Citation Nr: 21039749 Decision Date: 07/01/21 Archive Date: 07/01/21 DOCKET NO. 17-47 491 DATE: July 1, 2021 REMANDED Entitlement to service connection for a neck disability is remanded. Entitlement to service connection for a left knee disability, to include as due to service-connected disease or injury is remanded. Entitlement to service connection for a right knee disability, to include as due to service-connected disease or injury is remanded. Entitlement to service connection for a left foot nerve disability, to include as due to service-connected disease or injury is remanded. REASONS FOR REMAND The Veteran served in the U. S. Army from August 1986 to February 1998. This matter comes before the Board of Veterans' Appeals (Board) from a May 2017 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran attended a Board videoconference hearing in March 2021 with the undersigned Veterans Law Judge. A transcript of the hearing is associated with the claims file. 1. Entitlement to service connection for a neck disability The Veteran contends that he is entitled to service connection for a neck disability stemming from an in-service motor vehicle accident (MVA). Service treatment records (STRs) are associated with the claims file and do reflect reports of neck pain and treatment. The Veteran experienced a MVA in August 1988. Corresponding treatment revealed pain from the neck down. A May 1993 examination determined that the Veteran's spine was normal, and the Veteran explicitly denied any recurrent back pain or arthritis on the corresponding self-completed Report of Medical History form. In March 1997, the Veteran sought treatment for neck pain. In April 1997, the Veteran was referred for treatment for potential spondylosis, including the c-spine. June 1997 diagnostic testing revealed a normal bone scan. April 1998 diagnostic testing of the Veteran's c-spine was unremarkable. During May 1999 private treatment the Veteran reported back, leg and hip pain. He did not report neck pain. An April 2000 examination diagnosed the Veteran with chronic paraspinal spasm of the cervical area. The Veteran submitted a letter from his physician in October 2016, which stated that the Veteran's neck pain was most likely related to the 1988 MVA. No rationale or explanation accompanied the conclusion. The Veteran attended a VA examination in March 2017. The VA examiner determined that the Veteran's current neck disability was less likely than not caused by his service-connected back disability. However, about one week later, another VA examiner found that the neck disability was incurred in service citing the treatment with neck traction in 1997. Another addendum opinion was obtained in May 2017 from the first examiner in March 2017. The VA examiner determined that the Veteran's current neck disability was less likely than not related to his service, to include the 1988 MVA, because following his separation from service, the Veteran did not seek medical attention for his neck until December 2015. The examiner did not mention the April 2000 neck diagnosis and did not comment on the second March 2017 opinion that cited the period of neck traction in May 1997. As such, the examiner's opinion is based on the inaccurate factual premise that the Veteran did not seek any neck treatment following his separation until 2015, and there are conflicting opinions from two VA physician that require resolution. Accordingly, an addendum opinion is warranted. 2. Entitlement to service connection for a left knee disability, to include as due to service-connected disease or injury 3. Entitlement to service connection for a right knee disability, to include as due to service-connected disease or injury The Veteran contends that he is entitled to service connection for a right and left knee disability stemming from an in-service motor vehicle accident (MVA). STRs reflect periodic reports of knee pain and treatment. In December 1991, the Veteran sought treatment for knee pain. Diagnostic testing of the knees was negative. The Veteran reported knee pain in April 1997. During an April 1998 VA examination, the Veteran acknowledged knee pain in service but reported that his knees were "asymptomatic at this point." There appears to be a gap in the Veteran's claims file for medical records prior to 2015. On remand, the RO should attempt to associate any outstanding relevant treatment records with the claims file. The Veteran submitted a letter from his physician in October 2016 which stated that the Veteran's knee pain was most likely related to the 1988 MVA. No rationale or explanation accompanied the conclusion. The Veteran attended a VA examination in March 2017. The VA examiner determined that the Veteran's current knee disabilities were less likely than not caused by his service-connected back disability. She also determined that the Veteran's current knee arthritis was less likely than not related to his service because post-service medical records were silent for pain or treatment until 2015. She did not comment on the Veteran's the October 2016 private opinion. During his March 2021 Board hearing, the Veteran reported that he injured his knees during the 1988 MVA. He reported on-going in-service knee pain. He also stated that his knee disabilities may be due to the rigorous physical activity he performed in service. The March 2017 VA examination report did not discuss the potential impact of the Veteran's physically demanding time in the service. Accordingly, an addendum opinion is warranted. 4. Entitlement to service connection for a left foot nerve disability, to include as due to service-connected disease or injury The Veteran contends that he is entitled to service connection for a left foot nerve disability, secondary to his service-connected back disability. The Board notes that the August 1988 MVA reflects an injury to the left shin, and that the Veteran had several abrasions to his leg. STRs also reveal treatment for a left ankle sprain in May 1995. May 2016 VA treatment records reveal that the Veteran reported numbness in his left foot and excruciating shooting pain down his left leg. The examiner noted decreased left foot sensation during the March 2017 VA back examination but did not provide any opinion regarding the etiology. Instead, the examiner stated that there was no evidence of left lumbar radiculopathy. During the March 2021 Board hearing, the Veteran testified that he believed he had nerve damage in his left foot caused by back surgery. The Board cannot make a fully informed decision because the Veteran has not been afforded a VA examination and opinion. The matters are REMANDED for the following action: 1. Obtain any outstanding VA treatment records and associate them with the claims file. 2. Ask the Veteran to complete a VA Form 21-4142 for any relevant private treatment records. Make two requests for the authorized records unless it is clear after the first request that a second request would be futile. 3. Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran's neck disability is at least as likely as not related to the Veteran's service, to include the 1988 MVA. Review of the entire claims file is required. The examiner is asked to address the Veteran's reports of on-going symptoms and self-treatment in any opinion rendered. The examiner is requested to reconcile the conflicting opinions of the two VA examiners in March and May 2017 including the reference to treatment with neck traction in May 1997. The examiner must provide a complete rationale for all findings and opinions, and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. If there is any medical reason to accept or reject the proposition that the Veteran's reported symptoms in service and thereafter represented the onset of his current disability, this should be noted. Stated another way, do the Veteran's reports about his symptoms align with how the currently diagnosed disability is known to develop or are the Veteran's reports generally inconsistent with medical knowledge or implausible? 4. Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran's knee disabilities are at least as likely as not related to the Veteran's service, to include the 1988 MVA and in-service rigorous physical activity. Review of the entire claims file is required. The examiner is asked to address the Veteran's reports of on-going symptoms and self-treatment in any opinion rendered. The examiner must provide a complete rationale for all findings and opinions, and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. If there is any medical reason to accept or reject the proposition that the Veteran's reported symptoms in service and thereafter represented the onset of his current disability, this should be noted. Stated another way, do the Veteran's reports about his symptoms align with how the currently diagnosed disability is known to develop or are the Veteran's reports generally inconsistent with medical knowledge or implausible? 5. Schedule the Veteran for a VA examination for his left foot nerve disability. The examiner must review the claims file. If a diagnosis cannot be provided but the Veteran's condition manifests in symptoms that cause functional impairment, then the examiner should consider them a "disability" for the purpose of providing the requested opinion(s) below. The examiner is asked to provide a response to the following: (a.) Is the left foot nerve disability at least as likely as not related to service, including the 1988 MVA and the 1995 left ankle sprain? (b.) Is left foot nerve disability at least as likely as not proximately due to a service-connected disability, to include the Veteran's back disability and corresponding back surgery? (c.) Is the left foot nerve disability at least as likely as not aggravated, i.e., worsened, and if so beyond its natural progression, by a service-connected disability? The examiner must provide a complete rationale for all findings and opinions, and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. J.W. FRANCIS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board T. Fitzgerald, 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.