Citation Nr: 24013167 Decision Date: 03/28/24 Archive Date: 03/28/24 DOCKET NO. 18-06 236 DATE: March 28, 2024 REMANDED Entitlement to service connection for right shoulder disability is remanded. Entitlement to service connection for left knee disability is remanded. REASONS FOR REMAND The Veteran served on active duty from March 1996 to March 2000; from January 2009 to April 2009; from September 2009 to December 2009; from May 2011 to January 2012; and in October 2012. This matter comes before the Board of Veterans' Appeals (Board) on appeal from April 2016 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO). In January 2023, the Board, in pertinent part, denied the service connection claims for a right shoulder disability and a left knee disability. In an October 2023 Order, the Court of Appeals for Veterans Claims (Court) granted the parties' Joint Motion for Remand (JMR) and vacated the January 2023 decision. 1. Service connection for right shoulder disability 2. Service connection for left knee disability The Veteran contends that he has a right shoulder disability and left knee disability due to service. See April 2015 VA Form 21-526EZ, Application for Disability Compensation and Related Compensation Benefits. The Veteran is currently diagnosed with a right shoulder disability and left knee disability. See April 2021 VA examination reports. In the October 2023 JMR, the parties agreed that a remand was warranted to afford the Board an opportunity to reassess the adequacy and probative value of the March 2021 VA medical opinion for the right shoulder disability and left knee disability. The Board finds the March 2021 VA examination inadequate due to the following reasons. First, the VA examiner provided a negative nexus opinion for the right shoulder disability and left knee disability noting that the disabilities were related to post-service occupational and recreational activities, without identifying the activities. Second, the VA examiner provided a negative nexus opinion for the Veteran's right shoulder disability, noting the Veteran's report of right shoulder pain and his statement of ongoing right shoulder pain starting in service, but failed to address why this was not a continuation of the Veteran's in-service complaints. Third, the VA examiner provided a negative nexus opinion for the Veteran's left knee disability relying on the Veteran's June 2012 VA reporting "left knee condition was okay and the exam was normal," however the report noted "pain... in the knee 1/10...popping in the ankle and knees." See Reonal v. Brown, 458, 461 (1993) (a medical opinion based upon an inaccurate factual premise is not probative). The Board notes that if VA provides an examination, that examination must be adequate. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). Thus, because VA did not obtain adequate medical opinions of the Veteran's right shoulder disability and left knee disability, the Board finds that a remand is necessary to address the identified deficiencies. The matters are REMANDED for the following action: 1. Make reasonable efforts to associate any outstanding military personnel records and service treatment records with the claims file, to include any treatment records related to his reported 2011 deployment to Southwest Asia. All efforts to obtain such evidence (including negative responses) should be documented in the claims file. 2. Obtain an addendum medical opinion from an appropriate clinician to determine the nature and etiology of the Veteran's right shoulder disability and left knee disability, or provide an examination if deemed necessary. The reporting clinician must address the following questions: (A) Identify the Veteran's current right shoulder disability (all disabilities diagnosed since April 2015). Thereafter, opine whether it is at least likely as not that the Veteran's right shoulder disability had onset in service, or is otherwise due to his service. (B) Identify the Veteran's current left knee disability (all disabilities diagnosed since April 2015). Thereafter, opine whether it is at least likely as not that the Veteran's left knee disability had onset in service, or is otherwise due to his service. The clinician is asked to explain the reasons behind any opinions expressed and conclusions reached. The examiner is reminded that the term "as likely as not" does not mean "within the realm of medical possibility," but rather that the likelihood is at least approximately balanced or nearly equal, if not higher. Note that the lack of documented treatment in service, or a long period after, while probative, cannot serve as the sole basis for a negative finding. Additionally, the clinician must not rely solely on the absence of an in-service finding or diagnosis as the basis for a negative opinion. The Veteran's lay contentions must be considered in making the determination. M. C. WILSON Veterans Law Judge Board of Veterans' Appeals Attorney for the Board T. Griggs 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.