Citation Nr: 18160850 Decision Date: 12/28/18 Archive Date: 12/27/18 DOCKET NO. 18-04 692 DATE: December 28, 2018 ORDER Entitlement to service connection for a right knee disorder is denied. REMANDED The claim of entitlement to service connection for degenerative changes of the lumbar spine (claimed as herniated disk) is remanded. FINDING OF FACT The preponderance of the evidence is against finding that the Veteran has a current right knee disorder, to include slight lateral tilt of kneecap, due to a disease or injury in service, to include treatment for complaints of right knee pain. CONCLUSION OF LAW The criteria for entitlement to service connection for a right knee disorder have not been met. 38 U.S.C. § 1110 (2012); 38 C.F.R. § 3.303 (2018). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from December 1992 to December 1996. This matter comes before the Board of Veterans’ Appeals (Board) on appeal of a rating decision by a U.S. Department of Veterans Affairs (VA) Regional Office (RO). Entitlement to service connection for a right knee disorder The Veteran seeks entitlement to service connection for a right knee disorder. He contends that his current right knee disorder had an onset during his period of service or is related to right knee problems he experienced during his period of service. Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. § (2012); 38 C.F.R. § 3.303 (2012). The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter before the Board, the benefit of the doubt will be granted to the claimant. 38 U.S.C. § 5107 (2012); 38 C.F.R. § 3.102 (2018); Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on the merits, the preponderance of the evidence must be against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996). The question for the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. The record indicates that the Veteran has a current knee disability and experienced knee complaints in service. The medical evidence of record demonstrates he has a current diagnosis of slight lateral tilt of the right kneecap based on diagnostic testing. This is noted in VA treatment records and in a May 2014 VA examination report. And service treatment records (STRs) show that he received treatment for right knee problems during service. In July 1994, the Veteran complained of right knee pain and of a history of falling on flexed right knee while playing basketball. An examination indicated anterior knee tenderness, but an x-ray film was negative for knee fracture. The Veteran was diagnosed with anterior tibial/tibial tuberosity contusion of the right knee. A follow-up July 1994 service treatment record continued to show complaints of right knee pain, and findings of edema of the anterior femoral/tibial area with tenderness below the right patella as well as evidence of some laxity, but with full range of motion. He was later assessed with recurrent right knee tenderness following a history of anterior tibial tuberosity contusion. Service treatment records dated in February and April 1995 show assessment of patellar femoral pain syndrome (PFS) based on complaints of bilateral knee pain. The Veteran was prescribed PFS protocol for assisting with quadricep strengthening. The Veteran continued to complain of bilateral knee pain without improvement following treatment program in August 1995. It was noted that the Veteran demonstrated incorrect range of motion for PFS exercises, and he was instructed on proper PFS protocol exercises. He was again provided with proper PFS exercise in September 1995 following complaints of right knee pain. Service treatment records do not show further complaints or treatment for right knee problems after September 1995. The December 1996 examination prior to separation shows that his lower extremities were evaluated as normal, and the Veteran specifically denied having knee troubles on the associated report of medical history. The first post-service evidence of right knee problems is noted in a December 2013 VA ambulatory treatment record which showed the Veteran presented with complaints of chronic right knee pain. He denied any injury or trauma at that time, and he also denied seeking prior treatment from his primary care provider for knee problems. A follow-up December 2013 VA treatment record indicated findings of crepitus and painful motion with bending, and x-ray film revealed findings of slight tilt of kneecap, right, but no other abnormalities. The Board concludes that, while the Veteran has a current diagnosis of slight tilt of the right kneecap and evidence shows that in-service treatment for right knee problems, including patella femoral pain syndrome, the preponderance of the evidence weighs against finding that the Veteran’s diagnosis of slight tilt of the right kneecap began during service or is otherwise related to an in-service injury, event, or disease. VA treatment records show the Veteran was not diagnosed with slight tilt of the right kneecap until 2013, which comes more than a decade after his separation from service. While the Veteran is competent to report having experienced symptoms of right knee pain since service, he is not competent to provide a diagnosis in this case or determine that these symptoms were manifestations of slight tilt of the right kneecap. The issue is medically complex, as it requires knowledge of interpretation of complicated diagnostic medical testing. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). Further, the May 2014 VA examiner found that the slight tilt of the right kneecap was likely unrelated to an in-service injury, event, or disease, including treatment for right knee problems. The rationale was that while the Veteran was treated on more than one occasion for bilateral knee pain, he appears to have benefited from conservative management of his right knee problems. The Veteran sustained contusion to his right knee in 1994, and x-ray obtained demonstrated no fracture. The VA examiner noted that the Veteran’s service treatment records do not show any knee condition that would be expected to persist as a chronic knee disorder. In addition, the Veteran’s December 1996 separation examination showed his knees were evaluated as normal. The May 2014 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). While the Veteran believes his slight tilt of the right kneecap is related to an in-service injury, event, or disease, including treatment for right knee pain, he is not competent to provide a nexus opinion in this case. This issue is also medically complex, as it requires knowledge of musculoskeletal system and interpretation of complicated diagnostic medical testing. See Jandreau, supra. Here, the Board gives more probative weight to the May 2014 VA examiner’s medical opinion. Consequently, the preponderance of the evidence is against the claim and service connection for a right knee disorder is not warranted. As the preponderance of the evidence weighs against the claim, the benefit of the doubt rule is not for application. 38 U.S.C. § 5107(b), 38 C.F.R. § 3.102. REASONS FOR REMAND Entitlement to service connection for degenerative changes of the lumbar spine (claimed as herniated disk) is remanded. The Veteran seeks entitlement to service connection for a low back disorder, originally claimed as herniated disc. He asserts that his current low back disorder had an onset during his period of service and he has continued to experience low back problems since his period of service. A review of his service treatment records shows he sought treatment for low back pain on multiple occasions, and he was treated for low back weakness, low back pain, and mechanical low back pain. Post-service VA medical records show findings of degenerative changes in the lumbar spine based on a December 2013 lumbar spine x-ray. In the May 2014 VA report, the examiner concluded that back disability was likely unrelated to service. The VA examiner noted that there was no objective evidence to suggest that the Veteran sustained or developed herniated lumbar disc during service that would have persistent after service. The VA examiner further noted that medical literature indicates that individuals with herniated lumbar discs have excellent outcomes with nonoperative intervention 2-4 years after date of diagnosis. The VA examiner did not address, however, the evidence of degenerative changes in the lumbar spine. A remand is needed to obtain an addendum medical opinion addressing this aspect of the Veteran’s low back disability. The matter is REMANDED for the following action: 1. Update the claims folder with the Veteran’s VA treatment records dated since July 2017. 2. Obtain an addendum opinion which addresses the following question: Is it at least as likely as not (i.e., probability of 50 percent or greater) that degenerative changes in the lumbar spine were incurred during service or are otherwise related to service, to include treatment for low back pain. CHRISTOPHER MCENTEE Acting Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD J. Murray, Counsel