Citation Nr: 23004591 Decision Date: 01/25/23 Archive Date: 01/25/23 DOCKET NO. 16-34 384 DATE: January 25, 2023 REMANDED Entitlement to service connection for a right leg disorder is remanded. Entitlement to service connection for a right knee disorder is remanded. REASONS FOR REMAND The Veteran had active-duty service in the United States Navy from January 1972 to January 1975. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a December 2014 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Montgomery, Alabama. 1. Entitlement to service connection for a right leg disorder is remanded. 2. Entitlement to service connection for a right knee disorder is remanded. The Board finds that remand is required for additional development. These issues were previously remanded in an August 2022 Board decision and VA opinions were procured in September 2022. In separate September 2022 VA opinions, the examiner determined that the Veteran's right knee and right leg conditions were less likely than not related to service. The examiner stated that review of the STRs and medical records did not show evidence of a diagnosis, treatment, or symptoms suggestive of right knee pathology or right leg edema while on active duty or within one year of separation. It was noted that the Veteran was diagnosed with gonorrhea in 1974 and that he complained of right knee pain, which was suggested to be probable gonococcal arthritis. X-ray and laboratory evaluation, however, had ruled this out. The Veteran was diagnosed with right leg cellulitis and varicose veins many years following service. The Board finds that this opinion is inadequate for adjudication purposes. First, the Board notes that the opinion relied almost entirely upon lack of documentation in contemporaneous medical records. See Buchanan v. Nicholson, 451 F. 3d 1331, 1336-37 (2006) (holding that the lack of contemporaneous medical records does not, in and of itself, render lay evidence not credible). Second, the Board notes that the examiner's opinion did not actually address nexus. He simply noted that the Veteran had not had gonococcal arthritis in service, and noted the gap between discharge and the Veteran's eventual diagnoses for right leg conditions. As such, no opinion with proper rationale or medical explanation was provided by the examiner. A medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008). Finally, the Board notes that the examiner did not adhere to the prior Board remand directives. The Board is obligated by law to ensure that the RO complies with its directives. Stegall v. West, 11 Vet. App. 268, 271 (1998). RO compliance with remand directives is not optional or discretionary and the Board errs as a matter of law when it fails to ensure remand compliance. Stegall, 11 Vet. App. at 271. The examiner was instructed to address the Veteran's lay statements regarding his time in service. He was asked to consider the Veteran's credible statements regarding his two-week hospitalization for his right leg as well as his fall off of a plane wing. As these lay statements were not addressed, remand is required to fulfill prior Board remand directives. The matters are REMANDED for the following action: 1. Forward the Veteran's claims file to an appropriate clinician, other than the examiner from the September 2022 VA opinion (if possible), for an addendum opinion regarding the nature and etiology of the Veteran's right leg edema and right knee pain with functional loss; and any additional diagnosed disorders related to the right leg and knee. The need for an in-person examination is left to the discretion of the examiner. For each diagnosed disorder, the examiner is asked to opine whether it is at least as likely as not related to an in-service injury, event, or disease. The examiner should consider the treatment records which documented that the Veteran experienced "gonococcal arthritis," his credible lay reports that he was hospitalized for two weeks as a result of the swelling in his right knee and leg, and the Veteran's statement regarding a traumatic fall off of a plane wing in service. (Continued on the next page) A complete rationale for any opinion rendered must be provided. With respect to the Veteran's lay reports, the examiner is instructed that the Veteran is competent to report symptoms observable to a layperson, and such statements may not be dismissed solely due to lack of documentation in the medical record. H.M. WALKER Veterans Law Judge Board of Veterans' Appeals Attorney for the Board AK 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.