Citation Nr: 18150242 Decision Date: 11/14/18 Archive Date: 11/14/18 DOCKET NO. 13-26 291 DATE: November 14, 2018 ORDER Entitlement to service connection for a right knee disorder, diagnosed as degenerative osteoarthritis, is granted. REMANDED Entitlement to service connection for a low back disorder, to include sacroiliitis, and as secondary to service-connected right knee degenerative osteoarthritis, is remanded. Entitlement to service connection for a right hip disorder, to include as secondary to service-connected right knee degenerative osteoarthritis, is remanded. FINDING OF FACT The Veteran’s right knee disorder, diagnosed as degenerative osteoarthritis, is at least as likely as not related to active service. CONCLUSION OF LAW The requirements to establish entitlement to service connection for a right knee disorder, diagnosed as degenerative osteoarthritis, have been met. 38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had active service in the United States Army from August 1980 to August 2000. This matter comes to the Board of Veterans’ Appeals (Board) on appeal from rating decisions dated in May 2011 and June 2016. In a July 2017 decision, the Board remanded the Veteran’s service connection claims for fibrocystic breast disease and a right knee disorder. A subsequent September 2018 rating decision granted entitlement to service connection for fibrocystic breast disease. The grant of service connection for this disability constitutes a full award of the benefits sought on appeal. See Grantham v. Brown, 114 F. 3d 1156, 1158 (Fed. Cir. 1997). Thus, that issue is not before the Board. As to the Veteran’s service connection claim for a right knee disorder, the Board finds that the RO substantially complied with prior remand directives, to the extent possible, and no further action in this regard is warranted. See Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (concluding that a remand is not required under Stegall v. West, 11 Vet. App. 268 (1998) where there was substantial compliance with the Board's remand instructions). The record reflects that the June 2016 rating decision separately adjudicated the issues of entitlement to service connection for an unspecified low back condition and entitlement to service connection for sacroiliitis. Given the nature of the Veteran's claims, and in the interest of judicial efficiency, the Board has combined the issues into a single service connection claim for a low back disorder, to include sacroiliitis. 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). Every Veteran is presumed to have been in sound condition upon entry into service except as to defects, infirmities, or disorders noted at the time of such entry. 38 U.S.C. § 1111; 38 C.F.R. § 3.304(b). Only conditions recorded on examination reports are considered "noted" at entry into service. 38 C.F.R. § 3.304(b). In order to rebut the presumption of soundness, it must be shown with clear and unmistakable evidence that a disorder preexisted service and that the disorder was not aggravated by service. Id. 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 she has a right knee disorder that was incurred in active service. The record reflects that she has a current diagnosis of right knee degenerative osteoarthritis. See November 2016 VA examination; February 2018 VA medical opinion. The Veteran has asserted that her current right knee disorder is the result of long road marches and other activities she performed during service to maintain her physical fitness. See December 2013 Statement. The Veteran stated that the required road marches covered a distance of 7 miles and took place once a month for two years during service. During these marches, the Veteran carried a rucksack that weighed 10 to 20 pounds. The Veteran has indicated that she experienced progressively worsening right knee pain since service. See November 2016 VA examination. The Veteran’s service treatment records (STRs) reflect that she did not have any right knee problems at the time of her enlistment into active service. See July 1980 Enlistment Examination and Report of Medical History. The subsequent STRs are silent for any complaints related to the right knee until January 1984, when an STR noted the Veteran’s report of right knee pain that had been present for one day. The Veteran denied any recent injury. The record indicated that the Veteran had injured her knee years ago while playing soccer, and it became swollen at that time. However, there was no history of an operation or any other injury. Her main complaint was fatigue of her knee on road marches and discomfort at night when the barracks became cold. Upon examination, there was no effusion or tenderness, and her ligamentous stability was intact. The assessment was normal knee examination. She was advised to take aspirin on an as needed basis prior to marching. Subsequent service examinations and reports of medical history dated in July 1989 and January 1995 did not document any right knee problems. In February 2000, the Veteran denied having a trick or locked knee in a Report of Medical History completed in anticipation of her retirement. No “yes” or “no” answer was given for the category of arthritis, rheumatism, or bursitis. However, the Veteran’s retirement examination noted that her lower extremities were abnormal upon clinical evaluation. The report noted that the Veteran had a thickened right patellar tendon, and the summary of defects and diagnoses section stated that she had right patellar tendonitis that was mild. Approximately three months after the Veteran’s August 2000 separation from active service, a November 2000 VA examination was conducted in relation to the Veteran’s service connection claim for a right knee disorder. The Veteran reported that she began to experience right knee pain in 1997 and was treated symptomatically for it. The examiner stated that the examination of the Veteran's knee joints was within normal limits. There was no heat, redness, swelling, effusion, drainage; abnormal movement; instability; or weakness. The range of motion was full and without pain. Drawer and McMurray's tests were normal bilaterally. Upon range of motion testing, the knee showed 140 degrees of flexion and 0 degrees of extension. The Veteran’s gait was normal, and there was no limitation of function on standing and walking. In a reference to DeLuca v. Brown, 8 Vet. App. 202 (1995), the examiner stated that the DeLuca issue was negative for the knee joints. Based on November 2000 x-ray results, the diagnosis was right knee degenerative osteoarthritis. Following the examination, the Veteran reported having bilateral knee pain in a December 2004 private treatment record. The Veteran also stated in March 2005 that she intermittently experienced arthritis-related symptoms. The Board notes that the January 1984 STR indicated that the Veteran had a right knee injury prior to service. As no right knee abnormalities were noted in the Veteran's July 1980 enlistment examination, the presumption of soundness applies unless or there is clear and unmistakable evidence that the disability both preexisted and was not aggravated by service. However, the Board does not find that the record contains clear and unmistakable evidence that the Veteran’s right knee disorder preexisted service. The Veteran has indicated that her current right knee problems began during service. The information about the pre-service injury in the January 1984 STR also suggests that it did not require significant treatment, and the Veteran did not have any further complaints until the January 1984 manifestation of pain. Thus, the presumption of soundness has not been rebutted. Regarding the question of whether the Veteran’s current right knee degenerative osteoarthritis was incurred in active service, there are two negative medical opinions of record. In November 2016, a VA examiner based the negative opinion on the lack of objective medical evidence to confirm a diagnosis or treatment for the right knee disorder during service. In February 2018, a VA examiner opined that the Veteran’s current right knee osteoarthritis was not related to the right knee tendonitis that was diagnosed during service. However, the examiner also reported that the Veteran’s current osteoarthritis was related to the osteoarthritis diagnosed in 2000, noting that both diagnoses were based on the November 2000 x-ray. After considering these medical opinions, the Board does not find that they provide much probative value. Both examiners failed to address the Veteran’s reports of continuing right knee symptoms since service. In addition, neither examiner discussed the potential significance of the fact that there was an x-ray finding of right knee osteoarthritis only a few months after the Veteran’s discharge from active service. As noted above, the Veteran has indicated that her current right knee problems began during service in conjunction with the required road marches. The Veteran is competent to report observable events and symptoms. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). This report is also consistent with the details recorded in the January 1984 STR. The Board acknowledges that interim service examinations and reports of medical history were silent for a right knee problem until February 2000; and the Veteran’s current report is different from her statement during the November 2000 VA examination that her knee pain began in 1997. However, the Veteran has been consistent in reporting that her right knee pain began at some point during service. Although the Veteran did not demonstrate objective evidence of pain during range of motion testing in November 2000, the Veteran’s subsequent statements reflect that her continuous symptoms of arthritis have been intermittently present since service. Resolving all benefit of the doubt in favor of the Veteran, the Board finds her reported history of continuous right knee pain since service to be credible. After considering the documentation of right knee symptomatology during service, the close proximity of the post-service diagnosis to service, and the Veteran’s competent and credible reports of continuous right knee symptoms since they began in service, the Board finds that the most probative evidence establishes a nexus between the Veteran’s current right knee degenerative osteoarthritis and service. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. As such, entitlement to service connection for a right knee disorder, diagnosed as degenerative osteoarthritis, is warranted. See 38 C.F.R. § 3.303(a) (service connection must be considered on the basis of the places, types, and circumstances of his service as shown by his service records, the official history of each organization in which he served, his medical records, and all pertinent medical and lay evidence); see also Buchanan v. Nicholson, 451 F.3d 1331, 1335 (“[N]othing in the regulatory or statutory provisions [relating to evidence to be considered] require both medical and competent lay evidence; rather, they make clear that competent lay evidence can be sufficient in and of itself"). REASONS FOR REMAND 1. Entitlement to service connection for a low back disorder, to include sacroiliitis, and as secondary to service-connected right knee degenerative osteoarthritis; and entitlement to service connection for a right hip disorder, to include as secondary to service-connected right knee degenerative osteoarthritis, are remanded. The Veteran has not yet been afforded a VA examination in connection with her service connection claims for a right hip disorder and a low back disorder. In December 2004, a private treatment record indicated that the Veteran has right hip arthritis. The Veteran has also reported persistent symptoms of right hip and low back pain. See April 2016 VA treatment record. The Veteran contends that her claimed right hip and low back disorders are secondary to her right knee disability. The Veteran’s representative has also asserted that these disorders are related to an October 1985 motor vehicle accident that is documented in the STRs. See September 2017 Statement. In light of this evidence, the Board finds that VA examinations and medical opinions must be obtained. See McLendon v. Nicholson, 20 Vet. App. 79 (2006); Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991) (finding that when the medical evidence is insufficient, or, in the opinion of the Board, of doubtful weight or credibility, the Board must supplement the record by seeking an advisory opinion, ordering a medical examination, or citing recognized medical treatises that clearly support its ultimate conclusions). The matters are REMANDED for the following action: 1. The AOJ should request that the Veteran provide the names and addresses of any and all health care providers who have provided treatment for her right hip and low back disorder, to include sacroiliitis. After acquiring this information and obtaining any necessary authorization, the AOJ should obtain and associate these records with the claims file. The AOJ should also secure any outstanding, relevant VA medical records, to include records from the Washington DC VA Medical Center dated since October 2018. 2. After the preceding development in paragraph 1 is completed, schedule the Veteran for a VA examination to determine the nature and etiology of any right hip disorder that may be present. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran's service treatment records, post-service medical records, and assertions. A clear explanation for all opinions based on specific facts of the case as well as relevant medical principles is needed. The Veteran is competent to attest to matters of which she has first-hand knowledge, including observable symptoms. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. First, the examiner should identify all current right hip disorders. For each identified disorder, the examiner should provide an opinion as to the following questions: (a) Whether it is at least as likely as not (a 50 percent or greater probability) that such disorder was incurred in or is otherwise related to active service. In providing an opinion, the examiner should address the following: (1) Veteran’s December 2013 statement asserting that her hip problems were related to the physical activities during service, including the long road marches; and (2) the September 2017 statement from the Veteran’s representative indicating that her right hip disorder was related to an October 1985 motor vehicle accident during active service. (b) Whether it is at least as likely as not (a 50 percent or greater probability) that such disorder was caused or aggravated by the Veteran’s service-connected right knee degenerative osteoarthritis. 3. After the preceding development in paragraph 1 is completed, schedule the Veteran for a VA examination to determine the nature and etiology of any low back disorder, to include sacroiliitis, that may be present. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran's service treatment records, post-service medical records, and assertions. A clear explanation for all opinions based on specific facts of the case as well as relevant medical principles is needed. The Veteran is competent to attest to matters of which she has first-hand knowledge, including observable symptoms. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. First, the examiner should identify all current low back disorders, to include sacroiliitis. For each identified disorder, the examiner should provide an opinion as to the following questions: (a) Whether it is at least as likely as not (a 50 percent or greater probability) that such disorder was incurred in or is otherwise related to active service. In providing an opinion, the examiner should address the following: (1) the September 2017 statement from the Veteran’s representative indicating that her right hip disorder was related to an October 1985 motor vehicle accident during active service; and (2) the April 15, 2003 treatment record from the Woodbridge Family Health Clinic (FHC) noting the Veteran’s report of having a motor vehicle accident the previous Saturday that involved her being struck from behind. The assessment was low back pain/neck sprain status post motor vehicle accident. (b) Whether it is at least as likely as not (a 50 percent or greater probability) that such disorder was caused or aggravated by the Veteran’s service-connected right knee degenerative osteoarthritis. GAYLE STROMMEN Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD K.C. Spragins, Associate Counsel