Citation Nr: 21020971 Decision Date: 04/08/21 Archive Date: 04/08/21 DOCKET NO. 17-42 104 DATE: April 8, 2021 REMANDED Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD), unspecified anxiety disorder, unspecified neurocognitive disorder, and major depressive disorder, is remanded. Entitlement to service connection for a back disorder is remanded. Entitlement to service connection for a left knee is remanded. Entitlement to service connection for a right knee disorder is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Navy from October 1969 to May 1972. These matters come before the Board of Veterans’ Appeals (Board) on appeal from February 2015 and August 2015 rating decisions by the St. Petersburg, Florida Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified before the undersigned Veterans Law Judge in a March 2021 hearing regarding the issues on appeal. The claim of service connection for PTSD has been broadened and recharacterized in accordance with Clemons v. Shinseki, 23 Vet. App. 1 (2009), as there are multiple psychiatric diagnoses of record. 1. Entitlement to service connection for an acquired psychiatric disorder, to include PTSD, unspecified anxiety disorder, unspecified neurocognitive disorder, and major depressive disorder, is remanded. The Veteran contends psychiatric symptoms began during service and have continued since discharge from service. Specifically, the Veteran stated that he was assaulted by a fellow serviceman with a knife to the throat. The Veteran reported that he suffers from nightmares, flashbacks, recurring thoughts of trauma from active service, depression, anxiety, low energy, poor concentration, hyperarousal, irritability, chronic sleep difficulty, and disorientation. See March 2021, Board hearing; August 2014, VA Form 21-4138; VA treatment records dated April 2014, May 2014, and June 2014. VA treatment records include diagnoses of PTSD, major depressive disorder, and anxiety disorder with PTSD like symptoms. The Veteran was also prescribed Prozac and Seroquel to manage psychiatric symptoms. See VA treatment records dated April 2014, May 2014, and June 2014. In June 2015, a private physician reviewed the Veteran’s service treatment records, diagnosed PTSD, and found PTSD was caused by an in-service assault. It is unclear whether the private clinician relied upon the DSM-5 criteria to diagnose PTSD; accordingly, the Board is unable to rely on the PTSD diagnosis. See 38 C.F.R. § 4.125; June 2015, Private treatment record. In February 2015, a VA examiner diagnosed unspecified anxiety disorder and unspecified neurocognitive disorder but did not have the opportunity to consider the June 2015 positive private nexus opinion for PTSD or the Veteran’s March 2021 testimony; additionally, the VA examiner did not address the Veteran’s statements of continuity of psychiatric symptoms since discharge from service. The Board, accordingly, finds a new VA examination is warranted. 2. Entitlement to service connection for a back disorder is remanded. 3. Entitlement to service connection for a left knee is remanded. 4. Entitlement to service connection for a right knee disorder is remanded. The Veteran contends he injured his knees and back during service and has had continuous pain since discharge. Regarding his knees, the Veteran testified he received treatment for both knees from a private provider within six months after discharge from service and continued to receive treatment for the next four or five years, but those records are no longer available. The Veteran stated knee pain tends to develop after prolonged sitting and is markedly worse when climbing stairs. He further stated back pain runs from his buttocks up the right side of his back, radiates into the right leg, and is aggravated with lifting, especially if he does not lift with his legs. See March 2021, Board hearing; January 2018, VA Form 9; April 2014, VA treatment record. In light of the evidence presented, including the Veteran’s competent and credible report of continuous pain in his knees and back since discharge from service, the Board finds that the “low threshold” requirement under McLendon v. Nicholson, 20 Vet. App. 79 (2006) is met, and the Veteran should be afforded a VA examination to determine the nature etiology of any current bilateral knee and back disorder, to include pain that causes functional impairment. See Saunders v. Wilkie, 886 F.3d 1356, 1368 (Fed. Cir. 2018) (holding pain alone could constitute a disability under 38 U.S.C. § 1110 when it results in functional impairment). The Board also notes that the claims file has VA treatment records through July 2015. On remand, any previously unobtained records should be associated with the claims file. The matters are REMANDED for the following action: 1. Obtain any outstanding VA treatment records since July 2015. 2. Notify the Veteran that he may submit lay statements from himself and from other individuals who have first-hand knowledge, and/or were contemporaneously informed of his in-service and post-service psychological, back, right knee and/or left knee problems. The Veteran should be provided an appropriate amount of time to submit this lay evidence. 3. Schedule a VA psychiatric examination (or telehealth interview, review of the record, etc. if an in-person examination is not feasible). The examiner must identify and determine the nature and etiology of any current psychiatric disorder, to include PTSD, major depressive disorder, unspecified anxiety disorder, and unspecified neurocognitive disorder. A diagnosis of PTSD must be ruled in or excluded. The examiner is to opine as to whether each diagnosed disorder is at least as likely as not related to an in-service injury, event, or disease. The examiner is to address the June 2015 positive private nexus opinion, Veteran’s statements that psychiatric symptoms began during service after being assaulted by a fellow serviceman with a knife to the throat and said symptoms have been continuous since discharge from service. 4. Schedule a VA examination (or telehealth interview, review of the record, etc. if an in-person examination is not feasible to determine the nature, onset, and etiology of any right knee, left knee and back disabilities, to include pain that causes functional impairment. The examiner must opine whether it is at least as likely as not that a current disability of the knees and back are related to an in-service injury, event, or disease. The examiner is to address the Veteran’s credible complaints of continuous pain in the knees and back since discharge from service and the Veteran’s report that he received treatment for bilateral knee pain within six months of discharge from service. The examiner should provide a detailed rationale for any opinion expressed. If an opinion cannot be rendered without resorting to speculation, the examiner should state why that is so. STEVEN D. REISS Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board S. Straughn, 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.