Citation Nr: 21066547 Decision Date: 11/01/21 Archive Date: 11/01/21 DOCKET NO. 16-05 357 DATE: November 1, 2021 REMANDED Entitlement to an increased rating for a right knee disability, currently rated as noncompensable, is remanded. Entitlement to service connection for a left knee disability, including as secondary to a service-connected right knee disability, is remanded. Entitlement to a total disability rating due to individual unemployability (TDIU) is remanded. REASONS FOR REMAND The Veteran served on active duty from July 1977 to August 1981. This matter comes before the Board of Veterans' Appeals (Board) on appeal from January 2013 and April 2016 rating decisions of a Regional Office (RO) of the Department of Veterans Affairs (VA). In June 2019, the Veteran testified at a hearing held before the undersigned. Unfortunately, a written transcript of this hearing is unavailable. In July 2020, the Veteran was notified of the unavailability of the transcript. She was offered the opportunity to schedule an additional hearing by requesting one within 30 days of the notification. The Veteran has not requested an additional hearing. In February 2021, the Board remanded the claims addressed below for additional development. Although, an August 2021 rating decision indicated entitlement to a TDIU was moot, the Board finds the issue continues in appellate status under the holding in Rice v. Shinseki, 22 Vet. App. 447 (2009). An April 2021 rating decision allowed service connection for fibromyalgia. This issue is no longer in appellate status. VA's duty to assist requires reasonable efforts to assist the Veteran in obtaining these records. See 38 U.S.C. § 5103A; 38 C.F.R. § 3.159(c); see also Sullivan v. McDonald, 815 F.3d 786 (Fed. Cir. 2016). VA has a duty to ensure any medical examination or opinion it provides is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (overruled on other grounds, Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013)). A medical opinion is adequate where it is based upon consideration of the full medical history and describes a disability in sufficient detail so that the Board's evaluation will be fully informed. Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007). Where a decision on one issue would have a "significant impact" upon another, and that impact in turn could render any appellate review on the other claim meaningless and a waste of judicial resources, the two claims are inextricably intertwined. Harris v. Derwinski, 1 Vet. App. 180, 183 (1991). 1. Entitlement to an increased rating for a right knee disability, currently rated as noncompensable, is remanded. The Veteran seeks a compensable rating for a right knee disability. VA treatment records show she underwent a right knee total replacement surgery in November 2020 at a non-VA medical facility. Records of this treatment and related follow up care are not included in the claims file. The claim must be remanded to assist the Veteran in obtaining records of this surgery. See 38 U.S.C. § 5103A; 38 C.F.R. § 3.159(c); see also Sullivan v. McDonald, 815 F.3d 786 (Fed. Cir. 2016). Service connection for the "residuals right knee injury" was allowed in a December 1982 rating decision. This rating decision refers to in-service October 1977 reports of right knee pain, a diagnosis of a probable medial collateral ligament tear, and joint and bone studies showing normal results with no evidence of fracture or dislocation. The rating decision also refers to in-service June 1981 kneecap tenderness, with a diagnosis of possible chondromalacia, and the July 1981 separation examination, with the Veteran's reports of knee joint swelling, and locking or a "trick" knee. Other evidence of record includes the Veteran's September 2012 report to a VA examiner that "over the years she gets buckling and locking, pain almost daily." During a July 2015 VA orthopedic surgery consult, the Veteran described chronic right knee pain over many years. VA treatment records show the Veteran underwent an October 2017 right knee arthroscopy and medial meniscectomy. A March 2018 VA orthopedic consult note also includes the Veteran's report of a long history of chronic bilateral knee pain, right more than left. In August 2012, the Veteran filed a claim seeking an increased rating for her right knee disability. A September 2012 VA knee conditions examination was provided to evaluate her claim. The examiner diagnosed right knee patellofemoral syndrome and degenerative joint disease. He discussed the Veteran's report that she had shin splints and right knee pain during her active service and her recollection that she was told her kneecap was not tracking correctly. He stated, "this sounds like patellofemoral syndrome." He asserted the Veteran had patellofemoral syndrome during her active service and service connection was established for this condition and no other right knee injury or illness. He opined the current degenerative joint disease was not due to patellofemoral syndrome. He attributed the degenerative joint disease to the Veteran's obesity, age, and daily wear and tear. Here, it is not clear that the examiner's determination that service connection was established for only patellofemoral syndrome was based on a complete review of the medical evidence. In making this determination, it appears the examiner relied only on the Veteran's report of her in-service symptoms. There is no indication he reviewed the complete medical record, particularly the service treatment records and the December 1982 rating decision. His opinion is not based on a complete and accurate review of the Veteran's medical history. The examination is inadequate. See Stefl, supra. In February 2021, an additional knee conditions examination was provider. The examination was performed by the same examiner who conducted the September 2012 examination. In February 2021, he diagnosed bilateral knee arthritis, bilateral shin splints, and right knee patellofemoral pain syndrome. He noted the Veteran underwent a total knee replacement surgery in November 2020. This examiner repeated his September 2012 opinion that service connection was limited to patellofemoral syndrome and patellofemoral syndrome did not lead to arthritis (degenerative joint disease.) He reiterated this opinion in a May 2021 addendum.. In July 2021, another VA clinician provided an addendum opinion after review of the available records. This clinician opined that the Veteran did not experience any current symptoms due to patellofemoral pain syndrome, patellofemoral pain syndrome did not lead to arthritis, and the November 2020 right knee replacement was due to right knee arthritis. Unfortunately, this opinion relied on the September 2012 examiner's determination that the Veteran's service-connected right knee condition was limited to patellofemoral syndrome. As noted above, this determination was not based on a complete review of the Veteran's medical history. Thus, the July 2021 opinion is also inadequate. Id. Accordingly, the evidence of record is insufficient to evaluate the severity of the Veteran's service-connected "residuals right knee injury." A new VA examination must be provided. 2. Entitlement to service connection for a left knee disability, including as secondary to a service-connected right knee disability, is remanded. The Veteran seeks service connection for a left knee injury. During an April 2016 VA examination, she reported this injury was incurred in July 2015 when her right knee gave way and she fell after being struck by a wave in the ocean. In February 2021, the Board remanded the claim so that an addendum opinion could be obtained to evaluated whether the left knee condition was secondary to the service-connected right knee disability, including right knee symptoms which resulted in the July 2015 fall in the ocean. An additional VA etiology opinion was obtained in February 2021.. The examiner noted the left knee injury was due to trauma. He did not evaluate whether a service-connected right knee condition contributed to the fall which resulted in trauma to the left knee. The opinion is inadequate to evaluate the claim. See Stefl, supra. 3. Entitlement to a total disability rating due to individual unemployability (TDIU) is remanded. The issue of entitlement to a TDIU remains intertwined with the claims discussed above. Id. The matters are REMANDED for the following action: 1. Obtain any outstanding VA treatment records. 2. Ask the Veteran to complete a VA Form 21-4142 for any private medical treatment providers or facilities who may have records related to her right or left knee disabilities which are not yet included in the claims file. In particular, the Veteran should be asked to provide a VA Form 21-4142 for any medical provider or treatment facility which may have records of a November 2020 right total knee replacement surgery and associated treatment. Make two requests for the authorized records from any provider or facility identified unless it is clear after the first request that a second request would be futile. 3. Schedule the Veteran for an examination by an appropriate clinician, who has not previously provided an examination in this claim, to determine the current severity of her service-connected right knee disability (residuals right knee injury.) The examiner should consider all symptoms over the appeal period which are associated with the service connected "residuals right knee injury" disability. The examiner should describe the service-connected right knee disability based on review of the entire claims file including the service treatment records and the December 1982 rating decision. If the examiner finds that any right knee symptoms or diagnoses (including arthritis, a meniscal condition, or total knee replacement) over the appeal period are not associated with the service-connected condition, he or she must fully and clearly explain why this is so. The examiner is advised that the Veteran is competent to report her experience of right knee pain, locking, buckling, or other observable symptoms. If the examiner dismisses any such reports, a complete explanation for doing so must be provided. The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran's disability under the rating criteria. 4. After an examination is completed to determine the scope of the disability associated with the Veteran's service-connected right knee, schedule a VA examination to evaluate the etiology of her left knee disability. The examiner must review the claims file. If a diagnosis cannot be provided but the Veteran's condition manifests in symptoms that cause functional impairment, then the examiner should consider them a "disability" for the purpose of providing the requested opinion(s) below. The examiner is asked to provide a response to the following: Is a left knee disability at least as likely as not proximately due to the service-connected right knee disability? Is the left knee disability at least as likely as not aggravated, i.e., worsened beyond its natural progression, by the service-connected right knee disability? The examiner should fully discuss the Veteran's report that she fell and injured her left knee after her right knee gave way when she was struck by a wave in the ocean in July 2015. The Veteran is competent to report her symptoms and experiences. If the examiner rejects any such report, a full explanation for doing so must be provided. The opinion must address both causation and aggravation to be deemed adequate. The examiner must be advised aggravation means an increase in the severity of the underlying disability beyond its natural progression. If aggravation is found, the clinician should attempt to quantify the degree of additional disability resulting from the aggravation. M. HYLAND Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Jeanne Celtnieks 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.