Citation Nr: 21042376 Decision Date: 07/12/21 Archive Date: 07/12/21 DOCKET NO. 17-34 583 DATE: July 12, 2021 REMANDED Entitlement to service connection for a low 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 had military service from November 2005 to November 2009. His service included a tour in Southwest Asia for which he earned the Combat Action Ribbon. On initial review of these claims the Board remanded the case to the Agency of Original Jurisdiction (AOJ) for additional development. See 06/01/2020 BVA Decision. The AOJ endeavored to comply with the remand directives, but the Board finds less than substantial compliance. See Stegall v. West, 11 Vet. App. 268 (1998). 1. Entitlement to service connection for a low back disability is remanded. The AOJ arranged an examination of the Veteran as directed in the June 2020 remand directive. See 11/16/2020 C&P Exam, 1st Entry. The examiner noted the Veteran's report that he had to seek treatment for low back pain at a civilian emergency room in October 2009, the month prior to his separation from active service. See 03/16/2020 Hearing Transcript, P. 19. The nurse practitioner (NP) examiner noted further, however, that she found no records of such treatment in the claims file. See 11/16/2020 C&P Exam, 1st Entry, P. 2. The records of that treatment were provided by the Veteran after the examination. See 11/24/2020 Medical Treatment-Non-Government Facility, 3rd Entry. The AOJ arranged another examination by the same NP. See 04/20/2021 C&P Exam, 1st Entry. The examination report reflects that the Veteran was examined for the current state and severity of his low back disability, but the NP did not comment further on whether there is a nexus between the Veteran's currently diagnosed low back disability and his active service. Hence, another remand is indicated. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). 2. Entitlement to service connection for right and left knee disability is remanded. As noted in the June 2020 remand, the examination report of the Veteran's initial VA examination noted the 2012 diagnosis of lumbar spine degenerative disc disease (DDD) but the objective findings on clinical examination revealed no active symptomatology. See 10/21/2014 C&P Exam, 1st Entry, P. 17-23. The April 2021 examination report (04/20/2021 C&P Exam, 2nd Entry) notes a diagnosis of patellofemoral pain syndrome (PFS). Id. P. 2. The NP noted the Veteran's complaints of knee pain in service but also noted that his complaints were diagnosed as a left iliotibial band condition that did not involve the knee but instead involved the hip and thigh. Hence, she opined that there was no causal connection between the currently diagnosed PFS and the complaints and treatment documented in the STRs. Id. P. 24. The Board finds that the rationale is inadequate for appellate review purposes. See Barr, 21 Vet. App. 303. The matters are REMANDED for the following action: 1. The AOJ shall arrange a medical nexus review of the claims file by an appropriate physician clinician. Ask the clinician to opine on whether it is at least as likely as not that any currently diagnosed low back disability had onset in active service or is otherwise causally connected to active service, to include whether it is due to the stress and wear and tear of carrying heavy equipment? The Board requests that the opinion include a finding of whether it is at least as likely as not that the Veteran manifested with chronic low back pain at the time of his separation from active service. (Emphasis added). See Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018). Concerning whether there is a causal connection between the currently diagnosed lumbar spine DDD and the Veteran's active service, the clinician must provide a full explanation for all findings and opinions rendered. A full explanation must include a discussion of the lay testimony from both the Veteran's and his wife (who is a registered nurse) and how it factored into the opinion. If the absence of documentation of treatment is relevant, the clinician must explain the relevance. Inform the clinician that the Board has not made a finding on the accuracy and reliability of the Veteran's lay statements and testimony. The Board will make that determination when reviewing all of the evidence of record when the case is returned to the Board. 2. The AOJ shall also ask the physician clinician to opine on whether it is at least as likely as not that the Veteran's currently diagnosed bilateral knee disability had onset in active service or is otherwise causally connected to active service, to include the complaints and treatment noted in the service treatment records, and whether it is due to the stress and wear and tear of carrying heavy equipment. The clinician must provide a full explanation for all findings and opinions rendered. A full explanation must include a discussion of the lay testimony from the Veteran and his wife (who is a registered nurse) and how it factored into the opinion. If the absence of documentation of treatment is relevant, the clinician must explain the relevance. Inform the clinician that the Board has not made a finding on the accuracy and reliability of the Veteran's lay statements and testimony. The Board will make that determination when reviewing all of the evidence of record when the case is returned to the Board. Should the clinician advise that the requested opinions cannot be rendered without examining the Veteran, the AOJ will arrange the examinations. Eric S. Leboff Veterans Law Judge Board of Veterans' Appeals Attorney for the Board W. T. Snyder 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.