Citation Nr: 21064549 Decision Date: 10/20/21 Archive Date: 10/20/21 DOCKET NO. 17-22 221 DATE: October 20, 2021 REMANDED 1. Entitlement to service connection for bilateral shin splints is remanded. 2. Entitlement to service connection for a bilateral ankle disability is remanded. 3. Entitlement to service connection for a bilateral knee disability is remanded. REASONS FOR REMAND The appellant is a Veteran who served on active duty from December 1993 to March 2001, January 2003 to January 2005, November 2007 to June 2008, August 2009 to July 2010, and had additional service in the Army National Guard. These matters are before the Board of Veterans' Appeals (Board) on appeal of a June 2016 Department of Veterans Affairs (VA) rating decision. In October 2019, a videoconference hearing was held before the undersigned; a transcript is in the record. In February 2021, these matters were remanded for additional development. 1. 2. 3. Entitlement to service connection for bilateral shin splints, a bilateral ankle disability, and a bilateral knee disability. The February 2021 Board remand sought a VA medical advisory opinion regarding the etiology of the Veteran's current bilateral ankle, knee, and shin disabilities. The examiner was to note his reported parachuting activities with multiple hard landings, and multiple complaints and injuries noted in his service treatment records (STRs). If a diagnosed ankle, knee, or shin disability was found to not be directly related to service, the examiner was to opine whether it was secondary to his service-connected bilateral hip disability (any altered gait from the hip disabilities). The examiner was to specifically address whether ankle, knee, or shin disabilities were aggravated by the service-connected disabilities. In April 2021 (before additional STRs were associated with the record) and May 2021 (after additional STRs were associated with the record) opinions, a consulting provider opined the Veteran's diagnosed ankle and knee disabilities were less likely related to service and more likely related to obesity. The provider opined (without including rationale) that hip osteoarthritis is not associated with development of right knee arthritis, left knee strain, or the ankle pathologies and did not address aggravation. The provider disagreed with the June 2017 statement (that the Veteran's paratrooper duties contributed to his ankle and knee symptoms) noting there were no symptoms on clinical examination at separation in 2010 and ankle x-rays in 2016 were normal; the examiner did not clearly address the complaints of ankle pain at separation or include rationale related to the bilateral knee disabilities. Additionally, in the opinion against the claim of service connection for shin splints, the April/May 2021 consulting provider opined, stated any additional examination, that "there was no evidence of shin splints on the knee compensation and pension examination, including the one conducted on June 3, 2016." Notably, shin splints were diagnosed on physical examination on the June 2016 VA examination. The April/May 2021 consulting provider's opinion appears based on an inaccurate factual premise (and is therefore inadequate for rating purposes). Although obesity (of itself) is not a compensable disability, it may act as an "intermediate step" between an already service-connected disability and the disability for which secondary service-connection is sought under 38 C.F.R. § 3.310 (a). See VAOPGCPREC 1-2017; see also Marcelino v. Shulkin, No. 16-2149 (Vet. App. Jan. 23, 2018). A January 2019 VA treatment record notes the Veteran has diffuse arthralgia, to include hip pain due to arthritis and knee pain due to arthritis, and that he reported he has struggling to lose weight. Development for a fully adequate medical opinion in this matter is necessary. The matters are REMANDED for the following: Return the record to the April/May 2021 consulting provider for an addendum opinion regarding the etiology of his current bilateral ankle, knee, and shin disabilities. [If that provider is unavailable or unable to give an opinion sought, forward the record to another appropriate clinician for review and the opinion sought (and if further examination of the Veteran is deemed necessary for an opinion sought, such should be arranged).] The entire record (to include the complaints noted in service and any evidence of postservice continuity of complaints/symptoms) must be reviewed by the consulting provider. The consulting provider should: (a.) Identify (by diagnosis) each ankle, knee, and shin disability entity found/or shown by the record during the pendency of the claim. If a shin splint disability is not found, reconcile that conclusion with the diagnosis of shin splints by the June 2016 (during the pendency of the appeal) VA examiner on physical examination of the Veteran. (b.) Identify the likely etiology for each ankle, knee, and shin disability entity diagnosed. Specifically, is it at least as likely as not (a 50% or greater probability) that the disability is etiologically related to the Veteran's service (to include as due to his reported parachuting activities with multiple hard landings, and multiple complaints and injuries noted therein)? (c.) If a diagnosed ankle, knee, or shin disability is found to not be directly related to service, opine further whether it is at least as likely as not that the disability was caused or aggravated by (increased in severity due to) his service-connected bilateral hip disability (to include as due to an altered gait from his bilateral hip disabilities). [The opinion must address aggravation.] (d.) Is the Veteran's obesity at least as likely as not due to his service-connected disabilities (to include depressive disorder, sleep apnea, bilateral hip, and right shoulder disabilities? (e.) If so, was the obesity due to the service-connected disabilities at least as likely as not a substantial factor in causing his ankle, knee, and/or shin disability? Would the ankle, knee, and/or shin disability not have occurred but for the obesity due to service-connected disabilities? (f.) If a service-connected disability did not cause, but aggravated, an ankle, knee, or shin disability, specify, to the extent possible, the degree of disability (symptoms/impairment) that resulted from such aggravation. (g.) If a diagnosed ankle, knee, or shin disability is found to be unrelated to service and to not have been caused or aggravated by a service-connected disability, identify the etiology that is considered to be more likely (and explain why that is so). All opinions must include complete rationale. If an opinion sought cannot be provided without resort to mere speculation, there must be a complete explanation why this is so. Indicate whether the inability to provide a more definitive opinion (without mere speculation) is the result of a need for additional information (if so, identify what further information is needed) or due to limitations in the current state of medical knowledge. GEORGE R. SENYK Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A. Naumovich, 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.