Citation Nr: 21069303 Decision Date: 11/18/21 Archive Date: 11/18/21 DOCKET NO. 17-39 613 DATE: November 18, 2021 REMANDED Entitlement to service connection for a left knee disability is remanded. Entitlement to service connection for right wrist arthritis (claimed as right wrist condition) is remanded. REASONS FOR REMAND The Veteran had active service from September 1978 to September 1994. This case comes before the Board of Veterans' Appeals (Board) on appeal from a November 2015 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). In April 2019 this case was before the Board and the issue was remanded to the agency of original jurisdiction (AOJ) for additional development. The Board ordered new VA examinations for both the left knee and the right wrist as well as current x-rays of the right wrist. Service Connection - Left Knee The Veteran initially filed a claim for a left knee condition in June 1994. The Veteran had at least two injuries to the left knee while in service. In January 1978 a car door was opened into the Veteran's left knee. X-rays taken in January 1979 showing that the left knee was somewhat under penetrated and that an undisplaced fracture could not be excluded. Otherwise, the left knee was negative. An additional x-ray was completed soon after that did rule out a fracture of the left knee. Then in November 1985 the Veteran indicated that she injured herself while skiing. This resulted in decreased range of motion (ROM) and some instability. X-rays taken following the skiing accident showed no gross deformity. No additional treatment or complaints are available in the service treatment records (STRs). The Veteran's spouse submitted documentation indicating that the Veteran's left knee required frequent relief with ibuprofen and ace wraps. Following discharge from service a VA examination was completed in February 1995. The left knee was found to have normal ROM, no effusion, no swelling, no abnormalities, no instability, but tenderness was noted over the patellar tendon. This examination included x-rays of the left knee which found no significant bony or soft tissue abnormality. The left knee joint spaces were well maintained. A VA examination was completed in June 2017 which discussed the two incidents noted above. After a review of the records the examiner found it less likely than not that the in-service incidents were the cause of the Veteran's current left knee complaints. The examiner noted that the Veteran provided a history of her right knee giving out in July 2015 which caused her left knee to twist. She also indicated that she fell in August 2016 which caused a reinjury. The Veteran also noted continued pain following a March 2017 meniscal repair. The examiner noted a large gap in symptoms and treatment from 1985 to 2015. The examiner found contributing factors to the Veteran's knee problem including age, normal wear and tear, and the Veteran's weight which classified her as obese. Following the Board remand, the Veteran underwent a VA examination for the right knee in June 2019. Given that the left knee was also examined at this time it is worth noting here. The examiner noted a left knee meniscal tear in 2015 with a surgical repair. ROM was found to be normal with no pain noted on examination. There was additional loss of function found after completing three repetitions. There was no ankylosis, recurrent subluxation, history of lateral instability, or joint instability found. No opinion was provided on the nature and etiology of the Veteran's left knee complaints. An additional right knee VA examination in occurred in November 2019. The left knee was again discussed. The ROM was found to be abnormal with flexion to 115 degrees and extension to 0. There was pain on flexion and pain on weight bearing noted. Medial and lateral instability were noted. X-rays of the left knee were taken in December 2019 in accordance with the Board remand. These found no acute osseous abnormality. The Veteran was afforded a left knee VA examination in January 2020. The Veteran was diagnosed with a knee strain and a meniscal tear. The examiner noted that the left knee strain was a residual of the meniscectomy and was not related to service. The Veteran complained of aching and stiffness of the knee as well as an inability to squat. She also noted that the knee pops and snaps. ROM was measured at 130 degrees for flexion and 0 extension. ROM falls to 120 degrees with repeated use and during flare-ups. There was no ankylosis, recurrent subluxation, or lateral instability found. The examiner reviewed the Veteran's history and found it less likely than not that any left knee condition was related to or caused by her time in service. The examiner noted there was no definite chronic condition or diagnosis of the left knee in the Veteran's file. The examiner also noted that there had been no in-service treatment of the left knee, and that private treatment only began in 2017. However, this examiner failed to properly discuss the lay statements submitted by and on behalf of the Veteran regarding continued problems with the left knee since his time in service. These continued complaints indicate continuity of symptomatology since the in-service injuries noted above. The examiner also based this opinion on the fact that no specific diagnosis was given, but this fails to consider that pain alone may constitute a disability if it causes impairment in earning capacity. Saunders v. Wilkie, 886 F.3d 1356, 1364-65 (Fed. Cir. 2018). Accordingly, the Board finds the January 2020 VA examination inadequate for rating purposes. The Board therefore believes that a remand for a new VA examination is warranted. Service Connection - Right Wrist Arthritis The Veteran contends that her right wrist condition was caused by the removal of the ganglion cyst that she underwent while in service. This excision of the cyst occurred in April 1979. The Veteran also noted an October 1981 fall while roller skating which caused some trauma to the right wrist. At a February 1995 VA examination the Veteran's right wrist was examined. A well healed surgical scar was noted. No swelling was noted but there was point tenderness found over the surgical scar area. There was some pain noted while measuring ROM. X-rays taken at this examination found no significant bony or soft tissue abnormality and well-maintained joint spaces. The Veteran was afforded a VA examination for the right wrist in June 2017. ROM was found to be normal with no pain noted on examination. There was no evidence of crepitus and no evidence of pain with weight bearing. No functional impact was noted. Imaging studies were reviewed, and no degenerative or traumatic arthritis was found. The examiner found it less likely than not that any claimed right wrist condition was incurred in or caused by the Veteran's in-service injuries. The examiner provided a rationale which found no chronicity of treatment or symptoms following the removal of the cyst in April 1979. In a July 2017 rating decision, the Veteran was granted service connection for right wrist residuals following the removal of the cyst. This service connection was granted under Diagnostic Code 7805 which notes that any disabling effects not considered by the rating should be rated under the appropriate diagnostic code. Per the April 2019 Board remand new x-rays of the right wrist were completed in December 2019. No acute abnormalities of the right wrist were found. A right wrist VA examination was completed in January 2020. The Veteran had current complaints of stiffness and aches. The Veteran noted wearing a wrist brace at times. There were no flare-ups. ROM was noted as abnormal with flexion and ulnar deviation measurements being off 5 degrees each. There was no pain noted on examination. No ankylosis was found. There was again found to be a spot of tenderness in the middle of the wrist which was painful when touched. The examiner noted that this was not evidence of a joint disease or a specific diagnosis. The examiner did find that the Veteran's symptoms have a functional impact. The examiner noted that the Veteran cannot perform prolonged writing or use of the computer over 1-2 hours with a short rest of the wrist. The examiner again found it less likely than not that the Veteran's right wrist arthritis was incurred in or caused by the Veteran's in-service injuries. The examiner provided the same rationale as the June 2017 examiner. There was no continuity of symptomatology and there was no diagnosis of right wrist arthritis. This included in the December 2019 x-rays of the right wrist. An additional VA examination was completed in October 2020, but it contained no nexus opinion. ROM was found to be normal by this examiner, but pain was noted on both ulnar deviation and dorsiflexion, but this did not result in functional loss. No functional impact was found. The Veteran's attorney submitted argument in July 2020 noting that while the Veteran does not have a diagnosed right wrist condition that the Saunders case allows a Veteran to still have a disability for VA purposes even if there is no underlying diagnosis. The Veteran's attorney is correct as the term "disability" means impairment in earning capacity resulting from diseases and injuries and their residual conditions. 38 U.S.C. § 1110; 38 C.F.R. § 4.1; Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018). The Board acknowledges receipt of the argument from the Veteran's attorney and agrees that additional development is required in order to obtain a full picture of the Veteran's right wrist condition. As noted above, the Veteran is service connected under DC 7805 which requires any additional symptoms related to the scarring to be reviewed under the appropriate diagnostic code. The decision to grant this failed to properly account for any of the additional symptoms the Veteran described which could have been related to right wrist arthritis. Therefore, a new VA examination is required to determine if there are any severable residuals from the service-connection under DC 7805 that may be related to the Veteran's right wrist complaints including possible arthritis. The matters are REMANDED for the following action: 1. Obtain all outstanding VA treatment records. 2. With any necessary assistance from the Veteran, obtain any outstanding relevant private treatment records. 3. Then, schedule the Veteran for a VA examination by an examiner with appropriate expertise to determine the nature and etiology of the Veteran's left knee and right wrist complaints (including possible arthritis). The claims file must be made available to, and reviewed by, the examiner. Any indicated studies should be performed. Special consideration should be given to the lay statements regarding continued complaints of pain in the Veteran's left knee. The examiner should also consider that pain alone can constitute a disability if it impacts the Veteran's earning capacity as discussed above. Based on the examination results and a review of the record, the examiner should provide an opinion as to whether it is at least as likely as not (50 percent or better probability) that any currently present left knee disability or associated symptoms had its onset during the Veteran's active service or is otherwise etiologically related to such service. The examiner should specifically address the Veteran's lay statements regarding the onset and continuity of his symptoms. Based on the examination results and a review of the record, the examiner should provide an opinion as to whether it is at least as likely as not (50 percent or better probability) that any currently present right wrist disability or associated symptoms to include arthritis had its onset during the Veteran's active service or is otherwise etiologically related to such service. The examiner should specifically address the possibility of severable residual symptoms related to the Veteran's service-connected scars related to the removal of the ganglion cyst on the right wrist. Thorough rationale for all opinions expressed must be provided. 4. Confirm that the VA examination reports, and all medical opinions, provided comport with this remand, and undertake any other development determined to be warranted. 5. Then, readjudicate the remaining issues on appeal. If a decision is adverse to the Veteran, issue a supplemental statement of the case and allow appropriate time for response. Then, return the case to the Board. Z. Sahraie Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board D. Andrew Ledman II 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.