Citation Nr: 21074199 Decision Date: 12/14/21 Archive Date: 12/14/21 DOCKET NO. 17-61 982 DATE: December 14, 2021 REMANDED Entitlement to service connection for a right knee disorder, to include as secondary to service connected left knee patellofemoral pain syndrome, is remanded. Entitlement to service connection for a gynecological disorder, initially claimed as amenorrhea, is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from June 1985 to July 1986, and then again from November 1986 to December 1994, to include service in Southwest Asia. These matters come before the Board of Veterans' Appeals (Board) on appeal of a September 2015 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Nashville, Tennessee. The Veteran testified before the undersigned Veterans Law Judge in June 2020, with her representative present. A transcript of the hearing has been associated with the claims file. In July 2020, the Board remanded the claims for service connection for a chin disorder, a temporomandibular disorder, residuals of a dying tooth, residuals of dental surgery, a gynecological disorder and a bilateral knee disorder. A June 2021 rating decision awarded service connection for an unspecified left and right facial nerve disorder and a chin scar. An October 2021 rating decision awarded service connection for a temporomandibular joint disorder, left knee patellofemoral pain syndrome and residuals of dental surgery with dying tooth. Initial ratings were assigned for each of these disabilities. As these decisions represent full grants of the benefits sought with respect to these claims for service connection, such issues are no longer before the Board for consideration. See Grantham v. Brown, 114 F.3d 1156 (Fed. Cir. 1977). The Veteran was issued a Supplemental Statement of the Case (SSOC) as to the two remaining claims on appeal: entitlement to service connection for a right knee disorder and a gynecological disorder. The Board accordingly reasserts jurisdiction; however, for reasons to be further discussed in respective relevant parts below, the Board remands these two claims. While the Board sincerely regrets additional delay that may be incurred by this remand, the Board cannot escape the conclusion that it is precluded from issuing final determinations as to either issue. 1. Entitlement to service connection for a right knee disorder is remanded. In sum and substance, the September 2021 examination (which appears to be the basis for granting the left knee claim but denying the right knee claim) appears to state that the right knee disorder is less than 50 percent likely attributable to active duty service due to 20 years of normal civilian wear and tear. See VA Exam (Medical Opinion) ( Sept. 8, 2021 ), at Question No. 3a. However, the Veteran asserts that she first felt right knee pain about one year after the left knee injury. See contra VA Exam ( Sept. 8, 2021 ), at Question No. 2a. To the extent that the examiner found no in-service evidence of right knee pain or injuries in active duty service, an examination was inadequate where the examiner did not comment on a veteran's reports of in-service injury and instead relied on the absence of evidence in a veteran's service treatment records to provide a negative opinion. See e.g., Dalton v. Nicholson, 21 Vet. App. 23 (2007). Alternatively, the Board interprets the Veteran's assertions and narrative as one by which she claims that the right knee disorder may be the result of altered gait or other accommodation over 20 years due to a service-connected left knee disorder. There is no such secondary opinion in the record at this time. As the Board is remanding the claim anyway for an adequate opinion that considers the Veteran's assertion of pain in service (specifically one year after the left knee), the Board further concludes that the claim should be remanded for an etiological opinion as to whether service connection may be warranted for the right knee as secondary to the service-connected left knee. Finally, the Board could also alternatively conclude that when the Board ordered an etiological opinion for the right knee in July 2020, the failure to consider secondary theories as a failure to provide the Veteran substantial compliance with previous remand directives. See Stegall v. West, 11 Vet. App. 268, 271 (1998). Therefore, the claim is remanded. 2. Entitlement to service connection for a gynecological disorder, initially claimed as amenorrhea, is remanded. By way of background, the Board remanded this claim on July 21, 2020 so that an examiner could address the relevance (or lack thereof) of service treatment records diagnosing valva vaginitis and galactorrhea in February 1987, December 1987, and/or May 1992. See also Hearing Tr. (June 11, 2020), at Pages 10-15. These were not discussed in a September 2015 examination, nor were they discussed in subsequent examinations conducted in May 2021 and September 2021. In sum and substance, the most recent examinations appear to merely deny the diagnosis of amenorrhea. The Board concludes that the Veteran has not yet been afforded the substantial compliance with all previous remand directives to which she is entitled. See Stegall v. West, supra. This claim is therefore remanded. The matters are REMANDED for the following action: 1. The Veteran should be given an opportunity to identify any outstanding private or VA treatment records relevant to the claims on appeal. After obtaining any necessary authorization from the Veteran, all outstanding records, to include any VA treatment records, should be obtained. For private treatment records, make at least two (2) attempts to obtain records from any identified sources. If any such records are unavailable, inform the Veteran and afford her an opportunity to submit any copies in her possession. For federal records, all reasonable attempts should be made to obtain such records. If any records cannot be obtained after reasonable efforts have been made, issue a formal determination that such records do not exist or that further efforts to obtain such records would be futile, which should be documented in the claims file. The Veteran must be notified of the attempts made and why further attempts would be futile, and allowed the opportunity to provide such records, as provided in 38 U.S.C. § 5103A(b)(2) and 38 C.F.R. § 3.159(e). 2. After the receipt of any outstanding records, schedule the Veteran for all appropriate VA examinations to confirm specific diagnoses and to determine the etiology of the Veteran's claimed gynecological disorder and right knee disorder. A complete copy of the claims file, to include this remand, the Veteran's complete service treatment records, and the Veteran's complete medical treatment records, must be made available to the examiner. The need for a physical examination is left to the discretion of the examiner. For each of the above diagnosed disorders, the examiner is asked to respond to the following questions: (A) The examiner should conduct a comprehensive examination, and provide details about the onset, frequency, duration, and severity of all symptoms claimed to be associated with an undiagnosed illness, to include menstrual disorder(s). (B) The examiner should specifically state whether the Veteran's symptoms of menstrual disorders and other symptoms are attributed to known clinical diagnoses. (C) If any symptoms of a menstrual disorder(s) have not been determined to be associated with a known clinical diagnosis, the examiner should indicate whether the Veteran has objective indications of a chronic disability resulting from an undiagnosed illness, as established by history, physical examination, and laboratory tests, that has either (1) existed for 6 months or more, or (2) exhibited intermittent episodes of improvement and worsening over a 6-month period. (D) For each diagnosed disorder, is it at least as likely as not (50 percent or greater probability) that each of the Veteran's current disorders had onset in service, or is otherwise related to her active duty service, to include exposure to a chemical weapons leak while serving in Southwest Asia? For the claimed gynecological disorder, the examiner must specifically address the significance or lack thereof of valva vaginitis and galactorrhea, as noted in service treatment records in February 1987, December 1987, and May 1992. (E) For the claimed right knee disorder, is it is at least as likely as not (50 percent or greater probability that such is caused or aggravated by her service connected left knee patellofemoral pain syndrome? The examiner should specifically consider the Veteran's statement that pain in the right knee arose approximately one year after the onset of her now-service-connected left knee disorder. A rationale should be provided for all opinions offered. If it is not possible to provide a specific opinion regarding the above questions, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). The medical opinion must support the conclusions reached with an analysis that is adequate for the Board to consider and weigh against other evidence of record; medical opinions must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. If an opinion cannot be expressed without resort to speculation, ensure that the clinician so indicates and discusses why an opinion is not possible, to include whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. KRISTY L. ZADORA Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Michael B. Engle, 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.