Citation Nr: 18154760 Decision Date: 12/03/18 Archive Date: 11/30/18 DOCKET NO. 16-42 470 DATE: December 3, 2018 ORDER Service connection for bilateral knee condition is denied. FINDING OF FACT The preponderance of the evidence is against finding that the Veteran’s bilateral knee condition began during active service, or is otherwise related to an in-service injury, event, or disease. CONCLUSION OF LAW The criteria for service connection for a bilateral knee condition are not met. 38 U.S.C. §§ 1110, 1111, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from August 1998 to May 2005. The Board notes that during the pendency of this appeal, the Veteran has appointed a new representative in this case. The new representative is identified on the cover page of this decision. The Veteran’s representative on her behalf, has requested that this case be advanced on the docket (AOD) due to financial hardship. See 38 U.S.C. 7107(a)(2); 38 C.F R. 20.900(c). Appeals must be considered in docket number order, but may be advanced if sufficient cause, including severe financial hardship, is shown). In this case, the Veteran’s representative has submitted evidence demonstrating severe financial hardship and, accordingly, the appeal will be advanced on the docket. Service Connection Generally, to establish service connection, a claimant must show: (1) a present disability; (2) an 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. See 38 U.S.C. §§ 1110; 38 C.F.R. § 3.303; see also Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Certain chronic diseases will be presumed related to service if they were noted as chronic in service; or, if they manifested to a compensable degree within a presumptive period following separation from service; or, if continuity of the same symptomatology has existed since service, with no intervening cause. 38 U.S.C. §§ 1101, 1112, 1137; 38 C.F.R. §§ 3.303(b), 3.307, 3.309(a); Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2012). Bilateral knee Condition The Veteran is seeking service connection for a bilateral knee condition. She contends that her bilateral knee condition was due to her military service. Specifically, she contends that her bilateral knee condition is due to running 8-10 miles a week and completing a 12 mile march each year during service. She asserts that she experienced knee pain in service. The Board notes that the Veteran is not currently service connected for an ankle, thigh or hamstring condition, and as such secondary service connection is not available based on a contention that those in-service problems caused knee disabilities. The question for the Board is whether the Veteran has a current disability in either knee that either began during service or is at least as likely as not related to an in-service injury, event, or disease. The Board concludes that, while the Veteran has a diagnosis of a bilateral knee condition, specifically, patellofemoral pain syndrome, the preponderance of the evidence is against finding that it began during active service, or is otherwise related to an in-service injury, event, or disease. Service treatment records do not document any complaints, treatments or concern for a bilateral knee condition. However, the records show that the Veteran sought treatment for ankle, thigh and hamstring problems during service. Of note, a March 2004 general medical examination found the appearance of the knees to be normal, and noted that there was no pain on range of motion and no tenderness on palpation. The Veteran’s reports of when her knee problems onset has varied greatly through the course of her appeal. She has asserted injuring one knee in service, but also reported injuring both knees in the same incident. She has also reported that her knee pain had begun in service and progressively worsened, but she has also asserted that her knee problems began years after service. While the Veteran has reported being treated for knee problems while being deployed, there is no record of such. In fact, a service treatment record from March 2004, while she was deployed, found no knee problems, to include knee pain, on physical examination. The Veteran also reports the date of onset for her left knee condition is 2011, which is at least 6 years after her separation from service. In one statement, the Veteran reported that she did not seek treatment for her right knee condition until 2010, which is 5 years after separation from service. However, in a June 2017 statement in support of the claim, the Veteran stated that her knee condition had finally come to a head in 2015. In her notice of disagreement in 2015, the Veteran wrote that she had knee pain that had started “roughly two years” earlier, which would be years after service. While the Veteran is competent to report having experienced symptoms of knee pain intermittently since service, her reports are largely not credible due to internal inconsistency and inconsistency with other evidence in the record. For example, the Veteran’s representative stated on behalf of the Veteran’s that her bilateral knee condition occurred during combat, but the Veteran provided several statements asserting that the claimed knee condition was due to strenuous exercise during service. In addition, the Veteran submitted conflicting dates as to when she sought treatment. Buchanan v. Nicholson, 451 F.3d 1331, 1336-37 (Fed. Cir. 2006). Moreover, she is not competent to provide a diagnosis in this case or determine that these symptoms were manifestations of a bilateral knee disability. The issue is medically complex, as it requires knowledge of interpretation of complicated diagnostic medical testing. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). The record contains conflicting medical opinions regarding whether the Veteran’s bilateral knee condition is at least as likely as not related to an in-service injury, event, or disease. The May 2015 VA examiner opined that it was less likely than not that the Veteran’s knee disabilities were the result of military service. The rationale was primarily based on the review of provided medical records and examination. The examiner noted that ankle sprains, which are documented in the Veteran’s service treatment records, are usually self-limiting. However, the examiner explained that the Veteran was able (by her own report) to continue running 5-10 miles per week, participate in Ruck marches quarterly, and completed deployment. The examiner noted that the Veteran did report one visit to the Medic while deployed for right knee pain but unfortunately, there are no records of this. The examiner also considered the Veteran’s other bilateral lower extremity complaints and diagnosis during service, including a left hamstring strain that occurred November 1988; left ankle sprain that occurred June 1999; right ankle sprain that occurred September 2002; left thigh numbness that occurred March 2004; left hamstring strain that occurred February 2005; and/or unreported pain that occurred prior to release from active duty. The examiner then concluded that based on the lack of medical evidence regarding the Veteran’s left and or right knee conditions, the Veteran’s patellofemoral pain syndrome bilateral knee condition is less likely than not incurred in service or otherwise caused by left hamstring strain, left ankle sprain, right ankle sprain; left thigh numbness; left hamstring strain; and/or unreported pain that occurred prior to release from active duty. The VA examiner’s opinion is probative, because it is based on an accurate medical history and provides an explanation that contains clear conclusions and supporting data. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). In March 2017, private practitioner Mary Lisa Borgstadt RN, submitted a one-page medical statement in which she stated that the Veteran had chronic knee pain due to strenuous running, core exercises, jumping and marching during service. This opinion is, however, less probative than the VA examiner’s opinion. There is no indication that Mary Lisa Borgstadt RN physically examined the Veteran or reviewed pertinent medical evidence in the claims file. Instead, the opinion appears to be based on the Veteran’s self-reported unsubstantiated medical history, which is inconsistent with VA and private treatment records that show that the Veteran was not diagnosed with a bilateral knee condition until years after her separation from service. Reonal v. Brown, 5 Vet. App. 458, 460-61 (1993). Given the reliance on an inaccurate factual premise, the opinion is afforded no probative value. Given this determination, the opinion of the 2015 VA examiner is found to be the most probative opinion and is afforded the most weight. The Board notes that a VA June 2017 treatment note and a 2015 private physical therapy report, reiterates the Veteran’s self-reported medical history, including her report of strenuous in-service exercise as the cause of her bilateral knee condition. The treatment notes do not include a medical opinion from either medical professional. While the Veteran believes her bilateral knee, condition is related to an in-service injury, other lower extremities injuries, she is not competent to provide a nexus opinion in this case. This issue is also medically complex, as it requires knowledge of the interpretation of complicated diagnostic medical testing. Jandreau v. Nicholson, 492 F.3d at 1377 (Fed. Cir. 2007). Consequently, the Board gives more probative weight to the 2015 VA medical opinion. Certain chronic diseases will be presumed related to service if they were noted as chronic in service; or, if they manifested to a compensable degree within a presumptive period following separation from service; or, if continuity of the same symptomatology has existed since service, with no intervening cause. Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2012). Here, there is no x-ray evidence of bilateral knee arthritis manifesting to a compensable degree within one year of the Veteran’s release from active duty to warrant service connection based on presumption. As described, the criteria for service connection have not been met, and the Veteran’s claim is denied. MATTHEW W. BLACKWELDER Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD M. Franklin, Associate Counsel