Citation Nr: 22012197 Decision Date: 03/02/22 Archive Date: 03/02/22 DOCKET NO. 18-10 816 DATE: March 2, 2022 REMANDED Entitlement to service connection for chronic left leg disability to include left posterior leg strain is remanded. Entitlement to service connection for an acquired psychiatric disability to include posttraumatic stress disorder (PTSD), depression, and anxiety is remanded. REASONS FOR REMAND The Veteran served on active duty from November 1985 to November 1988. These matters come before the Board of Veterans' Appeals (Board) on appeal from September 2015 and July 2016 rating decisions of a Department of Veterans Affairs (VA) regional office (RO). Although the Board regrets the additional delay, a remand is necessary to ensure there is a complete record on which to decide the Veteran's claims. 1. Entitlement to service connection for chronic left leg disability to include left posterior leg strain is remanded. The Veteran contends that his chronic left leg disability is related to his active service. See July 27, 2021 Hearing Transcript. Generally, to establish service connection, a claimant must show: (1) a present disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service, the so-called "nexus" requirement. See 38 U.S.C. § 1110 (2018); 38 C.F.R. § 3.303 (2020); see also Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service treatment records show that the Veteran was treated several times while on active duty for left knee and leg pain. See November 8, 1988 STR-Medical. The Veteran underwent VA examination in July 2016 for knee and lower leg conditions. The Veteran reported that he started having left leg pain when he was in service doing a range walk (fast walk) and stepped into a gully with his left foot. He felt a sharp pain at the posterior calf, knee, and lower thigh. The Veteran also complained of a popping or stabbing sensation at the back of his left knee. Bilateral knee x-rays found no issues in the left knee and the examiner opined that the Veteran's left posterior leg strain was not caused by or the result of an event or injury during active service. See July 17, 2016 C&P Exam. Another VA examination in July 2019 noted that the Veteran does not have a left knee dislocation caused by injury during active service. See July 18, 2019 C&P Exam. In July 2021 hearing testimony, the Veteran testified that the actual name of his left leg condition is patellofemoral pain syndrome. See July 27, 2021 Hearing Transcript. However, no VA treatment records or examinations mention this condition. There is an indication that the Veteran's chronic left leg disability may be related to service, but there is insufficient evidence in the file to decide the claim. Another VA examination is warranted to determine the nature and etiology of the Veteran's chronic left leg disability. 2. Entitlement to service connection for an acquired psychiatric disability to include PTSD, depression, and anxiety is remanded. The Veteran contends that he has PTSD related to incidents that occurred while he was on active duty. See July 27, 2019 Hearing Transcript. The Veteran has several mental health diagnoses, and the Board will consider each as part of this claim. Service connection for PTSD requires: (1) medical evidence establishing a diagnosis of the condition; (2) credible supporting evidence that the claimed in-service stressor occurred; and (3) a link established by medical evidence, between current symptoms and an in-service stressor. 38 C.F.R. § 3.304(f). VA medical records indicate the Veteran has received mental health services. During a January 2020 mental health evaluation, the examiner noted that the Veteran had a prior history of depressive disorder. The examiner diagnosed him with generalized anxiety, unspecified depressive, and chronic stress disorders. The examiner added that an issue with pain compounds the Veteran's symptoms. See December 1, 2020 CAPRI. Individual lay statements from his mother and father note how they asked the Veteran to seek professional psychiatric help due to his disturbing behavior when he lived with them immediately after returning from active service. See October 28, 2019 Buddy/Lay Statement. However, no examiner has opined whether the Veteran's diagnosed psychiatric disorders may be related to his active service. The matters are REMANDED for the following action: 1. Obtain any outstanding VA and private medical records relevant to the Veteran's claim of chronic left leg disability. 2. Schedule the Veteran for a VA examination by an appropriate clinician to determine the nature and etiology of his chronic left leg disability to include left posterior leg strain and patellofemoral pain syndrome. The claims file should be reviewed, and the examiner should offer an opinion on the following: (a) Whether the Veteran's chronic left leg disability, to include left posterior leg strain and patellofemoral pain syndrome, had causal origins in service or is otherwise related to his active service. The examiner should accept the history of symptoms provided by the Veteran as true unless the examiner provides a rationale as to why the Veteran's recollection is affirmatively contradicted by the medical evidence. A clear rationale for all opinions must be provided and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. 3. Schedule the Veteran for an appropriate VA examination to determine the nature and etiology of all current psychiatric disorders. After examination of the Veteran and a review of the claims file: (a) The examiner should list all psychiatric disabilities diagnosed on examination. (b) For any psychiatric disability (other than PTSD) diagnosed on examination, the examiner should opine as to whether that disorder had its clinical onset in service or is otherwise related to active duty. (c) For any PTSD diagnosed on examination, the examiner must identify the stressor(s) which serve as the basis for the PTSD diagnosis. In offering the opinion, the examiner is asked to consider and discuss all pertinent evidence in the claims file, to include the appellant's lay statements regarding the history of his symptoms. A thorough and complete rationale for all opinions offered is (Continued on the next page) requested as adjudicators are precluded from making any medical findings. J. B. FREEMAN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board C.L. Hamilton, 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.