Citation Nr: 21070942 Decision Date: 11/27/21 Archive Date: 11/27/21 DOCKET NO. 18-11 646 DATE: November 27, 2021 REMANDED Entitlement to service connection for a right knee condition is remanded. Entitlement to service connection for a left knee condition is remanded. Entitlement to service connection for a right foot condition is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from March 1966 to March 1968. He was awarded the Parachutist Badge and the Combat Infantry Badge. The case comes before the Board of Veterans' Appeals (Board) on appeal from a February 2014 rating decision. In June 2021, the Veteran testified before the undersigned Veterans Law Judge during a videoconference hearing. A transcript of the hearing is of record. Although the Board regrets the additional delay, a remand is necessary to ensure that there is a complete record upon which to decide the Veteran's claims so that he is afforded every possible consideration. 38 U.S.C. § 5103A; 38 C.F.R. § 3.159. 1. Entitlement to service connection for a right knee condition is remanded. 2. Entitlement to service connection for a left knee condition is remanded. The Veteran asserts that his bilateral knee disabilities began in service. He contends that his knee injuries occurred during his airborne training as well as during the foot patrols he conducted while in Vietnam. As an initial matter, there is no dispute that the Veteran has current bilateral knee disabilities. However, a December 2017 examiner opined against a relationship to service. The examiner acknowledged that the Veteran was awarded the parachutist badge in 1967 but that he underwent surgery for his knees in 2009 and 2012, which is 40 years after jump school. The examiner noted that the Veteran's records dated in 2003 indicated a diagnosis of morbid obesity, and that his knee conditions were more than likely due to his morbid obesity. After this examination, the Veteran provided additional information about his in-service knee problems. During his June 2021 hearing, the Veteran expressed a belief that his bilateral knee and right foot conditions are due to general activities and events that he experienced including wear and tear while on active duty. He testified that, during active duty, before he went to Vietnam, he participated in airborne jump school and had to do jumps from a 250-foot tower, simulating jumps from an airplane, and then also had regular jumps from the airplane itself. He testified that, after airborne school, he went straight to Vietnam and was assigned to Long Range Reconnaissance Patrol; the patrols were on foot and lasted three to six days or longer. They walked the whole time, carrying all their food, water, ammunition, and equipment, with no vehicle support. There was not much downtime between patrols. His knees and feet hurt during this time, but when they were there, they forgot about the pain, as they were focused on just saving their lives. The Veteran also testified that he had been injured in a bunker collapse that led to a back injury for which he is now service-connected. He testified that he hurt his knees during this incident also, when the bunker fell, and his knees and chest were pinned together. He testified that this was a traumatic event, and he does not recall how long he was pinned there. The Veteran testified that he had a constant pain in his knees during the 70s, 80s, and 90s, and that he hoped it would go away, but it did not. He testified that he did see some providers during that time, but the providers are no longer present. He testified that walking was tough for him, and that his feet and knees began to hurt as time went by more and more. See June 2021 Hearing Transcript. Given the assertions of the Veteran and his additional description of symptoms during and since service, the Board believes an updated opinion should be ordered to assess the etiology of the Veteran's claimed bilateral knee disabilities. The Veteran also testified that he has received private treatment, and the record includes some private treatment records. On remand, the Veteran should be asked to submit, or authorize VA to obtain on his behalf, all records of private care that are not already associated with the record. 3. Entitlement to service connection for a right foot condition is remanded. The Veteran filed a claim of entitlement to service connection for a right foot disability in February 2014. As a result of his December 2017 foot examination, the VA examiner noted his diagnoses included a 2008 diagnosis of hammertoes and a 2012 diagnosis of status post bunionectomy. Private treatment records also not diagnoses of plantar fasciitis and tinea pedis. He is already in receipt of service connection for radiculopathy and diabetic peripheral neuropathy of the right lower extremity. Although the medical opinions of record address whether the Veteran's foot conditions may be related to service-connected diabetes, they do not adequately address whether such disability of the right foot may be related to impact and overuse injuries during service as described above. On remand, another opinion should be obtained. The matters are REMANDED for the following action: 1. Obtain and associate with the claims file outstanding VA treatment records. 2. Give the Veteran an additional opportunity to submit, or authorize VA to obtain on his behalf, any records of private treatment for the bilateral knees or the right foot that are not already associated with the claims file. All efforts to obtain these records should be fully documented. 3. After any outstanding records have been associated with the claims file, furnish the Veteran's claims file to an appropriate clinician to address the etiology of his claimed knee disabilities. The record must be made available for the clinician's review. The need for an additional examination is left to the discretion of the medical professional selected to write the addendum opinions. Following a review of the entire record, the examiner is asked to address the following: a) Identify all current bilateral knee disabilities. b) For each knee disability, is it at least as likely as not (50 percent or greater probability) that such had onset in, or is otherwise related to active-duty service, to specifically include wear and tear from the physical rigors of his service, including airborne training and foot patrol duties, and/or the 1967 bunker collapse? The examiner should specifically discuss whether the nature of the Veteran's current knee disability, from a medical perspective, is consistent with the Veteran's in-service airborne parachute training, foot patrol duties, or the 1967 bunker collapse and his lay reports of ongoing symptoms after service. The mere fact that he did not receive treatment following service cannot be the exclusive basis upon which a negative determination is made without further discussion as to why, medically, such observation is dispositive. c) For any knee disability less likely related to service, please address whether the Veteran's service-connected disabilities caused the Veteran to become obese, and whether such was an intermediate step between his service-connected disabilities and his knee conditions. In providing a response, the examiner should answer each of the following in sequence: i. Is it at least as likely as not (50 percent or greater probability) that the Veteran's service-connected disabilities (to specifically include his diabetes, spine disability, radiculopathy and peripheral neuropathy of his lower extremities) caused him to become obese, or aggravated his obesity? ii. If so, was the obesity that resulted from or was aggravated by the service-connected disabilities a substantial factor in causing the Veteran's right or left knee conditions? Please consider the December 2017 examiner's opinion linking the Veteran's conditions to obesity. iii. If the answer to question (ii) is "yes," would the Veteran's right or left knee disabilities not have occurred but for his obesity caused or aggravated by his service-connected disabilities? All opinions should be supported by a medical explanation or rationale. 4. After any outstanding records have been associated with the claims file, furnish the Veteran's claims file to an appropriate clinician to address the claimed right foot disability. The record must be made available for the clinician's review. The need for an additional examination is left to the discretion of the medical professional selected to write the addendum opinion. Following a review of the entire record, the examiner is asked to address the following: a) Identify all current right foot disabilities, other than radiculopathy and diabetic peripheral neuropathy. b) For each disability, is it at least as likely as not (50 percent or greater probability) that such had onset in, or is otherwise related to active-duty service, to specifically include wear and tear from the physical rigors of his service, including airborne training and foot patrol duties? c) Notwithstanding the above, for each disability, is it at least as likely as not (i.e., a 50 percent or greater probability) that such disability was caused or aggravated beyond its natural progression by his service-connected diabetes mellitus? In this regard, the Board emphasizes that causation and aggravation are two separate inquiries, and both must be answered. All opinions should be supported by a medical explanation or rationale. (Continued on Next Page) 5. Thereafter, readjudicate the issues on appeal. If the claim remains denied, send the Veteran a supplemental statement of the case. V. Chiappetta Veterans Law Judge Board of Veterans' Appeals Attorney for the Board L. Fulmer, 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.