Citation Nr: 21024703 Decision Date: 04/23/21 Archive Date: 04/23/21 DOCKET NO. 16-09 782 DATE: April 23, 2021 REMANDED Service connection for a left knee disability is remanded. REASONS FOR REMAND The Veteran served on active duty from June 1974 to February 1977 in the United States Army. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a July 2015 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). In February 2021, the Veteran testified before the undersigned during a virtual hearing. A transcript of the hearing is included in the electronic claims file. 1. Service connection for a left knee disability is remanded. Initially, other than the Veteran’s January 1977 service separation documents, his remaining service treatment records are missing. The record indicates that in 2015, VA contacted the National Personnel Records Center (NPRC) and all available records were provided. The claims file does not indicate, however, that VA requested records from any other entity, or that a request has been made for in-service inpatient hospitalization records specifically, including from Keller Army Hospital, the facility at which the Veteran reports he received surgical treatment for his left knee. Further efforts in this regard are required prior to appellate adjudication. Additionally, VA treatment records indicate that the Veteran receives disability benefits from the Social Security Administration (SSA). As the record indicates that these benefits were awarded due to complex regional pain syndrome of the left knee, the SSA records should be requested. See Golz v. Shinseki, 590 F.3d 1317 (Fed. Cir. 2010); see also 38 C.F.R. § 3.159 (c)(2). A VA examination is also needed before the Board adjudicates the claim. The Veteran has current status-post total left knee replacement with residual symptoms, including complex regional pain syndrome. At the February 2021 hearing and in written correspondence, the Veteran reports that he injured his left knee while playing football in service. He states that the injury required a left meniscus repair at Keller Army Hospital in West Point, New York, and that he was placed in a cast for 6-8 weeks following the procedure. In support, he submitted statements from three brothers and one sister recounting their memories of the Veteran’s injury at the time, including descriptions of seeing him in a cast. He also submitted a December 2016 buddy statement of J.R., his roommate and teammate, describing the in-service football injury and resulting treatment. On his January 1977 separation examination, the examiner noted the Veteran sustained strained knee ligaments while serving at West Point. In February 2016, a VA examination was conducted in relation to a claim for compensation under 38 U.S.C. § 1151 for complex regional pain syndrome of the left knee. In the report, the examiner noted that a military nexus “appear[ed]” applicable, but did not provide a rationale for the statement or more definitive findings. A VA medical opinion has not been obtained for the claim and one must be provided. The matter is REMANDED for the following action: 1. Request the Veteran’s missing service treatment records from all appropriate entities. Additionally, make a specific request for records of any in-patient treatment received during the Veteran’s period of service from June 1974 to February 1977, including from Keller Army Hospital directly. Document all requests for information, as well as any responses received, in the claims file. 2. Obtain from the Social Security Administration a copy of any decision regarding a claim for disability benefits filed by the Veteran, as well as copies of all medical records underlying the decision. 3. Schedule the Veteran for an examination to obtain an opinion addressing the nature and etiology of his left knee disability. A rationale must be provided for all conclusions reached. While a medical opinion is required, the examiner is asked to consider the Veteran’s lay reports and may state whether they are medically-consistent or medically-inconsistent with other evidence of record. (A.) The examiner is asked to first clearly identify all current disabilities of the left knee. (B.) Then, opine on whether it is at least as likely as not that any current left knee disability, including complex regional pain syndrome, began during active service or is related to an in-service injury, event, or disease, to include an in-service football injury. In rendering this opinion, please consider: • Lay statements of the Veteran’s three brothers, one sister, and J.R. describing an in-service football injury • January 1977 service separation examination documenting a strained knee ligament during service at West Point • February 2016 VA examiner’s statement that a military nexus appeared applicable, even in the absence of the Veteran’s service treatment records. M. Tenner Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Smith, 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.