Citation Nr: 1802587 Decision Date: 01/11/18 Archive Date: 01/23/18 DOCKET NO. 07-26 409 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Columbia, South Carolina THE ISSUES 1. Entitlement to service connection for a bilateral knee disability. 2. Entitlement to service connection for a right ankle disability. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD N. Whitaker, Associate Counsel INTRODUCTION The Veteran served on active duty with the United States Army from September 1981 to February 1982. She also served with the Reserves from July 1983 to June 1991. This matter comes before the Board of Veterans' Appeals (Board) from a February 2007 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Columbia, South Carolina, denying, among other issues, the claims currently on appeal. The Board notes that pursuant to a January 2014 Board remand, the Veteran's claims were returned to the Agency of Original Jurisdiction (AOJ) for further development, to include scheduling VA examinations. The development was properly concluded, and the appropriate VA examinations were obtained in March 2014. The Veteran's initial appeal included a claim for service connection for a right wrist disorder. This issue was also remanded in a January 2014 decision. A review of the record reveals that in a May 2014 rating decision, the Veteran was granted service connection for tendinitis of the right wrist and was assigned an evaluation of 10 percent disabling effective July 24, 2006. As the aforementioned issue has been resolved by a full grant of benefits and the Veteran has not submitted any documents indicating that she is unsatisfied with the RO's decision, the Board finds that the issues are no longer before the Board on appeal. See 38 C.F.R. § 19.26 (d) (2017). The Board recognizes that post-remand, the RO has considered the Veteran's remaining claims for entitlement to service connection based upon a theory of new and material evidence. This treatment occurred in error. Review of the record reveals that the Veteran filed a timely appeal of the February 2007 rating decision, and the Board previously considered the Veteran's claims on remand in April 2009, May 2012, and most recently, in January 2014. As the Board has yet to render a decision following the development ordered in January 2014, the Veteran's claims remain in appellate status. According, the Veteran's claim will be afforded appropriate appellate consideration in this decision. FINDINGS OF FACT 1. The Veteran's current bilateral knee disabilities were not caused or aggravated by active service. 2. The Veteran's right ankle sprain was not caused or aggravated by active service. CONCLUSIONS OF LAW 1. The criteria for service connection for a bilateral knee disability have not been met. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303 (2017). 2. The criteria for service connection for a right ankle disability have not been met. U.S.C.A. §§ 1110, 1111 (West 2014); 38 C.F.R. §§ 3.303 , 3.304 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duty to Notify and Assist VA is required to notify a claimant of what information or evidence is necessary to substantiate the claim; what subset of the necessary information or evidence, if any, the claimant is to provide; and what subset of the necessary information or evidence, if any, the VA will attempt to obtain. 38 C.F.R. § 3.159(b) (2017). Copies of compliant VCAA notices were located in the claim's file. In addition, the Board finds that the duty to assist a claimant has been satisfied. The Veteran's service treatment records are on file, as are various post-service medical records. A VA examination has been conducted and any necessary opinions obtained. Neither the Veteran nor her representative has raised any issues with the duty to notify or duty to assist. See Scott v McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board...to search the record and address procedural arguments when the veteran fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to duty to assist argument). As there is no allegation that the hearing provided to the Veteran was deficient in any way, further discussion of the adequacy of the hearing is not necessary. Dickens v. McDonald, 814 F.3d 1359 (Fed. Cir. 2016). After a careful review of the file, the Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). Laws and Regulations Service connection may be granted for any current disability that is the result of a disease contracted or an injury sustained while on active duty service. 38 U.S.C.A. § 1110, 1131 (West 2014); 38 C.F.R. §§ 3.303 (a), 3.304 (2017). Entitlement to service connection benefits is established when the following elements are satisfied: (1) the existence of a current disability; (2) in-service incurrence or aggravation of a disease or injury; and, (3) a causal relationship between the current disability and the disease or injury incurred or aggravated during service (the medical 'nexus' requirement). See Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004); 38 C.F.R. § 3.303 (a) (2017). Service connection also is permissible on a secondary basis for disability that is proximately due to, the result of, or aggravated by a service-connected disability. 38 C.F.R. § 3.310 (a) and (b) (2016). See also Allen v. Brown, 7 Vet. App. 439, 448 (1995). In order to prevail on the issue of entitlement to secondary service connection, there must be (1) evidence of a current disability; (2) evidence of a service-connected disability; and, (3) nexus evidence establishing a connection between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). In determining whether service connection is warranted for a disorder, 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 (West 2014); 38 C.F.R. § 3.102 (2017); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Analysis; Knees The Veteran contends that her current disabilities of the right and left knees were caused by or related to her active service. The preponderance of the evidence is against her claim. Review of service treatment records revealed that the Veteran complained of leg and knee pain in July 1983. A relevant treatment note describes swelling and discoloration of the left and right knee, with mild crepitation and effusion on the right knee. Oral medications were prescribed to treat the pain. No specific injuries or a formal diagnosis was rendered. A report of medical history, dated February 1986, indicated that the Veteran was examined and her lower extremities and feet were found to be clinically normal. No other complaints or treatment for symptoms related to a bilateral knee condition was noted. Post-service, VA medical records referenced numerous complaints of chronic knee and ankle pain. In December 2014, a radiologist note indicated that diagnostic images of the Veteran's right knee revealed normal joint spaces, with mild patellar spurring and no evidence of effusions or other bony findings. In December 2015, a telephone advice program note indicated that the Veteran called to report bilateral knee pain described as an 8 on a 10 point scale. During the call, she also reported aching and burning pain that impacts the arch of her right foot and hip. In November of the same year, the Veteran requested a steroid injection to treat her chronic knee pain. In February 2016, a nurse practitioner's note referenced the Veteran's complaints of progressively worsening pain in the right knee. During the examination, the Veteran denied suffering any recent injury, fall, or trauma to either knee. The record noted review of March 2015 diagnostic images of both knees which showed normal joint space and patellar spurring bilaterally. No evidence of effusions or other bony findings was indicated. Pursuant to a January 2014 Board remand, the Veteran underwent a VA examination in March of the same year. During the examination, the Veteran reported chronic bilateral knee pain and flare ups that caused difficulty walking. She noted a gradual onset of bilateral knee pain during active service without any associated injury. Oral medications and pain patches were used for pain management. Range of motion testing revealed normal flexion and extension of the left and right knee, with no evidence of painful motion. No additional limitation of range of motion was noted following repetitive use testing. Functional loss or impairment as to pain on movement of the right knee was indicated. Tenderness or pain to palpation of the joint was reported for both knees. Muscle strength and joint stability testing yielded normal results on both sides. No impact to the Veteran's ability to work was noted. Diagnostic testing did not reveal any evidence of degenerative or traumatic arthritis, patellar subluxation or dislocation. Bilateral shin splints were noted as an additional condition. On review of the record, the Veteran was diagnosed with a bilateral strain of the left and right knee. In reaching the above referenced diagnosis, the examiner noted evidence of an acute complaint of bilateral knee pain during service however, no further notes were found to suggest a chronic condition. Therefore, the examiner opined that it is less likely as not that the Veteran's current bilateral knee conditions are related to service. The examiner also opined that it is less likely than not that the conditions were caused by or related the Veteran's service-connected shin splints. In January 2016, the Veteran was afforded a subsequent VA examination. The examiner noted a diagnosis of bilateral knee strain to both knees in 2008, and shin splints in 1981. During the clinical evaluation, the Veteran indicated that her shin splints began during basic training. Her knee pain, however, gradually developed over time following discharge. As to her current symptoms, the Veteran indicated that her shin splints have remained unchanged; however, her bilateral knee pain has become progressively worse. On examination, range of motion testing revealed flexion of the right knee limited to 105 degrees and extension 0 to 105 degrees with evidence of pain on motion. The Veteran denied any current experience of flare-ups, however, there was evidence of pain on weight bearing. Range of motion of the right knee contributed to functional loss as to squatting and kneeling. No functional loss or functional impairment was indicated, regardless of repetitive use. Moderate tenderness to palpation of the right knee was noted both medially and laterally. Range of motion of the left knee was limited to 120 degrees flexion and 0-120 extension with no evidence of painful motion. No evidence of pain on palpation of the joint or functional loss due to range of motion was indicated. Repetitive use testing was performed with no additional functional loss. The Veteran's muscle strength was normal for both knees with no evidence of muscle atrophy or ankylosis. No history of instability, subluxation, or effusion was indicated. Joint stability testing yielded normal results for both knees. The examiner noted that neither pain, weakness, fatigability, nor incoordination significantly limited the Veteran functional ability after repetitive use of either knee. No additional contributing factors were listed. Although the examiner acknowledged the existence of the Veteran's current service-connected shin splints disability, it was nevertheless concluded that the condition does not affect the Veteran's range of motion. The examiner also opined that the Veteran's knee condition impacted her ability to work as it relates to walking and squatting down. In making all determinations, the Board has fully considered the evidence of record to include lay statements submitted by the Veteran and on her behalf. Generally, lay statements are deemed competent and credible as to descriptions of observable symptoms. Layno v. Brown, 6 Vet. App. 465 (1994). Additionally, when a condition may be diagnosed by its unique and readily identifiable features, the presence of the disorder is not a "medical" determination and is capable of lay observation. Lay evidence can be competent and sufficient to establish a diagnosis of a veteran's condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). In this case, the Veteran contends that she suffers from a chronic bilateral knee disability that was caused by or related to her active service. In support of her contention, she submitted lay statements from a supervisor and co-worker indicating that the her symptoms have existed since service, impact her posture, ability to sit or stand for extended periods and require regular use knee braces and/or heat patches. The statements also reference the Veteran's use of oral medications to treat her pain and frequent use of sick or annual leave due to recurrent and intensity pain. While the Board acknowledges that lay persons are competent to provide opinions on some medical issues, the specific issue in this case (whether the Veteran's bilateral knee condition was caused by or related to service) falls outside the realm of common knowledge of a lay person. See Kahana v. Shinseki, 24 Vet.App. 428, 435 (2011); Jandreau, 492 F.3d at 1377, n.4. As a result, the Veteran's lay statements cannot constitute competent medical evidence in support of her claim. Here, the medical evidence fails to show a causal connection between the Veteran's active service and her bilateral knee disabilities. In March 2014 and again, in January 2016, a VA examiner diagnosed the Veteran with a bilateral knee strain to both knees, but nevertheless concluded that the condition were not related to active service or the Veteran's service-connected shin splints disability. In both instances, the examiner's rationale reflected application of medical expertise to the factual background and the associated opinion was fully articulated and based on sound reasoning. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (20008). The Board finds that the VA opinions are most probative, as the opinions are based on clinical records and a physical exam. While the Board is sympathetic to the Veteran's complaints of chronic bilateral knee disabilities, the medical evidence does not support a causal connection between the condition and her active service. Accordingly, as the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application. See generally Gilbert v. Derwinski, 1 Vet. App. 49 (1990); Ortiz v. Principi, 274 F. 3d 1361 (Fed. Cir. 2001). The Veteran's claim must be denied. Right Ankle The Veteran also contends that her right ankle disability was caused by or related to her active service. However, as outlined below, the preponderance of the evidence of record demonstrates that the Veteran does not suffer from a current disability of the right ankle that manifested during, or as a result of, active military service. As a preliminary matter, the Board notes that the Veteran was diagnosed with tendonitis of the right ankle during the course of the appeal. Accordingly, the first criterion for establishing entitlement to service connection for a right ankle disability has been met. The remaining questions are whether the Veteran suffered a disease or injury of the right ankle that is at least as likely as not related to a current disability. Service treatment records noted that the Veteran complained of right ankle pain and tenderness to the lateral malleolus in July 1983. However, a physical examination performed in the same month yielded normal results and there is no evidence of a diagnosis of a right ankle sprain or any related treatment during active duty. Post service, VA medical records revealed periodic complaints of ankle pain, with no referenced to a specific treatment for a diagnosed condition. In March 2014, the Veteran underwent a VA examination. During the examination, the Veteran denied suffering a specific injury to the right ankle during active service. A gradual onset of pain following discharge, with no timeline or date specified was reported. During flare-ups, the Veteran noted difficulty walking and standing. Range of motion testing of the right ankle revealed plantar flexion ending at 30 degrees and dorsiflexion ending at 10 degrees. Evidence of painful motion was indicated. No additional limitation in range of motion was reported following repetitive use or during flare-ups. Functional loss or impairment was listed as less movement than normal and pain on movement. The Veteran's muscle strength was normal, with evidence of localized tenderness or pain on palpation to the right ankle. No significant diagnostic findings or evidence of ankylosis was discovered. Joint stability testing was not performed. On review of the record, the Veteran was diagnosed with tendinitis of the right ankle. In reaching the stated conclusion, the examiner noted that the Veteran complained of right ankle pain during service, however, service treatment records do not reveal ongoing symptoms or treatment so as to suggest a chronic condition. Thus, the examiner opined that it is less likely as not that the Veteran's current ankle condition is related to service or otherwise resulted from the Veteran's service-connected disabilities, to include her lumbar degenerative disc disease or shin splints disabilities. The Board has thoroughly reviewed the evidence, to include the Veteran's October 2017 Appellant's Brief (Informal Hearing Presentation (IHP)) asserting her entitlement to service connection for a bilateral knee and ankle disability. The Board recognizes the Veteran's competence to report on the observable symptoms and deems her lay statements credible. In this case, however, the Veteran's lay contentions are outweighed by competent and credible medical evidence which evaluated the nature and etiology of her right ankle condition based on objective data coupled with the Veteran's lay complaints. In this regard, the Board notes that the VA examiners have the training and expertise necessary to administer the appropriate tests for a determination of the type and degree of the impairment associated with the Veteran's complaints. For these reasons, greater evidentiary weight is placed on the examination findings. In this case, there is no evidence of treatment for many years post-service and the VA examiner did not find that the current disability was related to military service. A report of medical history, dated February 1986, indicated that the Veteran was examined in-service and her lower extremities and feet were found to be clinically normal. The Board notes that the record contains statement indicating the Veteran's report of intermittent pain in the knee joints and ankle. While the Board is sympathetic to Veteran's belief that her current right ankle condition relates to service, as a lay person, the Veteran has not shown that she has specialized training sufficient to render such an opinion. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007) (noting general competence to testify as to symptoms but not to provide medical diagnosis. Moreover, the question of whether the Veteran's symptoms experienced in service or thereafter are related to a current disability is a matter that also requires medical expertise to determine. See Clyburn v. West, 12 Vet. App. 296, 301 (1999) ("Although the veteran is competent to testify to the pain he has experienced since his tour in the Persian Gulf, he is not competent to testify to the fact that what he experienced in service and since service is the same condition he is currently diagnosed with."). Thus, the Veteran's own opinion regarding the etiology of her current condition is not competent medical evidence. As to the issue of causation, the Board finds the opinions of the VA examiner more probative. Accordingly, as the preponderance of the evidence is against the Veteran's claim, the benefit of the doubt rule does not apply. See generally Gilbert v. Derwinski, 1 Vet. App. 49 (1990); Ortiz v. Principi, 274 F. 3d 1361 (Fed. Cir. 2001). The Veteran's claim, is therefore, denied. ORDER Service connection for a bilateral knee disability, to include the left and right knee, is denied. Service connection for a right ankle disability is denied. ____________________________________________ B. MULLINS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs