Citation Nr: 21013312 Decision Date: 03/09/21 Archive Date: 03/09/21 DOCKET NO. 16-00 785 DATE: March 9, 2021 REMANDED Entitlement to service connection for a left knee disorder, to include as secondary to service-connected lumbar strain, bilateral shin splints, and status post left ankle fracture, is remanded. Entitlement to service connection for a right knee disorder, to include as secondary to service-connected lumbar strain, bilateral shin splints, and status post left ankle fracture, is remanded. REASONS FOR REMAND The Veteran served honorably in the United States Army from May 2003 to May 2006, including foreign service. She was awarded (among other decorations) the Army Service Ribbon and the Global War on Terrorism Service Medal. This appeal comes to the Board of Veterans’ Appeals (Board) from a May 2014 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). In September 2018, the Board remanded the issues for further development. See Stegall v. West, 11 Vet. App. 268, 271 (1998). Of note, the Veteran has been in receipt of the combined maximum evaluation since July 29, 2016. As such, any future awards of service connection or higher ratings will bear no impact on her compensation payments. 1. Entitlement to service connection for a left knee disorder, to include as secondary to service-connected lumbar strain, bilateral shin splints, and status post left ankle fracture, is remanded. 2. Entitlement to service connection for a right knee disorder, to include as secondary to service-connected lumbar strain, bilateral shin splints, and status post left ankle fracture, is remanded. Although the Board sincerely regrets the additional delay this will cause, further development is necessary prior to the adjudication of these appeals. The Veteran was afforded a VA examination and medical opinion for her knees in October 2019. The VA examiner diagnosed the Veteran with bilateral patellofemoral pain syndrome. During her examination, the Veteran reported that in 2005, she began to have pain on and off in her knees, but she had more pain towards the end of service. She had cracking in her knees and was informed that they were related to her back. The October 2019 VA examiner opined that the Veteran’s bilateral knees were less likely than not incurred in or caused by her military service. Based on review of the medical records, there was no supporting information found that the left knee or right knee condition began during service. It was acknowledged that there was a record of multiple joint pain complaints in June 2003; however, the bilateral knee exam at the time was unremarkable. There were no further records during active service showing left knee or right knee complaints. A post-service April 2007 record shows a history of tibia/fibular and shin splints during service; however, there was no diagnosis or records found to show chronicity from service. There were no records of left knee or right knee injuries during active service to correlate the post service knee complaints. The VA examiner concluded that the current bilateral knee disorders were less likely than not related to service. The October 2019 VA examiner also opined that the Veteran’s bilateral knee disorder was less likely than not proximately due to or the result of the Veteran’s service-connected back disorder. Based on a review of the medical records, it was acknowledged that the Veteran had a long history of back complaints; however, there was no evidence severe enough to state it had altered the mechanism of locomotion causing the right knee or left knee condition. The Veteran also had records of a right knee meniscus tear not related to the back condition. There was no record showing the back condition caused the right knee or left knee problems. The Veteran’s current bilateral knee disorder was less likely than not caused by or aggravated by the Veteran’s service-connected lumbar strain. The Veteran’s bilateral knee disorder was not at least as likely as not aggravated beyond its natural progression by her back condition. The VA examiner explained that there were no records found to state the right knee or left knee was aggravated by the service-connected back condition. The severity of the Veteran’s back condition could not be correlated to the severity of the current right knee or left knee condition The October 2019 medical opinion is inadequate. First, the VA examiner did not address the Veteran’s lay statements of in-service knee pain and incorrectly relied on the absence of in-service medical evidence in forming a negative medical opinion. Second, a January 2006 radiologic examination report in the Veteran’s service treatment records found that there was diffuse uptake within the Veteran’s knees, and ankles bilaterally consistent with stress-related changes. This finding was not addressed in the October 2019 medical opinion. Additionally, the VA examiner did not fully address how the nature of the Veteran’s service-connected lumbar strain impacted her bilateral knee disorder. Moreover, the VA examiner should also have addressed whether the Veteran’s bilateral knee disorder was secondary to her service-connected bilateral shin splints and status post left ankle fracture. The Veteran’s medical records revealed reports of knee pain along with ankle pain and shin splints. Thus, the Board finds that a secondary opinion should be provided because there is a possibility that the Veteran’s bilateral knee disorder could have been affected by her service-connected bilateral shin splints and left ankle disorder. Therefore, a remand is warranted to obtain an adequate VA medical opinion that addresses these matters. The matters are REMANDED for the following action: Obtain a VA addendum medical opinion regarding the nature and etiology of the Veteran’s right knee disorder and left knee disorder. If an opinion cannot be rendered without an examination, then an examination should be scheduled for the Veteran. A copy of this remand and claims file must be reviewed. The VA examiner should address the following: (1) Is it at least as likely as not that the Veteran’s right knee disorder and/or left knee disorder is related to her military service? The VA examiner must discuss the following: (a) The Veteran’s lay statements regarding complaints of in-service knee pain and pain continuing after service; (b) A January 2006 radiological examination report notating that the Veteran had stress-related changes in both knees. See STR notation dated January 25, 2006. (c) A June 2003 service treatment screening note showing that the Veteran complained of multiple joint pain, including pain in his knees. (a.) Is it at least as likely as not that the Veteran’s right knee disorder and/or left knee disorder is proximately due to, caused by, and/or aggravated (beyond its natural progression) by her service-connected lumbar strain, bilateral shin splints, and/or status post left ankle fracture? Here, the VA examiner must discuss the nature of the Veteran’s lumbar strain, bilateral shin splints, and status post left ankle fracture and whether these disabilities affected the Veteran’s bilateral knee disorder. Relevant current treatment records should be discussed. In formulating the opinions, the examiner is advised that the term “at least as likely as not” does not mean “within the realm of possibility.”  Rather, it means that the weight of the medical evidence for and against the claim is so evenly divided that it is as medically sound to find in favor of the claim as it is to find against it. All opinions must be supported by a sufficient rationale. A negative opinion cannot be solely based on a lack of medical evidence. Kate E. Kovarovic Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Crawford, 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.