Citation Nr: 20005302 Decision Date: 01/22/20 Archive Date: 01/22/20 DOCKET NO. 16-13 168 DATE: January 22, 2020 ORDER Entitlement to service connection for a left knee disability is denied. FINDING OF FACT The evidence of record does not establish that the Veteran’s left knee disability is proximately due to or aggravated by his service-connected right knee disability or bilateral pes planus disability. CONCLUSION OF LAW The criteria for service connection for a left knee disability have not been met. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served active duty in the United States Marine Corps from September 2000 to May 2004. In August 2017, the Veteran testified before the undersigned Veterans Law Judge at a Video Conference hearing. A copy of the transcript has been associated with the claims file. In November 2017, the Board denied the claim of service connection for a left knee disability. The Veteran filed a timely appeal to the Court of Appeals for Veterans’ Claims (Court). In a May 2019 Memorandum Decision, the Court vacated the November 2017 Board decision regarding this issue and remanded the appeal to the Board for further development. In October 2019, the Board remanded the appeal for further development. Service connection for a left knee disability The Veteran contends that his left knee disability is due to his period of service, to include as due to his service-connected right knee disability and/or bilateral pes planus. At the outset, the Board notes that the Veteran’s service treatment records are silent on treatment for or complaints of a left knee disability. As the Veteran has not met the criteria for direct service connection, the analysis will move to secondary service connection. The question for the Board is whether the Veteran has a current disability that is proximately due to or the result of, or is aggravated beyond its natural progress by service-connected disability. The Board concludes that, while the Veteran currently has left knee patellofemoral pain syndrome, the preponderance of the evidence is against finding that the Veteran’s right knee disability and/or bilateral pes planus is proximately due to or the result of, or aggravated beyond its natural progression by service-connected disability. 38 U.S.C. §§ 1110, 1131; Allen v. Brown, 7 Vet. App. 439 (1995) (en banc); 38 C.F.R. § 3.310(a). Service connection is warranted where the evidence of record establishes that a particular injury or disease resulting in disability was incurred in the line of duty in the active military service or, if pre-existing such service, was aggravated thereby. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Service connection may be established for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that disease was incurred in service. 38 C.F.R. § 3.303(d). Generally, to prevail on a claim of service connection on the merits, there must be competent evidence of (1) 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 or other competent evidence of a nexus between the claimed in-service disease or injury and the present disease or injury. See Hickson v. West, 12 Vet. App. 247 (1999); Jandreau v. Nicholson, 492 F.3d at 1372. Service connection may also be granted for a disability that is proximately due to, or aggravated by, service-connected disease or injury. 38 C.F.R. § 3.310. Turning to the evidence, in a December 2006 VA medical treatment record, in observation of the Veteran’s leg length, the examiner noted slight difference of PSIS height and grossly left medial joint line more inferior. The examiner also noted no muscular atrophy and no antalgic gait. In a June 2008 VA medical treatment record, the Veteran reported pain described as a pinching or twisting sensation that was located inside the left knee. The Veteran also reported that the pain was intermittent and occurred with prolonged walking, standing, or climbing stairs. The Veteran denied any recent trauma. The examiner noted that the Veteran’s left knee pain was a relatively new complaint and likely was also secondary to biomechanical imbalance issues. The examiner stated, however, that examination was concerning for a possible lateral meniscal tear which warranted further evaluation. Therefore, the examiner ordered an X-ray and MRI. In a September 2008 VA medical treatment record, an examiner performed an MRI. The examiner stated that the Veteran had chronic bilateral knee and ankle or feet pain attributed to pes planus and altered biomechanics due to overpronation and genus varus with mild recurvatum. The examiner also reported that most of the pain was localized to the medial compartment of the left more than the right knee per the day’s history. The examiner reported MRI impressions of small bilateral suprapatellar joint effusions with no evidence of meniscal or ligamentous injury. The Board notes that, while this description suggests the reason for the Veteran’s knee pain, no reasons or bases were given in determining the conclusion for attribution reached. In a September 2012 VA examination, the examiner stated that the Veteran had no compensatory gait with walking and no canes or walker that would abnormally load the joints. The examiner also stated that there was no compensatory mechanism. The examiner further explained that the Veteran had foot problems bilaterally and he was braced. The examiner noted that this again was bilateral and therefore there was no compensation or loading from one side to the other. The examiner therefore concluded that the left knee was not at least as likely as not service-related to the right knee or aggravated by the right knee as the Veteran had balanced gait. The Board notes that the Veteran was afforded a VA examination in April 2014 for his knee disabilities; however, the examiner did not provide an opinion regarding the nature and etiology of the Veteran’s left knee disability. In a November 2015 VA addendum opinion, the April 2014 VA examiner noted that patellofemoral pain syndrome by its nature generally did not cause significant range of motion decrement and it had not been a cause of significant degenerative disease in the Veteran and, therefore, had not caused chronic antalgic gait. The examiner also noted that, though the Veteran had bilateral symptoms (which was extremely common in patients with patellofemoral pain syndrome), the fact that both knees were affected was not because one was mechanistically linked to the other but rather because the knees shared an underlying propensity for this condition. The examiner stated that this ‘shared propensity,’ however, was not because one knee was ‘causal’ for the other. The examiner therefore determined that the Veteran’s left knee disability was neither due to nor aggravated by his right knee patellofemoral pain syndrome. The examiner went on to state that the Veteran’s left knee patellofemoral pain syndrome was neither due to nor aggravated by his service-connected pes planus. The examiner explained that there was no mechanistic or anatomic relationship between the effects of pes planus and the alignment of the kneecap (the major effector of which was the thigh muscles). Thus, the examiner stated that there was no plausible mechanism for the Veteran’s contention of left knee disability due to his service-connected pes planus. In a May 2016 VA medical opinion, the examiner determined that it was less likely as not that the Veteran’s shin splints or hallux valgus caused or aggravated his left knee condition, and it was less likely as not that his orthopedic conditions combined had caused or aggravated beyond normal progression his left knee condition. The examiner explained that, as opposed to the commonly-held idea that “favoring one leg” caused orthopedic conditions in other parts of the body, there was no clear evidence from review of orthopedic literature to suggest that an injury to one lower extremity would have any significant impact on the opposite or the uninjured limb or the joints of the same limb unless the injury resulted in a major muscle or nerve damage causing partial or complete paralysis of the damaged leg, and/or shortening of the injured lower extremity resulting in a limb length discrepancy of more than five centimeters so that the individual’s gait pattern had been altered to the extent that clinically there was an obvious lurching type gait (a significant limp). The examiner went on to explain that, in order for this type of gait to have impact on the opposite or uninjured leg or other joints, it was likely that the abnormal gait or limp would need to be present over an extended period of time, in terms of years. The examiner stated that, rationally, it would seem that patients with painful orthopedic conditions would tend to be more cautious and gentle with less risk of trauma to the other joints. The examiner went on to state that she did not find sufficient evidence of a moderate or severe, lurching-type limp in the Veteran’s available records. The examiner summarized her opinion, stating that she found insufficient evidence in review of the available record and in review of medical literature which would indicate a causative or permanently aggravating nexus between the Veteran’s service-connected disabilities and his left knee disability. In an August 2017 hearing, the Veteran, through his representative, asserted that from 2006 to 2009, three different doctors stated that, his left knee was a relatively new complaint, and his right knee was also secondary to biomechanical imbalance issues. The Veteran’s representative also asserted that prior medical opinions were negative based on the premise that there were no gait issues or imbalance, even though the VA records noted such issues in December 2006, June 2008, and September 2008. In a November 2019 VA addendum opinion, the examiner opined that it is less likely than not that the Veteran’s left knee disability is proximately due to or the result of his service-connected right knee or bilateral pes planus. The examiner noted that the record was reviewed, and the Veteran has a diagnosis of left patellofemoral pain syndrome. The examiner noted that it is well documented as less than the right knee with the same diagnosis. The examiner reiterated that the Veteran was not seen in the service for the left knee and had no injury for the left knee while on active duty. The examiner also stated that the theory of service connection of left knee secondary to the right knee has been reviewed multiple times over multiple years by multiple people and denied because no mechanism for compensation has ever been found that would support the left knee disability in response to any load or imbalance from the service-connected right knee or the bilateral pes planus of the feet. The examiner stated that this review and prior examinations are consistent with showing that the Veteran has mild patellofemoral pain syndrome. The examiner noted that the history of this does not give exact etiology of the left knee. The examiner contrasted this with the right knee, noting that the right knee was symptomatic during service, and therefore was service-connected due to complaints in service. The examiner stated that review of the medical record was consistent with previous minimal findings from his examination of the Veteran in December 2017. Citing the Veteran’s medical history, the examiner noted that the Veteran also has multiple documentations of normal gait in the record, to include eleven separate VA examinations. The examiner stated that normal gait does not reveal any compensation, and therefore, the etiology of the left knee is less likely than not related to the right knee or the feet. The examiner further noted that the Veteran also has bilateral shin splints, and again, this is bilateral and does not affect gait for balance. He stated that it is less likely than not a cause of the Veteran’s patellofemoral pain syndrome of the left knee. The examiner stated that the most common listed etiology for patellofemoral pain syndrome is thought to be due to excessive patellofemoral joint pressure from poor kneecap alignment which, in time, affects joint surfaces behind the knee cap. Citing medical literature, the examiner stated that overuse, running or jumping, and sports that put repetitive stress on your knee joint, can cause irritation under the kneecap, muscle imbalances, or weaknesses. The examiner went on to explain that patellofemoral pain can occur when the muscles around the hip and knee do not keep the kneecap properly aligned. The examiner explained that inward movement of the knee during a squat has been found to be associated with patellofemoral pain. The examiner also observed that injury or trauma to the kneecap, such as a dislocation or fracture, has been linked to patellofemoral pain syndrome. The examiner further noted that knee surgery, particularly repair to the anterior cruciate ligament using your own patellar tendon as a graft, increases the risk of patellofemoral pain. Returning to the Veteran’s medical history, the examiner reported that the Veteran has no injuries from the pes planus, the shin splints, or the right knee. The examiner emphasized that the Veteran has normal gait and no muscle imbalances have ever been found on examination over the years of examinations. The examiner noted that the Veteran has had no injuries or surgeries to the left knee. Therefore, the examiner explained that the etiology of the left knee pain is likely the most common etiology - that the Veteran has increased pressure behind his knee cap in the patellofemoral compartment of the left knee due to his anatomical alignment with which he was born. The examiner reiterated that this is common and is less likely than not secondary to his service-connected disabilities, as he has normal gait with documentation for years by multiple examiners. The examiner stated that a baseline for the left knee disability could not be determined. The examiner explained that the Veteran’s left knee was not aggravated by the Veteran’s service-connected disabilities. The examiner stated that, during his examination of the Veteran in 2017, the Veteran reported that the right knee was much worse than the left, and the right was mild in severity. The examiner also noted that the Veteran has documentation for years without any gait abnormalities, and therefore, the left knee is not aggravated beyond normal progression as the patellofemoral pain syndrome is mild to minimum and as expected for its progression because he has minimal symptoms on examination with no symptoms on gait. The examiner stated that some progression in gait would be expected if there was any relationship to the right knee, the pes planus or shins, and no progression is found in gait changes. The examiner stated that without any progression in gait, there is no baseline other than normal activity and motion and stability. The examiner further found that it is less likely than not that the Veteran’s left knee disability is aggravated by his service-connected disabilities. The examiner explained that the left knee is independent of the service-connected disabilities and has etiology of his variant anatomical alignment causing pressure in patellofemoral compartment, and this is minimal but also a normal common complaint. The examiner stated that, in this case, he was born with this alignment as he has normal gait. Therefore, the examiner opined that it is less likely than not that the left knee is aggravated by service-connected disabilities. The Board finds the November 2019 VA addendum opinion to be adequate for the purposes of adjudicating the claim. The examiner offered definitive conclusions based in rationale that considered relevant materials, including the medical history of record and relevant medical literature. The examiner gave a conclusive opinion regarding the Veteran’s claimed disability with a detailed analysis of the bases for the opinions reached. Therefore, the Board has found the opinion to be highly probative in nature. The opinion gave factual basis supported by medical literature, findings from several prior examiners, and previous examination of the Veteran by the examiner. Moreover, the opinion provided reason as to why the Veteran’s left knee disability is not related to his service-connected disabilities and offered a more likely alternative etiology based on the Veteran’s medical history and current medical literature. After review of the record, the Board finds that the evidence weighs against a finding of service connection for the left knee. The medical evidence of record indicates that the Veteran’s left knee disability is not proximately due to, or aggravated by his service-connected right knee disability, bilateral pes planus or bilateral shin splints. The Board notes that the November 2019 VA medical addendum makes clear that the Veteran’s left knee disability is minimal or mild in the nature of its severity. It also establishes that the Veteran’s normal gait indicates that there is no evidence of compensation for the Veteran’s other service-connected disabilities. As such, the Veteran’s left knee disability is not proximately due to, the result of or aggravated by the Veteran’s service-connected right knee, bilateral pes planus or bilateral shin splints. Therefore, service connection for a left knee disability is not warranted. The Veteran believes his left knee disability is proximately due to or the result a service-connected disability. The Veteran in this case is not competent to provide a nexus opinion regarding this issue. The issue is medically complex, as it requires knowledge of anatomical relationships. Therefore, it is outside the competence of the Veteran in this case because the record does not show that he has the skills or medical training to make such a determination. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007); see also Kahana v. Shinseki, 24. Vet. App. 428 (2011). Consequently, the Board gives more probative weight to the November 2019 VA addendum opinion. JENNIFER HWA Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board C. Ford 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.