Citation Nr: 21026218 Decision Date: 04/30/21 Archive Date: 04/30/21 DOCKET NO. 15-27 219 DATE: April 30, 2021 REMANDED Entitlement to service connection for the right tibial plateau fracture status post open reduction internal fixation (ORIF) and knee strain is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from January 1979 to May 1984. This matter is before the Board of Veterans’ Appeals (the Board) on appeal from an October 2014 Department of Veterans Affairs (VA) Regional Office (RO) rating decision. The rating decision denied service connection for right tibial plateau fracture status post ORIF and knee strain. The Veteran’s Notice of Disagreement (NOD) was received in December 2014. The Statement of the Case was issued in July 2015, and the Veteran’s VA Form 9, substantive appeal to the Board, was received n July 2015. Entitlement to service connection for the right plateau fracture status post ORIF and knee strain. The Veteran seeks service connection for the right plateau fracture. He contends that this disability is caused by his service-connected left knee disability. Specifically, the Veteran contends that he fractured his right tibia when his left knee gave way and he fell from a ladder in December 2013. The Veteran’s left knee injury with history of instability and degenerative arthritis, status post arthroscopy is service connected. In July 2014, the Veteran was afforded a VA examination for his claim. The VA examiner concluded that the Veteran’s right knee pain is secondary to the ladder fall in December 2013 and is unrelated to his left knee disability. For rationale, the VA examiner noted that the Veteran’s VA treatment records indicate that he was seen for complaints of left knee pain and not left knee instability. However, the Veteran’s VA treatment records indicate that the Veteran wears a left knee brace, suggesting some history of left knee instability. Specifically, a June 2009 VA treatment note indicates that the Veteran had a near fall and experienced left knee pain flare up, it was noted that he is recommended to wear a left knee brace for support. An October 2012 VA treatment note indicates that the Veteran underwent a left knee arthroscopy the same month. Finally, a September 2013 VA treatment note indicates that the Veteran requested a new left knee brace and was undergoing physical rehabilitation. In light of this, the July 2014 VA medical opinion is incomplete to the extent that it did not take into consideration the Veteran’s VA treatment records showing a history of wearing a left knee brace for support, as well as the Veteran’s reports that his left knee caused his December 2013 ladder fall, which in turn caused his right tibia fracture. When medical evidence is inadequate, VA must supplement the record by seeking an advisory opinion or ordering another medical examination. Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991); Hatlestad v. Derwinski, 3 Vet. App. 213, 216 (1992). Accordingly, an addendum VA medical opinion is necessary to address the Veteran’s claim that his service-connected left knee disability caused his fall and his right knee disability. The matter is remanded for further development and adjudication. The matter is REMANDED for the following action: 1. Obtain all outstanding VA treatment records and private treatment records and associate them with the claims file. 2. Obtain an addendum VA medical opinion on the nature and etiology of the Veteran’s right knee fracture. The VA examiner is requested to review all pertinent records associated with the claims file, including a copy of this remand. The VA examiner is requested to opine as to: (a.) Whether it is ate least as likely as not (a 50 percent probability or higher), that the Veteran’s right tibial fracture had its onset in service, or is otherwise causally related to service, to include the Veteran’s service-connected left knee disability. (b.) In providing this opinion, the VA examiner is requested to address the Veteran’s contentions that his left knee disability caused his ladder fall, which caused his right tibial fracture. (c.) In providing this opinion, the VA examiner is requested to address the Veteran’s June 2009 VA treatment note indicating a near fall and recommendation that he wear a left knee brace for support, the October 2012 VA treatment note regarding left knee arthroscopy, and the September 2013 VA treatment note indicating that he requested a new left knee brace and was undergoing physical therapy. (Continued on the next page)   (d.) A full rational for all opinions expressed must be provided. L. B. CRYAN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Kuksova, Kseniya 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.