Citation Nr: 21040313 Decision Date: 07/03/21 Archive Date: 07/03/21 DOCKET NO. 17-01 543 DATE: July 3, 2021 REMANDED Entitlement to service connection for a back disability is remanded. Entitlement to service connection for a right knee disability is remanded. Entitlement to service connection for a left knee disability is remanded. REASONS FOR REMAND The Veteran served on active duty from August 1990 to August 1994. This matter comes before the Board of Veterans' Appeals (Board) on appeal of a December 2015 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). 1. Entitlement to service connection for a back disability is remanded. 2. Entitlement to service connection for a right knee disability is remanded. 3. Entitlement to service connection for a left knee disability is remanded. The Veteran contends that her examinations were inadequate. For the reasons set forth below, the Board agrees. In October 2015, the Veteran underwent a back examination. There, the examiner apparently found no current disability, describing her back as "normal" with "no residual[s] to speak of" from her service. Since the examination, the Court of Appeals for the Federal Circuit has clarified that "pain alone, without an accompanying diagnosis of a present disease, can qualify as a disability." Saunders v. Wilkie, 886 F.3d 1356, 1369 (2018). But simply asserting subjective pain will not do. "To establish the presence of a disability, a veteran will need to show that her pain reaches the level of a functional impairment of earning capacity." Id. at 1367-68. When the Veteran filed her formal claim for service connection, she listed her disability as "lower back pain." At the examination, she rated her pain at 7 out of 10 and reported that prolonged standing, walking, and bending aggravated it. These are some of the same symptoms the Veteran reported during service when complaining of low back pain. Given that, the Board finds remand necessary to fully assess whether the Veteran's back pain causes functional impairment of earning capacity and if so, whether it is related to her service. During the appeal period, the Veteran also underwent a bilateral knee examination. Relevant here, the examiner could not review the Veteran's claims file, her electronic folder, or any other records because of technical difficulties. Instead, she completed the examination by relying on the medical history provided by the Veteran. Although not fatal in every case, failure to review the claims file is here because the examiner was not "informed of the relevant facts." Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 303 (2008). For instance, the Veteran reported seeking treatment for her left knee "multiple times" but "never" for her right. In fact, her service medical records show at least two trips to medical for right knee treatment. Perhaps the Veteran misremembered and meant to say that she sought treatment for her right knee multiple times but never for her left. But there are issues with this assumption because there is at least one treatment record showing left knee pain and another that likely shows a bilateral knee strain (though it is not clear). Because the examiner's opinion relied on an inaccurate medical history, the Board will remand to obtain an addendum medical opinion. Reonal v. Brown, 5 Vet. App. 458, 461 (1993). Finally, as the case is being remanded for additional development, any outstanding VA treatment records should be associated with the claims file. Lang v. Wilkie, 971 F.3d 1348, 1354 (Fed. Cir. 2020). The matters are REMANDED for the following action: 1. Obtain all outstanding VA treatment records and associate them with the claims file. 2. Then, arrange for an appropriate healthcare provider to review the Veteran's claims file and provide an opinion on whether it is at least as likely as not (50 percent probability or greater) that the Veteran's back disability had its clinical onset during service or is due to an event or incident of the Veteran's period of active service. If no identifiable disease or condition is diagnosed, the examiner should describe the Veteran's symptoms and provide an opinion on whether those symptoms cause functional impairment of her earning capacity. If so, the examiner must provide an opinion on whether it is at least as likely as not (50 percent probability or greater) that the Veteran's symptoms had their clinical onset during service or are due to an event or incident of the Veteran's period of active service. If the reviewing health care provider finds that physical examination or telehealth interview of the Veteran and/or diagnostic testing is necessary, such should be accomplished. A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. 3. Arrange for an appropriate healthcare provider to review the Veteran's claims file and provide an opinion on whether it is at least as likely as not (50 percent probability or greater) that the Veteran's left or right knee disability had its clinical onset during service or is due to an event or incident of the Veteran's period of active service. The examiner must address the Veteran's November 2015 complaint that she has been experiencing chronic bilateral knee pain for 20 years in the opinion. If the reviewing health care provider finds that physical examination or telehealth interview of the Veteran and/or diagnostic testing is necessary, such should be accomplished. A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. M. Donohue Veterans Law Judge Board of Veterans' Appeals Attorney for the Board C. Canedy, 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.