Citation Nr: 18146990 Decision Date: 11/05/18 Archive Date: 11/02/18 DOCKET NO. 16-19 413 DATE: November 5, 2018 ORDER Entitlement to service connection for a left knee disability is denied. Entitlement to service connection for residuals of a hysterectomy is denied. Entitlement to service connection for a surgical scar, residuals of a hysterectomy is denied. REMANDED Entitlement to a rating in excess of 10 percent for sinusitis is remanded. FINDINGS OF FACT 1. A left knee disability, diagnosed as diagnosed as degenerative arthritis, did not manifest in service and is not attributable to service, and did not manifest to a compensable degree within one year of separation from service. 2. There is no objective medical evidence that the Veteran had a hysterectomy during service or a surgical scar resulting from a hysterectomy. CONCLUSIONS OF LAW 1. The criteria for service connection for a left knee disability, diagnosed as degenerative arthritis, have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1131, 1137; 38 C.F.R. §§ 3.303, 3.306, 3.307, 3.309. 2. The criteria for service connection for residuals of a hysterectomy have not been met. 38 U.S.C. §§ 101, 105(a), 1110, 1131; 38 C.F.R. § 3.303. 3. The criteria for service connection for a surgical scar, residuals of a hysterectomy, have not been met. 38 U.S.C. §§ 101, 105(a), 1110, 1131; 38 C.F.R. § 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active naval service from May 1990 to August 1997. These matters come before the Board of Veterans’ Appeals (Board) on appeal from a February 2013 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. Service Connection Service connection will be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 1153; 38 C.F.R. §§ 3.303, 3.304, 3.306. In addition, arthritis will be presumed to have been incurred in or aggravated by service if it had become manifest to a degree of 10 percent or more within one year of a veteran’s separation from service. 38 U.S.C. §§ 1101, 1110, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. With chronic diseases shows as such in service or within the presumptive period so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. This rule does not mean that any manifestation of joint pain, any abnormality of heart action or heart sounds, any urinary findings of casts, or any cough, in service will permit service connection of arthritis, disease of the heart, nephritis, or pulmonary disease, first shown as a clear-cut clinical entity, at some later date. Continuity of symptomatology is required only where the condition noted during service or the presumptive period is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. When the fact of chronicity in service is not adequately supported, then a showing of continuity after service is required to support the claim. 38 C.F.R. § 3.303(b). This regulation pertains to “chronic diseases” enumerated in 38 C.F.R. § 3.309(a) (listing named chronic diseases). Walker v. Shinseki, 708 F.3d 1331, 1336-37 (Fed. Cir. 2013). The United States Court of Appeals for the Federal Circuit (Federal Circuit) noted that the requirement of showing a continuity of symptomatology after service is a “second route by which a veteran can establish service connection for a chronic disease” under subsection 3.303(b). Walker, supra. Showing a continuity of symptoms after service itself “establishes the link, or nexus” to service and also “confirm[s] the existence of the chronic disease while in service or [during the] presumptive period.” Id. (holding that section 3.303(b) provides an “alternative path to satisfaction of the standard three-element test for entitlement to disability compensation”). Service connection may also be granted for any 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). Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Medical evidence is not always or categorically required when the determinative issue involves either medical diagnosis or etiology, but rather such issue may, depending on the facts of the particular case, be established by competent and credible lay evidence under 38 U.S.C. § 1154(a). See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). Reasonable doubt concerning any matter material to the determination is resolved in the Veteran’s favor. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. Left Knee Disability The Veteran has contended that her left knee disability is related to her active service. Service treatment records (STRs) documented that the Veteran complained of left knee pain and was diagnosed with patellofemoral syndrome shortly after she entered service, in June 1990. However, the Veteran’s STRs are silent for any additional complaints of, treatment for, or diagnosis of a left knee disability over the next seven years. Moreover, the Veteran’s June 1997 separation examination did not reflect a left knee disease or injury. A review of post-service treatment records indicated that the Veteran received left knee injections. The Veteran was also afforded a VA examination in December 2011. The examiner opined that the Veteran’s left knee disability (diagnosed as degenerative arthritis) was less likely as not incurred in or caused by service. The examiner stated that the Veteran complained of mild anterior knee pain that was diagnosed as patellofemoral syndrome during service. The examiner noted that it was an overuse syndrome and that it was not a recurrent complaint. The examiner stated that the Veteran had degenerative arthritis in her left knee which was more likely related to the Veteran’s varus mechanical malalignment than service. In determining the probative value to be assigned to a medical opinion, the Board must consider three factors: whether a medical expert was fully informed of the pertinent factual premises (i.e., medical history) of the case; whether the medical expert provided a fully articulated opinion; and whether the opinion is supported by a reasoned analysis. The most probative value of a medical opinion comes from its reasoning. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Therefore, a medical opinion containing only data and conclusions is not entitled to any weight. In fact, a review of the s file does not substitute for a lack of a reasoned analysis. See Nieves-Rodriguez; see also Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) (“[A] medical opinion... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions.”). In this case, the examiner was aware of the Veteran’s medical history, provided a fully articulated opinion, and also furnished a reasoned analysis. The Board therefore attaches significant probative value to this opinion, and the most probative value in this case, as it is well reasoned, detailed, consistent with other evidence of record, and included an access to the accurate background of the Veteran. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000) (Factors for assessing the probative value of a medical opinion include the thoroughness and detail of the opinion). The Board acknowledges the lay assertions of record, including the Veteran’s sincere belief that her left knee disability is related to service. However, the Veteran’s opinion is not as competent as the medical opinion whether her left knee disability is related to service, as this particular inquiry is within the province of trained medical professionals; it goes beyond a simple and immediately observable cause-and-effect relationship. See Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011); Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). Accordingly, the Board finds that the preponderance of the evidence is against the claim and entitlement to service connection for a left knee disability is not warranted. 38 U.S.C. § 5107(b) (2012); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 1. Residuals of a Hysterectomy and Surgical Scar The Veteran has asserted that she had a hysterectomy and the residuals, to include a surgical scar, are related to her active service, including an in-service bilateral salpingo-oophorectomy performed in May 1996. The STRs are silent for any in-service complaints of, treatment for, or diagnosis of a hysterectomy. However, the STRs documented that the Veteran had been diagnosed with Turner’s syndrome at the age of 16. In June 1996, following a bilateral salpingo-oophorectomy to decrease her risk for gonadoblastoma, the Veteran’s uterus was noted to be small, mobile, and nontender. A review of post-service treatment records did not reflect that the Veteran had undergone a hysterectomy. The Veteran was afforded a VA examination in November 2011. The examiner noted that the Veteran had not undergone a hysterectomy. The examiner indicated that the Veteran was status post bilateral oophorectomy and had an associated abdominal scar. She opined that the Veteran’s Turner’s syndrome was a genetic condition that was not aggravated by service. The examiner stated that an oophorectomy was performed as a preventive measure against ovarian cancer. Therefore, the examiner opined that the Veteran’s surgical scar was not aggravated by service. The United States Court of Appeals for Veterans Claims (Court) has held that “Congress specifically limits entitlement for service-connected disease or injury to cases where such incidents have resulted in a disability. In the absence of proof of a present disability there can be no valid claim.” Brammer v. Brown, 3 Vet. App. 223, 225 (1992); see also Rabideau v. Derwinski, 2 Vet. App. 141, 143-44 (1992). Here, competent medical evidence indicates that the Veteran does not have the disabilities for which service connection is sought as she did not undergo a hysterectomy and thus also does not have a scar from that procedure. Accordingly, the Veteran cannot establish service connection for residuals of a hysterectomy or a surgical scar resulting from a hysterectomy. REASONS FOR REMAND The Board finds that additional development is required before the remaining claim on appeal is decided. The Veteran was last afforded a VA examination in November 2011 for her service-connected sinusitis. In a May 2018 Appellate Brief, the Veteran indicated that the severity of her service-connected sinusitis had increased since that time. Therefore, the Board finds that the Veteran should be provided new VA examinations to determine the current level of severity of all impairment resulting from her sinusitis. The matter is REMANDED for the following action: 1. Identify and obtain any pertinent, outstanding VA and private treatment records and associate them with the claims file. 2. Then, schedule the Veteran for a VA examination to determine the current level of severity of all impairment resulting from her service-connected sinusitis. The claims file must be made available to, and reviewed by the examiner. Any indicated studies must be performed. The examiner should provide all information required for rating purposes. 3. Confirm that the VA examination report and all medical opinions provided comport with this remand and undertake any other development determined to be warranted. 4. 5. Then, readjudicate the appeal. If the decision remains adverse to the Veteran, issue a supplemental statement of the case and allow the appropriate time for response. Then, return the case to the Board. J. CONNOLLY Acting Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD D. Ware, Associate Counsel