Citation Nr: 21029265 Decision Date: 05/13/21 Archive Date: 05/13/21 DOCKET NO. 11-03 634 DATE: May 13, 2021 REMANDED Entitlement to service connection for arthritis of the left knee as secondary to service-connected right total knee arthroplasty is remanded. Entitlement to service connection for arthritis of the left ankle as secondary to service-connected right total knee arthroplasty is remanded. REASONS FOR REMAND The Veteran honorably served on active duty in the United States Army from November 1974 to August 1979 with additional Reserve service. This matter comes before the Board of Veterans' Appeals (Board) on appeal of an April 2009 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO). This matter was previously remanded in February 2017 and again in October 2020. The claims for lumbar spondylosis and TDIU which were previously before the Board, have since been granted by the RO in a rating decision issued in November 2020. Those issues are no longer under the Board's jurisdiction. The remaining issues on appeal are now properly before the Board. 1. Left Knee. In November 2020, the Veteran was afforded a VA examination. The November 2020 examiner noted that the Veteran's left knee condition had its onset in 1993. The examiner also opined that it is less likely than not that the Veteran's left knee disorder is related to the right knee disorder. The examiner opined that the left knee degenerative arthritis was not aggravated by right knee arthritis. The examiner stated that while malalignment of joints is a risk factor for worsening of degenerative arthritis it is only relative to that specific joint and the evidence at hand shows the left knee to have been in a severe condition while the right knee was only moderate on an x-ray dated June 1997. The examiner determined that the evidence at hand also demonstrates that another event, 'twisting accident related to stepping in a hole in February 1996, on a track field while coaching," was more relavent to the left knee. Stepping in a hole is not assumed to be secondary to the right knee. Upon close review of the Veteran's claims file the Board finds that the Veteran complained of left knee pain beginning July 1976, while still in service. The Veteran also complained of severe limping, pain that progressively worsened in his back and left knee. The Veteran claimed that his left knee began to get bent like a bow. The Veteran's lay statements regarding his symptoms and complaints of pain while in service were not considered by the RO or the November 2020 VA examiner. 2. Left Ankle In November 2020, the Veteran was afforded a VA examination. The VA examiner considered the Veteran's left knee and left ankle conditions. The examiner noted that the Veteran's left ankle condition had its onset in 2000. The examiner opined that arthritis in one joint does not cause arthritis in another joint. The examiner stated that a thorough review of medical literature failed to show such a causal relationship. The examiner opined that it is not unusual for two joints to share properties in the same person, but one joint's disease does not 'spread' to another or cause damage to it. The examiner determined that therefore, the left ankle disorder is less likely than not related to the right knee disorder. The examiner opined that a nexus had not been established. The examiner opined that any changes in gait associated with the right knee are less likely than not to have caused or aggravated the left ankle. The examiner attributes the Veteran's left ankle condition to an incident when the Veteran twisted his ankle when stepping in a hole in February 1996 on a track field while coaching at work. The examiner opined that the February 1996 incident was much more likely to be related to the left ankle and was not a result of the right knee disorders. The examiner opined that there is no aggravation of the left ankle due to the right knee. As it pertains to the November 2020 VA examiner's opinion regarding the Veteran's left knee and left ankle, the Board finds that the VA examiner failed to substantially comply with the Board's remand instructions. The examiner failed to consider the Veteran's altered gait and right knee disorders and whether that caused instability or falls. While the examiner provided an opinion as to whether the Veteran's right knee disability caused or aggravated the Veteran's left knee disability and left ankle disability, the examiner did not consider whether the Veteran's current left knee disability and current left ankle disability were proximately due to or the result of service-connected disease or injury. The examiner's opinion was limited to aggravation and did not address proximate cause. In this case there is evidence that the Veteran is reporting that he began feeling pain in the left knee while in service around the same time he was diagnosed with his right knee disability. The examiner must consider all lay statements in the record as the Veteran is competent to report the onset of pain. Furthermore, if secondary service connection cannot be established, the RO must consider the service connection under direct service connection. The examiner must also provide a determination as to whether there is an etiological relationship between the Veteran's left knee and right knee. The Board must regrettably remand this matter again for a new opinion that clearly addresses proximate cause and aggravation as well as the etiological relationship between the pain the Veteran felt in his left knee while in service and the disability he is currently diagnosed with. Compliance with remand directives is not optional or discretionary, and the Board errs as a matter of law when it fails to ensure compliance. Stegall v. West, 11 Vet. App. 268 (1998). Therefore, remand is necessary to consider the Veteran's medical history, family history and other risk factors. The matters are REMANDED for the following action: 1. Obtain a new opinion from an appropriate clinician. The examiner should review the Veteran's entire claims file, including all lay statements, service treatment records and prior examinations and remands. The examiner should be provided a copy of this Remand. The examiner must indicate that the entire claims file has been reviewed. 2. Schedule the Veteran for a physical examination. The examiner must address the following question: a. Is the Veteran's left knee disability at least as likely as not related to, or proximately due to or aggravated beyond its natural progression by service-connected right knee disability? b. Is the Veteran's left ankle disability at least as likely as not related to, or proximately due to or aggravated beyond its natural progression by service-connected right knee disability? In offering such opinion the examiner should consider the Veteran's lay statements referencing complaints of pain in his left knee while in service, in 1976. The examiner is asked to determine the nature and etiology of the Veteran's left knee disability and left ankle disability. 3. A complete rationale must be provided for all opinions. If the examiner cannot provide the requested opinion without resorting to speculation, he or she should provide an explanation stating why this is so. B. MULLINS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board H. Hailu, 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.