Citation Nr: 21072028
Decision Date: 12/02/21	Archive Date: 12/02/21

DOCKET NO. 17-24 253
DATE: December 2, 2021

REMANDED

Entitlement to service connection for left knee condition, to include as secondary to his service-connected right foot disability, is remanded.

REASONS FOR REMAND

The Veteran served on active duty in the United States Army from June 1974 to June 1977.

This matter comes before the Board of Veterans' Appeals (Board) on appeal from a June 2016 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO).  The Board notes this matter has been before the Board in December 2019 and, most recently, in April 2021.  In the April 2021 Board decision, the issue was remanded for a VA examination and medical opinion.  The matter has now come back before the Board for adjudication.

Unfortunately, the Board finds another remand is necessary as the July 2021 VA examination and medical opinion are inadequate.  Specifically, the examiner found the Veteran did not have any diagnosed left knee condition and noted that the Veteran never underwent surgery on his left knee, to include a total knee replacement.  The medical evidence of record contains evidence of a diagnosis of left knee osteoarthritis.  In addition, the Veteran underwent a left total knee replacement in July 2017.  See VA Medical Treatment Records, Private Medical Treatment Records.  As such, the Board finds the July 2021 VA examination inadequate.

Furthermore, the July 2021 VA medical opinion completed in conjunction with the VA examination is inadequate.  First, the Board finds the medical opinion is based on an inadequate VA examination.  Next, the Board finds the examiner failed to provide adequate rationale to support the medical opinions.  The examiner merely provided an outline of the Veteran's medical history for his left knee condition and right foot disability.  Then, the examiner made a conclusory statement.  See July 2021 VA Medical Opinion Disability Benefits Questionnaire (DBQ), July 2021 VA Knee and Lower Leg DBQ.

As such, this matter is REMANDED for the following action:

The RO must schedule the Veteran for a VA examination for his left knee condition with an appropriate physician.  The claims file must be made available for review.  The examiner must provide a supporting rationale for the following opinions:

Whether it is at least as likely as not (at least an approximate balance of positive and negative evidence) that the Veteran's left knee condition was caused by his active military service.  The examiner must address the Veteran's testimony, to include, that he fell in service and injured his left knee.

Whether it is at least as likely as not (at least an approximate balance of positive and negative evidence) that the Veteran's left knee condition was proximately due to or aggravated by his service-connected disability, to include his right foot disability.  The examiner must address the Veteran's testimony that his right foot caused him to fall and injure his left knee.

 

 

A. C. MACKENZIE

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	Glaeser, Jennifer

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.