Citation Nr: 21001720 Decision Date: 01/11/21 Archive Date: 01/11/21 DOCKET NO. 14-31 710A DATE: January 11, 2021 ORDER Entitlement to service connection for a heart disorder, to include myocardial infarction and coronary artery disease, is granted. REMANDED Entitlement to service connection for a left knee disorder is remanded. Entitlement to service connection for a right knee disorder is remanded. Entitlement to service connection for a lumbar spine disorder is remanded. REFERRED As noted by the Board’s May 1995 decision, the issue of entitlement to service connection for costochondral junction sprain was raised in a March 1994 appellate brief but has not yet been adjudicated. This issue is once again referred to the agency of original jurisdiction (AOJ) for initial adjudication. FINDING OF FACT Resolving all reasonable doubt in the Veteran’s favor, his myocardial infarction and coronary artery disease are related to his active duty service. CONCLUSION OF LAW The criteria for service connection for myocardial infarction and coronary artery disease are met. 38 U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2019). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from July 1981 to July 1991. Service Connection The Veteran claims entitlement to service connection for a heart disorder. Specifically, during his January 2019 hearing, he stated that he began experiencing chest pain as early as 1982 after he was involved in a motor vehicle accident, and that his chest pains continued thereafter. See January 2019 Hearing Transcript, p. 7. He also stated that he had an abnormal echocardiogram during his July 1991 discharge examination, that he was subsequently prescribed nitroglycerin tablets in 1991, and that he underwent a stent placement in 2010. Id. at pp. 8-9. As will be explained, the Board concludes that the Veteran’s currently-diagnosed myocardial infarction and coronary artery disease are related to his military service. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a). A March 1982 service treatment record confirms that the Veteran was involved in a motor vehicle accident, and that he complained of chest pain. In connection with his July 1991 discharge examination, the Veteran underwent an echocardiogram which revealed sinus bradycardia; voltage criteria for left ventricular hypertrophy; possible inferior infarct, age undetermined; and a nonspecific ST abnormality. He was instructed to follow up with the VA. A November 1991 VA echocardiogram revealed normal sinus rhythm; voltage criteria for left ventricular hypertrophy; and could not rule out inferior infarct, age undetermined, with posterior extension. A November 1991 VA examiner noted that the Veteran’s heart was not enlarged, that its sounds were regular, that there was no gallop or murmur, and that examination revealed no abnormalities. The examiner opined that the Veteran likely did not have any arteriosclerotic heart disease; however, it was recommended that he undergo a stress test. Private treatment records and December 2014 Disability Benefits Questionnaire (DBQ) completed by Dr. N.I. reflect current diagnoses of a myocardial infarction and coronary artery disease. See, e.g., January 2011 Private Treatment Record; December 2014 DBQ. Moreover, this evidence demonstrates that the Veteran underwent a stent placement in 2010. In connection with the June 2019 remand, the Veteran underwent a VA examination in January 2020, and the examiner noted his diagnoses of an old myocardial infarction, and the examiner listed the date of diagnosis as 1984. Additionally, the examiner noted diagnoses of status post PCI, ischemic heart disease, and sinus arrhythmia. In a corresponding opinion, the January 2020 examiner concluded that the Veteran’s current heart problems were less likely than not related to his military service, reasoning that, after review of the Veteran’s service treatment records, they did not support the Veteran’s contention, and that it was less likely than not that his current heart problems were incurred in or caused by his military service. In an October 2020 letter, Dr. M.R. noted that she had reviewed the Veteran’s pertinent history, including the pertinent medical evidence of record, as well as the lay statements of record. She noted lay statements from the Veteran and his wife that he experienced a heart attack during active duty service, and she noted his report of ongoing atypical chest pain thereafter, as well as his report of using nitroglycerin. Dr. M.R then noted that the July 1991 echocardiogram was abnormal with Q waves in the inferior lead which was suggestive of an old inferior myocardial infarction. She then noted that the Veteran’s reports of shortness of breath with exertion was a common anginal (cardiac chest pain) equivalent. Dr. M.R. discussed the Veteran’s post-service treatment records, including a July 2010 stress test which revealed a small area of scarring of the heart involving the right coronary artery distribution inferiorly, and she stated that this finding was consistent with the findings in the July 1991 echocardiogram. Combined, these tests strongly support a finding that the Veteran suffered an inferior myocardial infarction during his active duty service. Also noted an August 2010 private treatment record which identified a fixed defect in the inferior cardiac wall, which was consistent with a myocardial infarction while on active duty. As for the Veteran’s military service, Dr. M.R. noted that cardiovascular signs or symptoms are listed amongst those signs or symptoms which may be manifestations of undiagnosed illnesses or medically unexplained chronic multisymptom illnesses that are associated with service in Southwest Asia. Dr. M.R. concluded that the Veteran’s coronary artery disease was likely present at the time of his active duty military service, and that it was likely caused or exacerbated by his active duty service in Southwest Asia. Upon review of the record, the Board finds the evidence to at least be in equipoise as to whether the Veteran’s current heart-related diagnoses, to include coronary artery disease and myocardial infarction are related to his active duty service. Significantly, although the January 2020 examiner concluded that the Veteran’s service treatment records did not support the Veteran’s contention, and that it was less likely than not that his current heart problems were incurred in or caused by his military service, the October 2020 letter from Dr. M.R. expressed that the Veteran’s current heart problems had their onset in service, or are otherwise related to service, to include his service in Southwest Asia and the July 1991 echocardiogram results. Accordingly, after resolving all doubt in favor of the Veteran, the Board finds that service connection for myocardial infarction and coronary artery disease is warranted as directly related to the Veteran’s active duty service. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. REASONS FOR REMAND Entitlement to service connection for a left knee disorder, a right knee disorder, and a lumbar spine disorder are remanded. As noted in a June 2019 remand, the Veteran claims entitlement to service connection for a right knee disorder and a left knee disorder. With regard to his right knee, the Veteran claims that he initially injured his right knee in a March 1982 motor vehicle accident. See January 2019 Hearing Transcript, p. 18. He claims that his right knee continued to bother him during service and following service, and that he received steroid injections after service. Id. at p. 19. With regard to his left knee, he claims that he initially injured it while playing sports during service, and that it continued thereafter. Id. at p. 21. He also reported that he sustained a blunt force injury to the left knee during service. He also indicated that he left knee disorder worsened as a result of favoring his right knee. Id. at p. 22. With regard to his lumbar spine disorder, the Veteran claims he initially injured his lumbar spine in 1984 while aboard the U.S.S. Kennedy. See January 2019 Hearing Transcript, p. 14. He stated that he subsequently reinjured his back in 1991, and that his problems continued following his discharge. Id. at p. 15. The Board also notes that a February 2011 private treatment record indicates that the Veteran’s lumbar spine disorder may be secondary to his bilateral knee disorders. In June 2019, the Board remanded the Veteran’s claims so that he could be afforded VA examinations to determine whether his right knee disorder, left knee disorder, and lumbar spine disorder were related to his military service; whether his left knee disorder was secondary to right knee disorder; and whether his lumbar spine disorder was secondary to bilateral knee problems. In doing so, the Board directed the examiner to review and consider the Veteran’s lay statements concerning the onset and continuity of his symptoms. Furthermore, the Board directed the examiner to specifically address the Veteran’s contention that his right knee symptomatology began after he was involved in a motor vehicle accident in March 1982, as well as the February 1984 service treatment record which noted his complaint of right popliteal pain. With regard to his left knee disorder, the examiner was directed to address the Veteran’s contention that his left knee symptomatology began in 1984 after injuring it while playing sports, as well as the November 1989 service treatment record which noted that he sustained a blunt trauma to the left leg. Finally, with regard to the Veteran’s lumbar spine disorder, the examiner was directed to address the Veteran’s report of injuring while aboard the U.S.S. Kennedy, as well as the May 1991 service treatment record which noted his complaint of low back pain. In January 2020, the Veteran underwent VA examinations, and he was diagnosed with the following: bilateral knee strains; left knee meniscal tear; bilateral knee degenerative arthritis; lumbosacral strain; degenerative arthritis of the spine; intervertebral disc syndrome; and spinal stenosis. In a February 2020 opinion, the January 2020 examiner concluded that the Veteran’s bilateral knee disorders were less likely than not related to his military service. The examiner noted that a review of the Veteran’s claims file did not support that his current bilateral knee problems were related to his bilateral knee problems in service. The examiner then stated that there were no documented records indicated in-service bilateral knee problems other than the 1982 and 1984 records. The examiner concluded that a nexus had not been established. In another opinion, the examiner concluded that the Veteran’s current lumbar spine disorder was less likely than not related to his military service. The examiner reasoned that, although the Veteran’s lumbar spine problems onset during his active duty service, there was no evidence of chronic and continuous treatment following his discharge until 2012, twenty-one years after his discharge. In another opinion, the examiner concluded that the Veteran’s left knee disorder was less likely than not due to his right knee disorder, reasoning that there was no clear evidence to suggest that an injury to one joint would have any significant impact on another unless the injury resulted in a major muscle or nerve damage causing partial or complete paralysis. However, the examiner opined that the Veteran’s left knee disorder was aggravated by his right knee disorder, reasoning that, because of joint pain and dysfunction, some individuals adopted compensatory gait mechanisms that shifted the load distribution from the affected to the healthy contralateral limb during weight-bearing activities, and that the resultant change in load history is speculated to contribute to bilateral disease onset. In another opinion, the examiner concluded that the Veteran’s lumbar spine disorder was less likely than not proximately due to, or the result of, his bilateral knee problems because arthritis in one joint did not cause arthritis in another joint. In another opinion, the examiner concluded that the Veteran’s lumbar spine disorder was less likely than not proximately due to, the result of, or aggravated by, his bilateral knee problems because there was no clear evidence to suggest that an injury to one joint would have any significant impact on another unless the injury resulted in a major muscle or nerve damage causing partial or complete paralysis. The Board finds that the February 2020 opinions of record are insufficient to adjudicate the Veteran’s remaining claims on appeal for a number of reasons. With regard to direct service connection, the examiner’s opinions are insufficient as they fail to reflect consideration of the Veteran’s lay statements concerning injury and onset, and do not adequately explain why symptoms documented in service were not initial manifestations of the current disability. When VA undertakes to obtain an evaluation, it must ensure that the evaluation is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). Given that the medical evidence of record fails to adequately address the issues raised, the Board finds that a new examination is necessary. On remand, the Veteran should be given the opportunity to identify any outstanding pertinent records. The matters are REMANDED for the following action: 1. Give the Veteran an additional opportunity to identify any outstanding pertinent evidence that has not already been associated with the claims file, to include any VA and/or non-VA treatment records. The AOJ should then attempt to obtain those records if the Veteran provides the appropriate authorization where necessary. 2. Schedule the Veteran for a VA examination to determine whether his bilateral knee disorders and/or lumbar spine disorder are related to his military service. The examination must also address whether his left knee disorder is secondary to his right knee disorder, as well as whether his lumbar spine disorder is secondary to his bilateral knee disorders. The record and a copy of this Remand must be made available to the examiner. Any indicated evaluations, studies, and tests should be conducted. The examiner should take a history from the Veteran as to the progression of his claimed disabilities. Following a review of the entire record, to include the Veteran’s lay statements concerning onset and continuity of symptomatology, the examiner(s) should address the following questions: a) For each identified bilateral knee disorders and/or lumbar spine disorder, is it at least as likely as not (i.e., a 50 percent or greater probability) that such had its onset in, or is otherwise related to his period of active duty service? i) With regard to the Veteran’s right knee disorder, the examiner should specifically address his contention that his right knee symptomatology began after he was involved in a motor vehicle accident in March 1982, as well as the February 1984 service treatment record which noted his complaint of right popliteal pain. ii) With regard to the Veteran’s left knee disorder, the examiner should specifically address the Veteran’s contention that his left knee symptomatology began in 1984 after injuring it while playing sports, as well as the November 1989 service treatment record which noted that he sustained a blunt trauma to the left leg. iii) With regard to the Veteran’s lumbar spine disorder, the examiner should specifically address the Veteran’s report of injuring while aboard the U.S.S. Kennedy, as well as the May 1991 service treatment record which noted his complaint of low back pain. In offering any opinion, the examiner must consider the full record, to include the Veteran’s lay statements regarding in-service incurrence and continuity of symptomatology, and the opinion should reflect such consideration. b) Notwithstanding the answers provided to the question above, is it at least as likely as not (i.e., a 50 percent or greater probability) that the Veteran’s left knee disorder was caused or aggravated beyond natural progression by his right knee disorder? In this regard, the Board emphasizes that causation and aggravation are two separate inquiries, and both must be answered. c) Notwithstanding the answers provided to the question above, is it at least as likely as not (i.e., a 50 percent or greater probability) that the Veteran’s lumbar spine disorder was caused or aggravated beyond natural progression by his bilateral knee disorders? In this regard, the Board emphasizes that causation and aggravation are two separate inquiries, and both must be answered. With regard to the Veteran’s lumbar spine disorder, the examiner should consider the February 2011 private treatment record which noted that the Veteran’s lumbar spine disorder may be secondary to his poor gait associated with his bilateral knee problems. A complete rationale must be provided for all opinions, and must be based on consideration of all pertinent lay and medical evidence. 3. Thereafter, and after any further development deemed necessary, the remaining issues on appeal should be readjudicated. V. Chiappetta Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board James R. Springer, 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.