Citation Nr: 1305885 Decision Date: 02/20/13 Archive Date: 02/27/13 DOCKET NO. 09-18 472 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Houston, Texas THE ISSUES 1. Entitlement to service connection for a right knee disability. 2. Entitlement to service connection for a left knee disability, to include as secondary to a right knee disability. REPRESENTATION Appellant represented by: Texas Veterans Commission WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Jennifer Hwa, Counsel INTRODUCTION The Veteran served on active duty from August 1971 to March 1973. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a June 2007 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Houston, Texas. In January 2012, the Veteran testified at a hearing before the undersigned at the San Antonio satellite office of the RO. A transcript of the hearing is of record. The Board remanded the claims for additional development in June 2012. The Board notes that, in addition to the paper claims file, there is a paperless, electronic (Virtual VA) claims file associated with the Veteran's claims. A review of the documents in such file reveals that certain documents, including a September 2009 x-ray of the knees and a March 2006 notification compliant with Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), are potentially relevant to the issues on appeal. Thus, the Board has considered these electronic records in its adjudication of the Veteran's case. FINDINGS OF FACT 1. A chronic right knee disability was not shown in service, and the most probative evidence fails to link the Veteran's current disorder to service. 2. A chronic left knee disability was not shown in service, and the most probative evidence fails to link the Veteran's current disorder to service or to a service-connected disability. CONCLUSIONS OF LAW 1. The criteria for establishing service connection for a right knee disability have not been met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2012). 2. The criteria for establishing service connection for a left knee disability have not been met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 The Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (Nov. 9, 2000) (codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, and 5126 (West 2002 & Supp. 2012)) redefined VA's duty to assist a claimant in the development of a claim. VA regulations for the implementation of the VCAA were codified as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a) (2012). The notice requirements of the VCAA require VA to notify the claimant of any evidence that is necessary to substantiate the claim, as well as the evidence VA will attempt to obtain and which evidence he is responsible for providing. 38 C.F.R. § 3.159(b) (2012). The requirements apply to all five elements of a service connection claim: veteran status, existence of a disability, a connection between a veteran's service and the disability, degree of disability, and effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). VCAA notice must be provided to a claimant before the initial unfavorable decision on a claim for VA benefits by the agency of original jurisdiction (in this case, the RO). Id.; see also Pelegrini v. Principi, 18 Vet. App. 112 (2004). However, the VCAA notice requirements may be satisfied if any errors in the timing or content of such notice are not prejudicial to the claimant. See Pelegrini, 18 Vet. App. at 121. In this case, in a December 2005 letter issued prior to the decision on appeal, the Veteran was provided notice regarding what information and evidence is needed to substantiate his claims for service connection, as well as what information and evidence must be submitted by the Veteran and what information and evidence will be obtained by VA. A March 2006 letter advised the Veteran of how disability evaluations and effective dates are assigned, and the type of evidence which impacts those determinations. Additionally, a June 2012 letter provided notice regarding what information and evidence is needed to substantiate the Veteran's claim for secondary service connection, as well as what information and evidence must be submitted by the Veteran and what information and evidence will be obtained by VA. Although the June 2012 notification was issued after the decision on appeal, the Veteran's case was subsequently readjudicated as evidenced by the December 2012 supplemental statement of the case, and he had the opportunity to submit additional argument and evidence. Therefore, the content timing error did not affect the essential fairness of the adjudication of the claims. Mayfield v. Nicholson, 499 F.3d 1317 (Fed. Cir. 2007) (Timing error cured by adequate VCAA notice and subsequent readjudication without resorting to prejudicial error analysis.). The record also reflects that VA has made reasonable efforts to obtain relevant records adequately identified by the Veteran. Specifically, the information and evidence that have been associated with the claims file include the Veteran's service treatment records, VA examination reports, and hearing testimony. Additionally, the prior remand instructions were substantially complied with. Instructions pertinent to the claims being decided included obtaining updated VA medical records (including the September 2009 x-ray of the knees), attempting to obtain any outstanding private medical records, sending VCAA notice regarding secondary service connection for the Veteran's left knee disability, and obtaining a VA addendum opinion that discussed the Veteran's lay statements of continuity of symptomatology and his theory of entitlement to service connection for his left knee disability on a secondary basis. In response, the RO/AMC obtained all available VA treatment records from the San Antonio VA Medical Center, including the September 2009 x-ray of the knees, and associated these records with the Veteran's Virtual VA claims file. In June 2012 correspondence, the RO/AMC requested that the Veteran complete authorization and consent forms for any private medical providers he had sought treatment with, but the Veteran did not respond to this request. See Wood v. Derwinski, 1 Vet. App. 190, 193 (1991) ("The duty to assist is not always a one-way street. If a veteran wishes help, he cannot passively wait for it in those circumstances where he may or should have information that is essential in obtaining the putative evidence."). Additionally, the RO/AMC sent VCAA notice regarding secondary service connection for the Veteran's left knee disability in a June 2012 letter. Finally, the RO/AMC obtained a September 2012 VA addendum opinion that discussed the Veteran's lay statements and theory of entitlement to secondary service connection. Accordingly, the Board finds that there has been substantial compliance with the prior remand instructions and no further action is necessary. See D'Aries v. Peake, 22 Vet. App. 97 (2008) (holding that only substantial, and not strict, compliance with the terms of a Board remand is required pursuant to Stegall v. West, 11 Vet. App. 268 (1998)). As discussed above, the VCAA provisions have been considered and complied with. The Veteran was notified and aware of the evidence needed to substantiate his claims, the avenues through which he might obtain such evidence, and the allocation of responsibilities between himself and VA in obtaining such evidence. The Veteran was an active participant in the claims process by providing evidence and argument, including at a travel board hearing. Thus, he was provided with a meaningful opportunity to participate in the claims process and has done so. Any error in the sequence of events or content of the notices is not shown to have any effect on the case or to cause injury to the Veteran. Therefore, any such error is harmless and does not prohibit consideration of these matters on the merits. See Dingess, supra; see also ATD Corp. v. Lydall, Inc., 159 F.3d 534, 549 (Fed. Cir. 1998). Analysis Service connection may be established for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. Evidence of continuity of symptomatology from the time of service until the present is required where the chronicity of a condition manifested during service either has not been established or might reasonably be questioned. 38 C.F.R. § 3.303(b). Regulations also provide that service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. § 3.303(d). Moreover, where a veteran served continuously for ninety (90) days or more during a period of war, or during peacetime service after December 31, 1946, and arthritis becomes manifest to a degree of 10 percent within one year from date of termination of such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137 (West 2002); 38 C.F.R. §§ 3.307, 3.309 (2012). Generally, in order to prove service connection, there must be competent, credible evidence of (1) a current disability, (2) in-service incurrence or aggravation of an injury or disease, and (3) a nexus, or link, between the current disability and the in-service disease or injury. See, e.g., Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Pond v. West, 12 Vet. App. 341 (1999). Service connection may also be established for disability which is proximately due to or the result of a service-connected disability. 38 C.F.R. § 3.310(a) (2012). Further, a disability which is aggravated by a service-connected disability may be service-connected to the degree that the aggravation is shown. 38 C.F.R. § 3.310 (2012); Allen v. Brown, 7 Vet. App. 439 (1995). The Board has reviewed all the evidence in the Veteran's claims file. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the appellant or obtained on his behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claims and what the evidence in the claims file shows, or fails to show, with respect to the claims. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). The Veteran contends that his right knee disability is due to an in-service right knee injury. He also alleges that his left knee disability is secondary to his right knee disability. After careful consideration of all procurable and assembled data, the Board finds that service connection for the Veteran's right knee disability and left knee disability is not warranted on any basis. Service treatment records are negative for any complaints, diagnoses, or treatment for a left knee disability. Regarding the right knee, service treatment records show that in January 1973, the Veteran received treatment for his right knee after he twisted it playing basketball. There was no effusion found, and an x-ray of the right knee revealed no significant abnormality. Ligaments were stable, and no crepitus was found. The Veteran was placed in a posterior splint, and it was recommended that he elevate the knee and apply ice to it. He was asked to return as needed, but the service treatment records are negative for any other complaints or treatment about the Veteran's right knee. The Veteran was recommended for administrative separation in December 1972 due to being diagnosed with Passive Aggressive Personality, but there is no separation examination of record. On VA examination in February 2006, the Veteran reported that his bilateral knee condition had existed since 1972. He stated that his condition was due to an injury that occurred in the gym. He complained that as a result of the injury, he suffered from knee weakness, stiffness, swelling, giving way, lack of endurance, locking, and fatigability. He indicated that he had experienced constant, localized knee pain for years that was an 8/10 in severity. He described the pain as burning, aching, sharp, and sticking. The Veteran reported that his knee condition did not cause incapacitation, and he was not currently receiving treatment for his condition. An x-ray of the bilateral knees revealed minimal bilateral knee osteoarthropathy. After examination, the Veteran was diagnosed with bilateral knee osteoarthropathy. The examiner found that the Veteran had subjective factors of pain and objective factors of crepitus. At a September 2009 VA examination, the Veteran reported that in 1972, he was doing calisthenics in the gymnasium when he twisted his right knee and heard a pop. He stated that he had experienced severe pain and had been taken by ambulance to the emergency room at Bergstrom Air Force Base. He indicated that he did not remember if x-rays had been made of his knee and did not recall an aspiration. However, he maintained that he had been placed in a cast for about a month and had been able to return to duty before the cast was removed. He also reported that he had assisted a flight surgeon in service when he performed physical examinations. Regarding his left knee, the Veteran stated that he had first noticed left knee pain in 1974, which he had attributed to overcompensation for the right knee. He maintained that he finally twisted his left knee and injured it as well. The Veteran complained of giving way, pain, stiffness, and tenderness in both knees, and of instability and weakness in the right knee only. An x-ray of the bilateral knees revealed mild narrowing of the right medial and lateral compartments, no significant bone and joint abnormalities on the left side, and no joint effusion on either side. After examination and a review of the claims file, the Veteran was diagnosed with bilateral knee pain/chondromalacia patella. The examiner opined that the Veteran's right knee complaints were not caused by or a result of the twisting injury noted in his service treatment records, and his left knee complaints were not caused by or a result of overcompensation for a service-connected right knee problem. He explained that there was no evidence of a significant right knee injury in service, as the Veteran was only treated for a mild right knee sprain, nor was there evidence that a chronic right knee condition requiring continuous treatment had developed from the in-service injury. The examiner also noted that there was no history of an injury to the left knee during service and that examination of both knees had revealed findings of patellofemoral syndrome or chondromalacia of the patella. He indicated that there were mild arthritic changes on the x-rays of the right knee, but concluded that these changes were insufficient to directly link them to an injury that had occurred 25 years ago. The Veteran testified before the Board at a travel board hearing in January 2012. Testimony revealed, in pertinent part, that the Veteran had twisted his right knee in January 1973 during service. The Veteran testified that he had been treated in the emergency room for the right knee injury and had been given a full leg cast for 30 days. He reported that his right knee had remained painful in service after the cast had been removed. He stated that he had sought private medical treatment for his right knee in 1978 because in addition to his worsening pain, his knee had started to give way. He indicated that the private physician had recommended knee surgery, but that he had declined it due to his lack of medical insurance at the time. He maintained that after he saw the private physician for his right knee in 1978, his left knee began to hurt as a result of him overcompensating for his right knee condition by not using his right knee as much. He also testified that he believed his knee condition was more than just arthritis because of the pain level he felt as well as the instability of his tendon. He indicated that not only had his right knee condition been symptomatic in service, but that he had continued to experience right knee symptoms since discharge from service. In a September 2012 addendum opinion, the September 2009 VA examiner provided further discussion to his opinions of the etiologies of the Veteran's right knee and left knee disabilities. Regarding the Veteran's contention of being placed in a full leg cast for one month for his right knee injury in service, the examiner noted that the service treatment records had indicated use of a posterior splint, and that this undoubtedly had been misinterpreted as a cast by the Veteran. The examiner also noted that the exact date of the right knee injury had been in January 1973, but the date of subsequent recommendation for surgery had not been stated. He stated that the recommendation for surgery had presumably occurred after discharge from service in March 1973 because the Veteran clearly could have had surgery during service for a knee injury sustained in service. As far as the extent of the original right knee injury, the examiner noted that there had been no effusion or crepitus, the ligaments had been stable, and x-rays had been normal. The Veteran had been instructed to return as needed, but no further follow-up components had been documented. The examiner explained that the specific lack of effusion was significant because an effusion after an injury was diagnostic of some type of internal injury. In addressing the specific points of the June 2012 Board remand, the examiner noted the Veteran's inability to obtain previous private treatment records from 1978. Per the Veteran's reported history, after 1978, he had not sought medical attention for his knees until 2012. He had been seen in 2006 and 2009 for VA examinations, but not for treatment. The examiner found that the documentation of record did not support any continuing claims of knee problems after 1973 until the filing of the Veteran's claim. He indicated that there was no evidence of a continuing disabling condition and that the Veteran's history was subjective. The examiner also reported that the Veteran was not competent to make a diagnosis of a knee injury. With respect to the Veteran's contention of "overcompensation" in the left knee (or excess pressure from avoiding use of his right knee), the examiner found that this was a vague and nebulous slang term that had no synonym in medical technology. The symptoms that the Veteran described, such as "knee pain," were not found to be diagnostic of any single condition and therefore did not support the later diagnoses of chondromalacia patella or mild degenerative changes. The Veteran's complaints of discomfort with stairs, prolonged sitting, and squatting during his 2009 VA examination were explained to be classic symptoms for chondromalacia patella and not for any traumatic injury. Regarding the theory of secondary service connection for the left knee, the examiner indicated that of particular note was the fact that the Veteran reported having a limp since 1978, but that at the time of examination in 2009, he did not have a significant limp or other gait abnormality which would cause an increase in pressure on the left knee. He also did not use a cane or crutches and stated that he had tried a right knee brace, but it had not helped. The examiner reviewed the medical literature on the PubMed database and found that problems in one joint could not be related to problems in another joint in the absence of a generalized inflammatory condition such as gout, spondyloarthropathy, or rheumatoid arthritis. The examiner found that there was no such diagnosis of an inflammatory condition in the Veteran's case, and even if there had been, the cause of the joint problems would be the original disease and not the other joint. Finally, with respect to the Veteran's lay statements of continuity of right knee symptomatology since service, the examiner reiterated that symptoms of pain were not diagnostic of any particular condition. He also explained that the Veteran's complaints of not being able to move laterally and of the knee giving way were usually associated with knee instability. However, the Veteran had not been found to have knee instability at the time of examination either in service or in 2009. He had instead been diagnosed with chondromalacia of the patella and early arthritic changes which were predominantly in the lateral compartment and suggested a possible previous meniscal tear or other injury laterally. The examiner noted the Veteran's testimony that his knee cartilage was very painful and damaged and that for this reason, he believed he had more than just knee arthritis. However, the examiner explained that deterioration of the articular cartilage was the definition of arthritis, and on x-rays, deterioration of the articular cartilage was seen as joint space narrowing. In summary, the VA examiner found that although the Veteran reported that he had experienced right knee pain ever since his injury in 1973, there was no documentation other than his subjective history that would indicate a chronic disabling condition and provide a nexus for his knee condition to service. He noted that the Veteran had been employed productively since discharge from service. He found that the Veteran's current status was that of a 60 year old man with degenerative changes in the lateral right knee radiographically and chondromalacia patella of both knees clinically. The examiner explained that the difference in both of the Veteran's knees did suggest a possible injury to the right knee, but the age of the injury was undetermined. As meniscal tears were known to produce significant arthritic changes within 10 to 15 years, the examiner found that if the Veteran had sustained a lateral meniscus tear or knee injury approximately 40 years ago during service, he would certainly expect that the Veteran's knees would have more advanced changes at this time. The examiner's final diagnoses of the Veteran were degenerative joint disease of the right knee and bilateral chondromalacia of the patella. He opined that it was less likely as not that the Veteran's right knee disability was related to service. He noted his aforementioned detailed rationale and concluded that as the records were silent for approximately 30 years for documentation for knee complaints or treatment, there was no history of documented continuing complaints or treatment to indicate a nexus for a chronic disabling right knee condition. The examiner also opined that it was less likely as not that the Veteran's left knee disability was caused or aggravated by his right knee disability. He again noted his aforementioned detailed rationale and concluded that the left knee chondromalacia patella was a very common condition that was usually present bilaterally. He reiterated that there was no evidence for a gait abnormality or inflammatory disease process to explain increased stress on the left knee and that "overcompensation" was a lay term with no medical meaning. Regarding service connection for a right knee disability, the Board reiterates that the Veteran's service treatment records only show one instance of treatment for a twisted right knee. In addition, right knee arthritis was not clinically shown to a compensable degree within one year following his discharge from service. Additionally, at no time did any of the Veteran's treating providers find that his right knee disability was due to his period of service. Rather, the September 2009 and September 2012 VA examiner reviewed the claims file, interviewed and examined the Veteran, and provided adequate reasoning and bases for the opinion that it was less likely than not that the Veteran's right knee disability was due to his in-service right knee injury. For these reasons, the September 2009 opinion and September 2012 addendum opinion by the September 2009 VA examiner are afforded great probative value. With regard to service connection for a left knee disability on a direct basis, the Board reiterates that the Veteran's service treatment records are negative for any complaints, diagnosis, or treatment of a left knee disability. In addition, left knee arthritis was not clinically shown to a compensable degree within one year following his discharge from service. Additionally, at no time did any of the Veteran's treating providers find that his left knee disability was due to his period of service. The Board acknowledges the Veteran's argument that his left knee disability is due to or aggravated by his right knee disability. However, in the Board's decision herein, service connection for a right knee disability has been denied. Therefore, consideration of a claim for service connection for a left knee disability that is secondary to a service-connected right knee disability is not warranted because the Veteran's right knee disability is not a service-connected disability. However, even assuming arguendo that the Veteran's right knee disability were service-connected, at no time did any of the Veteran's treating providers find that his left knee disability was due to or aggravated by his right knee disability. Rather, the September 2009 and September 2012 VA examiner reviewed the claims file, interviewed and examined the Veteran, and provided adequate reasoning and bases for the opinions that it was less likely than not that the Veteran's left knee disability was caused by his right knee disability, and that it was less likely than not that the Veteran's left knee disability had been aggravated by his right knee disability. For these reasons, the September 2009 opinion and September 2012 addendum opinion by the September 2009 VA examiner are afforded great probative value. Furthermore, the Board acknowledges that as the Veteran works in a home health care agency and worked as a medical assistant in service, he is competent to provide an opinion on certain medical matters, and he is credible in his beliefs. The Veteran made many complaints of right knee pain and asserted that he believed he had more than just right knee arthritis because his right knee cartilage was very painful and damaged. However, with respect to the Veteran's assertions of right knee pain, the Board notes that complaints of pain, alone, without evidence of underlying pathology, do not constitute a disability for VA purposes. See Sanchez-Benitez v. West, 13 Vet. App. 282, 285 (1999), appeal dismissed in part, vacated and remanded in part on other grounds sub nom. Sanchez-Benitez v. Principi, 259 F.3d 1356 (Fed. Cir. 2001); Evans v. West, 12 Vet. App. 22, 31-32 (1998). Indeed, the September 2009 VA examiner also found that the Veteran's assertions of right knee pain were not diagnostic of any single condition and did not support the later diagnoses of chondromalacia patella or mild degenerative changes in the right knee. The Veteran's assertion that he had more than just right knee arthritis was supported only by his feeling that his right knee was very painful and that his right knee cartilage was damaged. However, the September 2009 VA examiner noted that deterioration of the articular cartilage was the very definition of arthritis, and on x-rays, deterioration of the articular cartilage was seen as joint space narrowing. The Veteran also essentially opined that his right knee disability was due to his in-service injury because he had continuously experienced right knee symptoms since his 1973 right knee injury. However, the September 2009 VA examiner specifically considered the Veteran's continuous right knee symptoms since service as well as all of the evidence of record, including the Veteran's lack of effusion after his right knee injury, his self-reported lack of treatment for his right knee disability from 1978 to 2012, the fact that his knee complaints on examination were classic symptoms for chondromalacia patella and not for any traumatic injury, and the fact that the Veteran's right knee would show more advanced changes if he had sustained a lateral meniscus tear or knee injury approximately 40 years ago during service. The examiner provided a very detailed rationale supported by the clinical findings for the conclusion that the current right knee disability is not related to service. The VA opinion is more persuasive than the Veteran's bare assertions. Regarding the left knee disability, the Veteran asserted that his left knee pain began after his 1978 private treatment visit because he began "overcompensating" for his right knee by using his right knee less and thereby causing increased stress and pain to his left knee. However, the September 2009 VA examiner indicated that "overcompensation" was a nebulous and lay term that had no medical synonym. He also found that although the Veteran claimed that he had had a limp since 1978, there had been no limp or gait abnormality found on examination in 2009. The September 2009 examiner specifically considered the Veteran's assertions as well as all of the evidence of record, including the lack of a gait abnormality or an inflammatory disease process. The examiner provided a very detailed rationale supported by the clinical findings for the conclusion that the current left knee disability is not due to or aggravated by the right knee disability, and cited medical literature to explain that problems in one joint could not be related to problems in another joint in the absence of a generalized inflammatory condition such as gout, spondyloarthropathy, or rheumatoid arthritis. The VA opinion is more persuasive than the Veteran's bare assertions. For these reasons, the Board finds the opinions of the September 2009 VA examiner to be of significantly greater probative weight than the assertions of the Veteran regarding the etiologies of his right knee and left knee disabilities. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302-04 (2008) (holding that it is the factually accurate, fully articulated, sound reasoning for the conclusion that contributes to the probative value of a medical opinion). In sum, the Board finds that the most competent and probative evidence indicates that chronic right knee and left knee disabilities were not shown in service or for many years thereafter. The most probative evidence fails to link the Veteran's current right knee disability to service, nor does the most probative evidence link the Veteran's current left knee disability to service or to a service-connected disability. Accordingly, service connection for the Veteran's right knee disability and left knee disability is not warranted on any basis. See 38 C.F.R. §§ 3.303, 3.310(a) (2012). In reaching the conclusion above, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claims, that doctrine is not applicable in the instant appeal. See 38 U.S.C.A. § 5107(b); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1990). ORDER Entitlement to service connection for a right knee disability is denied. Entitlement to service connection for a left knee disability, to include as secondary to a right knee disability, is denied. ____________________________________________ TANYA A. SMITH Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs