Citation Nr: 21022861 Decision Date: 04/19/21 Archive Date: 04/19/21 DOCKET NO. 15-28 683 DATE: April 19, 2021 REMANDED Entitlement to service connection for a left knee disability, to include as secondary to service-connected right knee disability is remanded. REASONS FOR REMAND The Veteran served in the U.S. Navy from July 1968 to January 1972. The Veteran contends that he is entitled to service connection for a left knee disability. This case comes before the Board of Veterans' Appeals (Board) on appeal from a September 2014 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). This appeal was first before the Board in February 2019, at which time the Board observed that the September 2014 VA medical opinion was inadequate in that the examiner did not provide an opinion addressing the Veteran’s contention that he overcompensated with his left knee due to his service-connected right knee disability. The Board remanded the issue to obtain an adequate VA medical opinion on the issue of secondary service connection to include whether there is aggravation of the nonservice-connected left knee disability by the service-connected right knee. In December 2019, a VA examiner provided a medical opinion on secondary service connection. The case was returned to the Board in August 2020, at which time the Board found that the December 2019 VA medical opinion did not provide a supporting rationale for the opinion on aggravation. The Board also found that neither of the previous VA medical opinions addressed the Veteran’s contention regarding obesity resulting from his right knee disability. Thus, the Board remanded the matter for a new VA medical opinion addressing these issues. In September 2020, a VA examiner provided a medical opinion concerning the Veteran's left knee disability. While the VA examiner stated that he reviewed the article from 2005 from American College of Rheumatology, he did not discuss the study in the opinion, as had been specifically requested by the August 2020 Board remand directives. Additionally, while the examiner provided an opinion that the Veteran’s left knee was less likely than not aggravated by his right knee disability, the rationale provided is inadequate. The examiner appears to base part of his rationale on a finding that the Veteran’s bilateral knee disabilities are most likely due to aging and being overweight and thus it is not clear that the examiner understood that the Veteran’s right knee disability is service-connected. The examiner stated that the right knee injury in service would not create severe degeneration in the right knee equal to the left knee and then confusingly stated that the right knee injury created advanced degeneration and that the left knee would not have similar levels of degeneration except for aging and the routine nature of carrying too much weight. The examiner concluded by stating that the specific injury to the right knee 50 years ago would not support a degeneration nexus in the left knee. This rationale is inadequate as the examiner does not adequately explain their finding that the Veteran’s left knee disability was not aggravated by his right knee disability. The examiner also opined that it is less likely than not that the Veteran’s obesity is caused by his right knee disability. The examiner explained that obesity is a complex medical condition that does not have a nexus with healed meniscal injury at age 23. He stated that a meniscal injury that has healed would not preclude exercise and would not explain the caloric intake it requires to become obese. This rationale is inadequate as it is based on the inaccurate factual premise that the Veteran’s service-connected right knee disability consists merely of a “healed meniscus injury” instead of his actual service-connected right knee disability which is status post total knee arthroplasty. Accordingly, the Board finds that the September 2020 medical opinion does not substantially comply with the Board's August 2020 remand directives. See Stegall v. West, 11 Vet. App. 268 (1998). As such, the Board finds that remand is required in order to obtain a new VA medical addendum opinion that complies with the August 2020 Board remand. On remand, the Board also finds that any outstanding VA treatment records should also be obtained. See 38 U.S.C. § 5103A(b), (c); 38 C.F.R. § 3.159(b); see also Sullivan v. McDonald, 815 F.3d 786 (Fed. Cir. 2016); Bell v. Derwinski, 2 Vet. App. 611 (1992). The matters are REMANDED for the following action: 1. Obtain any outstanding available VA medical records concerning the Veteran that have not yet been associated with the claims file. 2. After any outstanding VA treatment records have been added to the claims file, ask an appropriate examiner who has not previously participated in this decision to provide a medical opinion concerning the nature and etiology of the Veteran's left knee disability. The necessity of an in-person examination, with any appropriate testing, is left to the discretion of the examiner. The entire claims file must be made available to and reviewed by the examiner in conjunction with the medical opinion. The examiner should specifically list all of the evidence that they considered in rendering their opinion, to specifically include the noted documents below. The examiner should opine as to whether the Veteran's left knee disability at least as likely as not was (a) caused by; or, (b) aggravated (i.e., worsened) by his service-connected right knee disability, to include any abnormal gait/weightbearing as a result of that disability. The examiner is reminded that he or she must address both prongs (a) and (b) above. In so addressing this secondary aspect, the examiner should specifically review and discuss the September 2005, American College of Rheumatology article: Secondary gait changes in patients with medial compartment knee osteoarthritis: increased load at the ankle, knee, and hip during walking. The examiner must discuss this article in his/her opinion and rationale. Further, the examiner should also opine whether the Veteran's service-connected right knee disability caused, in whole or in part, his obesity. If the examiner finds that the Veteran's service-connected right knee disability caused him to become obese, either in whole or in part, then the examiner must opine whether: (1) obesity was a substantial factor in causing or chronically worsening the Veteran's left knee disability; and, (2) whether his left knee disability would not have occurred or chronically worsened if but for the obesity caused by his service-connected right knee disability. All findings should be reported in detail and all opinions must be accompanied by a clear rationale. MARTIN B. PETERS Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Modesto, Victor 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.