Citation Nr: 21074056 Decision Date: 12/14/21 Archive Date: 12/14/21 DOCKET NO. 17-02 572 DATE: December 14, 2021 REMANDED Entitlement to service connection for a left knee disability is remanded. Entitlement to service connection for a bilateral ankle disability, to include as secondary to the service-connected bilateral foot disabilities, is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from March 1990 to July 1994. This matter comes before the Board of Veterans Appeals (Board) on appeal from an August 2014 decision by a Department of Veterans Affairs (VA) Regional Office (RO) which denied service connection for a left knee disability, bilateral ankle disability, bilateral plantar fasciitis, and a right shoulder disability. A September 2018 rating decision granted service connection for bilateral plantar fasciitis and a right shoulder disability; as this is considered a full grant of the benefits on appeal, these issues are no longer in appellate status before the Board. 1. Entitlement to service connection for a left knee disability is remanded. The Veteran contends that his left knee disability is due to service. Specifically, he reported injuring his knee in ranger school while practicing the "buddy rappel" and that "the ranger on my back was big he shifted causing my knee to torque to try to stop our fall...". See January 2017 VA Form 9. The Veteran was afforded a VA examination in September 2018 to determine whether the claimed left knee disability was at least as likely as not incurred in or caused by the claimed in-service injury, event, or illness. The examiner found that the claimed condition was less likely than not due to service. By way of rationale, the examiner found that the Veteran's service treatment records were silent for complaints for the disability. Turning to the evidence of record, the Veteran's service treatment records (STRs) document at least one complaint for knee pain during service; a May 1992 periodic exam documented knee pain. The Board finds that the September 2018 VA opinion is inadequate as it is based on an inaccurate factual premise. See Reonal v. Brown, 5 Vet. 460, 461 (1993) (an opinion based on an inaccurate factual premise has no probative value). The examiner failed to document and discuss the Veteran's documented complaints of knee pain in service and the lay statements of record discussing the incident in service and statements by the Veteran's father-in-law of continuity of symptomatology. Moreover, the Board notes that service connection is possible for disabilities first identified after service. 38 C.F.R. § 3.303 (d). The absence of documented treatment in service or thereafter is not fatal to a service connection claim, and the absence of evidence in the service treatment records is an insufficient basis, by itself, for a negative opinion. See Ledford v. Derwinski, 3 Vet. App. 87, 89 (1992). The Board finds this VA examination and opinion is inadequate for adjudicative purposes. A medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Here the rationale does not clearly support the conclusion. It relies, in part, on the fact that the Veteran had no complaints or diagnosis in service, which is contrary to record. Moreover, a lack of documentation does not alone foreclose a grant of service connection for a subsequently demonstrated disability. The examiner did not take into account the Veteran's competent and credible statements of in-service incidents and treatment when the opinion was rendered. 2. Entitlement to service connection for a bilateral ankle disability is remanded. The Veteran contends generally that his bilateral ankle disability is due to service or, in the alternative, as due to his service-connected bilateral feet disability. See August 2015 VA 21-4138 Statement in Support of Claim. Alternatively, the Veteran claims that the condition is caused or aggravated by his service-connected bilateral foot disabilities. The Veteran was afforded a VA examination in September 2018 to determine whether the claimed bilateral ankle disability was at least as likely as not incurred in or caused by the claimed in-service injury, event, or illness. The examiner found that the claimed condition was less likely than not due to service. By way of rationale, the examiner found that the Veteran's service treatment records were silent for complaints for the disability. Turning to the evidence of record, the Veteran's service treatment records (STRs) document at least one complaint for ankle pain during service; a May 1992 periodic exam documented ankle pain. Additionally, the Veteran has reported that he was also treated for his ankles in 1993 and 1994, but that the treatment was not documented in his STRs due to his service in Special Operations Command. See Ankle Conditions Disability Benefits Questionnaire, submitted September 3, 2018; Appellate Brief, submitted October 26, 2021. The Board finds that the September 2018 VA opinion is inadequate as it is based on an inaccurate factual premise. The examiner failed to document and discuss the Veteran's documented complaints of bilateral ankle pain in service and failed to discuss the secondary relationship, if any, with the Veteran's service-connected bilateral foot disabilities. To that extent, the Board further notes that during an August 2020 VA examination for the Veteran's service-connected bilateral foot disabilities, the examiner indicated that the foot condition began with ankle swelling and is currently manifested by ankle pain. See VA Foot Conditions Disability Benefits Questionnaire, submitted November 3, 2020. Moreover, as noted above, service connection is possible for disabilities first identified after service. 38 C.F.R. § 3.303 (d). The absence of documented treatment in service or thereafter is not fatal to a service connection claim, and the absence of evidence in the service treatment records is an insufficient basis, by itself, for a negative opinion. The Board finds this VA examination and opinion is inadequate for adjudicative purposes. A medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. Here the rationale does not clearly support the conclusion. It relies, in part, on the fact that the Veteran had no complaints or diagnosis in service, which is contrary to record. Moreover, a lack of documentation does not alone foreclose a grant of service connection for a subsequently demonstrated disability. The examiner did not take into account the Veteran's competent and credible statements of in-service incidents and treatment when the opinion was rendered. See October 2021 Appellate Brief. The matters are REMANDED for the following actions: 1. Update VA and private treatment records. VA treatment records date to September 2020. 2. Arrange for a medical opinion with an appropriate examiner for the left knee condition and the bilateral ankle condition. The need for an in-person examination of the Veteran is left to the discretion of the examiner. Following a review of the claims file and a copy of this Remand, the reviewing examiner is requested to furnish an opinion with respect to the following questions: a) The examiner should identify any current diagnoses the Veteran has presented related to the left knee and bilateral ankle disabilities at any time during the claim period (i.e., from May 2014 to the present). b) Is it at least as likely as not (i.e. a 50 percent probability or greater) that the left knee condition was incurred in, or is otherwise related to the Veteran's active service? In rendering his or her opinion, the examiner is asked to consider the following evidence: i. The Veteran's claim that the left knee condition manifested in and was treated several times while on active service. See October 2021 Appellate Brief. ii. The Veteran's claim that he has had left knee problems since service. See VA Form 9. iii. The Veteran's claim that the left knee condition was caused by an incident in ranger school during buddy rappel exercises. See VA Form 9. iv. STRs showing complaints of knee pain in service. v. Any and all relevant lay and medical evidence. A complete rationale for all opinions offered should be provided. Address the Veteran's documented history and assertions. All necessary tests and studies should be conducted. c) Is it at least as likely as not (50 percent probability or greater) that any diagnosed bilateral ankle disability had its onset in service or is otherwise related to the Veteran's military service; is caused by his service-connected bilateral foot disability; or is aggravated (worsened beyond normal progression) by his service-connected bilateral foot disability? An opinion should be given for pes planus, plantar fasciitis and acquired pes cavus, and any other bilateral foot diagnosis. In rendering his or her opinion, the examiner is asked to consider the following evidence: i. The Veteran's claim that the bilateral ankle conditions manifested in and were treated while on active service. See October 2021 Appellate Brief. ii. STRs showing complaints of ankle pain in service. iii. The Veteran's reports that he was also treated for his ankles in 1993 and 1994, but that the treatment was not documented in his STRs due to his service in Special Operations Command. See Ankle Conditions Disability Benefits Questionnaire, submitted September 3, 2018; Appellate Brief, submitted October 26, 2021. iv. An August 2020 VA examination for the Veteran's service-connected bilateral foot disabilities, indicating that the foot condition began with ankle swelling and is currently manifested by ankle pain. See VA Foot Conditions Disability Benefits Questionnaire, submitted November 3, 2020. v. Any and all relevant lay and medical evidence. A complete rationale for all opinions offered should be provided. Address the Veteran's documented history and assertions. All necessary tests and studies should be conducted. If the examiner cannot provide an opinion without resorting to mere speculation, the examiner should provide an explanation stating why. In so doing, the examiner should explain whether the inability to provide a more definitive opinion is due to the limits of the medical community or the limits of the examiner's medical knowledge. A. MARSH II Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Kelsey Love, 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.