Citation Nr: 20068340 Decision Date: 10/21/20 Archive Date: 10/21/20 DOCKET NO. 14-06 211 DATE: October 21, 2020 ORDER Entitlement to service connection for a left knee disability, to include as secondary to residuals of a right distal femur stress fracture, is denied. FINDING OF FACT A left knee disability was not manifested in service; arthritis of the left knee was not manifested within a year following the Veteran’s separation from service in April 1979; and any current left knee disability is not shown to be etiologically related to his service or to have been caused or aggravated by his service-connected residuals of a right distal femur stress fracture. CONCLUSION OF LAW Service connection for a left knee disability, to include as secondary to service-connected residuals of a right distal femur stress fracture, is not warranted. 38 U.S.C. §§ 1110, 1112, 1131, 1137, 5107; 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The appellant is a Veteran who served on active duty from September 1988 to April 1989 and from January 6, 1999 to February 5, 1999. This matter is before the Board of Veterans’ Appeals (Board) on appeal from an August 2012 rating decision. In July 2015, a Travel Board hearing was held before the undersigned; a transcript is in the record. In September 2015, December 2017, and July 2019, the Board remanded the claim for additional development. [The September 2015 Board decision also dismissed appeals seeking a rating in excess of 10 percent for residuals of a stress fracture of the right distal femur and entitlement to a total disability rating based on individual unemployability (TDIU) as the Veteran had withdrawn his appeals in those matters.] Entitlement to service connection for a left knee disability, to include as secondary to residuals of a right distal femur stress fracture, is denied. In November 2011, the Veteran filed a claim for entitlement to service connection for a left knee condition. He contends that the left knee disability resulted from his placing more strain on his left knee due to favoring his right leg. See 2015 Board Hearing Transcript. Legal Criteria Service connection may be granted for disability due to disease or injury incurred in or aggravated by active military service. 38 U.S.C. §§ 1110,1131; 38 C.F.R. § 3.303. Service connection may be granted for any disease initially diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). To substantiate a claim of service connection, there must be evidence of: a present disability (for which service connection is sought); incurrence or aggravation of a disease or injury in service; and a causal relationship between the claimed disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Where a veteran served 90 days or more of continuous, active service and a chronic disease, such as arthritis, becomes manifest to a degree of 10 percent within a year following the date of separation from such service, the disease shall be presumed to have been incurred in service even though there is no evidence of such disease during the period of service. 38 U.S.C. §§ 1112, 1137; 38 C.F.R. §§ 3.307, 3.309. Secondary service connection may be established for a disability that is proximately due to, or the result of, or aggravated by a service-connected disease or injury. To substantiate a claim of secondary service connection there must be evidence of: (1) a current disability (for which secondary service connection is sought); (2) an already service connected disability; and (3) that the current claimed disability was either (a) caused or (b) aggravated by the already service connected disability. 38 C.F.R. § 3.310(a); see also Allen v. Brown, 7 Vet. App. 439 (1995). The determination as to whether these requirements are met is based on analysis of all the evidence of record and an evaluation of its credibility and probative value. Baldwin v. West, 13 Vet. App. 1 (1999); 38 C.F.R. § 3.303(a). When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. When all of the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a fair preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). Factual Background Service treatment records (STRs) for the Veteran’s two periods of service show that he sought treatment for right knee, right hip, and right groin pain in October 1988. A November 1998 medical evaluation board (MEB) report notes a diagnosis of “healing stress fracture, distal one-third of the right femur” and that the Veteran is still complaining of right leg pain, walking with a limp, using a cane, and attending physical therapy while recovering from his injury with an expectation of another six months until he achieves a full recovery. A February 1989 physical evaluation board (PEB) evaluated the Veteran’s medical and physical impairment. The PEB considered the MEB’s findings and recommended separation from service based on his healing stress fracture of his right distal femur. The MEB records, PEB records, January 1989 separation examination, and January 1989 report of medical history are silent for any left knee issues. Prior to the Veteran’s second period of service, he reported no residual problems attributed to a prior right distal femur stress fracture in-service. A 1998 report of medical history and the entrance examination are silent for any left knee issues. He also submitted a private orthopedic opinion noting his ability to jog almost a mile daily, duck walk without any significant problem, squat completely, and walk on tiptoes as well as on heels; the provider opined that the Veteran would be able to engage in strenuous physical activity. After returning to basic training in January 1999, STRs show that he sought treatment for “painful knees and knee joints” and received a diagnosis of a “knee stress fx” based on x-rays. The record is silent for a separation examination for his second period of service. Private medical records show that July 2012 and April 2013 x-rays found mild osteoarthritis of the left knee and note the Veteran’s reports that his body ached, and of bilateral knee arthralgias. See e.g. February 2012, November 2013 Private Medical Records. Based on his reports of chronic pain, diffusive arthritis throughout his body, and abnormal labs, the Veteran was referred to a rheumatology clinic where he underwent testing for Sjogren’s Syndrome (SS) that yielded a positive test result. See September 2012 Private Treatment Records. The Veteran’s treating provider for his SS noted in April 2013 that his condition remained symptomatic despite his regimen of treatment and that his arthralgias are secondary to his osteoarthritis. The Veteran also reported bilateral knee pain on a state disability examination and received a diagnosis of patellofemoral pain syndrome. See July 2012 Private Treatment Records. On November 2012 VA (knee) examination, left knee osteoarthritis was diagnosed. The examiner noted a history of developing knee pain while running in basic training (in 1999) and his subsequent discharge for knee pain evaluated as an overuse/early stress fracture. After discharge, the Veteran reported to the examiner that he worked as an LPN in nursing homes, hospitals, and in a jail. He eventually developed pain in both hips and knees resulting in his quitting work in 2010 due to “arthritis all over.” His primary care provider referred him to a rheumatologist who evaluated him and diagnosed SS. The examiner opined that it was less likely than not the Veteran’s left knee condition was incurred in or caused by the claimed injury, event, or illness in service. The examiner noted that during his first enlistment the Veteran had right hip and knee pain with onset attributed to running during basic training. X-rays from the first period of service are consistent with a stress fracture of the (right) distal femur. The examiner noted that the Veteran’s reenlistment packet in 1998 included a letter from a private orthopedic surgeon to the military entrance processing station (MEPS) stating that the previous fracture was healed, and the Veteran was suitable for military service. The examiner acknowledged that the Veteran’s second period of service ended after he reported bilateral knee pain and received a diagnosis of “overuse/early stress fracture.” The examiner noted that the record is silent for any treatment within one to two years after his second discharge, and noted that his recent developments of diffuse joint pains are general osteoarthritis. The examiner cited to his rheumatology evaluation and diagnosis of SS as the likely cause of the arthritis. The examiner explained that SS is a chronic inflammatory disorder characterized by diminished lacrimal and salivary gland function, which occurs in a primary form not associated with other diseases and in a secondary form that complicates other rheumatic conditions. The examiner opined that it is more likely that the Veteran has a rheumatic condition, than he a chronic condition due to overuse/early stress fracture because the overuse and stress fractures typically heal when heavy exertion stops. The examiner explained that the veteran’s clinical presentation of diffuse arthritis in nearly all of his joints is not consistent with originating in his service-connected injuries. At a July 2015 Board hearing, the Veteran’s representative clarified that they only wished to proceed with the appeal of left knee osteoarthritis. The Veteran testified that he wears a brace on his left knee and believes his stress fractures in-service caused or aggravated his left knee condition. He acknowledged the absence of a limp, but stated his belief that he favors his right side thereby placing more strain on his left side to compensate. He related that he started treatment for a left knee condition with a rheumatologist four years ago. On November 2017 VA (knee) examination the examiner opined that it is less likely than not that the Veteran’s left knee condition is proximately due to or the result of his service-connected residuals of a right distal femur stress fracture. The examiner noted the Veteran’s report that his knee pain started over the past two years and that he attributes this pain to his service-connected residuals of a right distal femur stress fracture. The examiner cited the 1998 private orthopedic letter stating that he was fully healed prior to his second period of service. The examiner acknowledged that it is possible that physical training during his reenlistment led to overuse of his knees and aggravation of the stress fracture, but opined that once he was separated from service in 1998 there then should have been no further stress fracture problems as these minute fractures heal without residuals once the intense stress of physical training ceases. The examiner indicated that there should be no clinical residuals from a stress fracture over 25 years ago, and opined that the degenerative joint disease of the knees diagnosed in 2013 cannot be related to an old healed stress fracture in the distant past. The examiner further opined that without an antalgic gait there is mechanism for a healed stress fracture to impact on the development of degenerative joint disease in the knees. VA treatment records show that the Veteran’s left knee condition continued to worsen during resulting in a slight antalgic gait that required a left knee replacement in June 2018. See November 2017, March 2018, May 2018, July 2018 VA Treatment Records. On January 2020 VA (knee) examination, the examiner noted the 2013 diagnosis of degenerative left knee arthritis. Regarding direct service connection, the examiner noted the Veteran’s in-service history and his belief that stress fractures in-service caused his degenerative arthritis. The examiner opined that stress fractures were documented in the right leg only in service and that the Veteran acknowledged that he did not seek care for a knee condition until 2013 when he received a degenerative joint disease diagnosis. The examiner concluded that given the single episode of overuse pain in service, the absence of any documentation of persistent or recurring knee pain until 2013, and the fact that stress reactions and shin splints involve the tibia and do not involve the knee joint per se, it is less likely than not that his current condition is related to his military service. Regarding aggravation, the examiner stated that the Veteran is service connected for impairment of the right femur. In order for his right leg disability to exert an adverse effect on his left knee, the Veteran’s gait would have to be antalgic [due to the right knee disability] thereby shifting weight abnormally to the contralateral extremity. The examiner opined that as the Veteran’s gait is normal, it is less likely than not that the Veteran’s left knee condition was aggravated beyond its natural progression by his service-connected right knee condition (residuals of a right distal femur stress fracture.) Legal Analysis As an initial matter, it is not in dispute that the Veteran now has left knee arthritis. VA treatment records, private treatment records, and VA examination reports show diagnoses of left knee arthritis. What he still must show to establish service connection for the left knee arthritis is that such disability is etiologically related to his service or (as claimed) is secondary to the service-connected residuals of a right distal femur stress fracture. There is no evidence that left knee arthritis was manifested during the Veteran’s first period of service or in the first postservice year. While the record establishes that he sustained a right distal femur stress fracture in 1988 that use of a cane while recovering, the record is silent for a left knee disability. An October 1998 entrance examination report and a November 1998 private opinion provided by the Veteran on seeking entry for a second period of service are silent for any left knee issues. Consequently, service connection on the basis the arthritis became manifest in service and persisted or on a presumptive basis (for arthritis as chronic disease under 38 U.S.C. § 1112) is not warranted. The Board notes that presumptive service connection does not apply to the Veteran’s second period of service in 1999 as the Veteran does not meet the requirement of serving ninety or more days on active duty. See 38 U.S.C. § 1112; 1137; 38 C.F.R. § 3.309(a); 38 C.F.R. § 3.307. What remains for consideration is whether a left knee disability is otherwise shown to be etiologically related to the Veteran’s service, or is secondary to his service-connected residuals of a right distal femur stress fracture. Regarding direct service connection, in the absence of a finding of continuity, as here, whether a left knee disability may be related to remote service is a medical question not capable of resolution by mere lay observation; it requires medical expertise. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). The only medical evidence in the record that directly addresses that question is in the opinions offered on the November 2013 and January 2020 VA examinations that are against the Veteran’s claim. The examiners cited to supporting factual data, and cumulatively they identified a more likely etiology for the current left knee disability, i.e., his SS which was diagnosed and treated by his private rheumatologist. The November 2013 and January 2020 opinions reflect the examiners’ familiarity with the entire record and the Board finds them highly probative evidence in this matter. In the absence of competent evidence to the contrary, the Board finds them persuasive. Regarding secondary service connection, the Board acknowledges the Veteran’s statements that he believes he places more weight on his left side to compensate for his service-connected condition. See id. The only medical evidence in the record that directly addresses that question is in the opinions offered on November 2013, November 2017, and January 2020 VA examinations, each against the Veteran’s claim. The examiners cited to supporting factual data, and cumulatively identified a more likely etiology for the current left knee disability, i.e., the Veteran’s diffusive arthritis throughout his body and diagnosis with SS by his private rheumatologist. The Board acknowledges that VA treatment records document a slight antalgic gait in the fall of 2017 and in 2018 in the months leading up to his total knee replacement on his left knee. The records note the slight antalgic gait developed due to worsening of his left knee arthritis [not due to his service-connected residuals of a distal right femur stress fracture]. Furthermore, November 2017 and January 2020 opinions note the absence of an antalgic gait on examination, and the Veteran himself denied having an antalgic gait at the Board hearing. The VA opinions in the record reflect the examiners’ familiarity with the entire record and the Board finds them cumulatively highly probative evidence in this matter. In the absence of competent evidence to the contrary, the Board finds them persuasive. The Board acknowledges the Veteran’s belief that his current left knee disability is related to his service, and aggravated by his service connected condition. However, he is a layperson, and his own opinion is not competent evidence in this matter. Considering, the foregoing, the Board finds that the preponderance of the evidence is against the claim of service connection for a left knee disability; therefore, the benefit of the doubt rule does not apply. The appeal in the matter must be denied. GEORGE R. SENYK Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Michael Lederman, 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.