Citation Nr: 21011855 Decision Date: 03/02/21 Archive Date: 03/02/21 DOCKET NO. 16-34 837 DATE: March 2, 2021 REMANDED Entitlement to service connection for right knee condition, to include as secondary to the service-connected left ankle condition and left lower extremity restless leg syndrome condition is remanded. REASONS FOR REMAND The Veteran served on active duty from April 1962 to April 1964, with additional National Guard/Reserve service from April 1964 to March 1969. This matter is before the Board of Veterans’ Appeals (Board) on appeal from a September 2016 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). The Board issued prior remands in this case in October 2018, November 2019, and September 2020. 1. Entitlement to service connection for right knee condition, to include as secondary to the service-connected left ankle condition and left lower extremity restless leg syndrome condition is remanded. The Veteran's right knee has been diagnosed with right knee degenerative arthritis. The Veteran contends that his right knee condition is secondary to his service-connected left ankle condition. In the September 2020 Board remand, the RO was instructed to provide the Veteran with an addendum opinion for his right knee condition from an orthopedic specialist who is a Doctor of Medicine (M.D.) addressing the Veteran’s contention that his altered gait is to such a degree that it caused him to compensate with the right leg due to the condition of his left ankle which caused his right knee disability; a July 2016 VA treatment record that noted the Veteran reported he fell due to his left ankle instability; and a July 2016 VA treatment record that noted the Veteran’s gait impairment is secondary to his left ankle. In the October 2020 VA examination, the RO requested opinions for a right knee condition secondary to left ankle and left lower extremity restless leg syndrome conditions. The examiner opined that the Veteran’s right knee condition is less likely than not proximately due to or the result of the Veteran’s service-connected left ankle condition. The examiner further opined that the Veteran’s right knee condition is not at least as likely as not aggravated beyond its natural progression by the Veteran’s service-connected left ankle condition. The examiner noted the Veteran's VA treatment records since 2006 are silent for right knee pain until 2016. This is remote from his ankle injury and subsequent surgery. The treatment records prior to the Veteran's knee surgery consistently report his right knee pain was atraumatic in onset, through multiple reports to include the ER visit, orthopedic consults, and MRI request. It was not until several months later (July 2016) when he began his claim that the Veteran began to attribute his knee condition to his ankle. There is no indication in the file of a fall leading up to his development of right knee pain. Although there are treatment notes in the file from July 2016 from Podiatry indicating a fall was sustained months prior, this is not substantiated in the treatment notes documented at the time of the Veteran's care surrounding his right knee, with treatment notes from February and March of 2016 indicating atraumatic onset of right knee pain.” However, the examiner did not address the February 2016 VA Podiatry note where the Veteran reported “last week he was walking without the brace and fell awkwardly and hurt his right knee, and that is causing him more concern than his ankle at this time.” Thus, the opinion was based on an inaccurate factual premise. A remand is necessary to obtain a new VA medical opinion. Second, the examiner opined that the Veteran’s right knee condition is less likely than not proximately due to or the result of Veteran’s service-connected left lower extremity restless leg syndrome. The examiner noted there is “no medical connection between restless leg syndrome (Movement of legs during sleep) and development of arthritis in the opposite limb. There is no nexus between the conditions.” The Board finds this opinion inadequate. Of note, there was no opinion made regarding aggravation. On remand, an addendum opinion should be obtained. The matters are REMANDED for the following action: 1. Obtain an addendum opinion for the claimed right knee condition from an orthopedic specialist who is a Doctor of Medicine (M.D.) (return the report to the October 2020 examiner). The claims folder must be provided to the examiner for review. After a review of the claims file, the examiner should opine as to whether it is at least as likely as not (i.e., 50 percent or greater probability): (a) that the Veteran's right knee condition, is CAUSED or AGGRAVATED (beyond a natural progression) by his service-connected left ankle condition; or, (b) that the Veteran's right knee condition, is AGGRAVATED (beyond a natural progression) by his service-connected left lower extremity restless leg syndrome condition. The examiner should consider (1) the Veteran’s contention that his altered gait is to such a degree that it caused him to compensate with the right leg due to the condition of his left ankle which caused his right knee condition; (2) a February 2016 VA treatment record that noted the Veteran reported “he was walking without the brace and fell awkwardly and hurt his right knee”; and (3) a July 2016 VA treatment record that noted the Veteran’s gait impairment is secondary to his left ankle instability. Are any of the diagnosed conditions of the right knee consistent with the mechanisms of injury claimed by the Veteran? All opinions should be supported by a clear rationale, and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. TANYA SMITH Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Edwin B. Esmenda, 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.