Citation Nr: 21032216 Decision Date: 05/26/21 Archive Date: 05/26/21 DOCKET NO. 18-49 898A DATE: May 26, 2021 REMANDED Entitlement to service connection for a right knee disability is remanded. Entitlement to service connection for a back disability, to include as secondary to the right knee disability, is remanded. Entitlement to service connection for a right shoulder disability, to include as secondary to the back disability, is remanded. Entitlement to service connection for a left shoulder disability, to include as secondary to the back disability, is remanded. REASONS FOR REMAND The Veteran served on active duty from July 1986 to August 1989. This matter came before the Board of Veterans Appeals (Board) on appeal from June 2017 and August 2017 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified before the undersigned Veteran's Law Judge during a May 2021 hearing. The Board notes that the Veteran's September 2017 Notice of Disagreement also included the issue of service connection for PTSD, however service connection for PTSD was granted in a September 2018 rating decision. As this constituted a complete grant of the benefit sought on appeal, the issue is not before the Board. 1. Entitlement to service connection for a right knee disability The Veteran contends that her right knee disability began during active duty and continued after service and that she was on a restricted duty profile for almost a year due to her knee. The Board finds that remand for additional development is required. First, the record indicates that there may be outstanding relevant service treatment records. An August 2018 report stated that the Veteran reported orthopedic treatment in service at Patterson Army Community Hospital (ACH) and that she received treatment for approximately one year in 1988. The record shows that a request was then made for Patterson ACH inpatient records for knee treatment and prescription for pain medication from June 1988 to August 1988. While records from 1988 were obtained, those records related to treatment for chicken pox in August 1988 rather than to knee treatment. However, the response from Patterson ACH does not indicate whether the 1988 records were the only existing treatment records for the Veteran or records existed from the other years of the Veteran's active service. The Board therefore cannot be certain that the Veteran's complete treatment records have been obtained, particularly as the Veteran's reported approximate dates of treatment and the records request was confined to a narrow three-month period. Thus, to ensure compliance with the duty to assist, remand is required to request any outstanding records from Patterson ACH during the Veteran's period of active service from July 1986 to August 1989. The Veteran also has not yet been afforded a VA examination in connection with this issue. July 2007 VA treatment records notes right knee pain since service and an x-ray showed degenerative changes. At the May 2021 Board hearing, the Veteran submitted competent lay testimony of knee pain in service, which she is competent to report. December 1988 service personnel records indicate that she was remanded to remedial physical training after failing the army physical fitness test and an August 2018 Report noted the Veteran's report that knee pain was the underlying reason. The record therefore indicates that the Veteran has a current right knee disability that may be associated with active service, and remand for a VA examination is required. McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006). The threshold for determining whether the evidence "indicates" that there "may" be a nexus between a current disability and an in-service event is a low one. McLendon, 20 Vet. App. at 83. 2. Entitlement to service connection for a back disability, to include as secondary to the right knee disability 3. Entitlement to service connection for a right shoulder disability, to include as secondary to the back disability 4. Entitlement to service connection for a left shoulder disability, to include as secondary to the back disability Evidence indicates that there may be outstanding relevant VA treatment records. First the Board's review indicates that VA treatment records from February 2008 to February 2009 have not yet been associated with the claim file, including records from the Veteran's breast reduction surgery. February 2009 VA treatment records indicate that the breast reduction had been performed 2 weeks prior, indicating that it occurred in January 2009. The Veteran contends that her bilateral shoulder and back disabilities may be associated with the need for breast reduction, and July 2007 VA treatment records noted that macromastia was probably the reason for her upper back aches and shoulder pain and that she desired reduction. Remand is therefore required to obtain the records from February 2008 to February 2009. In addition, at the May 2021 Board hearing, the Veteran reported that she has continued to receive VA treatment for the disabilities on appeal, but the most recent VA treatment records in the file date from July 2019. Any VA treatment records are within VA's constructive possession, and are considered potentially relevant to the issues on appeal. A remand is required to allow VA to obtain them. The matters are REMANDED for the following action: 1. Contact Patterson Army Community Hospital to request any outstanding treatment records for the period from July 1986 to August 1989. As the Veteran was married during service, the request should include both her maiden and married names. 2. Obtain the Veteran's VA treatment records for the period from February 2008 to February 2009, and from July 2019 to the Present. 3. After the development in (1)-(2), schedule the Veteran for an appropriate VA examination, to determine the etiology of any current right knee disability. The examiner should review the file and provide a complete rationale for all opinions expressed. For any current right knee disability found to be diagnosed, the examiner should provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that any such disability is related to the Veteran's active service. In providing the opinion, the examiner should consider and discuss any lay statements of record, to include the Veteran's statements regarding the onset and persistence of her symptoms. The examiner is advised that competent lay statements should not be disregarded merely because they are unaccompanied by contemporaneous medical evidence. 4. If upon completion of the above action the appeal remains denied, the case should be returned to the Board after compliance with appellate procedures. E. I. VELEZ Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A. Arnold 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.