Citation Nr: 22016393 Decision Date: 03/22/22 Archive Date: 03/22/22 DOCKET NO. 16-38 838 DATE: March 22, 2022 REMANDED Entitlement to service connection for a right knee disability, to include as secondary to a service-connected left knee disability, is remanded. REASONS FOR REMAND The Veteran served on active duty from December 1975 to August 1983. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a July 2015 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). In May 2019, the Veteran testified at a hearing before the undersigned. A copy of the transcript of that hearing has been associated with the claims file. By way of background, this matter was initially before the Board in September 2019 and September 2021, when it was remanded for further development. Entitlement to service connection for a right knee disability, to include as secondary to a service-connected left knee disability, is remanded. During his May 2019 Board hearing, the Veteran testified that his right knee disability manifested while he was serving on active duty. Specifically, he reported that he injured his right knee while performing eight-count body builder exercises during service. The Veteran also stated that his current right knee disability may had been caused by wear and tear sustained while assisting search and rescue operations and from his military occupational specialty (MOS) as a machinist's mate, which is supported by his DD 214. To this end, he explained that machinist's mates' duties included carrying heavy objects, traversing ladders, and removing paint, and noted that he performed work requiring use of vibrating needle guns and deck growlers during service. See May 2019 Hearing Transcript, pages 2-12, 16-18; December 1983 Certificate of Release or Discharge from Active Duty (e.g., DD 214, NOAA 56-16, PHS 1867); March 2015 Certificate of Release or Discharge from Active Duty (e.g., DD 214, NOAA 56-16, PHS 1867). Alternatively, the Veteran indicated that his right knee disability may have been caused or aggravated beyond its natural progression by his service-connected left knee disability. See October 2016 VA Form 27-0820 Report of General Information. A review of the service treatment records (STRs) shows a December 1975 enlistment report of medical examination that notes the Veteran's lower extremities to be normal. A July 1981 medical record shows that the Veteran sought treatment for a right knee injury he sustained while performing eight-count body builder exercises. He indicated that he initially treated the injury, which had occurred one week prior, by wrapping it in an ace bandage. However, he noted that he was still experiencing pain, which prevented him from bending or standing on his knee and walking and caused him to lose control of both knees in water. A physical examination revealed crepitus and patella. The assessment was bilateral chondromalacia patellae right knee. Two weeks later, the Veteran requested to see a physician for continued right knee pain. At that time, he stated that his medication was not helping and that his pain had remained consistent since he last sought treatment. He further stated that both of his knees continued to "give out" when he swam. The assessment was questionable bilateral chondromalacia patellae right knee. However, the Veteran's lower extremities were noted to be normal on the June 1983 discharge report of medical examination. See March 2015 STR Medical. A review of the post-service treatment records shows that the Veteran underwent a knee x-ray in July 2003, which revealed moderate osteoarthritis, particularly medially. See July 2015 CAPRI. A private treatment record, dated in February 2006, shows that the Veteran reported that he had been experiencing intermittent, bilateral knee pain for the preceding few years, which had increased during the preceding few months. However, he denied trauma and previous knee surgeries. The assessment included degenerative joint disease of the knees. See October 2019 Medical Treatment Record Non-Government Facility. In February 2013, the Veteran reported that his left knee was giving out, which he attributed to the additional workload required to compensate for his service-connected right knee disability. Thereafter, in May 2013, the Veteran reported a recent crescendo of knee pain, which began three weeks prior, and indicated that he could not kneel on his right knee. At that time, he stated that he initially injured his right knee lifting weights during service. The assessment included osteoarthritis of the knee, and the Veteran expressed interest in receiving cortisone shots as treatment. During a June 2013 orthopedic consultation, the Veteran stated that he injured his knees while doing an extreme weight loss workout during service. An x-ray obtained in connection with the consultation revealed osteoarthritis with bone on bone in the lateral compartments of both of the Veteran's knees. See April 2015 Medical Treatment Record Non-Government Facility. The Veteran underwent a VA examination for knee and lower leg conditions in May 2016. The examiner noted that the Veteran had been diagnosed with a left knee meniscal tear and bilateral knee joint osteoarthritis. During the examination, the Veteran stated that his right knee pain manifested while he was serving on active duty and indicated that he began to seek treatment for his knee disabilities in 2009. The examiner also noted that the Veteran's STRs showed that he had a history of a left knee meniscal tear during service, though the Veteran stated that it was his right knee but was unsure. After performing an examination and reviewing the evidence of record, the examiner opined that it was less likely than not that the Veteran's right knee disability was incurred in or caused by the claimed in-service injury, event, or illness. In support of his opinion, the examiner explained that the Veteran did not have a mechanism of injury in service that could explain his current right knee degenerative changes. To the contrary, the examiner stated that the Veteran's right knee disability was more likely related to age. See May 2016 C&P examination. In support of his claim, the Veteran submitted a private medical opinion from a physician's assistant, dated in June 2019. The P.A. opined that he was certain that it was more likely than not that the Veteran's diagnosed osteoarthritis of the right knee was related to his active duty service. In support of his opinion, the P.A. noted that the Veteran reported that his knee troubles manifested after he performed eight-count body builders during service over 20 years prior. He further explained that the Veteran sought treatment for his symptoms, which had degenerated over time. See October 2019 CAPRI. The Veteran also underwent a VA examination for knee and lower leg conditions in February 2020. The examiner noted that the Veteran had been diagnosed with bilateral knee degenerative arthritis. During the examination, the Veteran reported that he injured his right knee while doing eight-count body builders during service. After performing an examination and reviewing the evidence of record, the examiner opined that it was less likely than not that the Veteran's right knee disability was caused by the claimed in-service injury, event, or illness. In support of the opinion, the examiner noted that the June 1983 discharge report of medical examination did not show any issues related to the Veteran's knees. Rather, the examiner opined that it was more likely than not that the Veteran's right knee disability was related to his years of working as an HVAC mechanic, which they characterized as very hard, labor intensive work. The examiner also noted that the Veteran's age and history of obesity could cause his current knee problems, explaining that the Veteran's weight was similar to carrying a ruck sack for multiple years. To this end, the examiner noted that such would put tremendous weight on the joints, wearing them out, and noted that the effect thereof was further exacerbated by his work as a HVAC mechanic. In addition, the February 2020 VA examiner opined that it was less likely than not that the Veteran's right knee disability was aggravated beyond its natural progression by his service-connected left knee disability. In support of the opinion, the examiner stated that there was no concrete evidence that the Veteran's left knee disability aggravated his right knee problems; rather, they explained that it was more likely than not that his current right knee disability was related to his work as an HVAC mechanic, age, and obesity. See February 2020 C&P examination. VA obtained an addendum medical opinion in November 2021. After performing a review of the evidence of record, the examiner opined that it was less likely than not that the Veteran's right knee disability was incurred in or caused by the claimed in-service injury, event, or illness. In support of his opinion, the examiner explained that there was no evidence that the Veteran had a chronic right knee condition during service. Rather, although he acknowledged that the Veteran had been diagnosed with chondromalacia patella following a one-week history of right knee pain in July 1981, the examiner determined that the Veteran's symptoms apparently resolved with proper treatment and rest, as there was no evidence of a chronic condition thereafter and as his June 1983 discharge report of medical examination was negative for left and right knee conditions. Thus, the examiner found that, although the Veteran had chondromalacia patella while in service, it was more likely than not that the condition had resolved and was absent at the time of separation from service. In addition, the examiner found that the Veteran did not develop right knee degenerative joint disease until approximately 2015, more than 30 years after he was discharged from active duty service. To this end, he noted that the Veteran did not have a current diagnosis of chondromalacia patella and that a single episode of such in service would not cause degenerative joint disease 30 plus years later. To the contrary, he explained that the Veteran's degenerative joint disease was age-appropriate at the time of onset and was generally considered to be caused by normal wear and tear over a lifetime. Therefore, the examiner opined that it was less likely than not that the Veteran's right knee disability had its nexus in service or was related to chondromalacia patella diagnosed in service, which subsequently resolved. The November 2021 VA examiner further opined that it was less likely than not that the Veteran's right knee disability was caused or aggravated beyond its natural progression by his service-connected left knee disability. Specifically, the examiner found that the Veteran's right knee degenerative joint disease had not been caused by any of his left knee conditions, which included meniscal injuries, surgery, and degenerative joint disease. In support of his opinion, the examiner noted that established medical knowledge and practice showed that a condition in one knee did not cause a condition in the contralateral knee. In this regard, he explained that gait accomodation, or favoring the left knee, would not cause the Veteran's right knee disability and that a simple antalgic gait would not account for the changes in the contralateral knee. The examiner acknowledged that rare exceptions to such included leg length discrepancies in excess of 5 percent and/or chronic exaggerated to Trendelenburg gait, but found that neither exception was present in the Veteran's case. To the contrary, the examiner explained that degenerative joint disease was a naturally occurring age-related condition caused by a lifetime of wear and tear. To this end, the examiner noted that the Veteran's degenerative joint disease was age-appropriate and bilateral at the time of its initial diagnosis in 2015, which further supported natural occurrence. Similarly, the examiner found that there was no evidence of aggravation of the Veteran's right knee disability beyond its natural course due to any costs, to include as due to gait accommodation for the left knee. Rather, the examiner explained that degenerative joint disease tended to progress naturally, often requiring medical intervention, injections or surgery, including a total knee arthroplasty. See November 2021 C&P examination. After a review of the evidence of record, the Board finds that a remand is required to obtain an addendum medical opinion. Specifically, the Board finds that the November 2021 addendum medical opinion was based, at least in part, on the finding that the Veteran's right knee degenerative joint disease manifested in or around 2015, approximately 30 years after he was discharged from active duty service. See November 2021 C&P examination. However, as noted above, VA treatment records show that the Veteran was diagnosed with osteoarthritis, particularly medially, following a July 2003 x-ray. See July 2015 CAPRI. In addition, a private treatment record, dated in February 2006, shows that the Veteran reported that he had been experiencing intermittent, bilateral knee pain for the preceding few years, and that he was subsequently diagnosed with degenerative joint disease of the knees. See October 2019 Medical Treatment Record Non-Government Facility. The Board notes that the aforementioned diagnoses were rendered approximately 10 years prior to the date of onset indicated by the November 2021 VA examiner and that the Veteran was 47 at the time of the July 2003 diagnosis and 49 when he was diagnosed with degenerative joint disease in February 2006. Thus, the Board finds that the November 2021 VA medical opinion is based, at least in part, on an incomplete factual premise, and as such, is currently inadequate to adjudicate the issue on appeal. See Reonal v. Brown, 5 Vet. 458, 461 (1993) (medical opinions based on an incomplete or inaccurate factual premise are not probative). VA has a duty to ensure any medical examination or opinion it provides is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). Thus, the Board finds that a remand is necessary to obtain an addendum medical opinion to determine the nature and etiology of the Veteran's diagnosed right knee disability. See Bowling v. Principi, 15 Vet. App. 1, 12 (2001) (emphasizing the Board's duty to return inadequate examination report). The matter is remanded for the following action: 1. With any necessary identification of sources by the Veteran, request all VA treatment records not already associated with the file from the Veteran's VA treatment facilities, and all private treatment records from the Veteran not already associated with the file. 2. After completion of the above development, obtain an addendum opinion from an appropriately qualified examiner to determine the nature and etiology of the Veteran's diagnosed right knee disability. It is up to the discretion of the examiner as to whether an in-person examination is necessary. The examiner should provide the following opinions: Is it at least as likely as not (50 percent or greater probability) that the Veteran's right knee disability had its onset in service or is otherwise etiologically related to his active duty service, to include as due to an injury sustained while performing eight-count body builder exercises and as due to wear and tear sustained while assisting with search and rescue operations and as a machinist's mate? Please explain why or why not. The examiner should specifically address the July 1981 record showing that the Veteran sought treatment for right knee pain and was subsequently diagnosed with chondromalacia patella following an injury he sustained while performing eight-count body builder exercises in service. In addition, the examiner should consider the July 2003 VA treatment record showing that the Veteran was diagnosed with right knee osteoarthritis, particularly medially, the February 2006 private treatment record noting that the Veteran had been diagnosed with degenerative joint disease, the June 2019 private medical opinion from a physician's assistant, and any conflicting medical evidence of record, to include the records identified in the body of this Remand. Reasons should be provided for any opinion rendered. If the examiner is unable to provide an opinion without resort to speculation, an explanation as to why this is so should be provided and any additional evidence that would be necessary before an opinion could be rendered should be identified. S. HENEKS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board K. Justis, 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.