evidence is at least in equipoise that the combined effects of the Veteran’s service-connected disabilities, have rendered him unable to secure and follow a substantially gainful occupation. Affording him the benefit of the doubt, entitlement to a TDIU on a schedular basis is granted effective May 1, 2011 (but excluding from August 21, 2018 to October 31, 2018). See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). REASONS FOR REMAND 1. Entitlement to service connection for degenerative joint disease of the left knee is remanded. 2. Entitlement to service connection for bilateral Achilles tendonitis is remanded. Although medical nexus opinions for direct and secondary service connection have been obtained since the May 2018 Board remand (ie. June 2019 VA examination), the Board finds these opinions inadequate and finds that another remand is required for a medical addendum opinion. First, with regards to the direct and secondary opinions for bilateral Achilles tendonitis condition, although the June 2019 VA examiner cited to medical literature (ie. achilles tendon weakens with age) in support of a negative nexus opinion, the other primary reason for the opinion was based on the finding that the Veteran does not have a current diagnosis of bilateral Achilles tendonitis. The June 2019 VA examiner diagnosed the Veteran with only bilateral calcaneal spur, and noted that the Veteran’s treatment records do not indicate evidence or a diagnosis of bilateral Achilles tendinitis. However, as pointed out by the Veteran’s representative (see May 2020 VA 21-4138 form), his treatment records do include a diagnosis of tendonitis (ie. January 2017 VA examination, diagnosing with left tendonitis); thus, it appears that the June 2019 VA examiner failed to review all pertinent records in furnishing the negative opinion, and the opinion was based on an inaccurate factual premise. As the examiner failed to address the Veteran’s diagnosis of tendonitis documented in his VA records (ie. January 2017 VA examination; which was provided within the appeal period), the Board finds that another addendum opinion for direct service connection is required. As for the secondary service connection opinion for bilateral Achilles tendonitis condition, as for aggravation, the examiner furnished an erroneous conclusion that his “service-connection condition, right knee disability, pes planus, or left ankle condition was not aggravated beyond its natural progression by military service,” and also without providing any rationale in support of that erroneous conclusion. Thus, another medical addendum opinion for secondary service connection is also required. As for the direct service opinion for degenerative joint disease of the left knee, although the June 2019 VA examiner explained that this being a bilateral and symmetrical condition (ie. bilateral knee degenerative joint disease) makes it consistent with aging, and thus, not related to his service, the Board finds this opinion inadequate, given that the examiner failed to explain specifically how his left knee disability is/is not related to service. Thus, the Board finds this opinion inadequate and finds another remand required. Finally, regarding the secondary service connection opinion (causation) for degenerative joint disease of the left knee, the Board also finds its rationale inadequate: “the Veteran’s left knee degenerative joint disease is not consistent with/due to bilateral pes planus, left ankle degeneration, or right patellofemoral syndrome. There is no evidence of leg length discrepancy. The right and left knee joints are not contiguous joints.” This opinion failed to address whether it is at least as likely not that the Veteran’s left knee condition is proximately due to the service-connected bilateral pes planus condition, and the opinion discussing absence of leg length discrepancy or the knee joints not being contiguous joints still does not explain how exactly the conditions are not related. As for the aggravation opinion (secondary opinion), although it was requested, the examiner provided the exact same opinion as for causation (“the Veteran’s left knee degenerative joint disease is not consistent with/due to bilateral pes planus, left ankle degeneration, or right patellofemoral syndrome. There is no evidence of leg length discrepancy. The right and left knee joints are not contiguous joints”). Thus, the Board finds another medical addendum opinion is required. The matters are REMANDED for the following action: 1. Obtain a medical addendum opinion from June 2019 VA examiner, or if unavailable, from another VA examiner. The examiner must review the complete claims file. Then, the examiner must address the following, with full supporting rationales: Is it at least as likely as not the Veteran’s bilateral Achilles tendon disability is proximately due to or is aggravated by the service-connected right knee disability, pes planus, or left ankle disability, or otherwise related to in-service disease or injury? In the 2019 opinion, the examiner failed to consider the Veteran’s diagnosis of tendonitis on the January 2017 VA examination in furnishing a direct service connection opinion. As for the secondary service connection opinion (aggravation), and examiner furnished an erroneous opinion by using a wrong standard. Please address both direct and secondary service connection. Is it at least as likely as not the Veteran’s degenerative joint disease of the left knee is proximately due to or is aggravated by the service-connected right knee disability, pes planus, or left ankle disability, or otherwise related to in-service disease or injury? In the 2019 opinion, the examiner failed to specifically address a potential nexus between his left knee disability and service in furnishing a negative direct service connection opinion. As for secondary service connection opinion, the examiner provided an identical opinion for both the aggravation and causation opinion, and without providing adequate rationales in support of the conclusion. Please address both direct and secondary service connection. MICHELLE L. KANE Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board C. Lee 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.