Citation Nr: 25005461 Decision Date: 04/23/25 Archive Date: 04/23/25 DOCKET NO. 17-36 278A REMANDED Entitlement to service connection for left knee disorder is remanded. Entitlement to service connection for left wrist disorder is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from August 1983 to April 1992. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a September 2013 rating decision, issued by a Regional Office (RO) of the Department of Veterans Affairs (VA). These matters were previously before the Board, most recently in July 2024, at which time the Board remanded the matters for further development, the matters have returned to the Board for further adjudication. In July 2021, the Veteran testified at a hearing before the undersigned Veterans Law Judge (VLJ), a transcript of the hearing is of record. 1. Entitlement to service connection for left knee disorder is remanded. Unfortunately, a further remand is necessary to ensure compliance with the Board's July 2024 remand directives. See Stegall v. West, 11?Vet. App.?268, 271 (1998) (holding veterans are entitled to compliance with Board remand instructions). The Veteran contends he has a left knee disorder he attributes to in-service injuries and to his collective physical activities during active service, to include playing basketball, physical training, and track and field. See e.g., January 2023 Appellate Brief. In a September 2024 VA medical opinion, the examiner opined it is less likely than not the Veteran's left knee degenerative arthritis was incurred in or is otherwise related to an in-service event, injury, or illness. See September 2024 VA Medical Opinion. As a rationale, the examiner pointed to: (1) his affirmative denial of experiencing knee symptoms upon separation from service; and (2) his documented in-service treatment for left knee contusions, which the examiner indicated have no correlation to his current left knee osteoarthritis first diagnosed in 2021, some 29 years after his separation from service. Id. In a December 2024 addendum VA medical opinion, the examiner specifically noted review of all relevant evidence of record the Board directed the examiner to consider on remand. See December 2024 VA Addendum Medical Opinion. Considering all such evidence of record, the examiner opined it is less likely than not the current left knee osteoarthritis was incurred in or is otherwise related to an in-service event, injury, or illness. Id. As a rationale, the examiner pointed to: (1) STRs documenting in-service treatment for acute left knee contusions; (2) current imaging showing no signs of left knee traumatic injury residuals or traumatic arthritis; (3) imaging documenting mild degenerative joint disease in 2021, consistent with age related wear and tear, some 29 years after his separation from service; (4) the Veteran's affirmative denial of experiencing knee symptoms upon separation from service; and (5) the Veteran's post service occupational history, including shipping international packages and delivering and sorting mail, which the examiner noted were physically demanding and included standing, walking, lifting, carrying, squatting, and bending. Id. The examiner specifically pointed to a lack of evidence supporting a relationship between the Veteran's acute left knee contusions treated during service and his diagnosed left knee osteoarthritis, first documented in 2021. Id. While the December 2024 VA examiner noted review of all relevant evidence of record the Board directed in its July 2024 remand, there is some confusion regarding whether the examiner reviewed and considered a medical study cited by the Veteran's representative in a January 2023 appellate brief. In the December 2024 addendum opinion, the examiner correctly noted the web address to the study as cited in the Board's July 2024 remand directive did not load as listed in the remand and was missing the letter "n" in "ncbi". See December 2024 Addendum Opinion. Thus, it is unclear whether the examiner was: (1) able to access the study from the correct web address cited in the Veteran's January 2023 appellate brief; and (2) considered the study in formulating the December 2024 addendum medical opinion addressing the etiology of the Veteran's left knee disorder. Therefore, a further remand is warranted to either: (1) confirm the examiner was able to access and considered the study from the correct web address cited in the Veteran's January 2023 appellate brief in formulating the December 2024 VA addendum medical opinion; or (2) if the examiner was unable to access and consider the study, for a further addendum VA medical opinion, considering the study, which can be accessed using the web address cited in the Veteran's January 2023 appellate brief. 2. Entitlement to service connection for left wrist disorder is remanded. Unfortunately, a further remand is necessary to ensure compliance with the Board's July 2024 remand directives. See Stegall v. West, 11?Vet. App.?268, 271 (1998) (holding veterans are entitled to compliance with Board remand instructions). The Veteran contends he has a left wrist disorder that was incurred in service and pain that has persisted since service. See e.g., January 2023 Appellate Brief. Specifically, he contends he injured his left wrist after falling off the back of a truck while stationed in Germany. See August 2012 VA Examination. Alternatively, the Veteran contends his left wrist disorder is due to physical activities during service including playing basketball, physical training, and track and field. See January 2023 Appellate Brief. In a September 2024 VA medical opinion, the examiner opined it is less likely than not the Veteran's left wrist disorder(s) were incurred in or are otherwise related to an in-service event, injury, or illness. See September 2024 VA Medical Opinion. As a rationale, the examiner acknowledged: (1) the Veteran's report of having sustained an in-service left wrist injury after falling from a truck; and (2) his alternative contention his left wrist disorder(s) are related to in-service physical activity to include playing basketball and physical training. Id. As to his report of in-service injury, the examiner noted his STRs document treatment for a left elbow injury after falling off a truck but do not document left wrist treatment, either at that time or at any time during his active service. Id. The examiner further pointed to his March 1992 separation report of medical examination and his February 1993 VA examination, which do not document any left wrist complaints. Id. In a December 2024 addendum VA medical opinion, the examiner specifically noted review of all relevant evidence of record the Board directed the examiner to consider on remand. See December 2024 VA Addendum Medical Opinion. Considering all such evidence of record, the examiner opined it is less likely than not the Veteran's left wrist disorder(s) were incurred in or are otherwise related to an in-service event, injury, or illness. Id. As a rationale, the examiner pointed to: (1) current left wrist imaging showing no signs of traumatic injury residuals and/or traumatic arthritis; (2) 2023 left wrist imaging, some 31 years after his separation from active service, documenting mild degenerative joint disease, consistent with age-related wear and tear; and (3) his post service occupations, to include shipping international packages and cargo and delivering and sorting mail, which the examiner noted were physically demanding and required repetitive handwork. Id. While the December 2024 VA examiner noted review of all relevant evidence of record the Board directed in its July 2024 remand, there is some confusion regarding whether the examiner actually reviewed and considered a medical study cited by the Veteran's representative in a January 2023 appellate brief. In the December 2024 addendum opinion, the examiner correctly noted the web address to the study cited in the Board's July 2024 remand directive did not load as listed in the remand and was missing the letter "n" in "ncbi". See December 2024 Addendum Opinion. Thus, it is unclear whether the examiner was: (1) able to access the study from the correct web address cited in the Veteran's January 2023 appellate brief; and (2) considered the study in formulating the December 2024 addendum medical opinion addressing the etiology of the Veteran's left wrist disorder. Therefore, a further remand is warranted to either: (1) confirm the examiner was able to access and considered the study from the correct web address cited in the Veteran's January 2023 appellate brief in formulating the December 2024 VA addendum medical opinion; or (2) if the examiner was unable to access and consider the study, for a further addendum VA medical opinion, considering the study, which can be accessed using the web address cited in the Veteran's January 2023 appellate brief. The matters are REMANDED for the following action: 1. In remanding these matters, the Board makes no credibility determination, express or implied, at this juncture.? 2. Contact the December 2024 VA examiner to confirm whether the examiner did in fact have access to, review, and consider the study cited in the Veteran's January 2023 appellate brief in formulating the December 2024 addendum opinions concerning the etiology of the Veteran's knee and wrist disorders. 3. Document all confirmation efforts in the claims file. 4. If and only if the December 2024 VA examiner is either: (1) unable to confirm having had access to, reviewed, considered, and having taken into account the study cited in the Veteran's January 2023 appellate brief in formulating the December 2024 VA addendum opinion concerning the etiology of the Veteran's knee and wrist disorders; or (2) cannot be contacted to confirm as much, please undertake the following development: 5. Obtain any outstanding VA treatment records and associate them with the claims file.? 6. After the above development has been completed, forward the claims file to the September 2024/December 2024 VA examiner or, if unavailable, to appropriate substitute clinician(s) for addendum medical opinions addressing: (1) the nature and etiology of the Veteran's left knee disorder; and (2) the nature and etiology of the Veteran's left wrist disorder. The need of a further in-person or telehealth examination of the Veteran is left to the discretion of the clinician(s) selected to write each opinion. After reviewing the claims file, including this Remand, the clinician(s) are asked to opine, respectively, as to the Veteran's left knee and left wrist disorders, on the following: (a.) Regarding the Veteran's left knee disorder, is it at least as likely as not (likelihood is in at least approximate balance or nearly equal, if not greater) the Veteran's left knee disorder was incurred in or is otherwise related to an in-service injury, event, or illness? The examiner must consider: (1) service treatment records documenting the Veteran's treatment for left knee pain on two separate occasions during service, in February 1988 and in May 1990; (2) the Veteran's reports of continuing left knee symptoms from service through present; and (3) the Veteran's contention his left knee arthritis is related to physical activity during service including playing basketball, PT, and track and field. The examiner should also consider the July 2021 Buddy statement addressing the Veteran's post-service left knee complaints and the veracity and relevance, if any, of the study cited by the Veteran's representative in his January 2023 appellate brief. Note: The Veteran testified he sought treatment for left knee pain after separation from service at a clinic that has since closed, due to which treatment records are unavailable. All findings must be reported in detail and all opinions must be accompanied by a clear rationale. If the clinician cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation for why an opinion cannot be rendered. In so doing, the clinician?shall explain whether the inability to provide a more definitive opinion is the result of a need for additional information, or that he or she has exhausted the limits of current medical knowledge in providing an answer to a given question.? (b.) Regarding the Veteran's left wrist disorder, is it at least as likely as not (likelihood is in at least approximate balance or nearly equal, if not greater) the Veteran's left wrist disorder was incurred in or is otherwise related to an in-service injury, event, or illness? The examiner must consider the Veteran's contentions: (1) he injured his left wrist during an in-service fall from a truck; (2) his left wrist arthritis is due to the collective exertion of physical activity during service including playing basketball, PT, and track and field; and (3) he has experienced ongoing left wrist symptoms from service through present. Note: While the Veteran's service treatment records do not document treatment for a left wrist condition during service, a May 1988 service treatment record documents treatment for a left elbow injury the Veteran contends occurred during the in-service fall in which he injured his wrist. The examiner should also consider the July 2021 Buddy statement addressing the Veteran's post-service left wrist complaints and the veracity and relevance, if any, of the study cited by the Veteran's representative in his January 2023 appellate brief. All findings must be reported in detail and all opinions must be accompanied by a clear rationale. (Continued on the next page) ? If the clinician cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation for why an opinion cannot be rendered. In so doing, the clinician?shall explain whether the inability to provide a more definitive opinion is the result of a need for additional information, or that he or she has exhausted the limits of current medical knowledge in providing an answer to a given question. G. A. WASIK Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Given, R. A. 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.