Citation Nr: 21030875 Decision Date: 05/19/21 Archive Date: 05/19/21 DOCKET NO. 16-38 565 DATE: May 19, 2021 REMANDED Entitlement to service connection for a right knee disability, to include as secondary to service-connected thoracolumbar strain, is remanded. REASONS FOR REMAND The Veteran honorably served in the United States Marine Corps from November 1990 to August 1994. This matter appears before the Board of Veterans' Appeals (Board) on appeal of a May 2014 rating decision. Most recently, in March 2019, the Board remanded the Veteran's claim to the Agency of Original Jurisdiction (AOJ) to schedule the Veteran for a VA examination. VA requested the examination in October 2019. While an examination and opinion were associated with the Veteran's claim, the Board finds that the examination is inadequate. Therefore, the Board does not find substantial compliance with its March 2019 remand directives. Stegall v. West, 11 Vet. App. 268, 271 (1998). Specifically, the Veteran underwent VA examination in October 2019. The examiner opined that the Veteran's right knee disability is less likely than not due to service because medical records do not demonstrate right knee pain onset during service. Further, the examiner opined that the Veteran's right knee disability was neither proximately due to nor aggravated by her service-connected thoracolumbar strain. The examiner opined that the Veteran's medical documentation did not indicate an association between her back and her right knee. The examiner noted the Veteran does not have an abnormal gait or radiculopathy to form a connection between her back and right knee. VA requested an addendum opinion in June 2020 to allow the examiner to clarify their initial opinions offered. Specifically, VA asked the examiner to address the evidence referenced in the Board's remand and clarify the timeline of diagnosis because it was inconsistent in the secondary opinions. The examiner opined that the Veteran's right knee was less likely than not related to service because there is no contemporaneous medical evidence documenting the Veteran's complaints of pain since service. The Board finds the examiner's rationale is inadequate, as it relies entirely on the absence of contemporaneous medical records. See Dalton v. Nicholson, 12 Vet. App. 23 (2007) (holding that the lack of documentary evidence during or after service cannot be the sole basis for an opinion against the claim); Buchannan v. Nicholson, 451 F.3d 1331, 1336-37 (Fed. Cir. 2006). Further, the examiner did not address the secondary opinion in the addendum opinion. The matters are REMANDED for the following action: Obtain an addendum opinion from an appropriate clinician, if possible a different examiner than the one who provided the October 2019 opinion and June 2020 addendum opinion, addressing: a) whether the Veteran's right knee disability is at least as likely as not related to service. b) whether the Veteran's right knee disability is at least as likely as not proximately due to service-connected thoracolumbar strain. c) whether the Veteran's right knee disability is at least as likely as not aggravated beyond its natural progression by service-connected thoracolumbar strain. In providing an opinion, the examiner must consider the following: (1) a June 2013 VA treatment record noting that before the Veteran injured her knee running for the bus in June, she woke up experiencing sharp pain in her knee in mid-May; (2) a November 2009 letter indicating that the right knee X-ray showed sclerosis; (3) the report from a May 2016 VA treatment record that the Veteran had right knee pain prior to the June 2013 injury when she was in the military; and (4) the Veteran's assertion that her report of "don't know" regarding whether she had a trick or locked knee in an August 1994 Report of Medical was made in reference to her right knee. The examiner is reminded that the lack of contemporaneous medical documentation is not to be the sole rationale for supporting an opinion. Further, the examiner is remined that for purposes of aggravation, the aggravation need not be permanent. A rationale must be provided for all opinions offered. Mary E. Rude Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board S. N. Fournier, 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.