Citation Nr: 1319819 Decision Date: 06/19/13 Archive Date: 06/27/13 DOCKET NO. 09-42 967 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Philadelphia, Pennsylvania THE ISSUE Entitlement to service connection for a left knee disorder. WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD K. Marenna, Associate Counsel INTRODUCTION The Veteran served on active duty from October 1993 to November 2005. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a November 2008 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Philadelphia, Pennsylvania, which denied the claim. The Board notes that the Veteran has relocated to Portland, Oregon. In April 2011, a Travel Board hearing was held before the undersigned Veterans Law Judge and a transcript of that hearing is of record. This case was previously before the Board in December 2011 and September 2012. For the reasons discussed below, the Board finds that the RO substantially complied with the mandates of the remands and will proceed to adjudicate the appeal. See Stegall v. West, 11 Vet. App. 268 (1998). This matter comes before the Board of Veterans' Appeals (Board) on appeal from a rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in FINDING OF FACT There has been no demonstration by competent medical, or competent and credible lay, evidence of record that the appellant has a left knee disorder that is related to service. CONCLUSION OF LAW The criteria for service connection for a left knee disorder have not been met. 38 U.S.C.A. §§ 1110, 1154, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION The Board has thoroughly reviewed all the evidence in the appellant's claims folder. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, each piece of evidence of record. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claim. The appellant must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to the appellant). The Board must assess the credibility and weight of all evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). I. Notice and Assistance VA has duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a). See also Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Dingess v. Nicholson, 19 Vet. App. 473 (2006). VA has met all statutory and regulatory notice and duty to assist provisions as to the appellant's claim. Appropriate notice was provided in a October 2008 letter. The claim was subsequently readjudicated, most recently in a March 2013 supplemental statement of the case. Mayfield, 444 F.3d at 1333; See Prickett v. Nicholson, 20 Vet. App. 370 (2006). VA's duty to assist has been satisfied. The appellant's service treatment records and VA medical records are in the file, including the VA treatment records from Coatesville, Pennsylvania and Portland, Oregon, requested by the Board in the September 2012 remand order. Private medical records identified by the appellant have been obtained, to the extent possible. The appellant has at no time referenced outstanding records that he wanted VA to obtain or that he felt were relevant to the claim. The duty to assist also includes providing a medical examination or obtaining a medical opinion when such is necessary to make a decision on the claim, as defined by law. McLendon v. Nicholson, 20 Vet. App. 79 (2006). If VA provides a claimant with an examination in accordance with the duty to assist, the examination must be adequate. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). The probative value of a medical opinion is derived from a factually accurate, fully articulated, and soundly reasoned opinion. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The RO provided the Veteran with VA examinations in January 2012 and November 2012. For reasons discussed below, the Board finds that the January 2012 VA examination is inadequate. However, the Board finds that the November 2012 examination conducted pursuant to the Board remand is adequate because it is based on a thorough examination, a description of the Veteran's pertinent medical history, a complete review of the claims folder and appropriate diagnostic tests, to include X-ray. The November 2012 opinion was rendered by a medical professional following a thorough examination and interview of the appellant. The examiner obtained an accurate history and listened to the appellant's assertions. The examiner laid a factual foundation for the conclusions that were reached. Therefore, the Board finds that the examination is adequate. See Nieves-Rodriguez, 22 Vet. App. at 304. As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of this case, the Board finds that any such failure is harmless. See Newhouse v. Nicholson, 497 F.3d 1298 (Fed. Cir. 2007). II. Service Connection Service connection is warranted if it is shown that a Veteran has a disability resulting from an injury incurred or a disease contracted in active service or for aggravation of a pre-existing injury or disease in active military service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. Service connection may also be granted for any disease diagnosed after discharge when all of the evidence establishes that the disease was incurred in service. See 38 C.F.R. § 3.303(d). Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in- service disease or injury and the present disability. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). Certain chronic disabilities, such as arthritis, if manifest to a degree of 10 percent or more within one year after separation from active duty, may be presumed to have been incurred in or aggravated by service. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. III. Analysis The Veteran contends that he has a left knee disorder as a result of an in-service injury. For the reasons that follow, the Board finds that service connection is not warranted. The November 2012 VA examination report reflects that the Veteran had a diagnosis of patella femoral syndrome of the left knee. As the Veteran has a diagnosis of a current left knee disorder, he has a disability for VA purposes, satisfying the first element of a service connection claim. An April 1993 enlistment examination report indicated the Veteran's lower extremities were normal. In an April 1993 report of medical history, the Veteran denied having a "trick" or locked knee. A June 2001 post-deployment health assessment report reflects that the Veteran indicated that his health in general was excellent. He indicated that he did not have any unresolved medical or dental problems that developed during the deployment. A September 2001 service medical examination reflects that the Veteran's lower extremities were normal. A May 2003 evaluation questionnaire indicated the Veteran did not have difficulty bending at his knees. A December 2003 physical therapy consultation report reflects that the Veteran's lower extremities were within full limits. A November 2005 separation service report of medical assessment reflects that the appellant stated that compared to his last medical assessment/physical examination, his overall health was the same. He stated that since his last medical assessment he had not had any illness or injuries that caused him to miss duty for longer than 3 days. He stated that he had not been seen by or treated by a health care provider, admitted to a hospital, or had surgery since the last medical assessment. He stated that he had not suffered from any injury or illness while on active duty for which he did not seek medical care. He stated that he did not have any conditions which limited his ability to work in his primary military specialty or required geographic or assignment limitations. He also stated that at the present time he did not intend to seek VA disability. Health care provider comments reflect that the appellant did not have any complaints. He had a normal gait. He was cleared for separation. The only condition noted was hypertension that was not well controlled. In an August 2008 VA treatment record, the appellant reported that he had a bullet wound of the left knee in 2001 and a history of a motor vehicle accident in 2001 when he was dragged underneath a trailer. In his September 2008 claim, the appellant stated that while he was deployed in Kuwait from March 2001 through June 2001, he was involved in an accident on the flight line involving his left knee. He stated that he was pushing an ammunition trailer being pulled/steered by his Captain when the front left wheel of the trailer in tandem behind him caught his pant leg and pulled him under the trailer. Due to the amount of aircraft noise, no one could hear him yelling to stop. He stated that it was not until his Captain noticed that the appellant was being dragged that he ordered everyone to stop. The appellant stated that he was dragged 5 to 6 feet by then. He stated that he was taken to the EMT on location. He suffered deep skin abrasions, blood loss, and mild shock. He was treated and released for light duty. No safety report or medical report was made due to the remote location of the site. He stated that he currently suffered from pain in his left knee including a popping sound and reduced mobility. In an April 2009 statement, J.A.I. stated that he worked with the appellant in Kuwait in 2001. During their tour, the appellant was injured while helping to push a 20 mm ammunition loading trailer out of an aircraft parking spot. The wheel of the ammunition trailer rolled up the back of his leg and caused his knee and shin to be dragged under the tire with the weight of the trailer on his leg. The dragging of the knee and lower leg ripped open his pants and caused a large chunk of flesh to be ripped off of the appellant's knee area. J.A.I. stated that consequently, the appellant was unable to work for a couple of weeks. He was limited to light office duty. The appellant and J.A.I. are competent to report symptoms capable of lay observation such as the in-service injury. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). The appellant's service treatment records do not contain any references to this incident and the appellant did not note the incident in his November 2005 separation medical report. However, as the appellant and J.A.I. are competent to report the incident and the appellant's statement is corroborated by the buddy statement, the Board finds the statements regarding the incident to be credible. A February 2009 private consultation report reflects that the appellant reported an injury to his left knee which was sustained when the leg was run over. He had been taking ibuprofen which helped with some of his symptoms. The examination did not reveal any synovitis. No increased joint laxity was noted on examination of the left knee. A February 2009 private MRI of the left knee reflects that there was a mild chronic MCL sprain. There was medial meniscal degeneration and no discreet meniscal surface tear. In an October 2009 substantive appeal, the appellant stated that he felt pain in his knees and had difficulty walking up and downstairs and working around aircraft, which is his career. A February 2012 VA treatment record reflects that the appellant reported he had chronic pain from a left knee injury. The appellant's left knee was evaluated at a VA examination in January 2012. The VA examination report reflects that the appellant had left knee degenerative joint disease. The VA examiner found that the claimed condition was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. In the rationale, the VA examiner noted that the description of the in-service injury by the appellant varied significantly from that offered in record by J.A.I. in the buddy report. As noted in the September 2012 remand, the Board disagrees with this statement and finds that the statement provided by J.A.I. corroborates the appellant's competent history of an in-service injury to his knee. However, the Board has found that the appellant is competent to report an in-service injury to his left knee. Lastly, the examiner reported that the care administered at the time of injury (bandaging the skin wound), the post injury recommendations of the ambulance crew (consisting solely of "keep the wound clean"), and the prompt return to duty indicates the medical personnel at the site (ambulance crew) did not identify any internal knee derangement. It is not clear how the examiner came to the conclusion that no internal knee derangement was identified in the absence of any record of in-service treatment. Thus, the Board finds that the VA opinion is inadequate and not probative. The appellant was afforded another VA examination in November 2012. The VA examiner found that the appellant had left knee patella femoral syndrome. The VA examiner stated that the appellant complained of an injury to the left knee in 2001 when he got run over. His knee was caught under a tire. He stated that the flight surgeon told him to put a bandage on it and never filed a report. He continued to serve in the service until 2005. He stated that he did not complain of problems while he was in the military because he just took ibuprofen and did not think about it. He took ibuprofen every time he ran because of the pain in his knee. He stated that when he left the military in 2005 he stopped running and working out because he no longer need to do these activities for the military. His left knee did not bother him at that time because he was not stressing it with physical activity. He then noticed some symptoms about 1 to 2 years after he left the military. It would bother him when sitting on an airplane for a while. He then noticed pain with stairs and squatting (patello-femoral stressors). The pain had always been right underneath his knee cap. He went for an MRI in 2009 and was told there was a chronic bruise on his knee. He stated that when he left the military he was doing wiring on aircrafts that he described as not very physically demanding. He did at times have to do some squatting in order to do the wiring work. He complained of daily pain of 2 out of 10 that can flare to 5 out of 10 based on activities that stress the patellofemoral joint. He reported that his current job is desk duty and is not limited by his knee condition. The November 2012 VA examiner found that the claimed condition was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The VA examiner stated that the proper diagnosis for his complaints of left knee pain was patella femoral syndrome. He did not have degenerative joint disease as diagnosed by the VA examiner in 2012. X-rays showed no evidence of degenerative joint disease. MRI findings of MCL thickening and increased signal posterior horn medial meniscus are very non-specific and common findings as one ages. They are MRI findings and do not in and of themselves constitute a diagnosis. He had no signs or symptoms of chronic MCL sprain or medial meniscus tear (and no tear was seen on MRI). He had no signs of ligamentous instability on physical examination. The VA examiner stated that his patella-femoral syndrome of the left knee was less likely than not related to his described injury in the military in 2001. The VA examiner stated that patella-femoral syndrome is a very common condition due to increased stress across the patella-femoral joint (the cap). It is often bilateral with one knee worse than the other. He did give a history of bilateral knee pain with running in the service, self treated with ibuprofen. These symptoms resolved when he left the military and no longer did activities stressing his patellofemoral joint. The symptoms returned when he resumed activities stressing his patellofemoral joint a couple of years after he left the military (including work on airplanes and sitting for prolonged periods of time while flying). He also had similar but less severe symptoms in his right knee, which was not injured in 2001. The VA examiner stated that if the appellant's current problem were directly related to the injury in 2001 one would expect the symptoms to only involve his left knee and to be continuous from the time of service. They involve both knees (though left more than right) and are not continuous from the time of service as stated in the history today. As the November 2012 VA examiner provided a thorough rationale for the opinion, the Board finds that opinion to be probative. The appellant has contended that he has a left knee disorder that is related to service. Although a lay person may be competent to report the etiology of a disability, patella femoral syndrome is not the type of disorder which is susceptible to lay opinion concerning etiology. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). Even if the appellant were competent to provide an opinion as to the etiology that condition, the Board finds that the probative value of any such opinion is outweighed by that of the November 2012 VA examiner, who has education, training and experience in evaluating the etiology of a left knee disorder. The VA examiner reviewed the appellant's claims folder and opined that it was less likely than not that the appellant's left knee disorder was related to service. For certain chronic conditions, if there is no evidence of a chronic condition during service, or during an applicable presumptive period, then a showing of continuity of symptomatology after service is required to support the claim. See 38 C.F.R. § 3.303(b). Patellofemoral syndrome is not a chronic condition as defined by 38 C.F.R. § 3.309 and thus service connection may not be granted on that basis. Nevertheless, the Board has considered whether service connection may be granted on the basis of continuous symptoms since service. See 38 C.F.R. § 3.303(a), (d). At the April 2011 hearing, the appellant stated that his knee had bothered him since the time of the accident. (April 2011 Board Hearing Transcript (Tr.) at p. 6). However, the November 2012 VA examination report reflects that the appellant stated that when he left the military in 2005 he stopped running and working out and his knee did not bother him at that time because he was no stressing it with physical activity. He then noticed some symptoms about 1 to 2 years after he left the military. The appellant is competent to report symptoms capable of lay observation, such as pain. However, based his contradicting statements at the November 2012 VA examination which indicated that he did not have continuous left knee symptoms since service, the Board finds the appellant's assertion that he had symptoms of left knee pain since service is less than credible. Based on the above evidence, the Board finds that a preponderance of the evidence is against the appellant's claim for service connection for a left knee disorder. As discussed above, the Board finds the appellant's description of the in-service incident where he was dragged under an ammunition trailer to be credible. Additionally, the appellant has a current left knee disorder, specifically patello-femoral syndrome. However, the evidence does not support a finding of a nexus between the appellant's current left knee disorder and the in-service injury. The November 2012 VA examiner found that the condition was less likely than not incurred in or caused by the claimed in-service injury. The Board finds the November 2012 VA opinion to be highly probative as the VA examiner provided a thorough rationale for the opinion and based the opinion on the evidence of record. As discussed above, the January 2012 VA examination report is not probative. The Board has considered the appellant's assertion that his left knee is related to the in-service injury. However, as discussed above, the Board finds the November 2012 VA opinion to be more probative. There is no other evidence of record linking the appellant's left knee disorder to service. Although the January 2012 VA examiner indicated the appellant had degenerative joint disease of the knee, the November 2012 VA examiner explained that the appellant did not have degenerative joint disease. As the evidence does not support a finding that the appellant had arthritis manifest to a degree of 10 percent or more within one year after separation from active duty, service connection is not warranted on a presumptive basis. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. Accordingly, the Board finds that a preponderance of the evidence is against the appellant's claim for service connection for a left knee disorder. Consequently, the benefit-of-the-doubt rule is not applicable, and the claim must be denied. 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). ORDER Entitlement to service connection for a left knee disorder is denied. ____________________________________________ M. E. LARKIN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs