Citation Nr: 23027167 Decision Date: 05/07/23 Archive Date: 05/07/23 DOCKET NO. 19-19 558 DATE: May 7, 2023 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 served on active duty in the United States Army from December 1972 to October 1976 and from January 1979 to August 1992. These matters come to the Board of Veterans' Appeals (Board) on appeal from a March 2016 rating decision. They were remanded by the Board in September 2019 for a new VA medical opinion. The Board notes that in the Veteran's March 2017 Notice of Disagreement, the Veteran also took issue with the denials of service connection for left and right lower extremity radiculopathy, and both of these issues were also remanded by the Board in September 2019. However, in a July 2021 rating decision, service connection for both conditions was granted. Accordingly, these matters have been resolved in the Veteran's favor and are no longer before the Board. Entitlement to service connection for a left knee disability and a right knee disability are remanded. Although the Board sincerely regrets the additional delay, these matters must be remanded for a new VA examination. VA's duty to assist a veteran in substantiating his claim includes obtaining a medical examination when necessary and ensuring that it is adequate to decide the claim. See 38?U.S.C. §?5103A(d); see Barr v Nicholson, 21?Vet. App.?303, 312 (2007). An examination report is inadequate if it provides an incomplete analysis or if it does not consider all the relevant evidence of record. Stefl v. Nicholson, 21?Vet. App.?120 (2007); Nieves-Rodriquez v. Peake, 22?Vet. App.?295 (2008); Dalton v. Nicholson, 21?Vet. App.?23 (2007). In this regard, the December 2019 medical opinion obtained pursuant to the previous remand fails to adequately consider whether the Veteran's left and right knee disabilities are secondary to the Veteran's service-connected back condition. At that time, the Veteran was service-connected for a lumbosacral strain. Based on his examination of the Veteran six months prior in April 2019, the examiner concluded that lumbosacral strains do not cause or aggravate knee strains unless there is a significantly abnormal gait that has been present for an extended period of time, which he said was not the case for this Veteran. However, additional findings at a subsequent July 2021 VA examination for the Veteran's back call into question the December 2019 examiner's conclusion. There, the Veteran was diagnosed with additional back conditions that were not considered by the previous examiner, including intervertebral disc syndrome, spinal stenosis, and degenerative disc disease status-post laminectomy (all of which are now encompassed by the Veteran's service-connected back condition). Additionally, the 2021 examiner found that the Veteran suffers from an antalgic gait, which the December 2019 examiner specifically identified as an indication that a back strain may have resulted in a knee strain. Based on the previous examiner's incomplete analysis in light of the Veteran's new back diagnoses, a new VA examination is warranted to consider whether the Veteran's left and right knee disabilities are secondary to his service-connected back conditions. Moreover, the record lacks an adequate opinion regarding direct service connection. At his April 2019 VA examination, the examiner concluded that it is less likely than not that the Veteran's knee strain is due to his active duty service because the Veteran reported that his knees did not become a significant problem until 2010, almost 20 years after separation. Indeed, the Veteran reported that he ignored treatment for his knees in the mid-1990s because he felt that his back was a more significant problem. However, in providing this negative nexus opinion, the examiner did not address the fact that the Veteran's service treatment records include complaints about his knees. The Veteran repeatedly sought treatment for bilateral knee issues, including right knee locking after running and painful knees during rapid weather changes. On his Report of Medical History dated June 1984, the Veteran noted swollen or painful joints and, in April 1985, he complained of knee pain that lasted for two weeks. It was indicated at that time that the Veteran specifically suffered from a "knee strain." In February 1989, the Veteran once again complained of intermittent bilateral knee pain after running several miles. Notably, at separation from service in July 1992, the Veteran complained of a "trick" or lock knee as well as swollen or painful joints. These complaints are consistent with two treatment notes from 2010, several years before the Veteran filed his claim, indicating that the Veteran experienced knee pain since the 1970s that he attributed to excessive physical activity in the Army, and worsening left knee pain that has been present since its onset during service in 1982. They are also consistent with the Veteran's November 2015 statement in which he attributes his knee pain to "hard infantry life for nearly 20 years." Given the Veteran's multiple complaints of knee pain during service and his competent statements of consistent pain since service, a new examination is warranted to specifically address whether the Veteran's current knee condition had its onset during service. The matters are REMANDED for the following action: Schedule the Veteran for a VA examination regarding his right and left knee disabilities. The examiner must review the claims file. If a diagnosis cannot be provided but the Veteran's condition manifests in symptoms that cause functional impairment, then the examiner should consider them a "disability" for the purpose of providing the requested opinions below. The examiner is asked to provide a response to the following: (a) Is the Veteran's left and/or right knee disability at least as likely as not related to service? The examiner is asked to specifically consider the multiple in-service complaints of knee pain outlined above, as well as the Veteran's competent reports of experiencing knee pain since service. (b) Is the Veteran's left and/or right knee disability at least as likely as not proximately due to any of the Veteran's service-connected back disabilities? (c) Is the Veteran's left and/or right knee disability at least as likely as not aggravated, i.e., worsened beyond its natural progression, by any of the Veteran's service-connected back disabilities? Provide a rationale to support the opinions. Wendy Daknis Veterans Law Judge Board of Veterans' Appeals Attorney for the Board F. J. Carmack, 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.