Citation Nr: 18147591 Decision Date: 11/05/18 Archive Date: 11/05/18 DOCKET NO. 11-15 006 DATE: November 5, 2018 ORDER Service connection for a left knee disability is granted. Service connection for a bladder disability is denied. FINDINGS OF FACT 1. The Veteran’s degenerative joint disease (DJD) of the left knee is related to service. 2. The Veteran’s bladder disability is not attributable to service, was not caused or aggravated by his service-connected lumbar spine disability, and calculi of the bladder was not manifest within one year of separation from service. CONCLUSIONS OF LAW 1. The criteria for service connection for DJD of the left knee have been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304. 2. The criteria for entitlement to service connection for a bladder disability have not been met. 38 U.S.C. §§ 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from January 1981 to April 1981, and November 1981 to July 1984 in the United States Army, with additional service in the National Guard. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a July 2011 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). In December 2010, the Veteran testified before a decision review officer (DRO), and in April 2015, he testified before the undersigned Veterans Law Judge (VLJ). Transcripts of these hearings have been associated with the claims file and reviewed by the Board. In July 2015, the Board remanded the above claims for further development. Also in July 2015, the Board remanded claims for service connection for a cervical spine disability and headaches. In July 2018, the RO granted service connection for these claims. They are no longer in appellate status and will not be addressed below. Service Connection Service connection may be established for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. Regulations also provide that service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. § 3.303(d). Generally, in order to show a service connection, there must be competent, credible evidence of (1) a current disability, (2) in-service incurrence or aggravation of an injury or disease, and (3) a nexus, or link, between the current disability and the in-service disease or injury. See, e.g., Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Pond v. West, 12 Vet. App. 341 (1999). Active military, naval, or air service includes any period of active duty for training (ACDUTRA) during which the individual concerned was disabled from a disease or injury incurred in or aggravated in the line of duty, or any period of inactive duty for training (INACDUTRA) during which the individual concerned was disabled from an injury, but not also disease, incurred in or aggravated in the line of duty, or when a cardiac arrest or cerebrovascular accident occurs during such training. 38 U.S.C. §§ 101(21), (24), 106; 38 C.F.R. § 3.6(a), (d). Service connection is also warranted for a disability which is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Such secondary service connection is additionally warranted for any increase in severity of a nonservice-connected disability that is proximately due to or the result of a service-connected disability. 38 C.F.R. § 3.310(b). Left Knee Disability The Veteran has current DJD of the left knee, documented on VA examination in March 2018. He reports that he injured his left knee in a 1986 parachuting accident. His service treatment records (STRs) and personnel records corroborate his report, and show that in January 1986, while on INACDUTRA, he fractured his lumbar spine during a parachute landing. He was evacuated on a backboard, and received emergency treatment. STRs surrounding the accident show that he reported pain and numbness in the left knee and leg. Following the accident, he was placed on physical profile that included no running, jumping, marching, stooping, standing for longer than 30 minutes, or lifting more than 10 pounds, for three months. Later in 1986, he underwent an arthroscopy to the bilateral knees. In May 1990, he was again placed on physical profile due to chronic knee and other pain. In 1995, he was prescribed Valium for ongoing left knee pain. In a December 1998 STR, he was noted to have arthritis in the knees. In a May 1999 Medical Board Consultation, it was noted he had undergone a second left knee arthroscopy in 1990, and had a partial meniscectomy performed at that time. He was noted to have chronic bilateral knee pain. Based on the January 1986 parachuting accident, VA awarded service connection for a lumbar spine disability in a March 2001 rating decision, and a cervical spine disability in a July 2018 rating decision. These records show that the Veteran was involved in a serious accident in January 1986. While a specific left knee diagnosis was not rendered at the time, the STRs document his reports of left knee pain which persisted for years following the accident and required multiple surgical treatments. VA has already determined that injuries from the accident were sustained in the line of duty while in INACDUTRA status. The Board thus finds the matter of an in-service left knee injury is established. In April 2009 and December 2010 private medical reports, Dr. B. noted STRs documenting left knee pain, including from 1999 and 2000. His report reflects that he believed service connection was already in effect for the left knee disability. However, in assessing the severity of the knee disability, he stated that the current knee problems were exactly the type of pathology he would expect status-post arthroscopy, as the menisci is often removed and this leads to advanced degenerative arthritis. Given the Veteran’s 1986 post-injury arthroscopy, Dr. B.’s opinion thus supports a link between the current DJD and the 1986 injury. On VA examination in May 2011, the examiner summarized the 1986 parachuting accident and the residual injuries, which included a compression fracture of the lumbar spine, chronic low back pain, and bilateral knee pain. She noted the Veteran had undergone arthroscopic procedures to the knees. The report focused on the matter of secondary service connection, and the examiner provided a negative opinion on in this regard. In doing so, however, she explained, “the veteran’s current left knee condition represents the progression of his prior left knee injury which resulted in the left knee partial meniscectomy and arthroscopy in 1990.” In making this statement, she attributed the current left knee disability to the 1986 left knee injury sustained in the parachuting accident. In considering the evidence under the laws and regulations as set forth above, and resolving all reasonable doubt in his favor, the Board concludes that the Veteran is entitled to service connection for his left knee DJD as directly related to service. The above evidence constitutes the entirety of the evidence on direct service connection. There is no evidence to the contrary; rather, the remaining medical opinions from May 2011 and March 2018 pertain to secondary service connection. The Court has cautioned VA against seeking a medical opinion where favorable evidence in the record is unrefuted. See Mariano v. Principi, 17 Vet. App. 305, 312 (2003). While the claim could be remanded for a more elaborate rationale, the Board finds the above opinions are adequate and a remand is avoidable. The 2011 examiner performed a clinical examination of the Veteran, and both physicians based their conclusions on an examination of the in-service and post-service medical records, including diagnostic reports. See Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007). As the evidence is at least in equipoise in showing that the Veteran has left knee DJD attributable to service, and resolving all doubt in his favor, the Board finds that service connection is warranted. Bladder Disability The Veteran has current urinary frequency and nocturia, documented on VA examinations in May 2011. Service treatment records do not document any complaints, diagnoses, or treatment pertaining to a bladder or urinary disability, to include in connection with the January 1986 accident. No abnormalities pertaining to the urinary system were documented on his May 1999 Medical Board Consultation, or in the March 2000 Physical Evaluation Board Report on discharge. In the private April 2009 and December 2010 reports, Dr. B. noted that the Veteran has frequent urination and small urination volumes, which suggest a neurogenic bladder secondary to lumbar or cervical spine disease. On VA examination in May 2011, the examiner opined that the current urinary frequency and nocturia were less likely than not caused by or a result of the lumbar spine injury in service because the Veteran’s spinal cord was not damaged in the accident. The examiner also opined that current urinary disability was less likely than not related to the lumbar scar, as the urinary symptoms preceded the scar. In April 2015, Dr. J. recounted the January 1986 parachuting injury. He noted that the Veteran has had urinary symptoms since that time. He opined that low-level involvement and neural irritation of the sympathetics and parasympathetics of the bladder can be traumatized and would not show up on an MRI scan. He stated that patients do not have to sustain spinal cord compression to have bladder symptoms following a trauma. On VA examination in March 2018, the examiner noted no evidence of bladder dysfunction during service or in the immediate years following service. She noted the Veteran’s reports of bladder symptoms since the 1986 parachuting accident. However, she noted that nocturia was not documented until 2014, and is a common condition related to aging. She opined that Dr. J’s statements were not supported by medical literature, and were not consistent with the known anatomy of the urinary system. Bladder problems related to spinal injuries occur when there is a cauda equina injury or a spinal cord injury, neither of which occurred in the Veteran’s accident. His spinal injury did not involve the middle or posterior columns of the spinal column, and the injury did not occur in a location that would be consistent with damage to the sacral nerve roots implicated in urinary dysfunction. His injury was not consistent with the type of injury that could cause residual neurological impairment resulting in a neurogenic bladder. Rather, the examiner found the current bladder problems attributable to his peripheral neuropathy and ataxia, as well as his prescription medications including opioids and valium. She concluded that it was less likely than not that the current bladder disability is related to or aggravated by his back, neck, or events in service. Considering the pertinent evidence in light of the governing legal authority, the Board finds that the preponderance of the evidence is against the claim. The probative evidence does not show that the Veteran’s bladder disability is related to his active military service, including to his January 1986 accident. The disability was not found in service or within one year of separation from service. Moreover, there were no pertinent complaints or findings on discharge. The fact that he sought treatment for other conditions after service, but not a bladder disability, weighs against the credibility of any statements that the disorders persisted since discharge. See AZ v. Shinseki, 731 F.3d 1303 (Fed. Cir. 2013). The medical opinion evidence is also persuasive. The March 2018 VA examiner addressed the contentions of direct service connection, but opined that the Veteran’s disorders were not related to military service. She examiner further addressed the matter of secondary service connection, but opined that the bladder disability was not caused or aggravated by the service-connected spine disabilities. Other etiologies, including non-service connected medical conditions and the side effects of prescribed medications, were identified. The examiner based her conclusions on an examination of the veteran and a review of the claims file, including post-service treatment records and diagnostic reports. She reviewed the reported history and symptoms in rendering the opinions, and provided a rationale for the conclusions reached. By contrast, the opinion of Dr. J. that the bladder “can” be traumatized without spinal cord compression is of diminished persuasive value to the extent it is speculative. Tirpak v. Derwinski, 2 Vet. App. 609 (1992) (medical evidence which merely indicates that the alleged disorder "may or may not" exist or "may or may not" be related, is too speculative to establish the presence of a claimed disorder or any such relationship). Moreover, it is outweighed by the opinion of the 2018 VA examiner who indicated it is not supported by medical literature, the anatomy of the urinary system, or the Veteran’s particular injuries. Similarly, the opinion of Dr. B. is of diminished persuasive value as it is not supported by any rationale. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (finding most of the probative value of a medical opinion comes from its reasoning.) The only evidence to the contrary of the VA examination reports is the lay evidence. The Board finds that the Veteran does not have the requisite medical knowledge, training, or experience to be able to render a competent medical opinion regarding the cause of the medically complex disorders of his bladder. See, e.g., Kahana v. Shinseki, 24 Vet. App. 428, 437 (2011). His bladder disability is medically complex because of its multiple etiologies and the fact that it can manifest symptomatology that overlaps with other disorders. The etiology of the Veteran’s current disability is a complex medical etiological question involving internal and unseen system processes, some of which are unobservable by the Veteran. The Board has considered the applicability of the benefit of the doubt doctrine, but as the preponderance of the evidence is against the Veteran's claim, that doctrine is not applicable to the claim. M. Tenner Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD J. Smith, Counsel