Citation Nr: 18144044 Decision Date: 10/23/18 Archive Date: 10/22/18 DOCKET NO. 12-41 854A DATE: October 23, 2018 ORDER Entitlement to service connection for a right knee disorder, diagnosed as degenerative joint disease, is granted. FINDING OF FACT The Veteran’s right knee disorder, diagnosed as degenerative joint disease, was at least as likely as not incurred during active service. CONCLUSION OF LAW The criteria for entitlement to service connection a right knee disorder, diagnosed as degenerative joint disease, have been met. 38 U.S.C. §§ 1101, 1110, 1131, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had active service in the United States Air Force from July 1981 to November 1991. This matter comes to the Board of Veterans’ Appeals (Board) on appeal from an August 2011 rating decision. The Veteran testified at a Central Office hearing before the undersigned Veterans Law Judge in October 2018. 1. Entitlement to service connection for a right knee disorder. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). 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. 2009) (quoting Shedden v. Principi, 38 F.3d 1163, 1167 (Fed. Cir. 2004)). The absence of any one element will result in denial of service connection. Service connection may also be granted for any disease initially diagnosed after service when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). In addition, for Veterans who have served 90 days or more of active service during a war period or after December 31, 1946, certain chronic disabilities, including arthritis, are presumed to have been incurred in service if they manifested to a compensable degree within one year of separation from service. 38 U.S.C. §§ 1101, 1112, 1113, 1131, 1137; 38 C.F.R. §§ 3.307, 3.309. For the showing of a chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity and sufficient observation to establish chronicity at the time. If chronicity in service is not established, a showing of continuity of symptoms after discharge is required to support the claim. 38 C.F.R. §§ 3.303(b), 3.309; Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). The Veteran contends that he has a right knee disorder that is related to active service. During the appeal period, the Veteran received a diagnosis of right knee degenerative joint disease. See June 2011 VA Examination. The record also indicates that he underwent a total right knee replacement surgery in March 2013. See February 2017 Authorization to Release Medical Records; October 2014 Private treatment record. The Veteran’s February 1981 enlistment examination reflects that no abnormalities related to the right knee were noted in the clinical evaluation. On July 18, 1984, an STR reported that the Veteran injured his right knee when he fell during a softball game. The assessment was right knee sprain. He was given a profile for 5 days. A July 18, 1984 right knee x-ray request noted that the Veteran injured his right knee while sliding into a base on July 16, 1984. The x-ray report noted that the bones, soft tissues, and joint spaces were normal. The impression was negative. Later on October 10, 1984, an STR noted that the Veteran had a recent history of a right knee injury, and he was there to follow up on his progress since his profile expired on July 23, 1984. On January 21, 1987, the Veteran sought treatment for a right knee abrasion. The impression was infected skin abrasion. Approximately five days later, an STR reported that the infected abrasion had healed. Later in March 1989, STRs reported that the Veteran fell off a bike. He was treated for a right leg laceration on March 20th, and he returned to the emergency room on March 22nd and March 31st for a suture check and removal. A medical care third part liability notification stated that no further care was needed. The Veteran’s lower extremities were marked as normal in the clinical evaluation of the October 1990 separation examination. The earliest available record of post-service treatment for right knee complaints is from May 2007. A private treatment record noted that the Veteran had been complaining of bilateral knee pain for the last couple of months, on the left more than the right. The record noted that he had not had any studies or other significant orthopedic problems in the past. The record did state, however, that the Veteran’s past history was notable for a sprained ligament in his knee while he was offloading an aircraft approximately 15 years ago in 1993. X-rays of the knees yielded an impression of bilateral osteoarthritis of the knees with genu varum. The record noted that he would knee total knee arthroplasties in the future. The Veteran has asserted that after service, he had constant knee pain and excessive limping. See Statement received in December 2011. The Veteran’s concern about these symptoms led him to seek treatment from an orthopedic surgeon in Leesburg, Virginia in January 1992. This doctor diagnosed the Veteran with right knee joint pain, and the Veteran’s treatment plan included antiinflammatory medication, cortisone injections, and instructions to receive continuous treatment as needed. The Veteran indicated that he was now unable to locate this doctor due to the time elapsed since the visit. As a result of his constant knee pain, the Veteran later sought a second opinion from the Commonwealth Orthopedic Practice in May 2007. The orthopedic surgeon at this provider diagnosed bilateral knee osteoarthritis and recommended knee replacement surgery. The Veteran stated that he then obtained another opinion from a different doctor who recommended that he wait to have the surgery performed. In December 2011, the Veteran submitted statements from G.H. and his wife. G.H. explained that he had been the Veteran’s coworker since 1993. From the time he began to work with the Veteran in 1993, G.H. had witnessed the Veteran experiencing knee problems and limping excessively. G.H. indicated that the Veteran previously reported seeing an orthopedic doctor in Leesburg, Virginia. G.H. added that the Veteran had left work on different occasions for his knee appointments, and the Veteran had missed work due to his knee problems. The Veteran’s wife noted that she had been the Veteran’s fiancé at the time of his separation from the Air Force in 1991. The Veteran’s wife also indicated that she knew the Veteran during his active service in the Air Force, stating that they communicated during that period, and she witnessed the injuries he sustained during service. She remembered that the Veteran was always limping, and he would see a doctor to find out what was wrong. In 1992, the Veteran’s wife accompanied him on a visit to an orthopedic doctor in Leesburg, Virginia who diagnosed the Veteran with degenerative arthritis. The Veteran is competent to describe having continuous symptoms of right knee pain after service. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). The Board also finds the Veteran’s reported medical history to be credible as it has been supported by the statements of G.H. and his wife who were able to observe the Veteran’s symptoms after his discharge from service. Although the Veteran’s wife has asserted that the Veteran received a diagnosis for arthritis in 1992, the Board does not find this statement to be probative as it conflicts with the Veteran’s recollection of events. As noted above, the Veteran recalled that he was diagnosed with knee joint pain 1992, and arthritis in 2007. The Board also acknowledges that the May 2007 private treatment record noted that the Veteran sustained a knee injury after service in 1993. However, the record did not state whether the right or left knee was involved in the injury. In addition, the Veteran, his wife, and G.H. have not indicated that there were any post-service right knee injuries. Resolving reasonable doubt in favor of the Veteran, the Board finds his description of continuing right knee pain after service to be credible. Regarding the question of nexus, the record contains two medical opinions. In June 2011, a VA examiner gave a negative nexus opinion after conducting a VA examination. In the examination report, the examiner noted the Veteran’s report that he had been diagnosed with right knee osteoarthritis. The examiner also stated that disorder had existed for 10 years, and it occurred over time. The examiner opined that the Veteran’s current degenerative joint disease of the right knee was less likely than not related to the knee sprain status post playing softball in July 1984. The examiner observed that the record did not show recurrence or chronicity. In addition, there were no further knee complaints until recently. In contrast, a positive opinion was offered by Dr. L. in a November 2011 letter. Dr. L. noted that the Veteran was currently receiving treatment for right knee degenerative joint disease, and he was under her care as an internist. Dr. L. had recently referred the Veteran to an orthopedic surgeon in relation to his degenerative joint disease, and she noted that the Veteran would require a total right knee replacement in the near future. Dr. L. explained that degenerative joint disease is a progressive disorder that develops over a period of 10 to 20 years. She observed that the Veteran reported sustaining several right knee injuries during his active service. She opined that it was very likely that the Veteran’s current right knee disorder was the direct result of the injuries he sustained while in the military. Dr. L. further indicated that she felt strongly that this disorder should be service-connected. In comparing these medical opinions, the Board finds that Dr. L.’s opinion carries the greatest probative weight. The June 2011 VA examiner’s opinion was largely based on the understanding that the Veteran’s right knee complaints after service were a fairly recent development. However, the competent and credible statements that were later received from the Veteran, his wife, and G.H. suggest that his right knee problems have been present since at least 1992. As the examiner was unable to consider these statements before reaching a conclusion, the negative opinion has diminished probative value. The Board finds that Dr. L.’s opinion has significant probative value as the opinion reflects a consideration of the relevant facts from the Veteran’s medical history. Based on the foregoing, the Board finds that the most probative evidence reflects that the Veteran's right knee disorder, diagnosed as degenerative joint disease, is related to his right knee injuries during active service. 38 U.S.C. §§ 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303. GAYLE STROMMEN Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD K.C. Spragins