Citation Nr: 21002042 Decision Date: 01/12/21 Archive Date: 01/12/21 DOCKET NO. 16-07 809 DATE: January 12, 2021 REMANDED The issue of service connection for a left shoulder disorder is remanded. The issue of service connection for a left knee disorder is remanded. The issue of service connection for a right knee disorder is remanded. The issue of service connection for low back disorder is remanded. The issue of service connection for sciatica, as secondary to a low back disorder, is remanded. REASONS FOR REMAND The Veteran served on active duty from December 1977 to December 1980. These matters come before the Board of Veterans’ Appeals (Board) on appeal from a May 2015 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). This case was previously before the Board in December 2019, on which occasion the issues on appeal, to include service connection for substance abuse, were remanded for further development. As will be discussed below, a review of the record reflects that the Agency of Original Jurisdiction (AOJ) failed to substantially comply with the August 2019 Board’s Remand directives. See Stegall v. West, 11 Vet. App. 268, 271 (1998). During the course of the appeal, an August 2020 rating decision granted service connection for substance abuse. The grant of service connection for substance abuse constitutes a full grant of the benefit sought on appeal. Accordingly, the issue of service connection for substance abuse is no longer on appeal. See AB v. Brown, 6 Vet. App. 35 (1993). In August 2019, the Veteran testified at a Board videoconference hearing. A transcript of the hearing has been associated with the virtual file. 1. The issue of service connection for a left shoulder disorder is remanded. The Veteran contends his left shoulder disorder is due to his military occupation specialty (MOS) as a heavy vehicle operator and gun operator. Specifically, the Veteran stated left shoulder pain began during active service from loading and unloading ammunition, cannons, and other heavy items onto his truck and carrying those items from his truck to guns. The Veteran further stated that pain in his left shoulder has been continuous since discharge from service. See August 2019, Hearing transcript; February 2016, VA Form 9. In January 2020, a VA examination for shoulders was conducted. The VA examiner found the Veteran’s left shoulder had less movement than normal due to ankylosis, adhesions, etc., but later indicated there was no ankylosis in the left shoulder. Additionally, the examiner, in contravention to the December 2019 Board Remand directives, failed to specifically address the Veteran’s statement that left shoulder pain has been continuous since discharge from service. The Board, accordingly, finds a new VA examination for the left shoulder is necessary. See January 2020, VA examination; see also Dalton v. Nicholson, 21 Vet. App. 23, 39-40 (2007) (a medical opinion is inadequate if it does not take into account the Veteran’s reports of symptoms and history); Reonal v. Brown, 5 Vet. App. 458, 460-61 (1993) (medical opinions based on an incomplete or inaccurate factual premise are not probative). The Board notes that the claims file only has VA treatment records through August 2017; however, the Veteran indicated he had surgery on his left shoulder in 2019. See August 2019, Hearing transcript. On remand, any previously unobtained ongoing relevant medical records should be procured and associated with the Veteran’s claims file. 2. The issue of service connection for a left knee disorder is remanded. 3. The issue of service connection for a right knee disorder is remanded. The Veteran contends his bilateral knee disorders are due to his MOS as a heavy vehicle operator and gun operator. Specifically, the Veteran stated bilateral knee pain began during active service from loading and unloading ammunition, cannons, and other heavy items onto his truck and carrying those items from his truck to guns. The Veteran also indicated forced marches in full combat gear and standing at attention for 15 to 20 minutes further injured his knees. The Veteran asserts that pain in his bilateral knees has been continuous since discharge from service. See August 2019, Hearing transcript; February 2016, VA Form 9. In February 2020, a VA examination for knees was conducted. The VA examiner found the Veteran’s knees had less movement than normal due to ankylosis, adhesions, etc., but later indicated there was no ankylosis in either knee. Additionally, the examiner, in contravention to the December 2019 Board Remand directives, failed to specifically address the Veteran’s statement that bilateral knee pain has been continuous since discharge from service. The Board, accordingly, finds a new VA examination for the knees is necessary. See February 2020, VA examination; see also Dalton, 21 Vet. App. at 39-40; Reonal, 5 Vet. App. at 460-61. 4. The issue of service connection for low back disorder is remanded. The Veteran contends his low back disorder is due to his MOS as a heavy vehicle operator and gun operator. Specifically, the Veteran stated low back pain began during active service from loading and unloading ammunition, cannons, and other heavy items onto his truck and carrying those items from the truck to guns. The Veteran recalled several times when he would attempt to pick up a heavy item and felt sharp pains in his back and shooting pain and tingling from his back down his left lower extremity. The Veteran further stated that low back pain has been continuous since discharge from service. See August 2019, Hearing transcript; February 2016, VA Form 9. In February 2020, a VA examination for the back was conducted. The VA examiner found the Veteran did not have flare-ups or functional loss but later noted the Veteran could not stand for long periods or bend over as a result of his back disorder. Additionally, the examiner, in contravention to the December 2019 Board Remand directives, did not specifically address the Veteran’s statement that low back pain has been continuous since discharge from service. The Board, accordingly, finds a new VA examination for the back is necessary. See February 2020, VA examination; see also Dalton, 21 Vet. App. at 39-40; Reonal, 5 Vet. App. at 460-61. 5. The issue of service connection for sciatica on the left side is remanded. The Veteran claims that his sciatic is secondary to his claimed low back disability. The claims of service connection for a low back disability and sciatic are intertwined, as the disposition of the claim of service connection for a low back disorder may directly impact the outcome of the claim of service connection for sciatica. The matters are REMANDED for the following action: 1. Obtain all outstanding records of VA evaluation and/or treatment records of the Veteran dated since August 2017 and associate them with the claims file. 2. After completing directive #1, obtain VA examinations to determine the nature and etiology of bilateral knee, left shoulder, and back disorders. The examiner should review the virtual file and address the following: (a.) Whether it is at least as likely as not (50 percent or greater probability) that a current left shoulder disorder manifested during or is otherwise related to the Veteran’s period of active service, to include loading, unloading, and carrying heavy objects during service and ongoing left shoulder pain since discharge from service. See August 2019, Hearing transcript; February 2016, VA Form 9. (b.) Whether it is at least as likely as not (50 percent or greater probability) that current bilateral knee disorders manifested during or is otherwise related to the Veteran’s period of active service, to include loading, unloading, and carrying heavy objects during service, participating in forced marches with full gear, standing at attention for 15 to 20 minutes, and ongoing bilateral knee pain since discharge from service. See August 2019, Hearing transcript; February 2016, VA Form 9. (c.) Whether it is at least as likely as not (50 percent or greater probability) that a current low back manifested during or is otherwise related to the Veteran’s period of active service, to include loading, unloading, and carrying heavy objects during service and ongoing low back and shooting pain down the left lower extremity since discharge from service. See August 2019, Hearing transcript; February 2016, VA Form 9. The examiner is advised that the Veteran is competent to report his symptoms and history, and such reports must be specifically acknowledged and considered in formulating any opinions. If the examiner rejects the Veteran’s reports of symptomatology, he or she must provide a reason for doing so. A comprehensive rationale for all opinions must be provided. All pertinent evidence, including both lay and medical, should be considered. If an opinion cannot be provided without resorting to speculation, the examiner must explain why this is so and state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), the record (additional facts are required), or the examiner (does not have the knowledge or training). JAMES L. MARCH Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board S. Straughn, 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.