Citation Nr: 21025344 Decision Date: 04/27/21 Archive Date: 04/27/21 DOCKET NO. 16-23 306 DATE: April 27, 2021 REMANDED Entitlement to service connection for a right knee disability is remanded. Entitlement to service connection for a left knee disability is remanded. Entitlement to service connection for a right ankle disability is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from February 1979 to September 1980. This matter come before the Board of Veterans’ Appeals (Board) on appeal from an August 2012 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). The appeal was previously before the Board in October 2019 and remanded to the Agency of Original Jurisdiction (AOJ) for further development including obtaining an adequate VA examination. The matter has returned to the Board for an appellate review. In view of the facts found, and to provide broader consideration on appeal, the Board has bifurcated the prior claim of entitlement to service connection for arthritis as three separate claims seeking entitlement to service connection for a right knee disability, left knee disability and right ankle disability respectively. Such bifurcation of a claim is generally within the Board's discretion. See Locklear v. Shinseki, 24 Vet. App. 311 (2011). 1. Entitlement to service connection for a right knee disability is remanded. 2. Entitlement to service connection for a left knee disability is remanded. 3. Entitlement to service connection for a right ankle disability is remanded. The Board cannot make a fully informed decision on these issues because the January 2020 VA medical opinions are inadequate. The Veteran contends that his currently diagnosed bilateral knee and ankle disabilities, are together related to service. Specifically, he asserts that he was involved in a motor vehicle accident (MVA) while serving active duty and that he has continued to have joint inflammation throughout the years. According to the Veteran, his current bilateral knee and ankle issues are attributable to this in-service accident, and he seeks service connection for all diagnosed knee and ankle disabilities on this basis. Although the Board has bifurcated the prior claim of entitlement to service connection for arthritis into three separate claims of service connection for bilateral knee and ankle disabilities, the analysis applicable to the claims is largely identical; as such, they will be considered simultaneously. The Veteran was afforded a Non-Degenerative Arthritis (Including Inflammatory, Autoimmune, Crystalline and Infectious Arthritis) and Dysbaric Osteonecrosis examination in October 2019. The examiner noted that the Veteran does not have a current diagnosis associated with an autoimmune disorder. See October 2019 C&P Examination. The Veteran was afforded a Knee and Lower Leg examination in October 2019. The diagnoses were: right knee strain and left knee degenerative arthritis. The examiner provided the following opinion and rationale: “The Veteran does not have a diagnosis of autoimmune inflammatory arthritis of the knees. Review of records does not show evidence of autoimmune diagnosis. The diagnosed right knee strain is less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. Review of records did not show evidence of right knee injury while in service. The diagnosed left knee arthritis is less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. Review of records did not show evidence of left knee injury/arthritis while in service.” See October 2019 C&P Examination. The Veteran was afforded an Ankle examination in October 2019. He was diagnosed of a right ankle tendonitis. The examiner provided the following opinion and rationale: “Veteran does not have a diagnosis of arthritis. Review of records does not show evidence of autoimmune disease. The diagnosed right ankle tendonitis is less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. Review of records did not show evidence of right ankle/Achilles injury while in service. See October 2019 C&P Examination. The Board finds the above October 2019 VA examinations inadequate. First, the examiner noted that review of records did not show evidence of left knee or right ankle disabilities. However, the Veteran’s service treatment records (STRs) noted probable knee arthritis and ankle pain. See Reonal v Brown,5 Vet.App.458,460-61 (1993) (holding that medical opinions based on incomplete or inaccurate factual premise are not probative). Second, the examiner appears to rely on the lack of diagnoses of these conditions in the Veteran's service treatment records as the basis for the medical opinion. However, the lack of documentation, alone, is not a sufficient reason to rule out service connection, if it does not consider the Veteran's reports of symptoms and history. Dalton v. Peake, 21 Vet. App. 23 (2007). The October 2019 opinion does not appear to take in consideration the Veteran’s reports of his joint disabilities resulting from the MVA during service. Therefore, for the afore-mentioned reasons, new examinations are necessary to decide the Veteran’s claims. The matters are REMANDED for the following action: 1. Obtain and associated with the Veteran’s claims file, all outstanding treatment records. 2. Schedule the Veteran for VA knee and ankle examinations to determine the etiology of his bilateral knee and ankle disabilities. The entire claims file and a copy of this remand must be made available to the examiner for review. The examiner must discuss all relevant medical and lay evidence of record and: (a). Identify any current right knee, left knee, and right ankle disabilities, or any joint disability that has been present any time since the date of claim. (b). For each diagnosis, opine whether it is at least as likely as not (50 percent or greater probability) that the disability is related to the Veteran’s military service, to include the documented in-service motor vehicle accident. **Please address the Veteran’s service records showing “probable traumatic arthritis” of the knee, and right ankle pain with effusion. A clear rationale for all opinions rendered must be provided.2 3. Thereafter, readjudicate the issues on appeal. Romina A. Casadei Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board N. M. Rogers, 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.