Citation Nr: 21040534 Decision Date: 07/05/21 Archive Date: 07/05/21 DOCKET NO. 16-53 214 DATE: July 5, 2021 REMANDED Entitlement to service connection for a left knee disability, to include as secondary to a left ankle disability, is remanded. REASONS FOR REMAND The Veteran served on active duty from December 1961 to August 1967. This matter is before the Board of Veterans' Appeals (Board) on appeal from a November 2015 rating decision. The Veteran testified before the undersigned at a hearing in January 2019. A transcript of the hearing is of record. The Board remanded this matter in June 2020 and March 2021. It is now returned to the Board for further appellate review. This appeal is advanced on the Board's docket pursuant to 38 C.F.R. § 20.902(c) (2019); 38 U.S.C. § 7107 (a)(2) (2012). The Veteran contends that his left knee disability is due to his active duty service, to include as secondary to his service-connected left ankle disability. Specifically, that wearing a cast on his left ankle and walking up and down ladders caused his left knee condition. The Board originally remanded this matter in June 2020, finding the November 2015 VA examination inadequate to adjudicate the Veteran's claim. The Board concluded the presumption of soundness attached to the Veteran's left knee and directed the Agency of Original Jurisdiction (AOJ) to obtain a new medical opinion and directed the selected clinician to presume the Veteran sound as to his left knee at entry into active duty service and disregard any evidence of a left knee injury prior to service. VA provided the Veteran an examination in July 2020. In March 2021, the Board remanded this matter to obtain a new medical nexus opinion, finding the July 2020 examination inadequate to adjudicate the Veteran's claim. In May 2021, a VA examiner opined the Veteran's left knee disability is less likely than not related to his active duty service, to include as secondary to his service-connected left ankle disability. Unfortunately, this opinion is inadequate to adjudicate the Veteran's claim. The May 2021 examiner provided a negative nexus opinion for direct service connection. The examiner attributed the Veteran's in-service complaints of left knee pain to an injury that occurred prior to active duty. As noted above, the Board previously found the presumption of soundness attached in this case and any evidence suggesting a pre-existing left knee injury must be disregarded in providing an etiology opinion. For these reasons, remand is warranted to ensure compliance with the Board's prior remand directives. See Stegall v. West, 11 Vet. App. 268 (1998). The May 2021 examiner provided a negative nexus opinion for secondary service connection. The examiner noted that there is a small amount of literature that supports the proposition that the veteran's left ankle could injure or aggravate his left knee. The examiner also reported there is literature that supports the proposition that an injured joint could cause transient pain in an uninjured joint due to altered gait; however, it has never been established to be more than transient pain. The examiner provided a medical excerpt to support his negative nexus opinion that, in sum, states an injury in one extremity rarely causes a major problem in the opposite or uninjured extremity. The examiner did not explain how the cited medical literature applies to the Veteran's particular situation and or how it supports a negative nexus opinion. Moreover, as noted above, the examiner reported that it has never been established that an altered gait causes anything more than transient pain in an injured joint; however, the examiner relied on a medical excerpt that indicates an injury in one extremity "rarely causes a major problem in the opposite or uninjured extremity." See May 2021 VA examination. The Board finds the examiner's supporting rationale internally inconsistent. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) (once VA undertakes to provide an examination, it must provide an adequate one). Moreover, the examiner did not specifically address the Veteran's contention that wearing an ankle cast in service and climbing up and down ladders between decks strained his left knee, as required in the March 2021 Board remand. Stegall v. West, 11 Vet. App. 268 (1998). The matter is REMANDED for the following action: 1. Obtain an opinion, preferably from a clinician other than the May 2021 examiner, regarding the etiology of the Veteran's left knee disability. Schedule the Veteran for an examination only if deemed necessary by the clinician selected to provide the opinion. The examiner must opine whether any left knee condition diagnosed is at least as likely as not related to an in-service injury, event, or disease, to include the documented left knee complaints in the Veteran's STRs. In providing this opinion, the examiner must disregard any evidence of a pre-existing left knee disability because no disability was noted upon the Veteran's entrance into military service and the Veteran was legally considered sound as to his left knee upon entrance into the military. The examiner must provide a comprehensive rationale for each opinion provided. The examiner is advised that the Veteran is competent to report his symptoms and history, and such reports are to be considered in formulating any opinion. The examiner may not dismiss the Veteran's competent reports of continued left knee symptoms solely on the basis that they are not documented in contemporaneous medical records and must specifically consider the Veteran's February 2021 statement that he did not seek treatment in service for his continued left knee symptoms because they did not interfere with his ability to perform his duties. (Continued on the next page) If the Veteran's current left knee disability is not found to be at least as likely as not directly related to military service, then the examiner must also opine whether any left knee disability is at least as likely as not (1) proximately due to any service-connected left ankle disability, or (2) aggravated beyond its natural progression by any service-connected left ankle disability. In responding to this request, the examiner must specifically address the Veteran's contention that wearing an ankle cast in service and climbing up and down ladders between decks strained his left knee, either causing or aggravating the left knee disability. Aggravation and causation are distinct theories and must be addressed separately and independently of each other. M. HYLAND Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Zachery S.C. Luce, 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.