Citation Nr: 21069910 Decision Date: 11/22/21 Archive Date: 11/22/21 DOCKET NO. 14-29 961 DATE: November 22, 2021 REMANDED Entitlement to service connection for a right knee disability is remanded. Entitlement to service connection for a right arm disability is remanded. Entitlement to service connection for a left hip disability is remanded. REASONS FOR REMAND The Veteran served on active duty from March 1974 to June 1977. These matters come before the Board of Veterans' Appeals (Board) on appeal from July 2007, November 2013, and June 2014 rating decisions by a Regional Office (RO) of the Department of Veterans Affairs (VA). The Board remanded these matters for further evidentiary development in December 2016 and May 2018. The case has returned to the Board for appellate review. While the Board sincerely regrets additional delay, the Board finds that the claims must be remanded to assure the Veteran is afforded a full and fair adjudication of his claims. 1. Entitlement to service connection for a right knee disability is remanded. 2. Entitlement to service connection for a right arm disability is remanded. 3. Entitlement to service connection for a left hip disability is remanded. The Veteran seeks entitlement to service connection for right knee, right arm and left hip disabilities. The Veteran contends that he has had a right knee disability and a right arm neurological disability since his separation from service. Specifically, he contends that he injured his knees playing sports throughout his military service and has experienced knee problems since then, and that he injured a nerve in his right arm during his military training due to wrapping himself in a sleeping bag very tightly and sleeping on his right side to avoid snakes in the field. The Veteran's complete service treatment records (STRs) are unavailable. His claims file includes a March 2017 memorandum and letter indicating that his STRs were established to be unavailable. In cases where the Veteran's STRs are unavailable through no fault of the Veteran, there is a heightened obligation to explain findings and to carefully consider the benefit of the doubt rule. O'Hare v. Derwinski, 1 Vet. App. 365 (1991). There is also a heightened obligation to assist the claimant in the development of his case. Id. The case law does not, however, lower the legal standard for proving a claim for service connection but rather increases the Board's obligation to evaluate and discuss in its decision all the evidence that may be favorable to the claimant. Russo v. Brown, 9 Vet. App. 46 (1996). Because of the missing records, the Board analyzes this claim with this heightened duty in mind. Pursuant to the May 2018 Board remand, the Veteran was afforded a VA examination in June 2021. The June 2021 examiner provided conflicting nexus opinions for the Veteran's left hip disability and negative nexus opinions for his right knee and right arm disabilities. Regarding the Veteran's right knee and right arm disabilities, the examiner provided the rationale that his right knee instability is associated with a post-service basketball injury and the Veteran's STRs are absent complaints of a right knee injury or a right upper extremity neurological disability, as the first representation of a right knee injury is noted in 1995 medical records. The examiner also provided that the Veteran's right arm disability is related to a December 2016 motor vehicle accident (MVA). Due to the inconsistencies in the June 2021 VA opinion concerning the Veteran's left hip disability, an addendum opinion was obtained in July 2021. The July 2021 examiner opined that the Veteran's left hip disability is not related to his service-connected left knee disability. The examiner provided the rationale that the two conditions are not medically related as the medical literature does not support a medical relationship because there is no clear evidence from review of orthopedic literature to suggest that an injury to one joint would have any significant impact on another or opposite uninjured joint or limb. The examiner, however, does not adequately address whether the Veteran's left hip was aggravated by his service-connected left knee disability. An August 2021 VA addendum opinion was obtained to clarify the opinion for the Veteran's right knee disability. The examiner opined that the Veteran's right knee disability is not due to his service-connected left knee disability. The examiner provided the rationale that there is nothing to support right knee issues being related to service and the medical literature does not support that the right knee was aggravated beyond its natural progression by the left knee disability because the medical literature shows that no more surveillance is needed for the contralateral knee, i.e., it will not be worsened. The Board notes that the medical literature the examiner cited is from a 2013 study on the effect of pain after total knee arthroplasty on the contralateral, nonreplaced knee. The study notes that pain in the index knee at three months after total knee arthroplasty did not appear to predict a symptomatic increase in pain in the contralateral knee over two years of follow-up in the cohort; the contralateral knee did not require any additional clinical surveillance over and above the patients' reports on their symptoms. The examiner, however, does not adequately address whether the Veteran's right knee was aggravated by his service-connected left knee disability. The Board finds these 2021 VA medical opinions to be inadequate for the purposes of determining service connection. See generally Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). Regarding the Veteran's right arm disability, the June 2021 examiner associated this disability with a post-service MVA and relies on the absence of right arm complaints in the Veteran's STRs. Which, the Board notes are incomplete. Regarding the Veteran's left hip disability, the June 2021 examiner provided positive and negative nexus opinions. The July 2021 examiner relies on the absence of evidence of an obvious gait in the Veteran's medical records. The Board notes that the Veteran's VA medical records indicate he periodically has an unsteady gait and uses a cane or walker to ambulate, which indicates an unsteady gait that could have an effect on his hip and needs to be addressed in an addendum opinion. Regarding the Veteran's right knee disability, the June 2021 examiner associated this disability with a post-service basketball injury, does not address secondary service connection, and relies on the absence of right knee complaints in the Veteran's STRs. Which again, the Board notes are incomplete. The August 2021 examiner addresses secondary service connection but relies on a 2013 study that does not appear to directly relate to the Veteran's contentions regarding his right knee. Additionally, none of the examiners addressed the Veteran's contentions and whether the disability pictures presented are consistent with the Veteran's accounts that manifestations of his current disabilities first appeared in service and have persisted since, as specifically requested by the May 2018 Board remand. Stegall v. West, 11 Vet. App. 268 (1998). The Board finds addendum VA medical opinions are necessary to make a fully informed decision on the Veteran's claim. The matters are REMANDED for the following action: 1. Obtain addendum opinions from a VA examiner(s) of appropriate expertise to ascertain the etiology of the Veteran's current right knee, right arm, and left hip disabilities. (If it is determined that additional examination is needed, it should be scheduled in accordance with applicable procedures.) The claims file should be made available to and be reviewed by the examiner in conjunction with the examination. The examiner should address the following: (a.) Right Knee: The VA examiner is asked to identify any currently diagnosed right knee disability, to include any right knee disability diagnosed at any time during the course of this appeal. For any diagnosed right knee disability, offer an opinion as to whether it is at least as likely as not (50 percent or greater likelihood) that any current right knee disability had its onset in service or is otherwise related to active service. This should include a discussion of whether any right knee disability found is proximately due to, the result of, or aggravated by the Veteran's service-connected disability, specifically to include his left knee disability. (b.) Right Arm: The VA examiner is asked to identify any currently diagnosed right arm disability, to include any right arm disability diagnosed at any time during the course of this appeal. For any diagnosed right arm disability, offer an opinion as to whether it is at least as likely as not (50 percent or greater likelihood) that any current right arm disability had its onset in service or is otherwise related to active service. (c.) Left Hip: The VA examiner is asked to identify any currently diagnosed left hip disability, to include any left hip disability diagnosed at any time during the course of this appeal. For any diagnosed left hip disability, offer an opinion as to whether it is at least as likely as not (50 percent or greater likelihood) that any current left hip disability had its onset in service or is otherwise related to active service. This should include a discussion of whether any left hip disability found is proximately due to, the result of, or aggravated by the Veteran's service-connected disability, specifically to include his left knee disability. (d.) The examiner(s) should provide a detailed rationale for the opinions, including a discussion of the evidence of record and medical principles which led to the conclusions reached. If an opinion cannot be provided without resort to speculation, the examiner should explain why it is not possible to provide an opinion. (e.) It should be noted that the Veteran is competent to attest to factual matters of which he had first-hand knowledge, including observable symptomatology. Specifically, the examiner is asked to address the Veteran's contentions that his disabilities are due to playing sports in service and wrapping himself tightly in a sleeping bag. The examiner should also address the indications in the Veteran's treatment records that indicate he has had an unsteady gait and how that may impact his right knee and left hip disabilities. 2. After the development requested has been completed, the RO should review the expanded record to ensure complete compliance with the directives of this REMAND. If any report is deficient in any manner, implement corrective procedures at once. Emily Tamlyn Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Frazier, Associate Attorney 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.