Citation Nr: 21062413 Decision Date: 10/07/21 Archive Date: 10/07/21 DOCKET NO. 12-32 107 DATE: October 7, 2021 REMANDED Entitlement to an increased rating for the residuals of a stress fracture of the distal left femur, currently evaluated as 10 percent disabling, is remanded. REASONS FOR REMAND The Veteran served on active duty from June 1984 to June 1985. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a June 2010 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO), which is the Agency of Original Jurisdiction (AOJ). In June 2016, September 2017, and October 2020, the Board remanded the case for further development. The case has since been returned to the Board for appellate review. Upon review, the Board finds that additional development is needed in this case. In a March 2021 VA examination report, the VA examiner noted that the Veteran had been diagnosed with a left knee meniscal tear, osteoarthritis, instability, residuals of a stress fracture of the proximal left upper femur and left knee, and osteochondritis dissecans. The examiner reported that there was no objective evidence of a left distal femur stress fracture on examination and that the Veteran had no symptoms and no impact on his range of motion of his left knee due to the residuals of the stress fracture. The examiner explained that the Veteran's osteochondritis dissecans was not caused by a stress fracture and that it was not considered a progression of the stress fracture. She noted that the presence of osteochondritis dissecans was a known risk factor for osteoarthritis and that the Veteran's osteoarthritis was believed to be a progression of his osteochondritis dissecans. She also opined that the Veteran's left knee meniscal tear was most likely due to his osteochondritis dissecans as a development of anatomical changes in the knee. She further noted that osteoarthritis of the knee was a risk factor for the development of a meniscal tear. In addition, the examiner indicated that the Veteran had mild instability of the left knee; however, she did not provide an opinion as to whether the instability was caused or aggravated by the Veteran's service-connected residuals of a left femur stress fracture or his nonservice-connected diagnoses. Thus, a remand is necessary to obtain a clarifying opinion to determine the nature and etiology of the Veteran's left knee instability. The matters are REMANDED for the following action: 1. The AOJ should request that the Veteran provide the names and addresses of any and all health care providers who have provided treatment for the Veteran's left knee disability. After acquiring this information and obtaining any necessary authorization, the AOJ should obtain and associate these records with the claims file. The AOJ should also obtain any outstanding VA medical records. 2. After completing the foregoing development, the AOJ should refer the Veteran's claims file to a VA examiner for a clarifying opinion to determine the nature and etiology of the Veteran's left knee instability. A physical examination is only needed if one is deemed necessary by the examiner. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran's service treatment and personnel records, post-service medical records, and statements, as well as the March 2021 VA examination report. It should be noted that the Veteran is competent to attest to factual matters of which he has first-hand knowledge, including observable symptomatology. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. The examiner should provide an opinion as to whether it is at least as likely as not that the Veteran's left knee instability is a manifestation of or attributable to his service-connected residuals of a stress fracture of the distal left femur or was either caused by or aggravated by his service-connected disability. (The term "at least as likely as not" does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of conclusion as it is to find against it.) A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. 3. The AOJ should review the examination report to ensure that it is in compliance with this remand. If the report is deficient in any manner, the AOJ should implement corrective procedures. 4. The AOJ should conduct any other development that may be indicated. J.W. ZISSIMOS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board K. Osegueda, 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.