Citation Nr: 1808227 Decision Date: 02/08/18 Archive Date: 02/20/18 DOCKET NO. 10-44 991 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to a rating in excess of 20 percent for service-connected left degenerative sacroiliitis and lumbar myositis. 2. Entitlement to service connection for bilateral patellofemoral dysfunction, to include as secondary to service-connected left degenerative sacroiliitis and lumbar myositis. REPRESENTATION Veteran represented by: The American Legion WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD Dominic Jones, Associate Counsel INTRODUCTION The Veteran served on active duty for training (ACDUTRA) from July 2002 to November 2002 and on active duty from February 2003 to August 2004. This matter is before the Board of Veterans' Appeals (Board) on appeal from a September 2009 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran had a Board hearing in January 2016. The case was most recently before the Board in July 2017. At that time, the Board denied service connection for a left hip condition. The Board also remanded the remaining claims for additional development. FINDINGS OF FACT 1. The Veteran's left degenerative sacroilitis and lumbar myositis has been characterized by forward flexion to no less than 35 degrees, but with functional loss in the form of pain, and difficulty standing, sitting, bending, and lifting equating to flexion to 30 degrees or less. 2. The Veteran's bilateral patellofemoral dysfunction is not attributable to his active service, or proximately due to or aggravated by his service-connected degenerative sacroilitis and lumbar myositis. CONCLUSIONS OF LAW 1. The criteria for a 40 percent rating, but no higher, for left degenerative sacroilitis and lumbar myositis have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code (DC) 5237 (2017). 2. The criteria for service connection for bilateral patellofemoral dysfunction, to include as secondary to service-connected left degenerative sacroiliitis and lumbar myositis, have not been met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Board has limited the discussion below to the relevant evidence required to support its finding of fact and conclusion of law, as well as to the specific contentions regarding the case as raised directly by the Veteran and those reasonably raised by the record. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015); Robinson v. Peake, 21 Vet.App. 545, 552 (2008). I. Increased Rating Claim The Veteran contends that his service-connected back disability warrants a higher rating. He is currently rated at 20 percent for his left degenerative sacroiliitis and lumbar myositis under 38 C.F.R. § 4.71a, Diagnostic Code 5237. Historically, a February 2009 Board decision denied the Veteran's claim for an initial rating in excess of 20 percent for his service-connected back disability. Subsequently, the Veteran filed the present claim for increase in March 2009. Legal Criteria Ratings are based on a schedule of reductions in earning capacity from specific injuries or combination of injuries. The ratings shall be based, as far as practicable, upon the average impairments of earning capacity resulting from such injuries in civil occupations. 38 U.S.C. § 1155. Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability. 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. When after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability such doubt will be resolved in favor of the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3. The General Rating Formula for disabilities pertaining to the spine provides for 100 percent evaluation for unfavorable ankylosis of the entire spine; a 50 percent evaluation for unfavorable ankylosis of the entire thoracolumbar spine; a 40 percent evaluation for unfavorable ankylosis of the entire cervical spine, or forward flexion of the thoracolumbar spine 30 degrees or less; or, favorable akylosis of the entire thoracolumbar spine; a 30 percent evaluation for forward flexion of the cervical spine 15 degrees or less; or, favorable ankylosis of the entire cervical spine; and a 20 percent evaluation for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, forward flexion of the cervical spine greater than 15 degrees but not greater than 30 degrees; or, the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, the combined range of motion of the cervical spine not greater than 170 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. 38 C.F.R. § 4.71a, DC 5237. Additionally, Note (1) provides: Evaluate any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, separately, under an appropriate diagnostic code. For VA compensation purposes, normal forward flexion of the thoracolumbar spine is zero to 90 degrees, extension is zero to 30 degrees, left and right lateral flexion are zero to 30 degrees, and left and right lateral rotation are zero to 30 degrees. The normal combined range of motion of the thoracolumbar spine is 240 degrees. 38 C.F.R. § 4.71(a) (2015), General Rating Formula, Note (2). When evaluating joint disabilities rated on the basis of limitation of motion, VA may consider granting a higher rating in cases in which functional loss due to pain, weakness, excess fatigability, or incoordination is demonstrated, and those factors are not contemplated in the relevant rating criteria. See 38 C.F.R. §§ 4.40, 4.45, 4.59 (2015); DeLuca v. Brown, 8 Vet. App. 202 (1995). The rating schedule also includes criteria for evaluating intervertebral disc syndrome (IVDS). Under DC 5243, IVDS is to be evaluated either under the General Rating Formula or under the Formula for Rating Intervertebral Disc Syndrome Based on the Incapacitating Episodes (IVDS Formula), whichever method results in the higher evaluation when all disabilities are combined. 38 C.F.R. § 4.71a, DC 5243. Under the IVDS formula, a 10 percent disability evaluation is warranted for incapacitating episodes having a total duration of at least one week but less than 2 weeks during the past 12 months. A rating of 20 percent is warranted where there are incapacitating episodes with a total duration of at least 2 weeks but less than 4 weeks during the past 12 months. A rating of 40 percent is warranted for incapacitating episodes with a total duration of at least 4 weeks but less than 6 weeks during the past 12 months. A maximum rating of 60 percent is warranted for incapacitating episodes with a total duration of at least 6 weeks during the past 12 months. 38 C.F.R. § 4.71a, DC 5243. For these purposes, an incapacitating episode is defined as a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician. 38 C.F.R. § 4.71a, DC 5243, Note (1). Facts The first VA back examination for the Veteran was conducted in July 2009. The Veteran had no urinary incontinence and no fecal incontinence. However, the Veteran did have numbness, paresthesias, leg or foot weakness, and unsteadiness. The Veteran had low back pain and characterized it as severe and constant on a daily basis. The pain would radiate to his legs. No flare-ups were reported, but there were episodes of incapacitating spine disease. In the past 12 months this occurred three times for about two to three days each time. The Veteran was able to walk one fourth of a mile. The Veteran's posture and gait were normal, there was no lumbar lordosis, scoliosis, or ankylosis. There was no spasm or atrophy but there was guarding, pain with motion, and tenderness. There was no weakness. Active range of motion was forward flexion to 41 degrees, extension to 22 degrees, left lateral flexion to 30 degrees, left lateral rotation to 30 degrees, right lateral flexion to 30 degrees, and right lateral rotation to 30 degrees. There was objective evidence of pain following repetitive motion, but no additional limitation in range of motion. There were incapacitating episodes of IVDS. His back had effects on his usual daily activities. The effect on chores, shopping, and exercise were noted as severe. His back prevented sports. His back had moderate effect on feeding, bathing, dressing, and toileting. The Veteran's VA treatment records around the time of this VA examination reflected complaints of low back pain. Thereafter, a December 2009 VA treatment note showed low back pain that radiated to the left leg and produced cramps in the posterior thigh. A January 2010 VA treatment note reflected chronic low back pain with increasing radiculopathic symptoms, weakness, giving way with high risk for falls. A March 2010 VA treatment note reflected chronic low back pain. A July 2011 VA treatment assessment highlighted chronic low back pain presenting with difficulty in range of motion, but normal strength. An August 2011 VA treatment note showed low back pain with functional limitations in bending, standing for long periods of time, walking for long periods, and difficulty lifting 15 to 20 pounds. He could sit for 15 minutes, stand for 30 minutes, walk for 30 minutes, and run for 30 minutes before the onset of pain. The assessment was difficulty in range of motion, but normal strength. He had poor flexibility noted with decreased soft tissue elasticity in the lumbar area, and did not experience numbness or tingling and radiating pain in the left lower extremity at that time. In a February 2013 VA treatment note, the Veteran complained of pain along the lower lumbar spine. He had some radiation to his left posterior thigh that tended to increase with greater levels of weight bearing activity. In the Veteran's February 2013 VA Form 9, he explained that his back condition altered his quality of life. He stated that at time because of the pain and discomfort, he would be unable to do any type of activities. He said that his period of incapacitation would last at least three to four days and that he had these periods almost every other month which interfered with his employment. An April 2013 VA treatment note showed persistent low back pain. The Veteran continued to have left sided pain that increased with weight bearing and there was tenderness along the lower lumbar facet plane. In May 2013, he complained of sharp pain along the left lower lumbar spine that extended to the posterior thigh that increased with greater levels of weight bearing activity. A June 2015 VA treatment note showed complaint of chronic low back pain that was centrally located with radicular symptoms to the left posterior thigh. The pain was sharp and was then characterized as a six out of ten. There was tenderness to palpation, his flexion was noted as limited as was his extension. An August 2015 VA chiropractic note described limited flexion and limited extension as well. The Veteran testified before the Board in January 2016. He noted he went to physical therapy two times per week for his back. He noted that an MRI in 2014 revealed bulging discs. He noted episodes where his doctor told him he needed to stay off of his feet. He stated that he wore a back brace and at time could not feel his left leg due to pain. He stated he could not throw a ball with his children due to back pain. He also noted at the time that he was currently working. Another VA examination as conducted in April 2016, pursuant to a prior Board remand. The Veteran complained of constant low back pain aggravated by most physical activities including lifting, prolonged standing, and walking. He had used all of his sick leave for the year and had to get special leave dispensations because of the "crippling nature" of his back pain. He reported flare-ups occurring several times per week due to repetitive use with a loss of function due to pain. His forward flexion was to 35 degrees, extension to 10 degrees, right lateral flexion to 20 degrees, left lateral flexion to 15 degrees, right lateral rotation to 20 degrees, and left lateral rotation to 15 degrees. The range of motion itself contributed to functional loss in the form of reduced mobility. All ranges of motion exhibited pain and there was pain on weight bearing as well as localized tenderness over the lumbar area. Upon repetitive use, there was no additional loss of function or range of motion. The examiner however was unable to say without mere speculation if pain, weakness, fatigability or incoordination significantly limited functional ability with repeated use over time. The examination was not conducted during a flare-up, and the examiner could not provide limitation of functional ability during flare-ups based on the hypothetical situation. At the examination there was guarding but it did not result in abnormal gait or spinal contour. The additional contributing factors of disability were less movement than normal due to interference with sitting, and interference with standing. Muscle strength was normal and there was no atrophy. The Veteran had no radiculopathy. The examiner noted the Veteran had IVDS of the thoracolumbar spine but the episodes did not require bed rest in the past 12 months. He used no assistive devices. Imaging studies were done and arthritis was documented but there was not thoracic vertebral fracture with loss of 50 percent or more of height. The functional impact of the Veteran's back disability as described by the examiner was such that would impact any job requiring prolonged or repetitive standing, lifting, bending or kneeling according to the examiner. Another VA examination was conducted in August 2017, pursuant to the Board's most recent remand. The current symptoms were really sharp pain to the left lower back. The Veteran reported flare-ups described as a sharp pain in the lower back where he could not do anything, and had to lay down until the pain subsided. The Veteran did not report having any functional loss. Forward flexion was to 40 degrees, extension was to 20 degrees, right lateral flexion was to 30 degrees, left lateral flexion was to 30 degrees, right lateral rotation was to 20 degrees, and left lateral rotation was to 20 degrees. The range of motion itself contributed to functional loss in that the Veteran could not bend down to tie his shoes. Pain was noted and caused functional loss. Forward flexion, right and left lateral flexion and right and left lateral rotation all exhibited pain. There was no localized tenderness, but the Veteran was able to perform repetitive use testing. There was no additional loss of function or range of motion after repetitive use. The examination was noted as consistent with the Veteran's statements describing functional loss with repetitive use over time. The examination was not conducted during a flare-up, and the examiner was unable to say without speculation whether pain, weakness, fatigability, or incoordination significantly limited functional ability with flare-ups. This was because the examination was not conducted during a flare-up. There was no muscle spasm and no guarding. The additional contributing factors to the disability were less movement than normal and interference with sitting and standing. The Veteran was unable to bend over to tie his shoes and had difficulty standing longer than 15 minutes or sitting longer than 15 minutes. Muscle strength was normal and there was no atrophy. He had no radiculopathy and no akylosis. This examiner stated that the Veteran did not have IVDS. The Veteran did not use an assistive device. Imagining studies were done but there was no arthritis documented. There was no objective evidence of pain on weight bearing and the passive range of motion was the same as the active range of motion. The examiner noted that due to the Veteran's difficulty with forward flexion, this made it difficult for him to bend over and grab things and that his ability to function in an occupational environment was somewhat limited, but at the time of the examination not affected greatly. The examiner stated the back condition did not impact the Veteran's ability to work. Analysis The Board finds that the Veteran's service-connected back disability more closely approximate a 40 percent rating, but not higher, throughout the entirety of the appeal period. This is so because even though throughout the appeal period the Veteran's forward flexion of the thoracolumbar spine was no less than 35 degrees, when accounting for functional loss as the Board must, the Veteran's overall disability picture more closely approximated that of a 40 percent rating. See 38 C.F.R. § 4.7. As early as his July 2009 VA examination, his forward flexion was to only 41 degrees. Furthermore, by his April 2016 VA examination this forward flexion had decreased to 35 degrees. By the August 2017 VA examination his forward flexion was only to 40 degrees. However, throughout this period the Veteran experienced functional loss in the form of limitation in standing, sitting, and walking for prolonged periods. For most of this period he also experienced symptoms of IVDS where he had to take leave from work. He also had trouble in bending and lifting during this period. The Veteran also described his inability to engage in sports with his children. Therefore, the Veteran's overall disability picture throughout the appeal period more closely approximated a 40 percent rating rather than a 20 percent rating. A rating in excess of 40 percent is not warranted, however, because at no time during the appeal period has the Veteran had ankylosis. None of the VA examination reports note such and the remaining evidence also does not show ankylosis. Moreover, while IVDS is noted, and incapacitating episodes were noted at one time, the evidence does not show that a physician has prescribed bedrest for this, particularly for at least six weeks during a 12-month period. Thus, a higher rating is not warranted under the IVDS formula. Furthermore, although there have been subjective complaints that may indicate some type of neurologic abnormality in the legs, the VA examinations have found no radiculopathy. While medical evidence is not categorically always required, Note 1 to the DC states to evaluate associated "objective" neurologic abnormalities. In this case, there are no objective neurologic abnormalities, including of the legs or other areas, such as the bowel or bladder. Lastly, the Board finds that further VA examination is not necessary. The VA examinations of record adequately provide evidence to make a finding regarding a 40 percent rating. Because there is no indication of ankylosis, further range of motion testing is not raised as an issue. In sum, the Board finds that a higher 40 percent rating is warranted for the Veteran's service-connected back disability. However, an even higher rating or separate rating is not warranted by the preponderance of the evidence. Thus, the benefit-of-the-doubt doctrine is not applicable. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3. II. Service Connection Claim The Veteran has advanced three theories of entitlement for his bilateral knee disability. First, the record reflects that his bilateral knee disability may be directly related to service. A September 2005 VA treatment note reflects the Veteran complaining of knee pain, and stating that the problem had been worsening since his basic training three years ago. Second, in a March 2014 statement, the Veteran stated that upon being released from active duty, he sought treatment at the San Juan VAMC and was diagnosed with a knee disability within one year, and thus should be presumptively service connected under 38 C.F.R. 3.307. Finally, he contends that his bilateral knee condition may be proximately due to or aggravated by his service-connected back disability. The Veteran noted in a July 2009 VA examination that he had bilateral knee pain since 2006 and that he attributes his knee pain to having to bend down to lift objects at his job since he cannot bend down effectively due to his service-connected low back condition. A. Direct Service Connection Legal Criteria Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. See 38 U.S.C. § 1110; 38 C.F.R. § 3.303. "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. 2010) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Where 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; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Analysis Preliminarily, the Veteran has a present bilateral knee disability in the form of bilateral patellofemoral dysfunction. See July 2009 VA examination. Furthermore, the Veteran had complaints of knee pain in service. See August 2017 VA examination report. Thus, the issue is whether the Veteran's present knee disability is causally related to these complaints. The Veteran's first VA examination to address this theory of entitlement was obtained in April 2016. The examiner reviewed the claims file. The examiner opined that the knee condition was less likely than not caused by the claimed in-service injury. The examiner was unable to find any medical care for chronic or recurrent bilateral knee conditions while the Veteran was in service. Furthermore, the examiner stated the Veteran was not diagnosed with his present knee disability while in service. The next VA examination to address this theory was conducted in August 2017, which was pursuant to the Board's recent remand. The examiner acknowledged the Veteran's report that his knees hurt while in basic training and that when he went to active duty both knees flared up in pain. Nonetheless, the examiner opined that the claimed disability was less likely than not incurred in service. The rationale provided was that the Veteran's service treatment records did not support the claim, and that there was no clear link between the Veteran's knee disability and service. The Board acknowledges that in his January 2016 Board hearing, the Veteran reported that he received an MRI or X-ray in 2014 or 2015. The record reflects a February 27, 2014 VA examination that documented a "9 mm radiodense foreign body in the medial subcutaneous tissues of the right knee." The August 2017 VA examination report commented on this object. The examiner stated that there were no records to support that the Veteran obtained this foreign body during service, and therefore this was less likely than not incurred in service. In its November 2017 brief, the Veteran's representative highlighted that the July 2017 Board decision remanded the Veteran's bilateral knee claim in order for an appropriate VA examination to be conducted to determine the nature and etiology of the Veteran's knee disability. The representative argued that the August 2017 VA examination was conducted by a nurse practitioner, but that the agency of original jurisdiction (AOJ) should have taken into consideration the type of disability and rather assigned an orthopedic physician to have conducted the examination. Therefore, it was argued, the August 2017 VA examination was inadequate. The Board finds that the August 2017 VA examination and medical opinion are adequate. 38 C.F.R. § 3.159(a)(1) defines competent medical evidence as "evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions." Similarly, VA operates under a rebuttable presumption of regularity that provides that in the absence of evidence to the contrary, there is a presumption that public officers have discharged their duties. See Rizzo v. Shinseki, 580 F.3d 1288, 1292 (Fed. Cir. 2009). Thus, in the case of competent medical evidence, VA also benefits from a presumption that it has properly chosen a person who is qualified to provide a medical opinion in a particular case. See Parks v. Shinseki, 716 F.3d 581 (Fed. Cir. 2013). In situations similar to the present case, nurse practitioners have the competency to provide a medical opinion. See Cox v. Nicholson, 20 Vet. App. 563, 569 (2007). Here, the nurse practitioner is a medical professional who has been qualified through training to offer the opinion in the August 2017 VA examination and is therefore competent to provide such opinion. Other than summarily concluding that the August 2017 examiner was not qualified, the Veteran's representative has not offered evidence to rebut the presumption that the August 2017 examiner was properly chosen. As such, the Board finds the August 2017 VA examination adequate. The Board therefore finds that service connection on a direct basis for the Veteran's bilateral knee disability is not warranted. This is so because based on review of the claims file, competent examiners have opined that the Veteran's disability was not incurred in service. While the earlier opinions did not address the foreign body, the August 2017 VA opinion cured that defective aspect of the prior opinions. The Veteran in a November 2010 statement raised 38 C.F.R. § 3.303(b) to highlight that he has been complaining as to the continuity of all of his symptoms. He highlighted that this provision requires continuity of symptomatology and not continuity of treatment, and the Veteran's testimony together with lay evidence of such continuity may be sufficient to link his disability to in-service symptoms. 38 C.F.R. § 3.303(b) provides that for chronic diseases shown as chronic in service so as to permit a finding of service connection, subsequent manifestations of the same chronic diseases at any later date, however remote, are service-connected. However, the provision goes on to emphasize that the rule does not mean that any manifestation of joint pain will permit service connection for arthritis, for example. Indeed, the provision states that for the showing of chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity, and sufficient evidence to establish chronicity at the time, as distinguished from merely isolated findings. Here, while the August 2017 VA examiner did note the Veteran's complaints of knee pain while in service, the other VA examiners highlighted that the Veteran was not diagnosed with patellofemoral syndrome while in service. 38 C.F.R. § 3.303(b) requires more than merely isolated findings of pain in service, and pain in the present. Moreover, the Veteran's separation examination was normal as to the knees. He also did not report a knee problem. In contrast, the Veteran did report problems with the left ear and back. This weighs against a continuity of symptomatology. Furthermore, 3.303(b) only applies to arthritis in this context, which has not been shown. Thus, the theory is not applicable and service connection on the basis of 38 C.F.R. § 3.303(b) is similarly not warranted. B. Presumptive Service Connection Legal Criteria Some chronic diseases, such as arthritis, are presumed by law and regulation to have been incurred in service even though there is no evidence of such disease during the period of service, if they become manifest to a degree of ten percent or more within a corresponding applicable presumptive period (one year for arthritis), and if following a period of service of 90 days or more of continuous active service. 38 U.S.C. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309. Thus the issue is whether the Veteran's knee disability is subject to any presumption. Analysis Here, the Veteran contends that his bilateral patellofemoral dysfunction should be service-connected on a presumptive basis because he sought treatment and was diagnosed within one year of service. However, the mere diagnosis of a disability within one year does not satisfy 38 C.F.R. § 3.307 or 3.309. The Veteran must first have a disease or disability subject to presumptive service connection and such disease or disability must have also manifested to a compensable degree within the relevant time frame applicable to that disease or disability. Here, as noted in the previously section, at no time has the Veteran been diagnosed arthritis of the bilateral knees. See August 2017 VA examination. Indeed, the Veteran's bilateral patellofemoral dysfunction is not a disease subject to any presumption of service connection. Without a diagnosis of a disability or disease subject to a presumption, the Board need go no further. C. Secondary Service Connection Legal Criteria Secondary service connection may be granted for a disability that is proximately due to, the result of, or aggravated by an established service-connected disability. 38 C.F.R. § 3.310; see also Allen v. Brown, 7 Vet. App. 439 (1995). Analysis The veteran is service connected for a back disability. Thus, the issue here is whether his bilateral knee disability is proximately due to or aggravated by his back disability. The first VA examination to address this theory was conducted in July 2009. The examiner opined the knee disability was less likely secondary to or related to the Veteran's back disability. The rationale was that on physical examination no biomechanical factors were identified which would interfere with knee function or would cause patellofemoral pain dysfunction. This theory was again addressed in a February 5, 2014 examination. The examiner opined that the bilateral knee disability was less likely than not caused by or the result of the Veteran's back disability. The rationale was that according to medical literature the back disability would not result in an anatomical shift of weight to the knee areas so as to cause an extra weight burden. Therefore, no extra stresses would be placed on that site so as to promote degenerative changes. Furthermore, the examiner explained that patellofemoral syndrome frequently occurred in teenagers, manual laborers, athletes, or on doing routine daily activities. Consequently, the examiner stated that it was more likely that the current knee condition arose from everyday activities as opposed to anatomically unrelated back conditions. Another VA examination was conducted on February 27, 2014. This examiner opined that the knee disability was less likely than not a result of the service-connected condition. The rationale was that after a review of the claims file the Veteran was not diagnosed with the bilateral knee disability secondary to his back while in service, nor after service. There was no objective evidence that the service-connected back disability "results or aggravates" bilateral patellofemoral syndrome due to a favoring of the affected extremity so as to cause an extra weight burden. Another VA examination was conducted in April 2016. This examiner opined that the knee disability was less likely than not due to or the result of the service-connected back disability. This was because a bilateral knee disability secondary to the back disability was not diagnosed in service or after service. The examiner went on to state that the Veteran did not meet the criteria for radiculopathy of the lower extremities including the knees and that there was no objective evidence in the medical literature that the Veteran's back disability results, causes, or aggravates bilateral patellofemoral syndrome. Yet another VA examination was conducted in August 2017, pursuant to the Board's recent remand. This examiner highlighted that the Veteran had no knee pain upon examination of his knees. Indeed, the Veteran could go from sitting to a standing position easily without evidence of pain. The examiner concluded by stating that there was no objective evidence to support a current diagnosis during that examination. The Board finds that the Veteran's bilateral knee disability is not proximately due to or aggravated by his service-connected back disability. This is so because of the numerous VA examinations that have provided opinions on the issue, none of them have provided the required causal relationship, including based on secondary aggravation. The Board notes that in his January 2016 Board hearing, the Veteran related that a doctor told him once that his back disability was the cause of his knee problems. The Board highlights that the Veteran is competent to relay what a medical professional told him. However, this is outweighed by the numerous VA examinations that opine that his back disability did not cause his knee problems. These examinations were conducted with an in-person examination of the Veteran, and the opinions rendered were based on the Veteran's statements and a thorough review of the entire claims file. The opinion relayed by the Veteran is not written down in the file, but more importantly it is not accompanied by sufficient explanation in contrast to the persuasive explanations provided by the VA examiners. Therefore, service connection is also not warranted on a secondary theory. In sum, the Board finds that the preponderance of the evidence is against the claim based on any of the theories. As such, the benefit-of-the-doubt doctrine is not applicable and service connection for bilateral patellofemoral dysfunction is not warranted. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. ORDER A rating of 40 percent, but no higher, for left degenerative sacroilitis and lumbar myositis is granted, subject to the laws and regulations governing the payment of monetary awards. Service connection for bilateral patellofemoral dysfunction, to include as secondary to service-connected left degenerative sacroilitis and lumbar myositis is denied. ____________________________________________ RYAN T. KESSEL Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs