Citation Nr: 1324473 Decision Date: 08/01/13 Archive Date: 08/13/13 DOCKET NO. 08-39 678 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Indianapolis, Indiana THE ISSUES 1. Entitlement to service connection for a left knee disorder. 2. Entitlement to service connection for a right knee disorder. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD N. Snyder, Counsel INTRODUCTION The Veteran had active service from July 1989 to April 1995. This appeal came before the Board of Veterans' Appeals (Board) from a decision of April 2008 by the Department of Veterans Affairs (VA) Regional Office (RO) in Indianapolis, Indiana. In January 2012, the Board remanded for additional development and due process concerns. FINDING OF FACT 1. On several occasions during active service, the Veteran complained of, and was treated for, bilateral knee pain; no x-rays of the knees were taken and no diagnosis other than knee pain was made in service. 2. Ten years after service, a diagnosis of bilateral chondromalacia of the knees was made with regard to the Veteran's knee pain. 3. It is at least as likely that the knee pain in service was the result of chondromalacia as it was the result of some other knee disorder. 4. Bilateral chondromalacia had its onset in service. CONCLUSIONS OF LAW 1. The criteria for service connection of chondromalacia of the left knee have been met. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002); 38 C.F.R. § 3.303 (2012). 2. The criteria for service connection of chondromalacia of the right knee have been met. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002); 38 C.F.R. § 3.303 (2012). REASONS AND BASES FOR FINDING AND CONCLUSIONS Service connection may be established for disability resulting from personal injury suffered or disease contracted in line of duty in the active military, naval, or air service. 38 U.S.C.A. §§ 1110, 1131. Service connection may be granted for a 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). To establish service connection for a disability resulting from a disease or injury incurred in service, or to establish service connection based on aggravation in service of a disease or injury which pre-existed service, there must be (1) competent evidence of the current existence of the disability for which service connection is being claimed; (2) competent evidence of incurrence or aggravation of a disease or injury in active service; and (3) competent evidence of a nexus or connection between the current disability and the disease or injury incurred or aggravated in service. Horn v. Shinseki, 25 Vet. App. 231, 236 (2010); Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. Sept. 14, 2009); cf. Gutierrez v. Principi, 19 Vet. App. 1, 5 (2004) (citing Hickson v. West, 12 Vet. App. 247, 253 (1999)). In many cases, medical evidence is required to meet the requirement that the evidence be "competent". However, when a condition may be diagnosed by its unique and readily identifiable features, the presence of the disorder is not a determination "medical in nature" and is capable of lay observation. Barr v. Nicholson, 21 Vet. App. 303, 309 (2007). In this case, a January 1991 service treatment record reflects the Veteran's two-month history of bilateral knee soreness after prolonged walking. Examination revealed normal findings, to include findings of no popping or grinding and normal range of motion. The Veteran was referred to a physician for further evaluation. The follow-up record reflects the Veteran's history of knee pain after walking 6 blocks. Examination revealed full range of motion and no tenderness. The Veteran was assessed with knee stiffness, acute soft-tissue injury, status-post increased activity. He was advised to follow-up if no better in two to three weeks. A September 1992 dental health questionnaire reflects the Veteran's history of chronic knee pain. An August 1993 "Medial Surveillance Questionnaire" indicates that the Veteran's current work activities had a potential hazard of knee pain. A September 1993 treatment record reflects the Veteran's history of intermittent right knee pain since May. Examination revealed no edema, discoloration, crepitus, masses, deformity, or pain on palpation; good range of motion; and normal strength. The Veteran was assessed with right knee pain and advised to take Motrin for two weeks; use an Ace Bandage and elevate the knee at home for seven days; and go on limited duty for seven days. He was told to return if the symptoms worsened or persisted. A November 1993 treatment record reflects the Veteran's one-day history of left knee pain. He reported that he drove 260 miles the previous day. Examination revealed no edema, crepitus, pain to palpation, masses, discoloration, or deformity, and range of motion and strength were normal. The Veteran was assessed with left knee pain of unknown etiology. He was provided medication, put on limited duty for seven days, and ordered to return if symptoms worsened or persisted. The April 1995 separation examination reflects the Veteran's negative history as to "trick' or locked knee." However, he did report mild bilateral knee pain with exertion and indicated that he was told that he had arthritis in his knees by a corpsman. Clinical evaluation of the lower extremities was normal. An April 2005 private treatment record reflects the Veteran's history of left knee pain. The Veteran explained that he "ha[d] had a lot of stiffness and soreness in the knee" and that he had "been doing a lot of bending and kneeling." He denied any previous history of injury, locking, or giving way. Examination revealed significant crepitus, pain with patellar grind test, and pain with squatting and arising from squatting. X-ray images were essentially within normal limits. He was diagnosed with patellofemoral syndrome with significant chondromalacia. The record indicates that the Veteran was advised to "work harder on home rehab exercises," which suggests that the Veteran was possibly provided physical therapy exercises for the knees prior to April 2005. An October 2005 private treatment record reflects the Veteran's history of continued knee pain. He explained that he had the same problem as the last time he was seen by the physician. Examination revealed mild crepitus, slightly positive grind test, and slightly positive patellar apprehension, and there was pain of the patellar retinacular structure. He was assessed with patellofemoral syndrome of the left knee with mild arthritis and advised to avoid squatting and climbing activities at work. A March 2006 follow-up treatment record reflects the Veteran's history of increased trouble with the left knee. He explained that he had "a lot of popping and swelling with prolonged weightbearing activities." Examination revealed crepitus, tenderness in the medial joint line, and significant discomfort with circumduction testing. He was assessed with internal derangement with possible meniscal tear and patellofemoral syndrome with chondromalacia. Magnetic resonance imaging (MRI) was done on the knee which revealed a horizontal tear in the posterior horn of the medial meniscus and significant chondromalacia. In April 2006, the Veteran underwent an arthroscopy which indicated that the Veteran's symptoms were the result of chondromalacia on the medial tibia and trochlea, for which he underwent a chondroplasty; there was no meniscal abnormality. Post-operative records indicate that the symptoms resolved until approximately August 2006, when the Veteran reported that the popping and pain had returned. Another arthroscopy was performed in October 2006, which revealed further chondromalacia under the patella and trochlea and some loose cartilaginous fragments, for which another chondroplasty was performed. In November 2006, the Veteran presented for treatment with a history of recurrent pain after standing all day at work. The record notes that the Veteran was given anti-inflammatory medication and light pain medication and told to ice the knee. In March 2007, the Veteran reported that he had switched jobs and was now a roofer. He indicated that he had noticed recurrent left knee pain and swelling after working. After examination, the physician diagnosed the Veteran with left knee pain. The physician noted that the Veteran's workload was stressing his pre-arthritic knee. The record notes that the Veteran was provided a cortisone shot for pain management. In October 2008, the Veteran presented for treatment with a two-week history of intermittent right knee pain which occasionally made it difficult to move the knee or weight-bear. He denied any specific injury. Examination revealed mild swelling, exquisite tenderness in the lateral joint line, and discomfort with circumduction testing. A palpable click was noted in the lateral joint line. The Veteran was assessed with internal derangement of the right knee secondary to a lateral meniscal tear and an MRI was ordered. A January 2012 VA examination record reflects the Veteran's history of bilateral knee pain during and since service. After examination, the Veteran was diagnosed with chondromalacia of the knees. The examiner opined that it was less likely than not that the knee disorders were incurred in or were caused by service. The examiner noted that the service treatment records reflected complaints of pain but no evidence of significant injury to the knee. The examiner also noted that on each occasion, no specific findings were noted as to the etiology of the pain and there was no significant follow-up or treatment plan initiated. Furthermore, the examiner noted that there was no significant follow-up for the knee complaints until nearly 10 years after separation. The examiner explained that there are multiple causes of chondromalacia and that, although it can occur without injury, it is usually a self-limiting disease in young people which only continues when there is "severe injury." The examiner reported that chondromalacia is a clinical diagnosis not normally seen on imaging tests. He added that there were no signs of degenerative changes in either patella on X-ray images. The examiner explained that it did not "appear that the current disorders were related to the service 'injury'" and he "could only conclude" that the current knee complaints resulted from an injury occurring years after discharge. Although the VA examiner is competent to render an opinion, the opinion carries little probative value in part because the examiner did not adequately address the in-service complaints or the Veteran's consistent denial of injury to either knee at any time (during service or outside of service). Thus, the Board requested an opinion from a Veterans Health Administration (VHA) specialist. In a March 2013 opinion, the specialist, an orthopedic surgeon, reported that it was not likely that the Veteran's bilateral knee condition, chondromalacia patella, was related to service unless there was a documentation of a severe direct blow to that patella in a fall or dashboard injury. The orthopedic surgeon added that the condition was idiopathic, generally non-progressive, and not a cause of a severe disability in the absence of another knee pathology. In June 2013, the orthopedic surgeon provided an addendum opinion revealing the determination that it was possible but unlikely that chondromalacia was the cause of the knee pain during service. The orthopedic surgeon explained that it is possible that chondromalacia can develop without an injury but noted that chondromalacia is "much more frequent in female than male patients and related to anatomical issues and to a history of subluxation or dislocation of the patella." The orthopedic surgeon added that without any medical evidence, he could not state with any certainty that the Veteran's chondromalacia was related to either his service or complaints of knee pain because there are myriad causes of knee pain, including tendinitis, bursitis, and overuse. However, the Board notes that a medical opinion need not be stated with certainty in order for service connection to be granted. Rather, the question is whether it was at least as likely that the knee pain in service was the result of, or an early symptom or manifestation of, chondromalacia, which was diagnosed ten years later, as opposed to its being more likely the result of some other cause or diagnosis. Unfortunately, the orthopedic surgeon did not state that it was more likely that the knee pain in service was caused by any one of the other causes mentioned, i.e., tendinitis, bursistis, or overuse. Therefore, the Board could request clarification of the opinion once again. However, given that chondromalacia was the diagnosis rendered ten years later to explain the complaints of knee pain and no other diagnosis has been rendered, the Board will resolve reasonable doubt in favor of the Veteran and find that his knee pain in service was the early onset of chondromalacia. Concerning this, the Board finds the evidence reveals the existence of a persistent knee disorder, rather than multiple acute episodes of knee pain, during service which continued after service and was ultimately diagnosed as chondromalacia. The Board acknowledges that the record does not reflect treatment for either knee until 10 years after separation and does not include a diagnosis of chondromalacia until approximately 10 years after service. Although the post-service medical records do not reflect continued complaints of knee pain prior to 2005, the Board finds the Veteran's history of the knee symptoms currently attributed to chondromalacia, particularly knee pain, during and since service is competent and credible. It is consistent with the evidence of record, notably the service treatment records and separation examination record which document ongoing bilateral knee pain; the Veteran's history that he was unable to obtain medical treatment for many years after service due to lack of medical insurance; the absence of a contradictory history in the post-service treatment records, i.e., a history of a recent onset of knee pain or negative history as to knee pain prior to initial treatment for the knee; the absence of contradictory medical findings, e.g., findings of no chondromalacia or normal radiographic images prior to April 2005; and the reference to home rehab exercises in the April 2005 treatment record. Furthermore, it is consistent with the nature of chondromalacia, which is primarily manifested by knee pain-it is otherwise known as patellofemoral pain syndrome-and not "commonly shown on imaging tests." See, e.g., Dorland's Illustrated Medical Dictionary 358 (31st ed. 2007). See also http://www.mayoclinic.com/health/chondromalacia-patella/DS00777. The Board acknowledges that physicians have determined it was not likely that the current chondromalacia was the cause of the in-service knee complaints. The physicians have not provided adequate rationale as to the possible cause of the in-service knee complaints, however. Although the physicians have reported that there are multiple possible causes for knee pain, they have not provided an explanation for why these causes are a more likely source of the Veteran's knee pain during service than the chondromalacia which was diagnosed 10 years thereafter. In the absence of such an explanation, the Board finds the physicians' opinions have limited probative value. Based on the foregoing, and giving the benefit of the doubt to the Veteran, the Board finds service connection is warranted for chondromalacia of the right and left knees. VA has a duty to notify and assist claimants for benefits. The decision above grants service connection for the knee disorders. Therefore, there is no further need to discuss compliance with the duties to notify and assist. ORDER Service connection for chondromalacia of the left knee is granted. Service connection for chondromalacia of the right knee is granted. ____________________________________________ KATHLEEN GALLAGHER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs