Citation Nr: 21075276 Decision Date: 12/20/21 Archive Date: 12/20/21 DOCKET NO. 12-14 596 DATE: December 20, 2021 REMANDED Entitlement to service connection for a left knee disorder, to include as secondary to service-connected bilateral pes planus, is remanded. Entitlement to service connection for a right knee disorder, including as secondary to a left knee disorder and/or as secondary to a left knee disorder or bilateral pes planus, is remanded. REASONS FOR REMAND The Veteran served on active duty from June 1960 to April 1966. He has additional reserve service. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a March 2010 rating decision issued by a Regional Office (RO) of the Department of Veterans Affairs (VA). The Veteran testified at a hearing before the RO in October 2014 and at a hearing before the undersigned at a hearing in January 2017. The Board has remanded this matter multiple times for additional development. This appeal is advanced on the Board's docket pursuant to 38 C.F.R. § 20.902(c); 38U.S.C. §7107 (a)(2). 1. Entitlement to service connection for a left knee disorder, to include as secondary to service-connected bilateral pes planus, is remanded. VA has a duty to ensure any medical examination or opinion it provides is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (overruled on other grounds, Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013)). A medical opinion is adequate where it is based upon consideration of the full medical history and describes a disability in sufficient detail so that the Board's evaluation will be fully informed. Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007). Here, the Veteran seeks entitlement to service connection for a left knee disability. In January 2017 testimony before the Board, in October 2014 testimony before the RO, and in additional written statements (including January 2010, April 2012, November 2014, November 2014, March 2015, April 2015, January 2018, and September 2018), he asserts in-service left knee injuries related to a twisting injury during military police training exercises at Fort Gordon in 1960. After this injury, he recalled a medic, who was present in the training area, evaluated his knee and determined nothing was broken. The Veteran did not seek any additional treatment because he believed he might be "recycled" if he did so. After completing his initial training, the Veteran was stationed in Germany. His performed duties which required prolonged standing, including working as a gate guard, participating in honor guards, and marching in parades. He wore boots that had been treated with glue to make them stiff. The stiffness preserved their shine to ensure they passed inspection. While stationed in Germany, the Veteran recalled seeking treatment for knee pain and receiving shoe inserts. In October 2014, the Veteran testified before the RO and explained that he did not visit the doctor for knee pain when he initially separated from active service. He recalled that his knees slowly worsened over time and he used his right knee to protect the left knee. In a March 2015 statement, the Veteran asserted he did not report knee problems during his reserve service because his duties did not require extensive standing and his objective was to complete 20 years of service. Private medical records show the Veteran was treated for post service left knee discomfort in November 1978; he injured his left knee in a November 1979 fall at work; and he underwent left knee surgery in January 1980. A January 1980 pathology report described left knee patellar shavings removed during the surgery as due to an "old injury." Additionally, service connection is established for bilateral pes planus and the issue of service connection for a left knee disability secondary to the bilateral foot disability is indicated. In July 2021, the Board found a February 2018 opinion was inadequate to evaluate the claim. The February 2018 examiner had not properly considered a January 1980 pathology report of an "old injury." He had dismissed the possibility that this "old injury" was onset during active service because the report had not "definitely" identified such an injury. The Board also noted a negative April 2017 etiology opinion addressing secondary service connection was inadequate because the supporting rationale was based on a finding that the Veteran's knee disability predated his service-connected foot disability. See Frost v. Shulkin, 29 Vet. App. 131 (2017). In August 2021, a new etiology opinion was obtained. The examiner opined the current left knee disability was less likely than not directly related to the Veteran's active service. He found the Veteran sustained an acute left knee injury in service. He observed an absence of evidence of "continuity of care" between the Veteran's 1966 separation from service and left knee treatment in 1978. The examiner failed to consider, or he dismissed without explanation, the Veteran's competent October 2014 testimony that, after separating from active service, he experienced progressively worsening left knee symptoms. The examiner observed the Veteran was treated for left knee discomfort in November 1978, sustained an additional left knee injury in November 1979, and underwent left knee surgery in1980. He noted a January 1980 pathology report described an "old injury" of the left knee. He attributed the "old injury" to the 1978 and 1979 left knee injuries because the pathology report did not "specifically" indicate the "old injury" was an in-service injury. The Board notes the pathology report did not "specifically" identify the "old injury" as being incurred in 1978 or 1979. The examiner did not provide a sufficient explanation for attributing the "old injury" to the more recent injuries rather than an in-service injury. Thus, it is not clear that the examiner's opinion is based on a complete and accurate medical history. The opinion is inadequate to evaluate the claim. See Stefl, supra. The August 2021 examiner also opined the current left knee disability was less likely than not proximately due to or aggravated by bilateral pes planus. He noted the Veteran's service treatment records describe the Veteran's pes planus as being corrected by arch supports and as being asymptomatic. There was no evidence of any altered gait during active service. The examiner concluded the left knee would not have been used in any fashion to compensate or correct for pes planus during active duty. The examiner did not consider or discuss whether service-connected pes planus caused or aggravated a left knee disability at any time after active service. The examiner has not considered the Veteran's complete medical history and the opinion is inadequate to evaluate the claim. Id. 2. Entitlement to service connection for a right knee disorder, to include as secondary to a left knee disability and/or as secondary to service-connected bilateral pes planus, is remanded. The Veteran seeks entitlement to service connection for a right knee disability. An April 2017 examiner opined the right knee disability was caused by his left knee disability. Service connection is not yet established for a left knee disability and the claim as to the right knee remains intertwined with the left knee claim. See Harris v. Derwinski, 1 Vet. App. 180, 183(1991) (where a claim is inextricably intertwined with another claim, the claims must be adjudicated together). In August 2021, a VA examiner opined the right knee disability was less likely than not secondary to pes planus. In support he stated there was no indication of altered gait due to pes planus during the Veteran's active service and a compensatory mechanism of the right knee was not indicated. As the examiner did not consider the Veteran's entire medical history, which would include post-service interaction between pes planus and the right, knee, the opinion is inadequate to evaluate the claim. See Stefl, supra. The matters are REMANDED for the following action: 1. Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran's left knee disability is at least as likely as not related to in inservice twist injury during training in 1960 at Fort Gordon, in-service duties which required prolonged standing, and/or wearing boots which were stiffened with glue. In providing this opinion, the examiner must fully discuss the January 1980 pathology report which identifies an "old injury" to the left knee. If the examiner determines it is more likely than not that the "old injury" refers to something other than an in-service injury, he or she must provide a full rationale for this finding. Observing that the pathology report is not specific or definite in identifying the particular "old injury" is not sufficient to support attributing this "old injury" to a post service injury vs. the in-service injury. If the examiner finds it is equally likely the "old injury" was incurred in service or post service, he must resolve the issue in favor of the Veteran and find the "old injury" refers to an in-service injury. The examiner must also opine whether any left knee disability is proximately due to service-connected pes planus or aggravated beyond its natural progression by service-connected pes planus. The examiner must consider whether causation or aggravation occurred at any time, not just during the Veteran's active service. The opinion must address both causation and aggravation to be deemed adequate. Aggravation means an increase in the severity of the underlying disability beyond its natural progression. If aggravation is found, the clinician should attempt to quantify the degree of additional disability resulting from the aggravation. In providing these opinions, the examiner must review the entire claims file. He or she must specifically review and discuss the Veteran's assertions as to his left knee as expressed in January 2017 testimony before the Board, in October 2014 testimony before the RO, and in additional written statements (including January 2010, April 2012, November 2014, November 2014, March 2015, April 2015, January 2018, and September 2018.) The examiner is advised that the Veteran is competent to report his observable symptoms and his experience of seeking or receiving medical care. If the examiner dismisses any such competent report, a complete rationale for doing so must be provided. Simply noting that the Veteran's reports are not confirmed by contemporaneous medical records, without additional supporting rationale, will be insufficient to support a dismissal of the competent reports. All opinions expressed must be supported by a complete rationale. 2. Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran's right knee disability is proximately due to service-connected pes planus or aggravated beyond its natural progression by service-connected disability. The examiner must consider whether causation or aggravation occurred at any time, not just during the Veteran's active service. In other words, the examiner must consider whether the right knee disability was caused or aggravated by the pes planus at any point after service as well as at any point in service. The opinion must address both causation and aggravation to be deemed adequate. Aggravation means an increase in the severity of the underlying disability beyond its natural progression. If aggravation is found, the clinician should attempt to quantify the degree of additional disability resulting from the aggravation. In providing these opinions, the examiner must review the entire claims file. He or she must specifically review and discuss the Veteran's assertions as to his right knee as expressed in January 2017 testimony before the Board, in October 2014 testimony before the RO, and in additional written statements (including January 2010, April 2012, November 2014, November 2014, March 2015, April 2015, January 2018, and September 2018.) The examiner is advised that the Veteran is competent to report his observable symptoms and his experience of seeking or receiving medical care. If the examiner dismisses any such competent report, a complete rationale for doing so must be provided. Simply noting that the Veteran's reports are not confirmed by contemporaneous medical records, without additional supporting rationale, will be insufficient to support a dismissal of the competent reports. All opinions expressed must be supported by a complete rationale. M. HYLAND Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Jeanne Celtnieks 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.