Citation Nr: 1315085 Decision Date: 05/07/13 Archive Date: 05/15/13 DOCKET NO. 05-33 225 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Nashville, Tennessee THE ISSUE Entitlement to service connection for a right knee disability. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD S. Mishalanie, Counsel INTRODUCTION The Veteran served on active duty from July 2003 to February 2004. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Nashville, Tennessee. In April 2009, February 2011, and September 2012, the Board remanded the claim for additional development. In addition to the paper claims file, there is a Virtual VA electronic claims file associated with the Veteran's claim. A review of the electronic claims file reveals no additional records relevant to the issue remaining on appeal. FINDING OF FACT A chronic right knee disability, including chondromalacia patella, was not demonstrated in-service, and there is no competent and credible evidence of a nexus between a current right knee disability and service. CONCLUSION OF LAW A right knee disability, including chondromalacia patella, was not incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 5103, 5103A (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 3.303 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION Duties to Notify and Assist Regarding the Veteran's claim of entitlement to service connection, the requirements of 38 U.S.C.A. § 5103 and 5103A have been met. There is no issue as to providing an appropriate application form or the completeness of the application. VA notified the Veteran in April 2004 of the information and evidence needed to substantiate and complete the claim, to include notice of what part of that evidence is to be provided by the claimant, and what part VA will attempt to obtain. In a May 2010 supplemental statement of the case, VA notified him of how disability ratings and effective dates are determined. The claim was most recently readjudicated in a March 2013 supplemental statement of the case. VA fulfilled its duty to assist the Veteran in obtaining identified and available evidence needed to substantiate the claims, and as warranted by law, affording VA examinations. In September 2012, the Board remanded the matter, in part, to obtain a VA medical opinion from a different physician addressing the nature and etiology of the Veteran's claimed right knee disability. A VA medical opinion was provided in March 2013. The examiner reviewed the claims file, noted the pertinent medical history, and provided a medical opinion with supporting rationale. For these reasons, the Board finds that all questions necessary to render the determination made herein have been answered. The medical examination, along with the March 2013 medical opinion, is therefore adequate. See Barr v. Nicholson, 21 Vet. App. 303 (2007) (defining adequacy with respect to medical examinations and opinions as those providing sufficient detail so that the Board can perform a fully informed evaluation). The RO/Appeals Management Center (AMC) therefore complied with the Board's remand instructions. Stegall v. West, 11 Vet. App. 268, 271 (1998). In sum, there is no evidence of any VA error in notifying or assisting the Veteran that reasonably affects the fairness of this adjudication. 38 C.F.R. § 3.159(c). Legal Criteria Service connection is established where a particular injury or disease resulting in disability was incurred in the line of duty in active military service or, if pre-existing such service, was aggravated during service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). Service connection requires competent evidence showing: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); Caluza v. Brown, 7 Vet. App. 498 (1995). The determination as to whether these requirements are met is based on an analysis of all the evidence of record and the evaluation of its credibility and probative value. Baldwin v. West, 13 Vet. App. 1 (1999); 38 C.F.R. § 3.303(a). Where there is a chronic disease shown in service, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.303(b). When a condition noted during service is not shown to be chronic, or the fact of chronicity in service is not adequately supported, then a showing of continuity of symptomatology after discharge is required to support the claim. 38 C.F.R. § 3.303(b); Walker v. Shinseki, 708 F.3d 1331, 1337 (Fed. Cir. 2013) (noting that the continuity of symptomatology provisions apply only to the chronic disorders as listed in 38 C.F.R. § 3.309(a)). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the VA shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107(b). Analysis In this case, the Veteran asserts that his current right knee disability was incurred in or is otherwise attributable to his military service. For the reasons explained below, the Board finds the preponderance of the evidence is against the claim of entitlement to service connection for a right knee disability. The Veteran's service treatment records reflect that at his April 2003 enlistment examination, his lower extremities were normal and he denied any knee trouble. It was noted that he had visited the emergency room for a laceration of the left knee in 1993, but that there were no sequelae. An August 2003 record notes that the Veteran complained of a two-day history of muscle aches and "knee pains" along with congestion, sore throat, nausea, and vomiting. No assessment or plan was noted, and there was no follow-up. At an October 2003 examination for sea duty, he denied having or having had a history of knee trouble. At his February 2004 separation screening, the Veteran complained of a two-day history of left knee pain. He said that he had a history of a knot on his left knee for one year. It was noted that he had Osgood-Schlatter disease and the assessment was patellar tendon strain. There was no mention of any right knee problems and the Veteran denied having had any injury or illness during active duty for which he did not seek treatment. The Board notes that entitlement to service connection for internal derangement of the left knee was granted in a June 2012 rating decision. With regard to the right knee, a March 2004 post-service private treatment record reflects that the Veteran complained of bilateral knee pain. The assessment was chondromalacia patella. The report of a June 2009 VA examination reflects the Veteran's complaints of bilateral knee pain, weakness, stiffness, swelling, instability, giving way, locking, and easy fatigability. He reported that the initial symptoms began in March 2004, and were of progressive onset with unknown etiology. On physical examination, the Veteran had limited flexion of the right knee with pain. Lachman's test was 0-1+, McMurray test was positive for medial joint line pain, and there was instability (0-1+) from 0 to 30 degrees. X-rays showed mild suprapatellar joint effusions with no significant degenerative changes or narrowing of the joint spaces. The examiner opined that the etiology of the Veteran's limited knee joint function was unknown. The June 2009 VA examiner was asked on four different occasions to provide clarification or supplemental medical opinions. None of these opinions are particularly probative. In April 2011, he opined that the Veteran's "service-connected injuries [were] the sole cause of his current disability"; however, there is no record of any injuries during service nor did the Veteran claim any specific injury. In a November 2011 addendum, he retracted his earlier opinion and stated confusingly that "[I]t was a Service-Connected injury indeed. The patient did not provide us a history that it was a Service-Connected injury." These statements are contradictory. Further, he did not provide an opinion as to the etiology of any knee disability. In a January 2012 addendum, the examiner noted that the Veteran reported that his symptoms began in March 2004, approximately within the time frame that he was discharged from service. The examiner opined that "[t]herefore, it is more likely than not that this patient's symptoms may have been a result of his Service-Connected duty. However, the patient could not identify an actual etiology or event that precipitated his symptoms." Because the examiner's opinion is equivocal and lacks rationale, the Board finds that it has little, if any, probative value. Furthermore, in an April 2012 addendum, the examiner went back to his previous assertion that the Veteran's "injuries to the knee are the result of a Service-Connected injury." Once again, the Veteran does not allege an injury during service nor are any injuries documented. Hence, this opinion also lacks probative value. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008) (a medical opinion that contains only data and conclusions is accorded no weight); Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (medical opinion based upon an inaccurate factual premise has no probative value); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) (A medical opinion "must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions.") As noted above, the Board remanded the claim in September 2012 to obtain a VA medical opinion by a different physician. In March 2013, another VA examiner reviewed the claims file and Virtual VA. The examiner opined that it was "not as least likely as not" that the Veteran's right knee disability was caused by or due to his military service. The examiner noted that there was only minimal mention of bilateral knee pain in August 2003 without any mention of follow up. Furthermore, the medical evidence did not reflect any ongoing pain or medical problems related to the right knee. The examiner also opined that the right knee disability was not caused by, due to, or aggravated by the service-connected left knee disability. The examiner opined that the suprapatellar joint inflammation shown during June 2009 VA examination was likely related to patellar dysfunction diagnosed as chondromalacia by the Veteran's private physician. The examiner noted that patellar chondromalacia is usually related to poor tracking of the patella congenitally. The examiner noted that the Veteran was not treated for this disorder in service and therefore, even if present, it was not caused by or aggravated beyond its usual course. In this case, the preponderance of the evidence reflects that the Veteran has right knee chondromalacia patella with suprapatellar joint inflammation. The first record noting this condition is shortly after service, in March 2004. Although there is a notation of "knee pains" in service in August 2003, it is unclear which knee the Veteran was referring to or whether he was referring to bilateral knee pain. In any event, these symptoms were reported along with a variety of other symptoms typically associated with a viral syndrome and there is no mention of any specific follow-up treatment for right knee pain. In fact, the Veteran denied having knee pain in October 2003. As such, assuming he had right knee pain, such symptoms were acute and transitory. To the extent the March 2013 VA examiner suggests that chondromalacia patella is congenital in nature, he did not specify whether it would be considered a congenital defect or disease. In either case, however, the Board finds that service connection must be denied. Assuming chondromalacia patella is a congenital disease, the examiner opined that it did not manifest in service nor was it aggravated beyond its usual course. Assuming chondromalacia patella is a congenital defect, VA regulations specifically prohibit service connection for a congenital or developmental defect - unless such defect was subjected to a superimposed disease or injury which created additional disability. See VAOPGCPREC 82-90 (July 18, 1990) (cited at 55 Fed. Reg. 45,711 ) (Oct. 30, 1990) (service connection may not be granted for defects of congenital, developmental or familial origin, unless the defect was subject to a superimposed disease or injury). Here, there is no evidence of superimposed disease or injury. Finally, assuming that the disorder may be service connected as an acquired disorder, the preponderance of the most competent and probative evidence is against finding that a right knee disorder is related to service. In reaching this conclusion, the Board has also considered the Veteran's lay statements. As a lay person, the Veteran is competent to report his history of knee pain and symptoms. See 38 C.F.R. § 3.159(a)(2); Layno v. Brown, 6 Vet. App. 465, 470 (1994). In this regard, the Veteran has reported onset of symptoms shortly after service and has not attributed these symptoms to any specific injury in service. The Board finds these statements credible. To the extent he asserts a nexus with his military service, such evidence must fail. Determining the etiology of a knee disability such as chondromalacia patella is a complex medical matter beyond the ken of a layperson. Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). The question of etiology goes beyond a simple and immediately observable cause-and-effect relationship. Whether his chondromalacia patella is related to service requires specialized training. As a lay person untrained in the field of orthopedic disorders the appellant is not competent to render an opinion on etiology in this case. For the foregoing reasons, the Board finds that the preponderance of the evidence is against the claim of entitlement to service connection for a right knee disability. The benefit of the doubt doctrine is not for application, and the claim is denied. See 38 C.F.R. § 3.102. ORDER Entitlement to service connection for a right knee disability, including chondromalacia patella, is denied. ____________________________________________ DEREK R. BROWN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs