Citation Nr: 21072273 Decision Date: 12/02/21 Archive Date: 12/02/21 DOCKET NO. 17-42 689 DATE: December 2, 2021 REMANDED Service connection for a right knee disorder is remanded. Service connection for a left knee disorder is remanded. REASONS FOR REMAND The Veteran, who is the Appellant, served on active duty from December 1968 to February 1989. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an October 2016 rating decision from a Regional Office (RO), which, in pertinent part, denied service connection for right and left knee disorders. The Veteran initially requested a Board videoconference hearing on the August 2016 substantive appeal; however, in written correspondence submitted September 2021, the Veteran withdrew the hearing request. 38 C.F.R. § 20.704(e). The issues of service connection for right and left knee disorders are remanded for further development. 1. Service connection for a right knee disorder is remanded. 2. Service connection for a left knee disorder is remanded. The Veteran contends that service connection for the right and left knee is warranted due to service. Specifically, the Veteran asserts that a pre-existing rheumatic fever did not affect his ability to join the Navy and that he had no problem with knee pain when he was inducted into service. The Veteran asserts that his military duties as an engineman required him to climb up and down the ship's ladder to his workstation, required lifting equipment weighing 20 to 50 pounds, and required him to crouch down on his knees for an hour at a time to perform maintenance tasks, which increased the stress on his knees over time, aggravating his knee pain beyond a natural progression. The Veteran asserts that his knees began to hurt during acting duty around 1974, and have remained painful since service. See July 2016 Statement in Support of the Claim, November 2016 Notice of Disagreement, August 2017 VA Form 9. A VA examination was provided in August 2016. The VA examiner diagnosed rheumatic fever involving the knees. The examiner opined that the current bilateral knee disorder was less likely than not caused by or incurred in service, and that the rheumatic fever involving the knees, which clearly and unmistakably existed prior to service, was less likely than not aggravated by service. The examiner explained that the Veteran had pain on movement and palpation of the bilateral knee upon examination that was likely due to rheumatic fever, and noted that the claims file contains several records with mention of rheumatic fever involving the knees since childhood and bilateral knee pain during service. However, the examiner notes that it is not feasible to comment on aggravation, as there is limited information in the claim file to establish a baseline of the Veteran's rheumatic fever involving the bilateral knees. See August 2016 VA examination report. A veteran will be considered to have been in sound condition when examined, accepted, and enrolled for service, except as to defects, infirmities, or disorders noted at entrance into service, or where clear and unmistakable evidence demonstrates that an injury or disease existed prior thereto and was not aggravated by service. 38 U.S.C. § 1111. Only such conditions as are recorded in examination reports are to be considered as noted. 38 C.F.R. § 3.304(b). A review of the service treatment records indicates that the Veteran self-reported a history of rheumatic fever on the August 1968 service enlistment Report of Medical History; however, the Veteran denied any history of swollen or painful joints and trick or locked knee at service entrance. The Veteran also reported good health at that time. As such, there is no indication of rheumatic fever affecting the knees based on the service enlistment Report of Medical History. Moreover, there is no corresponding enlistment Report of Medical Examination from August 1968 in the record. As such, the available service treatment records do not indicate that rheumatic fever was "noted" by a medical examiner during a service enlistment examination since there is currently no enlistment Report of Medical Examination of record. The RO should attempt to obtain the complete August 1968 service enlistment report, to include the August 1968 Report of Medical History and the corresponding Report of Medical Examination, to determine if rheumatic fever was actually "noted" on the examination report. Additionally, the August 2016 VA medical opinion is not adequate to decide the claim. The VA examiner indicated that the service treatment records note a history of rheumatic fever involving the knees since childhood, but the examiner was unable to establish a baseline for rheumatic fever in the knees to determine whether the Veteran's knee conditions were aggravated beyond a natural progression. However, the available service treatment records do not reflect a history of rheumatic fever involving the knees since childhood, and the examiner did not consider the effect of the Veteran's military duties on his knee conditions. As noted above, the August 1968 enlistment Report of Medical History indicates that the Veteran reported a history of rheumatic fever, but did not report any problems with the knees at that time. A November 1972 reenlistment Report of Medical Examination indicates that the lower extremities were clinically normal upon examination. However, in August 1976 the Veteran reported bilateral knee pain, soreness, puffiness, tenderness, stiffness, instability, and popping for three to four weeks, particularly with climbing and going down ladders. The Veteran was noted to have loud popping and pain on range of motion, grinding in the knees, and some laxity in the right knee. Diagnosis was chondromalacia of the knees, with no mention of involvement of rheumatic fever. See August 1968, November 1972 service treatment records. On the July 1988 annual Report of Medical History and the December 1988 retirement Report of Medical History, the Veteran reported a history of rheumatic fever as a child, noting that he had to repeat the second grade. However, he only reported pain and swelling in the knees since 1974, particularly with heavy use such as running or climbing, indicating an onset of problems with the knees during service. The Veteran was also noted to have bilateral knee crepitus during the annual and retirement clinical examinations in July 1988 and December 1988. The military physician listed bilateral knee crepitus in the summary of defects. See July 1988, December 1988 service treatment records. Since service, post-service treatment providers have diagnosed bilateral knee pain and osteoarthritis, and the VA examiner diagnosed rheumatic fever affecting the knees. See June 2016 private treatment record, December 2015 VA treatment record, August 2016 VA examination report. As such, a new opinion is necessary to assess whether the bilateral knee conditions clearly and unmistakably preexisted service, and whether the current bilateral knee conditions were caused by or aggravated beyond a natural progression by service. The matters are REMANDED for the following action: 1. The RO should request any outstanding service treatment records for the period from August 1968, to include the service enlistment Report of Medical Examination from August 1968. If records cannot be obtained, the Veteran should be informed, with a formal memorandum to the file to document all efforts. 2. Return the VA medical opinion report to the VA examiner who provided the medical opinion in August 2016. If the original VA examiner is unavailable, a new examiner may be assigned to address the requested opinion. The relevant documents in the record should be reviewed by the examiner and a detailed history of relevant symptoms should be obtained from the record. A rationale for all opinions and a discussion of the facts and medical principles involved should be provided. The examiner should offer opinions: a) Did the Veteran's current right and left knee disabilities, to include the diagnoses of bilateral knee osteoarthritis and rheumatoid fever affecting the knees, clearly and unmistakably preexist service? Clear and unmistakable evidence is evidence that is obvious, manifest, and undebatable, which is a very high likelihood. b) If the bilateral knee disabilities preexisted service, were the knee disabilities clearly and unmistakably not aggravated by service? The term "aggravated" in this context refers to a worsening of the underlying condition beyond the natural progress of the disease, as contrasted to temporary or intermittent flare-ups of symptomatology that resolve with a return to the baseline level of disability. The examiner should address the Veteran's contention that his military duties, including climbing ladder, carrying 20 to 50 pounds of equipment, and crouching on his knees to perform maintenance duties, placed strain on his knees over time, and that his knee pains began during service around 1974 and were worsened beyond a natural progression. Assume for the purposes of the next question only that the bilateral knee disability did not clearly and unmistakably preexist service. The examiner is requested to provide the following opinion: c) Is it at least as likely as not (a 50 percent probability or higher) that the Veteran's right and left knee disabilities had their onset during service, or are otherwise etiologically related to active service? The examiner should address the Veteran's contention that his military duties, including climbing ladder, carrying 20 to 50 pounds of equipment, and crouching on his knees to perform maintenance duties, placed strain on his knees over time, and that his knee pains began during service around 1974. E. BLOWERS Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Moore, Shanna 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.