Citation Nr: 1610735 Decision Date: 03/16/16 Archive Date: 03/23/16 DOCKET NO. 11-01 833 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Boise, Idaho THE ISSUE Entitlement to service connection for a right knee disability, diagnosed as patellofemoral syndrome. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States ATTORNEY FOR THE BOARD T.Ojo, Associate Counsel INTRODUCTION The Veteran had active duty service from February 1987 to July 1991. The Veteran was awarded the Combat Action Ribbon. This matter comes before the Board of Veterans' Appeals (BVA) on appeal from a January 2010 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Boise, Idaho. In March 2011, the Veteran testified at a hearing before a Decision Review Officer (DRO). A copy of the transcript of this hearing is associated with the claims folder. In February 2015, the Board remanded the issue on appeal for additional development. As the actions specified in the remand have been completed, the matter has been properly returned to the Board for appellate consideration. See Stegall v. West, 11 Vet. App. 268 (1998). This appeal has been processed through the Veterans Benefits Management System (VBMS) electronic paperless appeals processing system. FINDING OF FACT The probative medical evidence indicates that the Veteran's right knee disability, diagnosed as patellofemoral syndrome, is not related to his in-service knee injury or any other event in service. CONCLUSION OF LAW The criteria for entitlement to service connection for a right knee disability have not been met. 38 U.S.C.A. § 1131 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309 (2015). REASONS AND BASES FOR FINDING AND CONCLUSION Duties to Notify and Assist VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2014); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002); Dingess v. Nicholson, 19 Vet. App. 473 (2006). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the Veteran and his or her representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim, including apprising him or her of the information and evidence he or she is responsible for providing versus the information and evidence VA will obtain for him or her. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). The Board finds that the notice requirements have been satisfied. In September 2009, the Veteran was informed, prior to the rating decision, of all five elements of service connection, given examples of the types of evidence the Veteran could submit in support of his claim, and provided notice of the Veteran's and VA's respective responsibilities for obtaining such evidence. The correspondence also informed him of how disability ratings and effective dates are assigned, if service connection was to be granted. See Dingess v. Nicholson, supra. The Board concludes that the duty to assist has been satisfied. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c). The Veteran's service treatment records, post-service VA treatment records and lay statements are in the file. The Veteran underwent a VA examination in December 2009 to determine the etiology of his right knee disability, and an addendum opinion was obtained in March 2015. The December 2009 VA examination and March 2015 VA addendum opinion are adequate, as they are predicated on a review of the claims file, an interview of the Veteran, and examination findings supported by a complete rationale for the opinions stated. See 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c)(4). For the above reasons, the Board finds that VA has fulfilled its duties to notify and assist the Veteran. Therefore, the Veteran will not be prejudiced as a result of the Board proceeding to the merits of the claim. Service Connection Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by service. See 38 U.S.C.A. § 1110 (West 2014); 38 C.F.R. § 3.303(a) (2014). "To establish a right to compensation for a present disability, a Veteran must show: (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-the so-called "nexus" requirement." Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2010) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Disorders diagnosed after discharge will still be service connected if all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d); see also Combee v. Brown, 34 F.3d 1039, 1043 (Fed. Cir. 1994). Furthermore, service connection can be established through application of statutory presumptions, including for chronic diseases (such as arthritis) when manifested to a compensable degree within a year of separation from service. 38 U.S.C.A. §§ 1101, 1137; 38 C.F.R. §§ 3.307, 3.309. Under 38 C.F.R. § 3.303(b), if a chronic disease is shown in service, subsequent manifestations of the same chronic disease at any later date, however remote, may be service connected, unless clearly attributable to intercurrent causes. For a showing of a chronic disorder in service, the mere use of the word chronic will not suffice; rather, there is a required combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. When the fact of chronicity in service (or during the presumptive period) is not adequately supported, then a showing of continuity after discharge is required to support the claim. The provisions of 38 C.F.R. § 3.303(b) have been interpreted as an alternative route to service connection only for the specific chronic diseases listed in of 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102 (2015); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The Board notes that the Veteran had foreign service in Iraq, and was awarded the Combat Action Ribbon. See DD-214. However, the Veteran is not alleging that his disability is a result of combat, but rather that his disability is the result of his in-service football injury with no assertion of incurrence or aggravation during combat. As a result, the combat presumption is not for application in this case. See 38 U.S.C.A. § 1154(b) (West 2014); 38 C.F.R. § 3.304(d) (2015). The Veteran asserts that he has a right knee disability as a result of a football injury sustained during active service. See March 2011 DRO hearing. Service treatment records show a diagnosis of patellofemoral syndrome in May 1987. The Veteran's separation examination in March 1991 show no reports of a right knee disability. In addition, on his separation Report of Medical History he affirmatively denied having any joint deformity or issue and denied having a no locked or trick knee. The Veteran was afforded a VA examination in December 2009, in which he reported the aforementioned in-service football injury. The VA examiner diagnosed him with right knee patellofemoral syndrome. The VA examiner opined that the right knee patellofemoral syndrome was not caused by or a result of military service. The examiner stated that patellofemoral syndrome was a tracking problem that was activity specific, and that with quad strengthening and/or removal of the offending activity, the problem usually resolved. The examiner stated that recurrence was caused not by the original episode, but was strictly due to the circumstance of recurrence. The examiner noted that a VA treatment record in May 2009 showed that the Veteran complained of his hips hurting after a bicycle race and made no mention of his knees. The examiner stated that patellofemoral syndrome, if present, would have been aggravated by such activity. The examiner opined that there were many other circumstances in the Veteran's past 18 years that played a much larger role in his present right knee problems than his military service did. The Board acknowledged the rationale provided by the December 2009 VA examiner, but concluded that such opinion and accompanying rationale was inadequate. See February 2015 Board Remand. As such, an addendum opinion was obtained in March 2015. The examiner stated that there was no mention of any knee condition in the Veteran's VA records starting from 2004, when the Veteran was first seen at the Boise Vet Center. He reported that a note in the Veteran's July 2006 treatment records stated that the Veteran had gone bike riding. An orthopedic note from May 2009 mentions bilateral hip pain that started a year earlier when the Veteran was in a bike race in the mountains. However, the Veteran made no mention of knee pain. The examiner opined that bike riding, particularly racing, and in the mountains, is an activity that one would not even attempt if there was ongoing patellofemoral syndrome. He stated that if a patient had even mild patellofemoral syndrome at the time of such an event, he would have sought medical attention for his knees after the event, and would not only seek medical attention for his hips without making mention of his knees. The examiner stated that the absence of evidence that the Veteran sought medical attention for his knees between 2004 and May of 2009, coupled with the fact that he rode in a bike race in the mountains offers substantial evidence that his patellofemoral syndrome diagnosed in 1987 had resolved by May 2009. The examiner also stated that, once patellofemoral syndrome resolves, for it to reoccur there would have to be a new offending event. The examiner opined that the Veteran had no evidence of patellofemoral syndrome between 2004 and May 2009, which enabled him to participate in a bike race in the mountains. The examiner opined that any current knee pain that the Veteran is currently experiencing is due to the mountain bike race he participated in and not some event from service. Based on a careful review of all of the evidence, the Board finds that service connection for the Veteran's right knee disability, diagnosed as patellofemoral syndrome, is not warranted. The evidence does not show that the Veteran's current right knee disability is related to his in-service injury. Rather, the evidence shows that the Veteran's in-service diagnosed patellofemoral syndrome resolved upon exit from active duty service, and did not appear again until after the Veteran's bike race in the mountains in May 2009. The most probative evidence of record, the March 2015 VA addendum opinion, fully explains why the Veteran's right knee disability was not caused or aggravated by his in-service injury. The evidence shows that, given the nature of the right knee disability, any pain the Veteran currently experiences is the result of an event that occurred after service. The Board finds that the March 2015 VA opinion is the most probative evidence, as it is based on a review of the Veteran's medical records and contains a complete rationale with citation to evidence in the record. The only evidence of record supporting the Veteran's contentions that his right knee disability is related to his in-service May 1987 injury is the Veteran's lay statements. In March 2011, the Veteran testified at a DRO hearing that he injured his knee while playing football in service. He stated that he had rehab and wore a knee brace for about six months, and his knee has bothered him ever since. He stated that there was no mention of his knee on his March 1991 separation exam because "they were trying to check them out so fast, they were okay[ing] everything," and he was told that "the VA will take care of you." He stated that since leaving service, he has self-medicated his knee with Ibuprofen. He also stated that since getting out of service he worked in construction, but he never re-injured his knee. The Veteran is competent to report observable symptoms, such as pain in his right knee. However, the question of whether his current right knee disability is related to his in-service injury is a complex medical question, not capable of lay observation. See Jandreau v. Nicholson, 492 F.3d 1372, 1376 (2007). (noting that lay witness capable of diagnosing dislocated shoulder); Barr v. Nicholson, 21 Vet. App. 308-309 (2007) (finding that lay testimony is competent to establish the presence of varicose veins). Because the evidence does not indicate that the Veteran has the appropriate training, experience, or expertise to provide a medical opinion concerning a knee condition, he is not competent to comment on the etiology of his right knee disability. Accordingly, the competent evidence outweighs his unsubstantiated lay reports regarding etiology. Moreover, even if the Veteran was competent, his statements would be outweighed by the probative March 2015 VA opinion. The VA examiner reviewed the claims file, considered the reported history and provided rationale to support the conclusion. The examiner used his expertise in reviewing the facts of this case and determined that the Veteran's right knee disability was not related to his in-service injury. Therefore, as the preponderance of the evidence weighs against the Veteran's claim, the benefit-of-the-doubt rule does not apply, and service connection for a right knee disability must be denied. See 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER Entitlement to service connection for a right knee disability, diagnosed as patellofemoral syndrome, is denied. ____________________________________________ BRADLEY W. HENNINGS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs