Citation Nr: 22016247 Decision Date: 03/21/22 Archive Date: 03/21/22 DOCKET NO. 13-09 042A DATE: March 21, 2022 REMANDED Service connection for a left knee condition. Service connection for a right knee condition. REASONS FOR REMAND The Veteran served on active duty from September 1971 to September 1973. The case is on appeal from an October 2011 rating decision. In July 2015, the Veteran testified at a Board hearing. The claims were most recently before the Board in October 2021, at which time the Board remanded service connection for the right and left knee for new VA examinations and further development. At that time, the Board also granted service connection for hernias. 1. Service connection for a left knee condition. 2. Service connection for a right knee condition. The Veteran contends that he injured both knees during service, primarily during a three mile run when he tripped and fell while training at Parris Island, followed by the drill sergeant and master gun sergeant kicking and beating on him until he passed out. At the July 2015 Board hearing, he testified that his knees swelled after the fall, and he was hospitalized as a result but that care providers during the treatment could not determine what was wrong. In the October 2021 remand, the Board found that a new VA examination was required for clarification as to the Veteran's diagnoses, and that an April 2020 medical opinion did not substantially comply with the Board's prior January 2016 remand directives. Stegall v. West, 11 Vet. App. 268 (1998). Specifically, an opinion was not provided as to whether any diagnosed arthritis impacting the knees was manifested within one year of discharge of service, despite service treatment records (STRs) indicating polyarthritis of multiple joints, and the April 2020 examiner stating that his knee swelling suggests an autoimmune disease such as rheumatoid arthritis (RA). The Board finds that another remand is warranted for new medical opinions. In November 2021, the Veteran was afforded a new VA examination, and a new diagnosis of patellofemoral pain syndrome (PFS) was found, with reports of constant pain. Additionally, multiple opinions were provided, to include whether the Veteran has a direct link of his PFS disability to service, and whether any of his current service-connected conditions aggravate his PFS. The November 2021 opinions are determined to be inadequate. All of the examiner's opinions are limited to conclusory remarks without any real explanation or rationale. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008). Additionally, as for the limited conclusion made in finding a lack of direct service connection, it appears based on the absence of an initial in-service injury or lack of continuity and chronicity of care, which is an inaccurate factual premise. Reonal v. Brown, 5 Vet. App. 458, 461 (1993). STRs reflect polyarthritis of multiple joints, in addition to the Veteran's statements of an in-service injury. Further, the October 2021 remand directives requested the examiner to address and discuss whether the Veteran has any diagnosis of arthritis of the knees, in light of the STR entries of polyarthritis and the August 2020 examiner's statement that his knee swelling suggests possible RA. This was not completed, and a VA examination specifically for arthritis is additionally requested upon remand. In light of the remand, updated VA treatment records should be obtained. The matters are REMANDED for the following action: 1. Obtain updated VA treatment records since October 2021. 2. Schedule the Veteran for a VA examination (or telehealth interview, review of the record, etc., if an in-service examination is not feasible) with an appropriate specialist, in connection with the Veteran's left and right knee claims. The record, including a complete copy of this remand, should be made available for review. The examiner must conduct all necessary testing, unless it can be explained why such testing is not medically necessary. (a) The examiner is requested to complete an arthritis disability benefits questionnaire (DBQ), as well as any other appropriate identified DQB, as it relates to the Veteran's current bilateral knee condition. (b) The examiner should identify any diagnosis of the left and right knees, to include any diagnosis of arthritis of the knees, whether traumatic, degenerative, or autoimmune such as RA. In making this determination, the examiner should specifically address and discuss: (1) October 1971 STRs of polyarthritis with an unknown etiology; (2) the April 2020 opinion that his knee swelling suggests an autoimmune disease like RA; (3) VA treatment records of instability with use of a wheelchair and walker, difficulty walking with knee pain, and profound weakness in the bilateral knee flexors; and (4) the November 2021 diagnosis of PFS. If the Veteran does not have a diagnosis of arthritis of the knees, it must be stated as to how that determination was made. (c) The examiner is then asked to provide a response to each of the following for the Veteran's identified left and right knee conditions: (i) Is the condition at least as likely as not (at least an approximate balance of positive and negative evidence) related to service? (ii) Is it at least as likely as not that the condition (1) began during active service, (2) manifested within 1 year after discharge from service, or (3) was noted during service with continuity of the same symptomatology since service? (iii) Was the condition at least as likely as not caused by (i.e., proximately due to) a service-connected disability? (iv) Has the condition been at least as likely as not aggravated (i.e., worsened beyond its natural progression) by a service-connected disability? If it is determined that the knee conditions were either caused or aggravated by a different medical condition, the examiner is asked to identify the primary medical condition. The examiner is asked to consider whether the Veteran is diagnosed with obesity, which may act as an "intermediate step" between a service-connected disability and his bilateral knee disability, for a grant of service connection on a secondary basis. The examiner is also asked to consider the statements from the Veteran regarding his history of symptoms during and since service, and to explain why his statements make it more or less likely that the current knee conditions are related to service, and do the Veteran's reports about his symptoms align with how the currently diagnosed conditions are known to develop. The examiner should not rely on silence in the medical records unless it can be explained: (a) why the silence in the available records can be taken as proof that the symptom(s) did not occur, including why the fact would have normally been recorded if present, or (b) why the absence of medical records is medically significant. The examiner should provide rationale for all opinions expressed, including by citing to the record. RYAN T. KESSEL Veterans Law Judge Board of Veterans' Appeals Attorney for the Board S. Morford, 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.