Citation Nr: 21026629 Decision Date: 05/03/21 Archive Date: 05/03/21 DOCKET NO. 15-16 185 DATE: May 3, 2021 REMANDED Entitlement to service connection for bilateral knee disorder is remanded. Entitlement to service connection for a bilateral leg disorder, to include a neurological condition is remanded. REASONS FOR REMAND The Veteran served on active duty from September 1953 to August 1957. This case comes before the Board of Veterans' Appeals (Board) on appeal from an April 2017 rating decision of the Department of Veteran Affairs (VA) Regional Office (RO). In March 2021 the Veteran presented testimony at a virtual hearing before the undersigned Veterans Law Judge (VLJ). A transcript of that proceeding has been associated with the claims file. The issue of entitlement to clothing allowance was deferred during the March 2021 Board hearing. There is no claims file at this time and the issue is postponed until the claims file is uploaded. Bilateral Knee Disorders First, remand is required for an adequate VA opinion. Where VA provides the veteran with an examination in a service connection claim, the examination must be adequate. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). When a Veteran has provided competent lay statements of an in-service injury, the examiner must consider and address them when developing his rationale. See Dalton v. Nicholson, 21 Vet. App. 23, 39-40 (2007) (holding that when the Veteran has provided lay testimony of an in-service injury, an examiner cannot ignore that lay evidence and base his or her opinion that there is no relationship to service on the absence of in-service corroborating medical records). The Veteran received a February 2017 VA examination and opinion. The examiner opined the bilateral knee disorder was less likely than not incurred in or caused by service. The examiner stated a review of military records do not specifically show any evidence of military related injury to the knees during the Veteran's time in-service. First, the examiner did not address the credible Veteran's lay statements. See McKinney v. McDonald, 28 Vet. App. 15, 30-31 (2016) ("the VA examiner's failure to consider [a veteran's] testimony when formulating her opinion renders that opinion inadequate."). In the July 2017 notice of disagreement (NOD) the Veteran explained he was stationed on ship and worked on the flight deck for over a year. The Veteran stated his knees experienced extensive trauma jumping, going up and down stairs, and performing his duties. Second, the examiner's rationale provided a conclusion and lacked adequate explanation. A medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008). Additionally, during the March 2021 Board hearing the Veteran explained he did not go to sick call and just endured the knee pain. Accordingly, remand is required for an addendum opinion. Bilateral Leg Disorders Second, remand is required for an adequate opinion regarding the bilateral leg disorder. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). The February 2017 VA examiner opined the bilateral leg disorder was less likely than not incurred in or caused by service. The examiner stated the foreign body in leg, without specification of right or left appears, insignificant. The examiner stated there was no other mention or treatment of leg neurological deficits throughout the Veteran's military career and it is less likely than not a transient leg condition in appearance is the cause of current numbness. The examiner stated if there was a current deficit since 1956, the Veteran would have been paralyzed by now. First, the examiner's rationale provided a conclusion and lacked adequate explanation. Specifically, when considering the entire record. An October 1956 service treatment record (STR) noted foreign body in leg while attempting to upload. The February 2017 VA examination showed severe symptoms, decreased muscle strength, and regular use of a wheelchair. The examiner does not explain the finding that the leg injury as insignificant or why it is not the cause of current symptoms. Second, the examiner failed to address the Veteran's lay statements. See McKinney v. McDonald, 28 Vet. App. 15, 30-31 (2016). During the March 2021 Board hearing the Veteran explained he tripped while on ship duty. Accordingly, remand is required for an adequate opinion. The matters are REMANDED for the following action: 1. Contact the Veteran and afford him the opportunity to identify by name, address and dates of treatment or examination any relevant medical records. Subsequently, and after securing the proper authorizations where necessary, obtain all the records of treatment or examination from all the sources listed by the Veteran which are not already on file. All information obtained must be made part of the file. All attempts to secure this evidence must be documented in the claims file, and if, after making reasonable efforts to obtain named records, they are not able to be secured, provide the required notice and opportunity to respond to the Veteran and his representative. 2. After any additional records are associated with the claims file, obtain an addendum opinion regarding the etiology of the bilateral knee disorder from a VA examiner. The entire claims file must be made available to and be reviewed by the examiner. If an examination is deemed necessary, it shall be provided. An explanation for all opinions expressed must be provided. First, the examiner must provide an opinion regarding whether it is at least as likely as not (50 percent or greater probability) that the right knee disorder had onset in, or is otherwise related to, active service. Second, the examiner must provide an opinion regarding whether it is at least as likely as not (50 percent or greater probability) that the left knee disorder had onset in, or is otherwise related to, active service. The examiner must specifically address the following: 1) Veteran's statements regarding knee pain due to the rigors of ship duty that began in-service and have continued and 2) March 2021 Board hearing testimony 3. After any additional records are associated with the claims file, obtain an addendum opinion regarding the etiology of the bilateral leg disorder from a VA examiner. The entire claims file must be made available to and be reviewed by the examiner. If an examination is deemed necessary, it shall be provided. An explanation for all opinions expressed must be provided. First, the examiner must provide an opinion regarding whether it is at least as likely as not (50 percent or greater probability) that the right leg disorder had onset in, or is otherwise related to, active service. Second, the examiner must provide an opinion regarding whether it is at least as likely as not (50 percent or greater probability) that the left leg disorder had onset in, or is otherwise related to, active service. The examiner must specifically address the following: 1) October 1956 STR that noted a leg injury; 2) Veteran's statements regarding leg pain in-service and tripping; and 3) March 2021 Board hearing testimony. MARTIN B. PETERS Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board C. Bruton, 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.