Citation Nr: 20004834 Decision Date: 01/21/20 Archive Date: 01/21/20 DOCKET NO. 16-10 146 DATE: January 21, 2020 ORDER Entitlement to service connection for a right ankle disability is denied. Entitlement to service connection for a left ankle disability is denied. Entitlement to service connection for a left wrist disability, other than residual scarring is denied. Entitlement to service connection for a left wrist scar from a ganglion removal in service is granted. REMANDED The issue of entitlement to service connection for a right knee disability is remanded. FINDINGS OF FACT 1. The Veteran’s current right ankle disability was not shown as chronic in service and arthritis did not manifest to a compensable degree within the applicable presumptive period; continuity of symptomatology is not established; and the disability is not otherwise etiologically related to an in-service injury or disease, proximately due to, or aggravated by service-connected disability. 2. The Veteran’s current left ankle disability was not shown as chronic in service and arthritis did not manifest to a compensable degree within the applicable presumptive period; continuity of symptomatology is not established; and the disability is not otherwise etiologically related to an in-service injury or disease, proximately due to, or aggravated service-connected disability. 3. The Veteran’s current left wrist disability, other than residual scarring, was not shown as chronic in service and arthritis did not manifest to a compensable degree within the applicable presumptive period; continuity of symptomatology is not established; and the disability is not otherwise etiologically related to an in-service injury or disease, proximately due to, or aggravated by service-connected disability. 4. The Veteran has scar on his left wrist from an in-service ganglion removal. CONCLUSIONS OF LAW 1. The criteria for establishing service connection for a right ankle disability have not been met. 38 U.S.C. §§ 1110, 1112, 1113, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310. 2. The criteria for establishing service connection for a left ankle disability have not been met. 38 U.S.C. §§ 1110, 1112, 1113, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310. 3. The criteria for establishing service connection for a left wrist disability, other than residual scarring, have not been met. 38 U.S.C. §§ 1110, 1112, 1113, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310. 4. The criteria for establishing service connection for removal of a ganglion from the left wrist have been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from January 1976 to January 1980. The Veteran testified before the undersigned Veterans Law Judge during a February 2017 hearing; a transcript is of record. The matter was Remanded in September 2018. Service Connection Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303 (a). To establish entitlement to service-connected compensation benefits, 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. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2010). Service connection may be granted for any disease initially diagnosed after service 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). Service connection may also be granted for a disability that is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310 (a). This permits service connection not only for a disability caused by a service-connected disability, but for the degree of disability resulting from aggravation of a disability by a service-connected disability. See Allen v. Brown, 7 Vet. App. 439, 448 (1995). In the case of aggravation by a service-connected disability, a veteran may be compensated for the degree of disability over and above the degree of disability existing prior to the aggravation. Id; see also 38 C.F.R. § 3.310 (b). In addition, for veterans with 90 days or more of active service during a war period or after December 31, 1946, certain chronic diseases, including arthritis, are presumed to have been incurred in service if they manifested to a compensable degree within one year of separation from service. 38 U.S.C. §§ 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. Pursuant to 38 C.F.R. § 3.303 (b), where a chronic disease is shown as such in service, subsequent manifestations of the same chronic disease are generally service connected. If a chronic disease is noted in service but chronicity in service is not adequately supported, a showing of continuity of symptomatology after separation is required. Entitlement to service connection based on chronicity or continuity of symptomatology pursuant to 38 C.F.R. § 3.303 (b) applies only when the disability for which the Veteran is claiming compensation is due to a disease enumerated on the list of chronic diseases in 38 U.S.C. § 1101 (3) or 38 C.F.R. § 3.309 (a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits. VA shall consider all information and lay and medical evidence of record in a case and 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; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996). 1. Entitlement to service connection for a right ankle disability is denied. 2. Entitlement to service connection for a left ankle disability is denied. The Veteran contends that his current bilateral ankle disability is caused by in-service injuries where he twisted and sprained his ankles. See February 2017 Board Hearing Transcript. The Veteran’s service treatment record shows that he reported “broken bones” in his report of medical history at the entrance in January 1976. The physical examination at the entrance in January 1976 did not reveal ankle abnormality. As for his right ankle, subsequent service treatment records show that he sprained his right ankle on several occasions. The earliest of record is in May 1977, where he sprained the right ankle with no fracture, while playing softball. During this visit, the Veteran reported history of old fracture in the right ankle area. Then, he strained the right ankle while playing basketball in March 1978. In December 1978, he twisted the right ankle while playing basketball. As for his left ankle, service treatment records show that the Veteran complained about left ankle pain in January 1977 with normal x ray. A December 1979 separation examination shows no complaints or findings referring to the ankles. Post service treatment records show that the Veteran injured the right ankle while playing softball in August 1993. As for the left ankle, a December 1986 post-service treatment record shows that he reported his left knee gave away and twisted his left ankle. The x ray taken at the time revealed no significant abnormality of the bone, joints, or adjacent soft tissues. No fracture was found and he was diagnosed with left ankle sprain. A November 1992 medical treatment record shows left ankle strain while playing basketball; he reported that he “came down on someone’s leg who fell after being tripped” hurting his left ankle. The x ray taken then showed chip fracture of lateral malleolus of the left ankle. In August 1993, the Veteran again strained the left ankle while playing softball when he slid into the third base and got the left foot caught under the base. The x ray taken at the time revealed the injury from November 1992, but no recent fracture. At a May 2014 VA examination, the Veteran reported continued bilateral ankle pain, popping, and instability. He denied uses of ankle braces or surgeries or injections in the ankle. The x ray reviewed at the examination showed old avulsion fracture fragments at the medial malleolus and small posterior and plantar calcaneal enthesophytes for the right ankle. For the left ankle, it showed small posterior and plantar calcaneal enthesophytes, otherwise normal.” At a February 2016 VA examination, the Veteran was diagnosed with mild osteoarthritis of bilateral ankles. It appears that the diagnosis was provided based on crepitation in ankles. The examiner stated that “x ray adds nothing” and that “there is mild – mod arthrosis although x ray is normal as the x ray findings are the last to show and, in the future, they will be seen as arthritis on x ray likely.” Moreover, the examiner determined that the ankle strains from the late 1970’s have been resolved. The Board finds that the Veteran ‘s osteoarthritis of the bilateral ankles did not manifest in service or within one year since separation, with no showing of any symptomatology of such condition. Therefore, presumption of chronic disease under 38 C.F.R. § 3.307 is not applicable. Therefore, the issue before the Board is whether the Veteran’s current mild osteoarthritis of the bilateral ankles is related to his sprain injuries to the bilateral ankles or aggravated by service. On this matter, a medical opinion is associated with the Veteran’s claims file. The February 2016 VA examiner stated that the Veteran’s current bilateral ankle condition is not related or aggravated by service or is proximately due to his service-connected disabilities. The rationale was that the medical evidence of records, generally understood causation rationale supported by accepted standards and literature in the medical community, and biologically plausible scientific rationale do not support a connection with service. Based on the above, the Board finds that a preponderance of the evidence is against the claims. Indeed, although service treatment records reveal complaints of bilateral ankle strain during service, no disability was diagnosed and clinical evaluation at separation was normal. As the February 2016 VA examiner determined, this supports that the Veteran’s bilateral ankle sprain was resolved before the end of service period. Moreover, the Board affords the February 2016 VA examiner’s opinion significant probative value since it was offered by medical professionals following a review of the claims file and application of relevant medical principles to the facts of the case, with rationales consistent with the evidence of record. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (most of the probative value of a medical opinion comes from its reasoning; threshold considerations are whether the person opining is suitably qualified and sufficiently informed). To the extent either examiner failed to fully support every aspect of any of each conclusion, it is clear that the examiner had a complete understanding of the pertinent evidence, reviewed the entire claims file and considered the appellant’s contentions. See Monzingo v. Shinseki, 26 Vet. App. 97, 106 (2012) (the fact that the rationale provided by an examiner “did not explicitly lay out the examiner’s journey from the facts to a conclusion,” did not render the examination inadequate); Acevedo v. Shinseki, 25 Vet. App. 286, 294 (2012) (medical reports must be read as a whole and in the context of the evidence of record). The Board notes that the medical treatment records for the period from August 1988 to August 2013 were associated with the claims file after the February 2016 VA examination. However, the Board finds that this evidence does not add any information material to determination of a nexus between osteoarthritis of the bilateral ankles and the Veteran’s service, to include service-connected disabilities; the medical treatment records refer to additional incidents of ankle sprains incurred while playing sports, but mechanism of injury reported by the Veteran involves collisions with a player or a base in the baseball field. The Board acknowledges the competent and credible lay statements from the Veteran regarding symptomatology. Nevertheless, to the extent that the Veteran attributes his disability to service, he is not competent to opine on the etiology of a complex medical condition such as arthritis, and his statements are therefore afforded no weight. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). In sum, the most probative evidence of record shows that the current bilateral ankle disability is not incurred in service and is not caused or aggravated by service-connected disability. Further, as stated above, no osteoarthritis of the bilateral ankles was compensably disabling within one year of separation from service. 38 C.F.R. § 3.309 (a). The Board also observes that the most probative evidence indicates that osteoarthritis of the bilateral ankle did not exist and were not “noted” in service or within one year of separation from service. Thus, the provisions of 38 C.F.R. § 3.303 (b) pertaining to chronicity or continuity of symptomatology are not for application. Accordingly, the claims must be denied. In reaching this decision the Board considered the doctrine of reasonable doubt, however, as the preponderance of the evidence is against the claims, the doctrine is not for application. 38 U.S.C. § 5107. 3. Entitlement to service connection for a left wrist disability, other than residual scarring, is denied. 4. Entitlement to service connection for a left wrist scar from a ganglion removal is granted. The Veteran contends that he has a current left wrist disability that is related to a wrist injury while in service or ganglion cyst on the left wrist removed while in service. See February 2017 Board Hearing Transcript. At the outset, the Board notes that recent examinations have reported a left wrist scar from a ganglion removal that was conducted during service. As such, service connection for that scarring is in order. The remainder of the decision below should be taken as consideration of other left wrist impairment, other than the residual scarring. A January 1976 entrance examination did not reveal abnormal wrist. The Veteran developed ganglion cyst on the left wrist, which was resected in August 1978. He also had left wrist contusion in 1978, with negative x rays. The December 1979 discharge examination notes a 4 mm scar/body mark in the left wrist from the operation. A February 2005 post-service medical treatment record indicates that he had an injury to the left wrist. The x ray taken at the time revealed normal left wrist. At a May 2014 VA examination, the Veteran reported tenderness at the bottom of his wrist with any type of pressure and that his fingers cramp up when the scar is hit. He also described weakness in the left hand. The x ray taken at the examination revealed no fracture, subluxation, or dislocation with joint spaces maintained. Peripheral soft tissues were unremarkable. The examiner determined that there is no functional impact from the Veteran’s wrist condition on his ability to work with restriction of no lifting more than 25 pounds with the left hand. The scar examination reflects a well-healed scar to volar left wrist well embedded in the distal wrist crease. The linear scar of length 1.5 cm was not painful or unstable. At a February 2016 VA examination, the Veteran was provided with a current diagnosis of osteoarthritis of the left wrist. The examiner noted that there was no fasciitis as noted in the clinic, but found crepitations of mild arthrosis on physical examination. There was objective evidence of localized tenderness or pain on palpation in the area of volar ganglion excision from long time ago over the well healed scar of the length 1 cm. The examiner noted that the Veteran underwent a simple, uncomplicated ganglion removal in the late 1970’s with no current residuals. The examiner noted that the Veteran has arthritis over time, not due to the ganglion or service. At the February 2017 Board hearing, the Veteran testified that the cyst along the thumb area is returning and had a surgery at VA in Phoenix, Arizona. A January 2017 VA treatment record indicates that the veteran had excision of the left Dupuytren’s contracture of the first, third, and fourth fingers in May 2016. The Veteran stated a callus on his left thumb bothers him. The Board finds that a preponderance of the evidence is against his claim for left wrist impairment, other than the residual scarring. The February 2016 VA examiner determined that there is no current residual from the in-service excision of ganglion cyst from the left wrist. Rather, the examiner found that the Veteran has a mild osteoarthritis. Also contrary to what the Veteran indicated at the February 2016 Board hearing, the Veteran does not have a returning ganglion cyst, though he seems to have a callus, on the wrist and the surgery he underwent is for Dupuytren’s contracture, not for a cyst, as evidenced in the January 2017 VA treatment record. Moreover, the February 2005 x ray result shows that the Veteran did not have osteoarthritis at that time. Thus, the evidence preponderates against finding that the Veteran’s current osteoarthritis manifested in service or within one year after separation. No evidence indicates, nor the Veteran claims, that his left wrist condition is proximately due to or aggravated by service-connected disability. Therefore, the issue before the Board is whether the Veteran’s current osteoarthritis of the left wrist is related to the in-service excision of the ganglion cyst from the left wrist. On this matter, a medical opinion is associated with the Veteran’s claims file. The February 2016 VA examiner stated that the Veteran’s current left wrist disability is not related or aggravated by service. The rationale was that the medical evidence of records, generally understood causation rationale supported by accepted standards and literature in the medical community, and biologically plausible scientific rationale do not support a connection with service. Based on the above, the Board finds that a preponderance of the evidence is against the claims. Indeed, although service treatment records confirm the excision of a ganglion cyst from the left wrist, no residual was found (other than the scarring) and clinical evaluation at separation was normal. As the February 2016 VA examiner determined, this supports that the Veteran’s ganglion cyst was resolved without residual before the end of service period. Moreover, the Board affords the February 2016 VA examiner’s opinion significant probative value since it was offered by medical professionals following a review of the claims file and application of relevant medical principles to the facts of the case, with rationales consistent with the evidence of record. See Nieves-Rodriguez, supra. To the extent either examiner failed to fully support every aspect of any of each conclusion, it is clear that the examiner had a complete understanding of the pertinent evidence, reviewed the entire claims file and considered the appellant’s contentions. See Monzingo, supra; Acevedo, supra. The Board notes that the medical treatment records for the period from August 1988 to August 2013 were associated with the claims file after the February 2016 VA examination. However, the Board finds that this evidence does not add any information material to determination of a nexus between osteoarthritis of the left wrist and the Veteran’s service; the medical treatment records refer to additional incidents of left wrist injury in 2005, but the evidence does not raise a possibility that this left wrist injury is related to the in-service ganglion cyst removal. The Board acknowledges the competent and credible lay statements from the Veteran regarding symptomatology. Nevertheless, to the extent that the Veteran attributes his disability to service, he is not competent to opine on the etiology of a complex medical condition such as arthritis, and his statements are therefore afforded no weight. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). In sum, the most probative evidence of record shows that the current left wrist disability is not incurred in service and is not caused or aggravated by service-connected disability. Further, as stated above, no osteoarthritis of the left wrist was compensably disabling within one year of separation from service. 38 C.F.R. § 3.309 (a). The Board also observes that the most probative evidence indicates that osteoarthritis of the left wrist did not exist and were not “noted” in service or within one year of separation from service. Thus, the provisions of 38 C.F.R. § 3.303 (b) pertaining to chronicity or continuity of symptomatology are not for application. Accordingly, the claims must be denied. In reaching this decision the Board considered the doctrine of reasonable doubt, however, as the preponderance of the evidence is against the claims, (other than residual scarring) the doctrine is not for application. 38 U.S.C. § 5107. REASONS FOR REMAND 1. The issue of entitlement to service connection for a right knee disability is remanded. The Veteran contends that he has a current right knee disability that is caused by an in-service injury where he twisted his right knee. A November 1977 service treatment record shows that the Veteran had pain on palpation of medial collateral ligament and diagnosed with strain. In March 1978, the Veteran twisted his right knee in the medial aspect while playing basketball. An August 1986 An April 1986 post-service treatment record shows that the Veteran was diagnosed with chondromalacia of the right knee. In February 2009, the Veteran injured the right knee. In June 2009, the Veteran was diagnosed with degenerative joint disease of the right knee. In July 2009, the Veteran underwent repair of torn meniscus of the right knee. His right knee condition has been well documented since this surgery as evidenced by the medical records following this surgery to the present. An October 2013 MRI of the right knee shows that the veteran has chondromalacia in the right knee. None of the medical opinions associated with the claims file addresses whether the Veteran’s right knee chondromalacia, first diagnosed in 1986, is related to his service. Upon remand, such medical opinion must be obtained. Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991). The matters are REMANDED for the following action: Obtain an addendum medical opinion from an appropriate clinician addressing (a) whether chondromalacia of the right knee, diagnosed in 1986, is at least as likely as not related to an in-service injury, event, or disease, to include the twisting injury in service; and   (b) whether it is at least as likely as not (1) proximately due to service-connected disability, to include left knee disability, or (2) aggravated by service-connected disability, to include left knee disability. MICHAEL D. LYON Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Y. Taylor, Associate Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential, and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.