Citation Nr: 18158809 Decision Date: 12/18/18 Archive Date: 12/17/18 DOCKET NO. 18-02 905 DATE: December 18, 2018 ORDER Entitlement to service connection for a left knee disability is denied. Entitlement to service connection for a right knee disability is denied. Entitlement to service connection for pseudofolliculitis barbae (PFB) is granted. REMANDED Entitlement to service connection for a left-hand disability is remanded. Entitlement to service connection for a left ankle disability is remanded. Entitlement to service connection for a right ankle disability is remanded. FINDINGS OF FACT 1. The weight of the evidence is against a finding that that the Veteran’s left knee disability had its onset in service or is otherwise related to active military service. 2. The weight of the evidence is against a finding that the Veteran’s right knee disability had its onset in service or is otherwise related to active military service. 3. The evidence of record is at least in equipoise as to whether PFB is related to the Veteran’s active service. CONCLUSIONS OF LAW 1. The criteria for service connection for a left knee disability have not been met. 38 U.S.C. § 1131; 38 C.F.R. § 3.303. 2. The criteria for service connection for a right knee disability have not been met. 38 U.S.C. § 1131; 38 C.F.R. § 3.303. 3. The criteria to establish service connection for PFB have been met. 38 U.S.C. §§ 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active military service from September 1981 to August 1985. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a September 2016 decision. Service Connection Service connection may be granted for a disability resulting from a disease or injury incurred or aggravated in active military service. 38 U.S.C. §§ 1131, 1131; 38 C.F.R. § 3.303 (a). 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). Generally, establishing service connection requires (1) evidence of a current disability; (2) medical, or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the current disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107 (b). 1. Entitlement to service connection for a left knee and a right knee disability is denied. The Veteran contends that he has left and right knee disabilities that are related to active military service. In assessing the Veteran’s service connection claims for a left knee and a right knee disability, the evidence of record must show a current diagnosis of the claimed disability. An August 2016 VA disability benefits questionnaire (DBQ) reveals a current diagnosis of degenerative arthritis in both knees. The service treatment records (STR) reveal that the Veteran sought treatment for both of his knees during active service. In a June 1984 STR, the physician noted that the Veteran had a mild left knee strain after twisting the knee while playing basketball the previous evening. The physician also noted that there was no swelling or point tenderness and that the Veteran’s left knee had a full range of motion. In an August 1984 STR, the Veteran sought treatment for his left knee. The physician noted that the knee was normal at the time of examination except for slight ligament weakness. A November 1984 STR documented the Veteran’s complaint of pain in both knees. The Veteran had described that his pain began while playing basketball but that there was no pain at the time of treatment and that the pain was not constant. VA treatment records are silent for complaints of knee pain in either knee. During a February 2016 VA history and physical medical check-up, the Veteran denied any joint pain or swelling. In a January 2018 statement in support of his claim, the Veteran reported that both of his knees stiffen up and cause him pain and that they have continued to do so since his injury during active service. With respect to whether the Veteran’s current left knee and right knee disabilities are related to active service, the claims file contains a negative medical opinion for each knee. For the Veteran’s left and right knee each, the examiner opined that the Veteran’s degenerative arthritis was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. In separate opinions, the examiner reasoned that for both of the Veteran’s knees, there is no record of a significant knee injury during service and that the symmetrical nature of the current x-ray findings did not suggest that an acute injury to either knee is the cause of degenerative arthritis in either knee. The Board acknowledges the Veteran’s belief that his current right knee and left knee disabilities are related to his active military service. Lay persons can provide an account of observable symptoms, such as pain in service with a continuity of symptomatology since service. See Jandreau, 492 F.3d at 1377. However, lay assertions regarding certain medical matters, such as an opinion whether his right and left knee arthritis are related to active military service, fall outside the realm of common knowledge of a lay person. See Kahana v. Shinseki, 24 Vet. App. 428 (2011). The Veteran is not a trained health care professional; therefore, the lay evidence offered by him is not competent medical evidence and has no probative value as to the question of a relationship between the Veteran’s current right knee and left knee disability and active military service. Based on the foregoing, the weight of the evidence is against a finding that the Veteran’s current right knee and left knee disabilities had their onset in or are otherwise related to active military service. Accordingly, the Veteran’s service connection claims for a right knee and a left knee disability are denied. 2. Entitlement to service connection for pseudofolliculitis barbae The Veteran contends that his PFB is related to his military service. The Board concludes that, resolving all reasonable doubt in the Veteran’s favor, he has a current diagnosis of PFB that began during active duty service, continued throughout active service, and has persisted since service. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303 (a). A review of service treatment records shows that the Veteran was treated on numerous occasions for PFB beginning in March 1982. The Veteran underwent several supervised, mandatory trainings at a hospital’s PFB clinics lasting from four to eight weeks each time. During those trainings at PFB clinics, the Veteran was provided a waiver to keep a neat stubble. In a February 1985 STR, the Veteran was again instructed to not shave the skin with a conventional razor. In an August 2016 DBQ, the examiner diagnosed the Veteran with PFB. The examiner documented the Veteran’s report that PFB began in 1981 with shaving bumps on the superior lip and on the right and left neck line whenever he has used the razor. The examiner opined that the Veteran’s PFB was less likely than not incurred in or caused by his military service. The examiner reasoned that there was no evidence of continuation of PFB and that PFB is a reversible condition caused by shaving too closely among people who are predisposed to PFB. The examiner also reasoned that PFB generally resolves after shaving is ceased. In a January 2018 statement, the Veteran reported that he has had PFB since his military service. The Veteran also stated that he has been unable to use a conventional razor to shave and has not been able to clean shave since his PFB diagnosis during service. He noted that if he were to shave a week prior to his August 2016 examination, then his skin would have had several swollen bumps. The Veteran stated that his PFB has not gone away but has been managed since service due to his grooming habits of not shaving with a conventional razor. Following a review of the lay and medical evidence, the Board finds the evidence is at least in relative equipoise regarding whether the Veteran’s current diagnosis of PFB is related to service. Though the VA examiner found that Veteran’s PFB (and generally all PFB) resolves after shaving, the Veteran stated he continues to have symptoms from PFB and is unable to use a conventional razor without experiencing bumps and skin defects. As a layperson, the Veteran is competent to report that he has personally observed bumps and experienced irritation after shaving. Further, service treatment records establish the Veteran was treated for PFB throughout service. Resolving all reasonable doubt in the Veteran’s favor, the Board concludes that service connection for PFB has been established. 38 U.S.C. §5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). REASONS FOR REMAND 1. Entitlement to service connection for a left-hand disability is remanded. Several VA treatment records document the Veteran’s complaints of continued pain in his left hand. In a January 2018 statement, the Veteran stated that he injured his hand in service. A May 1984 STR reveals that the Veteran was treated for a puncture wound in his left hand after suffering an injury during a parachute jump. The Veteran has not been afforded a VA examination in connection with this claim. Accordingly, the Board finds a remand is necessary to ascertain the nature and etiology of the Veteran’s left-hand disability. See McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006). 2. Entitlement to service connection for left ankle and right ankle disabilities is remanded. With regard to both ankles, the examination report shows diagnoses of retrocalcaneal heel spur of the left ankle and anterior talofibular ligament sprain of the right ankle. The VA examiner opined that the Veteran’s current ankle disabilities are less likely than not related to service. In support of this conclusion for the right ankle disability, the examiner reasoned that there is insufficient evidence to suggest that the diagnosed right ankle anterior talofibular ligament sprain is related to service because no right ankle complaints are cited during military service. In support of his negative opinion for the left ankle, the examiner opined that the twisting injury that the Veteran sustained in service is not considered a risk factor for development of a heel spur. The August 2016 VA opinions do not show adequate consideration of the Veteran’s history of ankle injuries and treatment in service (to include the nature of these injuries) and the extent to which these injuries contributed to the development of the currently diagnosed disabilities. In addition, the opinions do not show adequate consideration of the Veteran’s reported history of symptoms and self-treatment since service. For instance, an October 1982 STR reveals that the Veteran had a swollen right ankle that had previously been swollen for nights prior the treatment record. Therefore, the examiner’s reasoning for his right ankle disability is based on an inaccurate factual premise that there were no documented right ankle complaints in service. As for the left ankle, the September 1984 STR confirms that the Veteran suffered a left ankle twist, however, the examiner did not consider the subsequent STRs, such as in April 1985, where the Veteran complained of recurrent left ankle pain. In the same April 1985 STR, the physician noted that the Veteran had residual left ankle weakness following a sprain. Therefore, the April 1985 STR indicates that the Veteran had a more severe injury than a twisting injury that resolved quickly as indicated by the August 2016 examiner. The Board notes that the August 2016 VA opinions lack a clear medical rationale and seem to rely excessively on the absence of documented treatment or diagnosis to rule out a causal relationship between the currently diagnosed disabilities and events in service. For these reasons, adequate opinions are not of record. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120 (2007). On remand, VA should obtain addendum opinions that address whether the Veteran’s currently diagnosed ankle disabilities are etiologically related to events or injuries in service. The matters are REMANDED for the following action: 1. Obtain updated VA treatment records. 2. After completing directive (1), schedule the Veteran for a VA examination with an appropriate examiner for his left-hand disability. The Veteran’s record, to include this remand, must be made available to the examiner for review. All indicated tests and studies should be completed. The examiner should offer an opinion on the following: (a.) Identify all left-hand disabilities. (b.) As to each diagnosed disability, is it at least as likely as not (a 50% or higher degree of probability) that the disability is related to service? Detailed rationales for all opinions should be provided. 3. After completing directive (1), forward the claims file to the individual who conducted the August 2016 examinations, or another examiner if that individual is unavailable, to provide an addendum opinion. (A full VA examination should not be scheduled unless it is deemed necessary by the examiner or otherwise required by the evidence.) With regard to any right ankle and left ankle disability identified, the examiner should respond to the following: Is it at least as likely as not (probability of 50 percent or more) that the Veteran’s currently diagnosed ankle disabilities are related to an event, disease, or injury in service? The opinion must consider the Veteran’s history of ankle injuries and treatments in service, as well as his reported history of symptoms since service. The examiner must provide a comprehensive medical rationale for each opinion offered. In forming an opinion, the examiner should not rely solely on the absence of corroborating evidence (of either treatment or a diagnosis). Rather, the examiner should consider the extent to which there is a medical nexus between any in-service symptoms and the current ankle disabilities. If the examiner cannot offer an opinion without resorting to speculation, he or she should explain why and state what additional evidence, if any, would be required to offer an opinion. ERIC S. LEBOFF Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Hammad Rasul, Associate Counsel