Citation Nr: 21023540
Decision Date: 04/20/21	Archive Date: 04/20/21

DOCKET NO. 15-04 238A
DATE: April 20, 2021

REMANDED

Entitlement to service connection for a left knee disability, to include as secondary to service-connected thoracolumbar spine disability, is remanded.

REASONS FOR REMAND

1. Entitlement to service connection for a left knee disability, to include as secondary to service-connected thoracolumbar spine disability is remanded.

The Veteran contends that his diagnosed left knee strain and patellofemoral pain syndrome are related to an in-service motor vehicle accident. Alternatively, he contends that his left knee disability was caused or aggravated by his service-connected thoracolumbar spine disability.

When this matter was last before the Board in November 2020, it was remanded to obtain an addendum medical opinion as to aggravation of the Veteran’s left knee by his service-connected thoracolumbar spine disability. Such opinion was obtained in January 2021; however, while the examiner addressed the matter of aggravation of the Veteran’s left knee disability, a thorough review of the claims file indicates that no examination of record adequately addresses whether the Veteran’s left knee disability was caused by his thoracolumbar spine disability. 

To the above point, the two medical opinions that address causation under the theory of secondary service connection, dated in February 2020 and January 2021 only cites that (1) there was no evidence of a left knee disability at enlistment, (2) any left knee injury during service was resolved, and (3) there was no evidence of such condition at separation. These opinions address the Veteran’s claims under the theory of direct service connection, but not whether his left knee disability is caused by the pain and altered gait attributable to his thoracolumbar spine disability.

Based on the foregoing, the Board finds that a remand is necessary to obtain an adequate opinion for the Veteran's secondary service connection claim.

The matters are REMANDED for the following action:

1. They AOJ must obtain all updated VA and private treatment records, with the Veteran’s assistance regarding the latter.

2. Thereafter, the AOJ must obtain an addendum opinion from the examiner who provided the February 2020 opinion, or if unavailable, an appropriate clinician, regarding whether the Veteran’s left knee disabilities are at least as likely as not (a 50 percent or greater probability) caused by his service-connected thoracolumbar spine disability.

The examiner must address the Veteran’s lay statements regarding his left knee disability being related to the pain and altered gait caused by his thoracolumbar spine disability. The Veteran is competent to attest to factual matters of which the Veteran has first-hand knowledge, including observable symptomatology. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation.

3.  Thereafter, the AOJ must readjudicate the Veteran’s appeal based on the totality of the record.  If the benefit sought is not granted to the fullest extent, the AOJ must provide the Veteran and his representative with a copy of the readjudication and afford them an appropriate period to respond.  

 

 

SCOTT W. DALE

Acting Veterans Law Judge

Board of Veterans’ Appeals

Attorney for the Board	A. Marsh II, 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.