Citation Nr: 21029745 Decision Date: 05/14/21 Archive Date: 05/14/21 DOCKET NO. 17-19 150 DATE: May 14, 2021 REMANDED Entitlement to service connection for a left knee disability, to include as secondary to a service-connected right knee patellofemoral pain syndrome, is remanded. REASONS FOR REMAND The Veteran has periods of active service dated from: (1) January 13, 2004, to May 13, 2004; (2) February 14, 2005, to April 15, 2006; (3) May 16, 2006, to June17, 2007; (4) October 4, 2007, to June 28, 2008; (5) September 7, 2009, to September 30, 2010; and (6) June 19, 2011, to February 14, 2012. The Veteran testified before the undersigned Veterans Law Judge (VLJ) of the Department of Veterans Affairs (VA) Board of Veterans' Appeals (Board) at a February 2021 video-conference hearing. A hearing transcript is in the claims file. Entitlement to service connection for a left knee disability, to include as secondary to a service-connected right knee patellofemoral pain syndrome, is remanded. The Veteran, in his January 2016 Notice of Disagreement (NOD), asserted that he injured his left knee during service in 2012 and did not submit a claim of entitlement to service connection for such until now due to insufficient paperwork from the service department, namely, a line of duty determination which is unavailable. In an August 2015 statement, the Veteran asserted that on May 12, 2012, at Fort Irwin, California at 19:15 hours, he was training during infantry tactics and injured his left knee when he fell down a rocky hill with low visibility, hitting a rock. He reported that the first responder, the medic, conducted an evaluation and assigned two service members to carry the Veteran down the hill for transport to the medical hold in the field. He asserted that he was later assessed with a left knee injury, with some swelling and tenderness, and was released back to his unit with strict bed rest orders. He reported that six months later, he began to experience pain in the left knee. In a February 2021 statement, the Veteran's platoon leader asserted that on May 12, 2012, during a training rotation at Fort Irwin, California, they were conducting an ambush on steeply sloped and rocky terrain. They reported that on or about 19:15 hours, she was notified that there was an injury and they took the medic to the location where the Veteran had fallen and was clearly in obvious pain and discomfort. They asserted that she tasked two service members to help the Veteran to the casualty collection point passed on the medic's recommendation and the amount of pain the Veteran was experiencing. They reported that once the Veteran was returned to his unit, he was kept off his knee and allowed to rest and ice the area. VA treatment records dated on May 15, 2012, indicate that the Veteran complained of left knee pain that started suddenly; he described being on patrol on May 14, 2012, and walking down a hill and sliding, hitting his left knee on a rock. He reported that he could not bear weight on his left knee and was limping; he was diagnosed with left knee sprain. VA treatment records dated in December 2013 indicate that the Veteran complained of continuing left knee stiffness and occasional pain on weight-bearing; X-ray examination revealed minimal degenerative joint disease changes. During his February 2021 Board hearing, the Veteran's representative discussed that the VA Regional Office (RO) had adjudicated the claim to include consideration of direct service connection and asserted that the Veteran sought service connection for his left knee disability on a secondary basis related to his service-connected right knee patellofemoral pain syndrome. The Veteran asserted that his left knee symptoms began four-to-six months prior to claim, filed in August 2015, that he started noticing problems getting in and out of his truck, kneeling, and getting up off of the floor. He asserted that because he had pain in his right knee, he would favor his left knee to compensate and had a limp for the past three-to-four years. He denied left knee treatment. To date, it does not appear that the Veteran has been afforded a VA examination. On remand, the RO should conduct appropriate development to determine the duty status of the Veteran from May 12, 2012, to May 15, 2012, and afford him a VA examination to determine the etiology of his left knee disability, considering his assertions made during the appeal, as well as the clinical evidence of the May 2012 left knee injury. Of record is an April 2016 VA Form 21-4142a, General Release for Medical Provider Information to the VA, for records from Fort Irwin, California, dated from April 30, 2012, to June 1, 2012, noted by the Veteran as the medical facility in the field at the time of his injury. While the RO sought the Veteran's service treatment records from many sources over the course of the appeal, and during prior appeal periods, and there is a VA treatment records dated in May 2012, cited above, reflecting treatment for the Veteran's left knee injury days prior, records from Fort Irwin dated from April 30, 2012, to June 1, 2012, do not appear to be included in his service treatment records. On remand, the RO should seek such service treatment records. Also, the most recent VA treatment records available for Board review are dated in May 2016; on remand, the RO should obtain and associate with the claims file the Veteran's updated VA treatment records. The matters are REMANDED for the following action: 1. Obtain the Veteran's VA treatment records for the period from May 2016 to the present. 2. Obtain the Veteran's service treatment records from Fort Irwin, California, dated from April 30, 2012, to June 1, 2012. 3. Conduct all appropriate development to determine the duty status of the Veteran from May 12, 2012, to May 15, 2012. A list of retirement points or other list that does not designate the specific dates and type of the Veteran's duty in May 2012 is not sufficient. 4. Then, schedule the Veteran for a VA examination for his left knee disability. The examiner must review the claims file. The examiner is asked to provide a response, with complete rationale, to the following: (a) Is it at least as likely as not (at least 50 percent probability) that the Veteran's left knee disability is related to service, including his May 2012 left knee injury, diagnosed as sprain, from sliding down or falling on a rocky hill? (Continued on the next page) (b) Is it at least as likely as not that the Veteran's left knee disability is proximately due to his service-connected right knee patellofemoral pain syndrome? In this regard, the examiner must consider and discuss the Veteran's lay statements that because he had pain in his right knee, he would favor his left knee to compensate and had a limp for the past three-to-four years. (c) Is it at least as likely as not that the Veteran's left knee disability is aggravated, i.e., worsened beyond its natural progression, by his service-connected right knee patellofemoral pain syndrome? In this regard, the examiner must consider and discuss the Veteran's lay statements that because he had pain in his right knee, he would favor his left knee to compensate and had a limp for the past three-to-four years. P.M. DILORENZO Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Department of Veterans Affairs 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.