Citation Nr: 21012267 Decision Date: 03/04/21 Archive Date: 03/04/21 DOCKET NO. 16-22 679 DATE: March 4, 2021 REMANDED Entitlement to service connection for a right knee disability is remanded. REASONS FOR REMAND The Veteran served on active duty from January 1988 to May 1988. He has additional service in the Army Reserves, the Army National Guard, the Air Force National Guard, and the Air Force Reserves. This matter is before the Board of Veterans’ Appeals (Board) on appeal of a March 2015 rating decision of a Regional Office (RO) of the Department of Veterans Affairs (VA). In July 2019, the Veteran testified at a hearing before the undersigned. In February 2020, the Board remanded the claim for additional development. 1. Entitlement to service connection for a right knee disability 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). Under the duty to assist, VA must make reasonable efforts to assist the Veteran in obtaining outstanding relevant private treatment records. See 38 U.S.C. § 5103A; 38 C.F.R. § 3.159(c); see also Sullivan v. McDonald, 815 F.3d 786 (Fed. Cir. 2016). When there has been a determination regarding SSA benefits, the records concerning that decision must be obtained, if relevant. Tetro v. Gober, 14 Vet. App. 100, 108-09 (2000); Murincsak v. Derwinski, 2 Vet. App. 363, 372 (1992). In cases where VA is uncertain as to the relevance of the records, VA should be guided by the principles underlying the pro-claimant VA system. See Golz v. Shinseki, 590 F.3d 1317, 1323 (Fed. Cir. 2010). The Veteran seeks service connection for a right knee disability. As noted in the Board’s prior remand, the Veteran testified that he injured his right knee in March 2000 while participating in a training run during a period of weekend reserve service. Service treatment records include a document labeled “DD Form 1380” and “U.S. Field Medical Card.” This card reflects a right knee injury on Sunday, March 5, 2000. Following the Board’s February 2020 remand, documents confirming the Veteran’s participation in Inactive Duty Training (INACDUTRA) on March 5, 2000 were added to the claims file. In September 2020, a VA knee conditions examination was provided. The examiner described the Veterans “long history of right knee pain” and diagnosed right knee strain, right knee meniscal tear, and right knee degenerative arthritis. She noted right knee pain was onset following the March 2000 fall and the Veteran “underwent arthroscopy in the early 2000s.” She observed prior treatment included a 2017 meniscal surgery, physical therapy, aqua therapy, steroid injections, PRP (platelet-rich plasma) injections, and used a TENS (transcutaneous electrical nerve stimulation) unit. The examiner opined the Veteran’s current knee conditions were less likely than not causally related to the March 2000 fall. In support of this opinion, she observed the service treatment records included a March 2002 medical examination which did document any report of right knee problems. She also explained that the VA treatment records included the Veteran’s reports that his right knee injury was incurred in March 2000, but the claims file did not include any private medical records to “validate” the March 2000 injury. The examiner did not discuss the March 2000 “ U.S. Field Medical Card,” indicating a March 5, 2000 right knee injury. Accordingly, it is not clear that the examiner fully considered the Veteran’s medical history. Also, it appears that the examiner dismissed the Veteran’s reports of a March 2000 fall, with continuing knee pain, based on the lack of contemporaneous medical records. This etiology opinion is inadequate to evaluate the claim. See Stefl, supra; see also Dalton v. Nicholson, 21 Vet. App. 23, 39-40 (2007); Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) (that reports of symptomatology are not supported by contemporaneous clinical evidence does not render them inherently not credible). Further, it appears there may be outstanding private medical records which are relevant to the Veteran’s claim. The Veteran submitted a January 2015 return to work note from his private physician,Dr. D. C. This note indicates Dr. D. C. has treated the Veteran since March 5, 2000. No other records from Dr. D. C. are included in the claims file. The Veteran also submitted a partially redacted December 2014 letter from Dr. A. C., which refers to additional treatment from a different physician. The file also includes the Veteran’s reports of continuing treatment with Dr. G. O. however the only records included in the claims file from Dr. G. O. are a November 2016 MRI report and scheduling, discharge instructions, and billing documents related to a February 2017 surgery. VA medical records from May 2020, include the Veteran’s report that he continues to receive treatment from a private orthopedist. Additional attempts to assist the Veteran in obtaining outstanding relevant private treatment records are required. See 38 U.S.C. § 5103A; 38 C.F.R. § 3.159(c). Finally, an April 2020 Social Security Administration (SSA) inquiry is of record. This inquiry indicates the Veteran may be receiving SSA payments based on disability. As records associated with the SSA claim may be relevant to the issue now before the Board, VA must obtain the outstanding records. Id. The matters are REMANDED for the following action: 1. Obtain the Veteran’s disability records from the Social Security Administration, to include any medical records upon which any application for disability was decided. Document all requests for information as well as all responses in the claims file. 2. Ask the Veteran to complete a VA Form 21-4142 for any medical professional who may have records relevant to this claim, including Dr. G. O, Dr. A. C., Dr. D. C, and any medical facility or hospital, which may have records related to knee surgery or other knee treatment. Make two requests for the authorized records from any medical professional or medical facility identified, unless it is clear after the first request that a second request would be futile. 3. Following efforts to obtain additional supporting documentation, schedule the Veteran for a VA examination for his right knee condition. The examiner must review the claims file. The examiner is asked to provide a response to the following: Is any right knee disability at least as likely as not related to service, including a March 5, 2000 fall while running? The examiner must specifically discuss the March 2000 U.S. Field Medical Card included in the service treatment records in providing this opinion. Is it at least as likely as not that the any right knee arthritis (1) began during active service, (2) manifested within one year after discharge from service, or (3) was noted during service with continuity of the same symptomatology since service? The examiner must provide a comprehensive rationale for each opinion provided. The examiner is advised that the Veteran is competent to report his symptoms and history, and such reports are to be considered in formulating any opinion. If the examiner rejects any report from the Veteran, a rationale for doing so must be provided. The absence of contemporaneous medical records, without additional explanation, is not a sufficient reason to dismiss these reports. 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.