Citation Nr: 21066338 Decision Date: 10/29/21 Archive Date: 10/29/21 DOCKET NO. 17-13 686 DATE: October 29, 2021 REMANDED Entitlement to service connection for right knee disorder is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from April 1978 to April 1981. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a November 2014 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO). In January 2021, the Veteran testified before the undersigned Veterans Law Judge. A hearing transcript has been associated with the record. 1. Entitlement to service connection for right knee disorder is remanded. In March 2021, the Board remanded this matter to the RO for further development to include obtaining updated VA treatment records and an etiology opinion. A VA etiology opinion was obtained in July 2021. A July 2021 VA examiner opined that the Veteran's claimed right knee disorder is less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness as there is no evidence of an acute or chronic right knee condition while in service or a notation regarding the Veteran's reported twisting injury while running. The examiner noted that the Veteran reports being diagnosed with degenerative joint disease, but there is no imaging documentation to confirm this and it is feasible that the Veteran has bilateral degenerative joint disease of the knees given his age. The examiner noted that the 2011 VA examination report addressed only the left knee, so it is apparent the Veteran did not have a right knee condition as late as 2011 that records dated January 2018 note a one-month history of right knee pain and that records dated May 2018 note one-week history of right knee pain. The examiner noted that it is clear the Veteran had onset of knee pain in late 2017 or early 2018. The examiner further explained that degenerative joint disease is considered a natural aging process and was age-appropriate at the time of diagnosis, if conceded, and that the type of injury described by the Veteran as occurring in service would not predispose the Veteran to age-appropriate degenerative joint disease, 25 years later. Thus, even if the diagnosis of degenerative joint disease is conceded, it is less likely than not due to service or events in service, including the claimed twisted injury, if conceded. The examiner opined that any injury significant enough to predispose the Veteran to degenerative arthritis other than naturally would have been evident at that time or proximate to it, and certainly before 2018. However, a March 2003 VA treatment note reflects the Veteran's reports of recent right knee locking and pain while a June 2004 VA treatment note reflects the Veteran's reports of recurrent knee pain with crepitus and an impression of systemic lupus erythematous (SLE) with predominately joint symptoms. A January 2007 VA treatment note indicates that the Veteran had SLE with joint involvement that including worsening chronic joint pain. Thus, the July 2021 VA opinion appears to be based on an inaccurate factual premise. See Reonal v. Brown, 5 Vet. App. 460, 461 (1993) (an opinion based on an inaccurate factual premise has no probative value). On remand, an addendum opinion should be obtained. See Stegall v. West, 11 Vet. App. 268 (1998). The matter is REMANDED for the following action: 1. The Veteran should be given the opportunity to identify any outstanding private or VA treatment records relevant to the claim on appeal. After obtaining any necessary authorization from the Veteran, all outstanding records should be obtained, to include updated VA treatment records. For private treatment records, make at least two (2) attempts to obtain records from any identified sources. If any such records are unavailable, inform the Veteran and his representative and afford him an opportunity to submit any copies in their possession. For federal records, all reasonable attempts should be made to obtain such records. If any records cannot be obtained after reasonable efforts have been made, issue a formal determination that such records do not exist or that further efforts to obtain such records would be futile, which should be documented in the claims file. The Veteran must be notified of the attempts made and why further attempts would be futile, and allowed the opportunity to provide such records, as provided in 38 U.S.C. § 5103A(b)(2) and 38 C.F.R. § 3.159(e). 2. Following the receipt of outstanding records, obtain an etiology opinion by an appropriate clinician to determine the nature and etiology of the Veteran's claimed right knee disorder. The examiner should review the entire claims file and note such review in the opinion. The need for further in-person examination is left to the discretion of the examiner. The examiner should respond to the following question: Is it at least as likely as not (50 probability or greater) that the Veteran's current right knee disorder had its onset during service or is otherwise related to service? The examiner should specifically address the Veteran's contention that his right knee disorder is the result of his in-service physical training and/or a result of a twisting injury while running on a road. The examiner should specifically address the Veteran's post-service treatment records, to include the reports of recent right knee locking and pain in a March 2003 VA treatment note, the Veteran's reports of recurrent knee pain with crepitus and an impression of systemic lupus erythematous with predominately joint symptoms in a June 2004 VA treatment note and a January 2007 VA treatment note indicates that the Veteran had systemic lupus erythematous with joint involvement that including worsening chronic joint pain. Ensure that any medical opinion obtained includes a complete rationale for the conclusions reached. Any medical opinion must support the conclusions reached with an analysis that is adequate for the Board to consider and weigh against other evidence of record; any medical opinion must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. If an opinion cannot be expressed without resort to speculation, ensure that the clinician so indicates and discusses why an opinion is not possible, to include whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. See Jones v. Shinseki, 23 Vet. App. 382 (2010). The examiner is reminded that the term "as likely as not" does not mean "within the realm of medical possibility," but rather that the evidence of record is so evenly divided that, in the examiner's expert opinion, it is as medically sound to find in favor of the proposition as against it. KRISTY L. ZADORA Veterans Law Judge Board of Veterans' Appeals Attorney for the Board B. Adeyemi, 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.