Citation Nr: 1104722 Decision Date: 02/04/11 Archive Date: 02/14/11 DOCKET NO. 07-13 185 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Denver, Colorado THE ISSUES 1. Entitlement to service connection for a torn left anterior cruciate ligament (ACL), to include as secondary to service connected bipolar disorder. 2. Entitlement to service connection for bilateral patellofemoral pain syndrome (PFPS), to include as secondary to service connected bipolar disorder. REPRESENTATION Appellant represented by: Daniel G. Krasnegor, Attorney- At-Law ATTORNEY FOR THE BOARD W.H. Donnelly, Counsel INTRODUCTION The Veteran served on active duty with the United States Navy from October 1988 to February 1989. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a December 2005 rating decision by the Denver, Colorado, Regional Office (RO) of the United States Department of Veterans Affairs (VA), which denied entitlement to the benefits sought. In March 2009, the Board issued a decision denying entitlement to service connection for a torn left ACL and bilateral PFPS. The Veteran appealed this denial to the Court of Appeals for Veterans Claims (the Court). In September 2010 the Court, based on a Joint Motion, vacated the Board decision and remanded the matters for further appellate consideration. Subsequent to the March 2009 Board decision, the Veteran submitted additional private treatment records documenting current bilateral knee problems. These have not been previously considered by the RO, nor has the Veteran waived such consideration. However, as the new records address only the already established fact of current disability and include no information regarding the circumstances of injury or any relationship to service, they are not pertinent to the ultimate question on appeal, and remand to the RO is not required. 38 C.F.R. § 20.1304. The issue with respect to bilateral PFPS has been recharacterized to better reflect the allegations of the Veteran and the evidence of record. FINDINGS OF FACT 1. A torn left ACL was incurred as a result of anxiety and panic attacks related to service connected bipolar disorder 2. Bilateral PFPS was incurred as a result of the need to rehabilitate a service connected left knee injury. CONCLUSIONS OF LAW 1. The criteria for service connection of a left torn ACL have been met. 38 U.S.C.A. §§ 1131, 5107 (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2010). 2. The criteria for service connection of bilateral PFPS have been met. 38 U.S.C.A. §§ 1131, 5107 (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2010). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. VA's Duties to Notify and Assist The Board is granting in full the benefits sought on appeal. Accordingly, any error committed with respect to either the duty to notify or the duty to assist was harmless and will not be further discussed. II. Evidence The Veteran was granted service connection for bipolar disorder in a May 1993 rating decision. Examination reports in connection with that decision refer to a history of anxiety and paranoia. SSA records reveal reports by the Veteran and her mother of "panic attacks" in the early 1990's. These are described as responses to fear of crowds and people. Doctors do not identify any panic attacks or behaviors. They do again refer to a heightened level of paranoia and resulting behavior. VA treatment records reveal ongoing treatment for bipolar disorder. The Veteran was being treated effectively with a combination of medications. In December 2001, Dr. EW commented that the condition was marked by moodiness (predominantly dysthymia) and manic episodes. The manic periods manifested with increased energy, decreased sleep, and delusions, including feeling that she was someone else or could see through herself. The propensity for impulsive behavior was also noted. Anxiety was noted in February 2002 in relation to family and financial situations. Records indicate the Veteran continued to "worry" over a variety of issues, including fears of physical attack. In May 2003, a mental health treatment plan was formulated. At that time the Veteran was noted to be mostly successful in managing her illness with medication. No mention was made of panic attacks, though the Veteran felt tension over family problems. A private emergency room note from HNS Medical Center dated in August 2003 indicates in the history of the present illness that the Veteran had injured her left knee when she "stepped down" from an amusement park ride and fell when her knee buckled. She felt it pop. She had continued to ambulate since that time, but the knee continued to crackle and pop. She had "some pain" in the knee. The emergency room note makes no reference to any panic attacks and undue anxiety. In September 2003, VA treatment notes show a report of telephone contact indicating that the Veteran called to inform VA that when "getting [off] of a ride" at an amusement park she had torn her ACL. She did not refer to a panic attack or jumping from the ride, nor did she do so in subsequent contacts or appointments. The veteran began to regularly describe anxiety symptoms and complaints after October 2003, following the death of her brother. She began to feel stressed over growing marital problems and fears regarding her adolescent daughter. In June 2005, she apologized for being "panicky" when talking to a nurse; the nurse had noted in May 2005 that the Veteran was anxious about an upcoming party for her daughter. Loud noises associated with such "caused more panic associated symptoms." She continued to complain about stress and tension in her life, but doctors not that she coped with such. In August 2005, the Veteran notified VA that she had a panic attack in her car over concern regarding her father's brain tumor and car trouble. Private treatment records from Dr. JJ dated between February 2004 and May 2008 reveal ongoing symptomatic treatment for left and right knee problems. Dr. JJ did not address the circumstances of the injuries. A VA mental disorders examination was conducted in September 2005. She reported at that time that she was very depressed, with low energy and motivation levels. She had two episodes of mania in recent years. In 2005, she believed her heating vents were releasing poison into the air, and shut off the heat in the middle of winter. She feared ghosts, and had trouble sleeping. She stayed up for several nights in a row. She also feared poison, in her daughter's toothpaste, during a 2000 manic episode. She was delusional at that time. The Veteran also reported "frequent panic attacks." These are not detailed, but she stated that they often occurred when driving, so she avoided the car. She did not say when these attacks began. In an April 2006 statement, Dr. EW reported that he had been treating the Veteran since December 2001 for bipolar disorder. He described her symptoms as cyclic mood swings, impulsive and sometimes obsessive behavior, significant anxiety, and a fear of being alone. He related that in August 2003, the Veteran's husband had helped her onto an amusement park ride. "Just as the ride stopped" she saw that her husband was leaving. "She panicked in fear that she was going to be left alone and jumped precipitously down from the ride." Her knee was injured in the jump, and while riding a stationary bike in rehabilitation for the knee, she caused additional knee problems. Dr. EW opined that, based on events as the Veteran related them, the knee injury was related to her service connected disability. In a November 2008 statement, the Veteran's husband reported that in August 2003, he left his wife on a ride to go find a child, "even though [she] was panicky." When he went to her on the ground, she immediately had said that she had jumped off the ride. When rehabbing the injured left ACL, his wife had been obsessive about riding the stationary bike, doing so every day without fail until diagnosed with PFPS. III. Analysis A. Left ACL Service connection will be granted if it is shown that the veteran suffers from a disability resulting from personal injury suffered or disease contracted in the line of duty, or for aggravation of a preexisting injury suffered or disease contracted in the line of duty, during active military service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. A disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. 38 C.F.R. § 3.310(a). The Veteran has alleged that a panic attack associated with her service connected bipolar disorder caused her to dismount an amusement park ride in a rushed or unsafe manner, and she injured her left knee. Medical records and lay statements preceding the August 2003 injury do reflect the occurrence of panic attacks or, at the very least, the presence of impulsive behaviors reflecting increased anxiety and paranoia. The attacks do not appear to have occurred frequently, but the competent evidence does establish that they did occur prior to August 2003. Medical records show that subsequent to August 2003, they began occurring more frequently. The Veteran has stated that she felt panic on the ride when she saw her husband walking away. This is consistent with her husband's observations regarding her demeanor at the time of the accident. Further, the circumstance of being left alone is one which doctors have specifically indicated triggers anxiety in the Veteran. The Veteran is competent to describe her state of mind, and her husband is competent to describe his observations of her demeanor and behavior. Layno v. Brown, 6 Vet. App. 465 (1994); Barr v. Nicholson, 21 Vet. App. 303, 309 (2007). While contemporaneous private and VA treatment records make no reference to a panic attack at the time of the injury, they also do not directly contradict the allegation of a panic attack. They describe how the injury occurred getting off of a stopped amusement park ride. The haste or motivation for the exit was not relevant to the treatment being provided, and so the absence of a notation regarding a panic attack is not dispositive. Further, the treatment was provided hours, days, weeks, and months after the injury, when no panic attack was occurring and hence that fact does not appear to have been relevant to the treating doctors. In short, the Veteran has competently described a service connected panic attack as her motivation in leaving the ride as she did, causing her left knee injury. There is no evidence of record directly contradicting her allegation. All reasonable doubt is resolved in favor of the Veteran; the evidence of record supports a finding that the torn left knee ACL was caused or substantially contributed to by service connected bipolar disorder. B. Bilateral PFPS The Veteran additionally alleges that her currently diagnosed bilateral PFPS, as shown in VA and private records, is related to the now service connected left ACL tear. In rehabilitating the left knee, she obsessively rode a stationary bike, causing the PFPS. The Veteran and her husband have both competently described her rehabilitation behavior as obsessive. Her treating doctors, Dr. EW, has also done so, and other doctors, not specifically referring to the bike riding, have commented on the capacity for some obsessive compulsive behavior. The sole medical opinion of record on this issue is from Dr. EW, who opined that the obsessive bike riding worsened the knee problems. Further, the Veteran has reported that the knee pain in connection with the rehabilitation activity. She is competent to report such; the records of Dr. JJ support the allegation and, while they do not endorse the statement, also do not contradict it. Treatment records demonstrate that the bilateral knee complaints began only after the rehabilitation program began. The preponderance of the evidence supports the claim; there is no reasonable doubt to resolve. Service connected bipolar disorder caused the Veteran to overwork the knees, resulting in PFPS bilaterally. Service connection is warranted. ORDER Service connection for a torn left ACL is granted. Service connection for bilateral PFPS is granted. ____________________________________________ RONALD W. SCHOLZ Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs