Citation Nr: 21077599 Decision Date: 12/30/21 Archive Date: 12/30/21 DOCKET NO. 16-11 934 DATE: December 30, 2021 REMANDED Entitlement to service connection for left knee condition is remanded. Entitlement to nonservice connected pension is remanded. REASONS FOR REMAND The Veteran had a period of active duty for training (ACDUTRA) from July 29, 1972 to January 27, 1973 with the United States Marine Corps Reserves. The Board note that the Veteran also had a period of ACDUTRA from August 4, 1973 to August 18, 1973. A September 2020 Board decision granted service connection for low back condition due to an injury that occurred during the August 1973 period of ACDUTRA; thus, veteran status is established for that period. In July 2021, the Board remanded the case for further development, to include a VA examination and medical opinion. Stegall v. West, 11 Vet. App. 268, 271 (1998). 1. Entitlement to service connection for left knee condition Once VA undertakes the effort to provide an examination, it must provide an adequate one. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). In July 2021 the Board remanded for a VA examination to identify the Veteran's left knee conditions and provide a medical opinion on the nature and etiology of any diagnosed conditions as the opinion of record was inadequate. The Veteran attended a VA examination in August 2021. The examiner only provided a diagnosis of patellofemoral pain syndrome and reported that no diagnostic studies were performed in conjunction with the examination. The examiner opined that a nexus for patellofemoral pain syndrome is not established as the record is silent for other diagnosis, complaints, or chronicity of care related to the knee during military service or after military service and there is no diagnosis or x-ray to substantiate any diagnosis manifesting within a year of discharge from service. The Board finds this opinion inadequate as it again relies on the absence of evidence and fails to consider the appellant's reports of symptoms and medical history reflecting complaints of knee pain and arthritis of the patella. See Fountain v. McDonald, 27 Vet. App. 258, 272-75 (2015) (indicating that a VA examiner may not generally rely on the absence of evidence as negative evidence). An addendum opinion was obtained in August 2021. The examiner opined that while the images from October 2013 may have found arthritis of the patella, it is less likely than not related to service as there is no credible medical evidence to support development of arthritis after one acute knee strain. The examiner deemed the Veteran's reports of symptoms credible but concluded that arthritis was more likely due to the cumulative effect of wear and tear over the years as it is a common condition in most adult over the age of 50, as opposed to a minor event that occurred while on active duty, noting the diagnosis was confirmed 40 years after service. The Board also finds this opinion inadequate as the rationale is conclusory. The examiner finds the Veteran's lay statements credible and cites a medical article that lists joint injury as well as aging as a risk factor for osteoarthritis but concludes there is no credible medical evidence to support the development of arthritis. A medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. See Nieves- Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). Furthermore, the examiner's findings are inconsistent with the VA examination report as the examiner did not provide a diagnosis of arthritis or conduct diagnostic testing to confirm an arthritis diagnosis. 2. Entitlement to nonservice connected pension Currently, the Veteran is not service connected for any disabilities stemming from his period of ACDUTRA from July 29, 1972 to January 27, 1973. However, if it is determined that the Veteran was disabled from an injury to the left knee incurred in the line of duty during ACDUTRA and achieves "veteran" status for that period, he will have the requisite service necessary to demonstrate entitlement to nonservice-connected pension benefits given that his ACDUTRA period falls within a period of war. Thus, because a decision on the remanded claim of service connection for a left knee disability could significantly impact a decision on the issue of entitlement to nonservice-connected pension benefits, the issues are inextricably intertwined. A remand of the claim for nonservice-connected pension benefits is required. The matters are REMANDED for the following action: 1. Obtain updated VA and/or private treatment records. If such records are unavailable, the Veteran's claim file must be clearly documented to that effect and the Veteran notified in accordance with 38 C.F.R. § 3.159(e). 2. Schedule the Veteran for a VA examination for his left knee disability. Appropriate evaluations, studies, and testing, such as x-rays should be conducted, and the results included in the examination report. The examiner must review the claims file. The examiner should identify or diagnose each left knee disability, to include arthritis of the patella. If a diagnosis cannot be provided but the Veteran's condition manifests in symptoms that cause functional impairment, then the examiner should consider them a "disability" for the purpose of providing the requested opinion(s) below. The examiner is asked to provide a response to the following for each identified condition: Is it at least as likely as not that the Veteran's left knee disability (1) began during or is otherwise related to active service, to include a period of ACDUTRA, including a diagnosis of left knee strain in December 1972, (2) manifested (i.e., arthritis) within one year after discharge from service, or (3) was noted during service with continuity of the same symptomatology since service? The examiner must consider and address the following: 1) the Veteran's description of his in-service injury and symptoms as well as his post-service symptoms; and 2) the medical treatment records reflecting complaints of left knee arthritis in May 2009 and an October 2013 imaging study of arthritis of the left patella. In providing the requested opinion, consider the Veteran's description of his in-service injury and symptoms as well as his post-service symptoms. Stated another way, do the Veteran's reports about his symptoms align with how the currently diagnosed disability is known to develop or are the Veteran's reports generally inconsistent with medical knowledge or implausible? The opinion and rationale must go beyond a generalized statement that a review of medical literature does not support the Veteran's claim. The rationale should reflect the specific facts and medical principles specific to the Veteran's claim. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. A complete rationale containing clear conclusions with supporting data and a reasoned medical explanation connecting the two is required for all medical opinions. The examiner should also identify and explain the relevance or significance, as appropriate, of any history, clinical findings, medical knowledge, or literature, etc., relied upon in reaching the conclusion(s). If the medical professional cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation for why an opinion cannot be rendered. In so doing, the medical professional shall explain whether the inability to provide a more definitive opinion is the result of a need for additional information, or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question(s). 3. After completing the above, and any other development as may be indicated, the Veteran's claims should be readjudicated based on the entirety of the evidence. If the claims remain denied, the Veteran and his representative should be issued a supplemental statement of the case (SSOC). An appropriate period of time should be allowed for response. Thereafter, the case should be returned to the Board for further appellate consideration, if otherwise in order. G. A. WASIK Veterans Law Judge Board of Veterans' Appeals Attorney for the Board S. A. Prinsen 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.