Citation Nr: 1326172 Decision Date: 08/16/13 Archive Date: 08/26/13 DOCKET NO. 09-27 676A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Denver, Colorado THE ISSUES 1. Entitlement to service connection for a bilateral knee disability. 2. Entitlement to service connection for a low back disability. REPRESENTATION Appellant represented by: Colorado Division of Veterans Affairs ATTORNEY FOR THE BOARD D. Johnson, Counsel INTRODUCTION The Veteran served in the Air National Guard from November 2001 to November 2007 with periods of active duty from September 2002 to February 2003, February 2005 to July 2005, and December 2005 to January 2007. This matter is before the Board of Veterans' Appeals (Board) on appeal from a July 2008 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran requested a hearing on his July 2009 substantive appeal form, but subsequently withdrew his hearing request. In May 2012 and December 2012, the Board remanded the case for further development. Stegall v. West, 11 Vet. App. 268, 271 (1998). FINDING OF FACT Chronic bilateral patellofemoral pain syndrome of the bilateral knees and chronic lumbosacral strain/sprain (also referred to as mechanical low back pain syndrome) were incurred as a result of military service. CONCLUSIONS OF LAW 1. The criteria for service connection for chronic bilateral patellofemoral pain syndrome of the bilateral knees have been met. 38 U.S.C.A. §§ 1110, 5103A (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303 (2012). 2. The criteria for service connection for chronic lumbosacral strain/sprain have been met. 38 U.S.C.A. §§ 1110, 5103A (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303 (2012). REASONS AND BASES FOR FINDING AND CONCLUSIONS The Veterans Claims Assistance Act of 2000 (VCAA) VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. The Board is granting in full the benefit 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. Analysis The Veteran seeks service connection for a bilateral knee and a low back disability. He avers that these disabilities were incurred in service because his duties involved excessive standing and bending, and lifting heavy equipment (such as 20-man life rafts) often without assistance. He denies any specific injury to his knees or back during service. Generally, to establish entitlement to compensation for a present disability, a Veteran must show: (1) a present disability; (2) an 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, the so-called "nexus" requirement. All three elements must be proved. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed.Cir. 2004). Service connection may also be granted for disability shown after service, when all of the evidence, including that pertinent to service, shows that it was incurred in service. 38 C.F.R. § 3.303(d). VA must give due consideration to all pertinent lay and medical evidence in a case where a Veteran is seeking service connection. 38 U.S.C.A. § 1154(a). Competent lay evidence is any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159(a)(2). This may include some medical matters, such as describing symptoms or relating a contemporaneous medical diagnosis. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Competent medical evidence is evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may include statements conveying sound medical principles found in medical treatises. 38 C.F.R. § 3.159(a)(1). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the Veteran. 38 U.S.C.A. § 5107(b). Service treatment records do not reflect complaints or diagnoses related to the knees or the back. Post-service VA treatment records show complaints of back and knee pain. The Veteran was afforded VA examinations for his back and knees in April 2008, shortly after separation from service. At that time an examiner diagnosed mechanical low back syndrome and bilateral patellofemoral syndrome, but did not opine as to whether these conditions were incurred in or were otherwise related to the Veteran's military service. In May 2012, the Board determined that the April 2008 VA examination report was inadequate and remanded the claim for another VA examination and nexus opinion. At a VA examination in June 2012, a different examiner provided diagnoses of degenerative joint disease of the thoracolumbar spine, mechanical low back pain syndrome, and patellofemoral syndrome, resolved. The examiner stated that neither disability is related to service, essentially because there is no documentation of back and/or knee injuries, complaints, or diagnoses in service. In December 2012, the Board determined that the June 2012 VA examination report was inadequate and remanded the claim for yet another VA examination. At a March 2013 VA examination, an examiner reviewed the claim file in its entirety, interviewed the Veteran, and performed a clinical evaluation. With respect to both disabilities, the examiner noted that the Veteran competently reported the onset of his knee and back symptoms was during military service and related to his military occupational activities. The examiner also noted that the Veteran reported recurrent symptoms over time, and denied any knee and/or back injuries prior to or since departing military service. The examiner determined that the Veteran has chronic bilateral patellofemoral pain syndrome of the knees, which is at least as likely as not related to events that occurred during active military service. The examiner noted that the duties the Veteran performed in service, including inspecting life rafts and sitting for prolonged periods at an industrial sewing machine operated by foot pedals, were significant enough to cause his chronic symptoms of bilateral patellofemoral pain syndrome. The examiner explained that patellofemoral pain syndrome is one of the most common causes of knee pain, and it is common knowledge that this condition can result from overuse activities, particularly in the context of sub-optimal ergonomic positions, as the Veteran describes. The examiner further explained that repetitive kneeling and squatting place stress on the knee joint, including the patella, and contribute to symptoms of patellofemoral pain syndrome. With respect to the Veteran's low back disability, the examiner provided a diagnosis of chronic lumbosacral strain/sprain, also referred to as mechanical low back pain syndrome, and an opinion that this disability is at least as likely as not related to events that occurred during active military service. The examiner explained that the Veteran's in-service physical activities (i.e. inspecting/packing parachutes, inspecting life preservers, and sitting for prolonged periods at an industrial sewing machine) were significant enough to chronically strain/sprain the lower back. The examiner also noted that it is common medical knowledge that repetitive, sustained, biomechanically awkward positions may cause chronic strain/sprain of the lower back. The examiner found that the Veteran does not have degenerative joint disease of the lumbar spine. By the examiner's review of the records, x-rays at the June 2012 VA examination did not show degenerative joint changes. The examiner explained that the radiologist in June 2012 reported mild loss of disk height at L5-S1; however, upon current x-ray, another radiologist indicated the current films do not show degenerative disk or degenerative joint changes of the lumbosacral spine. The examiner determined that the Veteran presently has no signs or symptoms of lumbosacral radiculopathy; this supports the current imaging findings (normal disks and joints of the lumbosacral spine). The June 2012 VA medical opinion, which determined the Veteran's bilateral knee and low back disabilities are not related to service, is inadequate for adjudication purposes for several reasons and thus is not probative. The Veteran has competently and credibly described his in-service duties, the in-service onset of his back and knee symptoms, and the recurrence of such symptoms after discharge. The Veteran has also competently and credibly reported that he did not seek care for his knee and back pain in service because it was not part of the military culture to be sick or complain, and he mistakenly believed the pain would cease when he left military service. This competent and credible lay evidence is evidence in favor of the claim. See Layno v. Brown, 6 Vet. App. 465 (1994); Jandreau, 492 F.3d 1372 (Fed. Cir. 2007); see also 38 C.F.R. § 3.303. The March 2013 VA opinion is adequate for evaluation purposes and reflects compliance with the Board's remand directives. The opinion is also competent and probative as to the question of causal nexus because it is based on the examiner's medical experience and expertise as a physician, claim file review, the Veteran's clinical interview, and a physical examination. Further, the opinion was supported with a clear and well-reasoned rationale. See Stefl v. Nicholson, 21 Vet. App. 120, 124-25 (2007); Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). In short there is competent medical evidence, which is uncontroverted by any other competent and probative medical evidence of record, that the Veteran's chronic bilateral patellofemoral pain syndrome of the bilateral knees and chronic lumbosacral strain/sprain is causally related to his active military service. This places the preponderance of the evidence in favor of the claim. Service connection for chronic bilateral patellofemoral pain syndrome of the bilateral knees and chronic lumbosacral strain/sprain, also referred to as mechanical low back pain syndrome, is warranted. ORDER Service connection for chronic bilateral patellofemoral pain syndrome of the bilateral knees is granted. Service connection for chronic lumbosacral strain/sprain is granted. ____________________________________________ RONALD W. SCHOLZ Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs