Citation Nr: 21003645 Decision Date: 01/22/21 Archive Date: 01/22/21 DOCKET NO. 16-05 948 DATE: January 22, 2021 REMANDED Entitlement to service connection for a left knee disorder, to include as secondary to service-connected right knee and ankle disabilities, is remanded. Entitlement to service connection for a low back disorder, to include as secondary to service-connected right knee and ankle disabilities, is remanded. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is remanded. REASONS FOR REMAND The Veteran served on active duty from August 1979 to December 1988. This matter comes to the Board of Veterans’ Appeals (Board) on appeal from a rating decision issued in April 2015 by a Department of Veterans Affairs (VA) Regional Office. In February 2019, the Veteran testified at a Board hearing before the undersigned Veterans Law Judge. A transcript of the hearing is of record. In September 2019, the Board remanded the issues on appeal, as well as the appeal as to whether new and material evidence had been received in order to reopen a claim of entitlement to service connection for a gastrointestinal disorder. In July 2020, a rating decision awarded service connection for gastroesophageal reflux disease. As such constitutes a full grant of such claim, it is no longer before the Board. See Grantham v. Brown, 114 F.3d 1156, 1158-59 (Fed. Cir. 1997); AB v. Brown, 6 Vet. App. 35, 38 (1993). The remaining issues now return for further appellate review. In regard to the characterization of the claims on appeal, the Board notes that rating decisions issued in February 2010 and June 2011 most recently denied the Veteran’s applications to reopen his claims for service connection for left knee and low back disorders, respectively. While on remand, relevant service department records that existed but had not been associated with the claims file at the time of such denials were associated with the record in December 2019. Consequently, the Board will reconsider the claims on a de novo basis and has characterized such accordingly. 38 C.F.R. § 3.156(c). 1. Entitlement to service connection for a left knee disorder, to include as secondary to service-connected right knee and ankle disabilities. As noted above, relevant service department records were associated with the claims file in December 2019. As pertinent to the instant claim, service treatment records dated in July 1985, July 1988, and September 1988 reflect reports of left knee pain, and a finding of possible ligament strain of the left knee was noted in July 1985. Additionally, records from the Social Security Administration (SSA), which also were associated with the claims file in December 2019, indicate the Veteran had surgery for left knee meniscus damage in 1989. Further, a December 2001 letter from a private physician, M.M., which was included with the SSA records, shows the Veteran reported a skiing injury to both knees while in the military. Pursuant to the September 2019 Remand, the Veteran was afforded a VA examination in order to determine the nature and etiology of his left knee disorder in February 2020. At such time, a VA examiner identified left knee diagnoses of ACL tear and reconstruction and mild knee arthritis, and stated that, according to the record, the former was reported as due to an injury in 1996, whereas the latter was identified via X-ray examination in 2016. In this regard, he noted the Veteran reported a post-service injury had caused the left knee ACL tear and subsequent surgery, and found the Veteran’s left knee was normal prior to the ACL tear in 1996. The VA examiner further indicated that degenerative joint disease was common and expected after trauma, such as ACL tears. According to him, there was no indication that other joints were the cause of the left knee injury. He also added that the Veteran had a normal ankle joint according to X-ray examination. However, in offering such opinion, the VA examiner did not address the relevant findings in the service treatment records or the indication that the Veteran had surgery for left knee meniscus damage in 1989. Additionally, he did not address whether the Veteran’s left knee disorder was aggravated by his right knee and ankle disabilities, or provide a rationale for his opinion regarding secondary service connection. As a result, the Board finds a remand is warranted in order to obtain an addendum opinion addressing such matters. 2. Entitlement to service connection for a low back disorder, to include as secondary to service-connected right knee and ankle disabilities. As previously noted, relevant service department records were associated with the claims file in December 2019. As pertinent to the instant claim, a July 1988 service treatment record reflects the Veteran’s report of low back pain following a football game four days prior. The assessment was “multiple minor soft tissue trauma”. In addition, the December 2001 letter authored by M.M. shows the Veteran reported injuring his back when he fell down a hill while in the military in October 1988. Pursuant to the September 2019 Remand, the Veteran was afforded a VA examination in order to determine the nature and etiology of his low back disorder in February 2020. At such time, the VA examiner identified diagnoses of spina bifida occulta, shown on a 1993 X-ray, and lumbar spine degenerative disc and stenosis, L4-L5, L5-S1, with central and neuroforaminal stenosis, as demonstrated on a CT scan in 1994. He further found there was no evidence of any low back condition during active duty as seen in the service treatment records; rather, back symptoms were first reported around 1993 at the VA. The VA examiner further stated there was no evidence to support a finding that any falls or military-required duties had any direct impact on the lumbar spine, and there was no documented back pain related to active duty status. Additionally, a 2000 magnetic resonance imaging (MRI) was the first time degenerative arthritis was mentioned. Moreover, the VA examiner opined mild degenerative joint disease of the bilateral knees and intact left knee ligaments are less likely than not the cause of arthritic changes, which were not evident until 2000. Rather, he found the Veteran’s body habitus and spina bifida occulta diagnoses was more likely than not the cause of his back pain that developed over the years. Upon review, the Board notes the VA examiner’s finding regarding in-service evidence is directly contradicted by the July 1988 service treatment record. In addition, he did not provide an adequate rationale for his unfavorable opinion regarding the relationship between the Veteran’s low back disorder and his right knee disability, address a possible nexus to the Veteran’s right ankle disability, or consider whether his low back disorder is aggravated by his right knee and ankle disabilities. As a result, the Board finds a remand is warranted in order to obtain an addendum opinion addressing such matters. 3. Entitlement to a TDIU. As the Veteran’s claim for a TDIU is inextricably intertwined with the claims remanded herein, adjudication of former matter must be deferred pending the development and readjudication of the latter claims. Tyrues v. Shinseki, 23 Vet. App. 166, 177 (2009) (en banc); Harris v. Derwinski, 1 Vet. App. 180, 183 (1991). The matters are REMANDED for the following action: Forward the record, to include a copy of this Remand, to the VA examiner who conducted the February 2020 VA examinations in order to obtain addendum opinions as to the etiology of the Veteran’s current left knee and low back disorders. After review of the record, the examiner should address the following inquiries: (A) For each currently diagnosed left knee disorder, identified as ACL tear and reconstruction and mild knee arthritis, and low back disorder, identified as spina bifida occulta, shown on a 1993 X-ray, and lumbar spine degenerative disc and stenosis, L4-L5, L5-S1, with central and neuroforaminal stenosis, the examiner should offer an opinion as to whether it is at least as likely as not (i.e., a 50 percent or greater probability) that such is related to the Veteran’s military service, to include the documented in-service falls and his reported injuries repelling out of helicopters and carrying heavy radios. In this regard, the examiner must address the July 1985, July 1988, and September 1988 service treatment records that reflect reports of left knee pain and the July 1988 service treatment record showing a report of low back pain subsequent to a football game. (B) If arthritis of the left knee and/or low back is diagnosed, the examiner should offer an opinion as to whether such manifested within one year of his separation from active duty in December 1988 (i.e., by December 1989). In this respect, the clinician should address the evidence in the record indicating the Veteran had surgery for left knee meniscus damage in 1989. (C) For each currently diagnosed left knee disorder and low back disorder, as identified previously, the examiner should provide an opinion as to whether it is at least as likely as not (i.e., a 50 percent or greater probability) that such disorder is proximately due to and/or aggravated by his service-connected right knee and/or right ankle disability, to include as a result of an altered gait and/or falls caused by such disabilities. For any aggravation found, the clinician should state, to the best of his or her ability, the baseline of symptomatology and the amount, quantified if possible, of aggravation beyond the baseline symptomatology. In offering any opinion, the examiner should consider the Veteran’s statements regarding the onset and continuity of symptomatology of his claimed disorders. A rationale should be provided for any opinion offered. A. JAEGER Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. M. Celli, 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.