Citation Nr: 21032239 Decision Date: 05/26/21 Archive Date: 05/26/21 DOCKET NO. 19-11 421 DATE: May 26, 2021 REMANDED Entitlement to service connection for a left leg disability, to include as secondary to service-connected left knee disability is remanded. REASONS FOR REMAND The appellant is a Veteran who had active service from January 1986 to November 1986. This matter is before the Board of Veterans' Appeals (Board) on appeal from the April 2017 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO) denying, in part, service connection for a left leg condition. In December 2020, the issue was before the Board and remanded for further development, to include new examination and medical opinion (finding that a May 2017 VA examination was inadequate). In January 2021, a new medical opinion was obtained; however, the Board finds that the AOJ did not substantially comply with the remand directives because the opinion did not include an etiology, nor did it reflect consideration of lay statements, private DBQs, and private treatment records as directed. See Stegall v. West, 11 Vet. App. 268, 271 (1998). Therefore, the claim must be remanded again. The agency of original jurisdiction (AOJ) is advised that this appeal has been remanded by the Board twice (including the remand herein), with this remand caused by Stegall violations. See Stegall, 11 Vet. App. at 271. Expeditious treatment and substantial compliance with remand directives are required. This appeal has been advanced on the Board's docket pursuant to 38 U.S.C. § 7107(a)(2); 38 C.F.R. § 20.900(c). Entitlement to service connection for a left leg disability, to include as secondary to service-connected left knee disability is remanded. The Veteran asserts that service connection for her left leg condition is warranted, to include as secondary to her service-connected left knee disability. A review of the record revealed an April 1986 military orthopedic consultation (following a fall and injury to left knee) noting "incidental finding of cystic lesion [lat] condyle of femur on x-ray. Presented with painful swelling and [?] knee effusion." A May 1986 military examination report noted thigh weakness. An October 1986 separation examination report noted the Veteran reported having cramps in legs. A March 2016 physician's certification for employee accommodations form noted left knee pain with post-operative swelling to the leg. The Veteran reported wearing thigh high compression stocking for swelling. A May 2016 private CT scan of the left knee revealed small 4mm loose body in the suprapatellar pouch. In August 2016 medical treatment records were added to the claims file. A review of the record revealed the following: an August 2012 notation of hamstring muscle tightness on palpation; an October 2012 follow-up for left leg swelling; a May 2013 report of left leg swelling and pain from mid-calf down to foot; an August 2013 report of left leg pain from the top of the left knee and lower calf; an April 2016 report of pain, swelling and numbness in the left leg and foot affecting her mobility; a May 2016 notation that Veteran had nerve injury during surgery which limits her left foot dorsiflexion; and a June 2016 report of pain in the left leg. In an August 2016 correspondence, a private examiner opined that the Veteran's left leg weakness was directly and causally related to her low back condition. In December 2016, knee and lower leg disability benefits questionnaire (DBQ) completed in May 2016 was added to the Veteran's claims file indicating atrophy of the left quadricep noted as post-operative sequelae. The Veteran reported weakness and "giveaway" of the left leg/knee, and swelling with increased activity. The examiner noted "knee shows fatigue to the quadriceps with repetitive use and mechanical dysfunction secondary to hardware." A December 2016 VA treatment records reflect report of left leg and thigh pain affecting her ability to walk since her last knee surgery in December 2015. A February 2017 private physical therapy report noted moderate to severe left leg nerve pain with sensation of leg buckling. A March 2017 private physical therapy report noted limitation in her knee flexion both passively and actively due to weakness in quadriceps and habitual movement patterns. A May 2017 VA scars examination report noted mild bilateral quadricep wasting. A negative opinion noted that medical records showed no evidence of left knee injury in 1985 or any other treatment records. A February 2018 VA knee and lower leg examination report noted left leg atrophy and mild quadriceps wasting noted on left leg compared to the right approximately 1 centimeter. A May 2018 private treatment note reflects a report of swelling in the left leg. In response to the December 2020 Board remand, a January 2021 VA peripheral nerve condition and bilateral knee examination was conducted. The VA medical examiner noted that after reviewing all medical records, remand letter and performing physical exams, there was no current pathology of a left leg condition to render a medical opinion. The examiner did not provide adequate supporting rationale; and failed to address the Veteran's left leg quadriceps atrophy noted during both VA and private treatment examinations, the Veteran's private medical treatment records from 2012 to 2017, or lay statements made by the Veteran during examinations. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (holding that a remand by the Board confers upon the Veteran, as a matter of law, the right to compliance with the Board's remand order). Accordingly, while the Board finds the additional delay inherent with yet another remand regrettable, the Board that another remand to ensure compliance is necessary. The matters are REMANDED for the following action: Schedule the Veteran for a VA examination with an orthopedic examiner to determine the etiology of the Veteran's claimed left leg condition. The record and a copy of this Remand must be made available to the examiner. Any indicated tests and studies must be accomplished, and all clinical findings must be reported in detail and correlated to a specific diagnosis. A clearly stated rationale for any opinion offered should be provided and must not be based solely on the lack of any in-service records. Following a review of the entire record, the Veteran's competent lay statements, as well as the Veteran's report regarding the onset and progression of her current symptomatology, the examiner should opine as to the following: a. Whether it is at least as likely as not (50 percent probability or more) that the Veteran's left leg condition is due to her service-connected left knee disability. b. Whether it is at least as likely as not (50 percent probability or more) that the Veteran's left leg condition is aggravated by her service-connected left knee disability. If secondary service connection is not established, the examiner should opine as to whether it is at least as likely as not (50 percent probability or more) that the Veteran's left leg condition had its onset during, or is otherwise related to, her active duty service. In offering any opinion, the examiner must consider the full record, to include lay statements, private treatment records, private DBQs, and VA examinations. The examiner should consider the following: (1) in-service notation of incidental finding of cystic lesion of femur and thigh weakness; (2) a May 2016 notation that Veteran had nerve injury during surgery which limits her left foot dorsiflexion; (3) a May 2016 record indicating atrophy of the left quadricep noted as post-operative sequelae; (4) a December 2016 VA treatment report by Veteran of left leg and thigh pain affecting her ability to walk since her last knee surgery in December 2015; (5) a May 2017 VA scars examination report that noted mild bilateral quadricep wasting; and (6) a February 2018 VA knee and lower leg examination report noted left leg atrophy and mild quadriceps wasting. A clearly stated rationale for any opinion offered must be provided and not based solely on the lack of any in-service records. R. Erdheim Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board C. Camille NeSmith, 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.