Citation Nr: 1815779 Decision Date: 03/15/18 Archive Date: 03/23/18 DOCKET NO. 14-39 086 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Houston, Texas THE ISSUES 1. Whether new and material evidence has been received to reopen a claim for entitlement to service connection for a right knee disability. 2. Whether new and material evidence has been received to reopen a claim for entitlement to service connection for a left knee disability. 3. Entitlement to service connection for a right knee disability, to include as secondary to service-connected pes planus. 4. Entitlement to service connection for a left knee disability, to include as secondary to service-connected pes planus. REPRESENTATION Veteran represented by: Texas Veterans Commission WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD N.S. Pettine, Associate Counsel INTRODUCTION The Veteran served on active duty from January 1987 to December 1994, including service in the Southwest Asia theater of operations. These matters come before the Board of Veterans' Appeals (Board) on appeal from an April 2014 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in New Orleans, Louisiana. Jurisdiction of the Veteran's claims file now resides with the Houston, Texas RO. In December 2016, the Veteran testified at a Board hearing before the undersigned Veterans Law Judge. A transcript of that hearing is of record. The Board notes that the Veteran previously filed a claim for entitlement to service connection for bilateral knee disabilities that was denied in a September 2011 rating decision. The Veteran was notified of that denial in October 2011 and, as the Veteran neither appealed nor submitted additional evidence within one year of the decision, it became final. Pursuant to 38 C.F.R. § 3.156, a claimant may reopen a finally-adjudicated claim by submitting new and material evidence. The Board finds that such evidence has been received and it will reopen the pending claims for service connection. As such, the case is in a posture such that the Veteran's claims may be addressed on their merits. VETERAN'S CONTENTIONS The Veteran asserts that his right and left knee disabilities were caused or aggravated by his service-connected bilateral pes planus. For this reason, he believes he is entitled to service connection. FINDINGS OF FACT 1. The current medical evidence of record documents active right and left knee diagnoses. Specifically, an April 2017 VA orthopedic surgery note stated that the Veteran had bilateral knee degenerative joint disease. Additionally, a July 2017 VA treatment record included patellofemoral syndrome of the bilateral knees as one of the Veteran's active medical problems. 2. The Veteran is service connected for bilateral pes planus. 3. In a March 2014 VA knee and lower leg conditions examination, the examiner diagnosed the Veteran with "mild age related degeneration" of both knees. The examiner then it opined that it was less likely than not that the Veteran's bilateral knee condition was proximately caused by or the result of the service-connected pes planus. In support of this conclusion, the examiner stated that evidence-based medicine indicated that one abnormal joint could not cause abnormalities or symptoms in another joint. The examiner cited a 2005 article by a Dr. Harrington in support of that proposition. 4. In September 2014, another VA medical opinion was provided in regard to the Veteran's bilateral knee claim. Similar to the March 2014 opinion, the clinician opined that it was less likely than not that the Veteran's bilateral knee condition was proximately caused or the result of the service-connected pes planus. In support of this opinion, the clinician stated that pes planus in most people did not produce symptoms or disability. The clinician then stated that 90 percent of all professional athletes and dancers had pes planus. Lastly, the clinician stated there was no evidence-based medicine that would indicate that pes planus could aggravate other joints, including the knees. In fact, the clinician stated, evidence-based medicine would indicate the opposite. Again, Dr. Harrington's 2005 article was cited in support of this negative nexus opinion. 5. In December 2016, VA received a medical opinion regarding the etiology of the Veteran's bilateral knee conditions from G.U., an Advanced Registered Nurse Practitioner. G.U. opined that it was at least as likely as not that the Veteran's current right and left knee conditions were secondary to, related to, or aggravated by compensatory walking strategies due to pes planus. In support of this determination, G.U. stated that the Veteran had confirmed diagnoses of patellofemoral syndrome and degenerative joint disease. G.U. then cited additional research by Dr. Harrington and stated that any condition that caused pain in a lower extremity bone or a soft tissue injury could produce an antalgic gait. Due to the severity of the Veteran's pes planus and associated pain, G.U. explained that the Veteran developed an antalgic gait pattern with limping that the medical literature associates with secondary biomechanical changes that cause abnormal kinetics to occur within both of the lower extremity joints. G.U. concluded that this then hastened the development and progression of the Veteran's bilateral knee disabilities. 6. In August 2017, VA received another opinion from G.U. regarding the Veteran's pending bilateral knee claims. In this August 2017 opinion, G.U. cited to a January 2015 supplemental statement of the case and pointed out inaccuracies in the prior VA medical opinions. G.U. then reiterated her conclusions from her December 2016 opinion. CONCLUSIONS OF LAW 1. The criteria for service connection for a right knee disability have been met. 38 U.S.C. §§ 1110, 1131, 5107(b) (2012); 38 C.F.R §§ 3.102, 3.303, 3.310 (2017). 2. The criteria for service connection for a left knee disability have been met. 38 U.S.C. §§ 1110, 1131, 5107(b) (2012); 38 C.F.R §§ 3.102, 3.303, 3.310 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Service connection may be established for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. Regulations also provide that service connection is warranted for a disease first diagnosed after discharge 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). Establishing service connection generally requires competent evidence of three things: (1) a current disability; (2) an in-service precipitating disease, injury, or event; and (3) a causal relationship, i.e., a nexus, between the current disability and the in-service event. Fagan v. Shinseki, 573 F.3d 1282, 1287 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a). Service connection may also be established for a disability that is proximately due to or the result of a service-connected disability. 38 C.F.R. § 3.310(a). As indicated above in the Conclusions of Law section, after reviewing the evidence of record, the Board finds that the Veteran is entitled to service connection for right and left knee disabilities. The Board will grant the Veteran service connection on a secondary basis. In support of this determination, the Board first finds that the Veteran currently has disabilities of both the right and left knee-as indicated above in the Findings of Fact section. Next, the Board acknowledges that the Veteran is already service-connected for pes planus. Lastly, the Board finds that the evidence of record contains competent nexus opinions linking the Veteran's right and left knee disabilities to his pes planus. Specifically, the Board is basing its determination upon G.U.'s opinions received in December 2016 and August 2017-described above in the Findings of Fact section. The Board finds these opinions to be adequate for adjudicative purposes. See, e.g., Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). In reaching this conclusion, the Board acknowledges the March and September 2014 VA medical opinions of record. However, the Board finds them to be of lesser probative value as G.U. indicated that their conclusions regarding a lack of a possible link between pes planus and a knee disability were unsupported in additional medical literature. Accordingly, in light of the above, the Board will grant the Veteran's claims. See 38 C.F.R. § 3.310. ORDER Service connection for a right knee disability is granted. Service connection for a left knee disability is granted. ____________________________________________ S.C. KREMBS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs