Citation Nr: 21066918 Decision Date: 11/02/21 Archive Date: 11/02/21 DOCKET NO. 16-33 971 DATE: November 2, 2021 REMANDED Entitlement to service connection for a left knee disability is remanded. REASONS FOR REMAND The appellant is a Veteran who served on active duty from February 1971 to April 1991. This matter is before the Board of Veterans' Appeals (Board) on appeal of a November 2014 Department of Veterans Affairs (VA) rating decision. In his July 2016 VA Form 9, the Veteran requested a Board hearing. In 2017 correspondence, he withdrew his hearing request. In November 2018 and March 2021, this matter was remanded for additional development. [The November 2018 and March 2021 remands requested addendum medical opinions.] Entitlement to service connection for a left knee disability is remanded. The March 2021 Board remand ordered development for a VA examination to ascertain the nature and etiology of the Veteran's left knee disability. The provider was to specifically opine whether the left knee disability was caused or aggravated by his service-connected disabilities. On July 2021 VA (knee and lower leg conditions) examination, the examiner opined that that the Veteran's status post left knee arthroscopic surgical repair of his meniscus tear occurred after he got out of the service and a nexus has not been established. The originating agency (AOJ) noted several deficiencies in the medical opinion provided by the July 2021 VA provider, and requested an addendum medical opinion. In a September 2021 VA addendum (to the July 2021 knee and lower leg conditions examination) medical opinion, the provider, a nurse practitioner, addressed secondary service connection and opined that the left knee disability and service-connected disabilities are not medically related. The provider stated, in part, that orthopedic literature shows no clear evidence to suggest that an injury to one joint would have any significant impact on another or opposite uninjured joint or limb, unless the injury resulted in a major muscle or nerve damage causing partial or complete paralysis. The examiner found that this level of severity is not supported based on the record. Notably, the Veteran's service-connected spine disability is manifested by bilateral lower extremity neuropathy, which is also service-connected and rated as incomplete paralysis. Thus, the rationale provided for the negative nexus opinion tends to contradict, rather than support, the opinion, and the opinion is inadequate for rating purposes. Development for another (fully adequate) medical advisory opinion is necessary. See Stegall v. West, 11 Vet. App. 268, 271 (1998). The record also shows that pertinent private treatment records appear to be outstanding. In a September 2010 statement, the Veteran asserted that his service-connected back injury caused him to fall from a ladder and sustain a left knee injury in 2001 (in essence, an alternate secondary service connection theory of entitlement that has been, although not argued more recently, raised but not addressed. A late October 2001 VA treatment record, notes that the Veteran presented with his left knee in an immobilizer (and in a wheelchair) for a complaint of pain due to an injury sustained in a 4-rung fall from a ladder, sustained about 6 days prior. That initial notation of a knee injury in the record (when the Veteran did not report his back to be an etiological factor for the fall), suggests he may have received evaluation and treatment for the injury on the day of the fall itself, perhaps at a non-VA facility. The record does not reflect that medical records of any evaluation or treatment the Veteran may have received on the day of the fall or earlier than 6 days after the fall. The matters are REMANDED for the following action: 1. Ask the Veteran to describe the circumstances surrounding his fall from a ladder in October 2001. In particular he should explain whether there were witnesses, and whether he was seen anywhere/by any medical provider for the injury on the day it occurred (e.g., local E.R.) or at any time prior to October 26, 2001 when he was first seen for related complaints at VA. If he was not seen by a medical provider prior to October, 26, 2001, ask him to explain how he came about to wearing an immobilizer on the knee (and was in a wheelchair) when he was first seen. If there were witnesses or he received medical attention prior to October 26, 2001, arrange for exhaustive development to secure for the record (with the Veteran's co-operation by providing identifying information and any authorizations required) any documentation of the circumstances of the fall (invite him to submit statements from any witnesses) and complete clinical records of any medical evaluations or treatment he reports he received for the fall injury prior to October 26, 2001. 2. When the development requested above is completed, arrange for the Veteran's claims file to be forwarded to an appropriate clinician (in orthopedics) for review and a medical advisory opinion regarding the likely etiology of his left knee disability. [If further examination of the Veteran is deemed necessary for an opinion sought, such should be arranged.] The examiner should provide opinions that respond to the following: (a.) Identify (by diagnosis) each left knee disability entity shown during the pendency of this claim. (b.) Identify the likely etiology for each left knee disability entity diagnosed. Is it at least as likely as not (a 50 percent or better probability) that the diagnosed disability was caused or aggravated by the Veteran's service-connected (including back and bilateral upper and lower extremity radiculopathy) disabilities? [The rationale provided must address his service-connected radiculopathy of both lower extremities (in the context of the September 2021 addendum opinion suggesting that a back disability may impact development or increase in knee pathology, if manifestations include partial (incomplete) nerve paralysis) .] (c.) If evidence received in response to #1, above, suggests that the Veteran's service-connected back disability may (may being a low threshold requirement) have been the cause of his fall from a ladder in October that resulted in knee injury, because that is a medical question, opinion whether Veteran's service connection back disability was (at the time of the knee fall injury) of such nature and severity that it indeed would have caused the fall. (d.) If a left knee disability diagnosed is found to not have been caused, but to have been aggravated, by a service-connected disability, identify the baseline severity of such disability prior to the aggravation and the level of severity of the disability following aggravation. All opinions must include rationale that cites to supporting factual data and/or medical literature, as deemed appropriate. If an opinion sought cannot be provided without resort to mere speculation, there must be explanation why that is so. GEORGE R. SENYK Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Lederman, Michael 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.