Citation Nr: 21024140 Decision Date: 04/22/21 Archive Date: 04/22/21 DOCKET NO. 15-37 305 DATE: April 22, 2021 REMANDED Entitlement to service connection for a left knee disability is remanded. REASONS FOR REMAND The Veteran served on active duty from December 1970 to August 1973. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a June 2014 rating decision by the Department of Veterans Affairs (VA). This case was remanded in April 2019 for further development. In August 2018, the Veteran testified at a Board hearing before the undersigned Veterans Law Judge; a transcript of that hearing is of record. Entitlement to service connection for a left knee disability. The Veteran asserts that he injured his left knee while stationed at Fort Lee, Virginia, in 1971 and was treated at the hospital. He stated that a pebble-like object was embedded in his knee. His leg was in a full cast, but then he fell down a set of stairs, busted the cast, and it had to be re-cast. See, e.g., August 2018 Board hearing. In August 2012, the Veteran reported that he could not afford a civilian doctor and he had chronic left knee pain for years. See August 2012 VA treatment records. January 2013 VA treatment records reflect a left knee tibial calcium deposit. The Veteran’s service treatment records (STRs) do not reflect a knee injury. However, sometimes hospital records are not included in STRs. Thus, remand is necessary to attempt to obtain any medical records available directly from the hospital at Fort Lee. The Veteran underwent a VA knee examination in November 2019 and the examiner diagnosed degenerative joint osteoarthritis. The examiner opined it was less likely than not that the disability was related to service. Although the examiner noted that left knee x-rays from September 2013 reflected mild osteoarthritis in the form of bone spurs and such changes would be typical for a Veteran that is 60 years of age, the examiner primarily relied on the absence of evidence in STRs and treatment records immediately after service. Because the examiner relied on the absence of medical evidence and did not discuss the Veteran’s lay reports of injuring his knee during service and continuing chronic knee pain, remand for a new opinion is necessary. The matter is REMANDED for the following action: 1. The AOJ should obtain in-patient hospital records from the Fort Lee, Virginia hospital during the Veteran’s military service. Because such records are presumably in the custody of a Federal department or agency, the amount of effort needed to be expended in obtaining these records is governed by 38 C.F.R. § 3.159(c)(2). If such records are not received pursuant to the AOJ’s request, the Veteran should be so notified and the AOJ’s efforts should be documented in the claim file. 2. The AOJ should obtain copies of VA treatment records from November 2020 to the present. 3. After the development in the first two directives is completed, the AOJ should arrange for a VA medical opinion, with examination or telehealth interview of the Veteran only if deemed necessary by a medical professional, to determine the nature and likely cause of any left knee disability. The examiner should review the claim file (including this remand) and note such review was conducted. Based on review of the record, the examiner should provide an opinion with detailed rationale that responds to the following: For each left knee disability diagnosed, is it at least as likely as not (50% or greater probability) that such disability was either incurred in or otherwise related to the Veteran’s military service? Please explain why. The examiner must consider the Veteran’s lay reports of injuring his knee with a pebble-like object during service, regardless of whether there is evidence in STRs; the examiner may not rely solely on the absence of medical evidence during or immediately after service. The examiner must discuss the Veteran’s report of a history of chronic left knee pain in August 2012, the January 2013 note of a left tibia calcium deposit, and the November 2019 VA examiner’s opinion that the Veteran’s disability is due to his age. CONTINUED ON NEXT PAGE 4. If upon completion of the above action the issue remains denied, the case should be returned to the Board after compliance with appellate procedures. E. I. VELEZ Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Sandler, 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.