Citation Nr: 21075802 Decision Date: 12/21/21 Archive Date: 12/21/21 DOCKET NO. 17-50 691 DATE: December 21, 2021 REMANDED Entitlement to service connection for a neck disability, to include as secondary to service-connected back disability, is remanded. Entitlement to service connection for a right knee disability, to include as secondary to service-connected back disability, is remanded. Entitlement to service connection for a left knee disability, to include as secondary to service-connected back disability, is remanded. Entitlement to service connection for a right ankle disability, to include as secondary to service-connected back disability, is remanded. Entitlement to service connection for a left ankle disability, to include as secondary to service-connected back disability, is remanded. Entitlement to a rating in excess of 40 percent for osteoarthritis of the dorsal and lumbar spine (back disability) is remanded. REASONS FOR REMAND The Veteran had active service from June 1969 to July 1970. These matters are before the Board of Veterans' Appeals (Board) on appeal from a rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). These matters were last before the Board in October 2020, when they were remanded for additional development. 1. Entitlement to service connection for a neck disability, to include as secondary to service-connected back disability, is remanded. 2. Entitlement to service connection for a right knee disability, to include as secondary to service-connected back disability, is remanded. 3. Entitlement to service connection for a left knee disability, to include as secondary to service-connected back disability, is remanded. 4. Entitlement to service connection for a right ankle disability, to include as secondary to service-connected back disability, is remanded. 5. Entitlement to service connection for a left ankle disability, to include as secondary to service-connected back disability, is remanded. 6. Entitlement to a rating in excess of 40 percent for osteoarthritis of the dorsal and lumbar spine (back disability) is remanded. In a January 2019 statement the Veteran reported that he injured his knees in 1969 when a truck in the motor pool slipped out of gear and pinned him against another truck. He reported that because of his injuries he had to work as a supply clerk rather than in his military occupational specialty as an infantryman. At his December 2020 VA cervical spine examination, he reported that he also injured his neck during the 1969 incident. He noted that because of his injuries he was given a light duty profile for two weeks. The service treatment records associated with the claims file do not document his reported injury or light duty profile. Additionally, his service personnel records have not been obtained. As the Veteran reported that his in-service duties changed following his injury, his service personnel records may corroborate the reported incident. On remand, reasonable efforts should be made to obtain the Veteran's service personnel records. The evidence indicates there may be outstanding relevant VA treatment records. A January 27, 2021 VA treatment record indicates that the Veteran was to return for a follow up appointment in July 2021. VA treatment records subsequent to March 2021 have not been associated with the claims file. Additionally, on an August 1970 VA Form 21-526, the Veteran reported that he received treatment at the VA hospital as early as January 1970. While the record contains a VA hospital summary noting that the Veteran was admitted from October 1, 1970 to October 14, 1970, the associated inpatient treatment records have not been obtained. Additionally, while the Veteran reported ongoing VA treatment since 1970 there are no VA records from October 15, 1970 to May 10, 1993 associated with the claims file. As the Veteran reported ongoing VA treatment and the earliest VA treatment record from May 10, 1993 notes that it was a follow up appointment, there appear to be outstanding VA records from October 15, 1970 until May 10, 1993. Additionally, there are VistA Imaging records that have not been associated with the claims file. VA treatment records from September 16, 2014 indicate that "HBPC" records from August 20, 2014 were scanned into VistA Imaging. A December 27, 2016 VA record indicates that an October 21, 2016 non-VA record was scanned into VistA Imaging. A September 29, 2016 VA record indicates that a September 1, 2016 non-VA record was scanned into VistA Imaging. A May 11, 2016 VA record indicates that an April 25, 2016 non-VA record was scanned into VistA Imaging. A July 19, 2017 VA record indicates that a July 11, 2017 non-VA record was scanned into VistA Imaging. VA records from January 8, 2018, May 29, 2018, June 14, 2018 indicate that an October 16, 2017 non-VA record was scanned into VistA Imaging. A June 21, 2018 VA record indicates that a May 1, 2018 non-VA record was scanned into VistA Imaging. A July 11, 2018 VA record indicates that a non-VA record from July 5, 2018 had been scanned into VistA Imaging. An October 16, 2018 VA record indicates that a September 26, 2018 non-VA record was scanned into VistA Imaging. An October 22, 2108 VA record indicates that an October 6, 2017 non-VA record was scanned into VistA Imaging. A March 27, 2019 record indicates that an October 1, 2017 VA record was scanned into VistA Imaging. VA records from June 21, 2019 indicate that non-VA records from April 4, 2019 and February 14, 2019 were scanned into VistA Imaging. A November 12, 2019 VA record indicates that an October 14, 2019 was scanned into VistA Imaging. VA records from July 18, 2020 and August 26, 2020 indicate that non-VA records from April 14, 2020 were scanned into VistA Imaging. An August 31, 2020 VA record indicates that non-VA records from August 3, 2020 were scanned into VistA Imaging. It does not appear that the referenced records have been associated with the claims file. A remand to obtain them is required. The record also indicates that there are outstanding private treatment records. VA treatment records from April 10, 2019, April 15, 2019, and April 26, 2019 indicate that the Veteran received treatment at Harris Emergency Room and The Orthopedic and Sports Medicine Institute for his ankle and knee. These records have not been requested or otherwise obtained. On remand, reasonable efforts should be made to obtain them. The October 2020 remand requested addendum opinions addressing whether the Veteran's neck disability was related to his service-connected back disability. An opinion was obtained in March 2021. In addressing aggravation, the examiner stated that the Veteran's neck disability was not aggravated beyond its natural progression by his service-connected back disability because there was no medical literature to support "a causal relationship." As the examiner's rationale addressed causation not the aggravation, an addendum opinion is required. The October 2020 remand requested addendum opinions addressing whether the Veteran's knee disabilities were related to his service-connected back disability. While opinions were obtained in March 2021, the examiner's rationale regarding the aggravation prong of secondary service connection addressed direct service connection. Specifically, the examiner stated that there was no evidence of aggravation because the Veteran did not suffer any knee injury after he got pinned between trucks during service. Therefore, an addendum opinion is required. The October 2020 remand requested an addendum opinion to address the Veteran's ankle claims. While opinions were obtained in March 2021, the examiner did not acknowledge or address January 3, 2013 radiology report noting a diagnosis of bilateral ankle arthritis or the August 19, 2020 record noting a history of a right ankle fracture. Additionally, as the examiner did not acknowledge the diagnosis of ankle arthritis the examiner did not, as requested, opine whether it was at least as likely as not that the arthritis manifested within one year following the Veteran's separation from service. Accordingly, further clarification is required. The matters are REMANDED for the following actions: 1. Ask the Veteran to provide the names and addresses of all medical care providers who have recently treated him for his claimed disabilities, including Harris Emergency Room and The Orthopedic and Sports Medicine Institute. After securing any necessary releases, request any relevant records identified. In addition, obtain all inpatient treatment records from the Veteran's October 1, 1970 to October 14, 1970 hospitalization at Shreveport VA Medical Center, all VA treatment records dated from October 15, 1970 until May 10, 1993, updated VA treatment records dated since March 3, 2021, as well as the VistA Imaging records referenced in the September 16, 2014, December 27, 2016, September 29, 2016, May 11, 2016, July 19, 2017, January 8, 2018, May 29, 2018, June 14, 2018, June 21, 2018, July 11, 2018, October 16, 2018, October 22, 2108, March 27, 2019, June 21, 2019, November 12, 2019, July 18, 2020, August 26, 2020, and August 31, 2020 VA record entries. If any such records are determined to be unavailable, issue a formal finding of unavailability and notify the Veteran of this fact. 2. Obtain the Veteran's complete service personnel and service treatment records, including treatment related to his reported injury in 1969 and his reported light duty profile. All efforts to obtain these records must be documented in the claims file. If any such records are determined to be unavailable, issue a formal finding of unavailability and notify the Veteran of this fact. 3. After records development is completed to the extent possible, forward the claims file to a VA clinician to obtain an addendum opinion regarding the Veteran's neck disability claim. If an examination is deemed necessary to respond to the questions presented, one should be scheduled. Following review of the claims file, the clinician should opine whether it at least as likely as not that the Veteran's cervical spine is worsened beyond natural progression (aggravated) by his service-connected back disability? If the clinician finds that the Veteran's neck disability was aggravated by his service-connected back disability, the clinician should attempt to quantify the level of aggravation beyond the baseline level of the neck disability. A complete rationale should be provided for all opinions and conclusions expressed. 4. After records development is completed to the extent possible, forward the claims file to a VA clinician to obtain an addendum opinion regarding the Veteran's right and left knee claims. If an examination is deemed necessary to respond to the questions presented, one should be scheduled. Following review of the claims file, the clinician should opine whether it at least as likely as not that any right and left knee disability is worsened beyond natural progression (aggravated) by his service-connected back disability? If the clinician finds that the Veteran's right and left knee disability was aggravated by his service-connected back disability, the clinician should attempt to quantify the level of aggravation beyond the baseline level of the neck disability. A complete rationale should be provided for all opinions and conclusions expressed. 5. After records development is completed to the extent possible, forward the claims file to a VA clinician to obtain an addendum opinion regarding the Veteran's right and left ankle claims. If an examination is deemed necessary to respond to the questions presented, one should be scheduled. Following review of the claims file, the clinician should opine: (a.) Whether it is at least as likely as not (50 percent probability or greater) that any right or left ankle disability had its onset during service or is otherwise related to service, to include the reported accident in 1969 wherein he was pinned between two trucks. (b.) Whether it is at least as likely as not (50 percent probability or greater) that the any right or left ankle disability was caused by the service-connected back disability? (c.) If not caused by the service-connected back disability, is it at least as likely as not that any right or left ankle disability is worsened beyond natural progression (aggravated) by his service-connected back? If the clinician finds that the Veteran's right or left ankle disability was aggravated by his service-connected back disability, the clinician should attempt to quantify the level of aggravation beyond the baseline level of the disability. In so opining, the clinician should address the January 3, 2013 radiology report noting a diagnosis of bilateral ankle arthritis and the August 19, 2020 record noting a history of a right ankle fracture. (d.) For the documented diagnosis of ankle arthritis, state whether it at least as likely as not (50 percent probability or greater) that the disability, if diagnosed as arthritis, manifested within one year following separation from service? A complete rationale should be provided for all opinions and conclusions expressed. 6. If additional records are obtained corroborating the Veteran's assertions regarding an incident in 1969 where he was pinned between two trucks, obtain addendum opinions addressing whether the Veteran's neck disability or right and left knee disabilities had their onset during service or are otherwise related to service, to including any documented incident where he was pinned between two trucks. A complete rationale should be provided for all opinions and conclusions expressed. K. A. BANFIELD Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Anderson 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.