Citation Nr: 20042437 Decision Date: 06/23/20 Archive Date: 06/23/20 DOCKET NO. 17-48 621 DATE: June 23, 2020 ORDER Service connection for right knee patellofemoral syndrome is granted. Service connection for left knee patellofemoral syndrome is granted. REMANDED Entitlement to service connection for traumatic brain injury (TBI) is remanded. FINDINGS OF FACT 1. The Veteran’s current right knee patellofemoral syndrome was incurred coincident with his active service. 2. The Veteran’s current left knee patellofemoral syndrome was incurred coincident with his active service. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for right knee patellofemoral syndrome have been met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a). 2. The criteria for entitlement to service connection for left knee patellofemoral syndrome have been met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from October 1997 to October 2001 in the Marines and from May 2002 to January 2006 in the Army. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a January 2017 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO). In March 2020, the Veteran testified before the undersigned at a Travel Board hearing at the Portland, Oregon RO and a transcript of that proceeding is of record. 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–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)). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107(b). The Board has reviewed all the evidence in the Veteran's claims file, with an emphasis on the evidence relevant to this appeal. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (holding that VA must review the entire record but does not have to discuss each piece of evidence). Therefore, the Board will summarize the relevant evidence where appropriate and the Board's analysis below will focus specifically on what the evidence shows, or fails to show, as to the claims decided herein. Lay statements may serve to support a claim for service connection by supporting the occurrence of events subject to lay observation or the presence of disability or symptoms of disability subject to lay observation. 38 U.S.C. § 1153(a); 38 C.F.R. § 3.303(a); Jandreau v. Nicholson, 492 F.3d 1372 (Fed Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006). Although lay persons are competent to provide opinions on some medical issues, some issues fall outside the realm of common knowledge of a lay person. See Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011); see also Jandreau, 492 F.3d at 1372 (stating that lay persons not competent to diagnose cancer). Entitlement to service connection for bilateral patellofemoral syndrome The Board notes that the Veteran was diagnosed with patellofemoral syndrome of the bilateral knees at an October 2016 VA examination. 10/26/2016 C&P Exam. Accordingly, the Board finds that the Veteran has a current disability, which thereby satisfies the first element of a claim of entitlement to service connection. The Board further notes that it is undisputed that the Veteran had repeated complaints of chronic bilateral knee pain while on active service. See 01/20/2006 STR – Medical. Notably, the Veteran’s service treatment records (STRs) contain a December 2002 diagnosis of bilateral patellofemoral syndrome. See id. at 58. Regarding nexus, the October 2016 VA examiner opined that the Veteran’s current patellofemoral syndrome of the bilateral knees was less likely than not related to his active military service. 10/26/2016 C&P Exam. The examiner’s rationale was that although the Veteran’s current diagnosis was similar to his in-service diagnosis in 2002, he had not shown that he had a chronic knee condition present since service. See id. Here, however, the Board finds that the October 2016 examiner did not address the Veteran’s lay statements regarding continuing symptoms since separation from active duty service. Further, the examiner failed to address the Veteran’s reports of swollen, stiff, or painful joints contained in his June 2003 Post-Deployment Health Assessment. 01/20/2006 STR – Medical at 72. As such, the Board finds that the October 2016 opinion is inadequate. At the Veteran’s March 2020 Board hearing, he testified, in sum, that he has suffered from chronic bilateral knee pain, as well as numbness, popping, aching, and weakness in the bilateral knees. See 05/01/2020 Hearing Transcript. He testified that he began to experience these symptoms in service, and they have continued through the present. In weighing the Veteran’s testimony, the Board notes that the Veteran is competent to assert the presence of symptoms subject to lay observation, in this case localized pain, numbness, and weakness in his knees. The Board finds that the Veteran is highly credible in this regard as his current diagnosis and associated symptoms mirror the reports contained in his STRs. Given the fact that there is no adequate nexus opinion of record, the Board finds that the evidence of record, including the Veteran’s credible statements regarding continuing symptoms since separation, supports a grant of service connection for bilateral patellofemoral syndrome of the knees. See 38 C.F.R. § 3.303(a) (stating that service connection must be considered on the basis of the places, types, and circumstances of the Veteran’s service as shown by service records, the official history of each organization in which he served, his medical records, and all pertinent medical and lay evidence); see also Jandreau, 492 F.3d at 1372; and Buchanan, 451 F.3d at 1336. After a careful review of the record, the Board finds that that the competent evidence is at least in equipoise regarding a finding that the Veteran’s bilateral patellofemoral syndrome was incurred coincident to his active military service. 38 C.F.R. § 3.102, 3.303(a). Accordingly, entitlement to service connection for bilateral patellofemoral syndrome is granted. REASONS FOR REMAND Entitlement to service connection for TBI The Veteran seeks service connection for TBI, which he contends is the result of head injuries he suffered while deployed in Kosovo, Afghanistan, and Iraq. At his March 2020 Board hearing, the Veteran and his wife testified that he has current residuals of his in-service TBI, to include headaches, tinnitus, bilateral hearing loss, dizziness, and memory loss. See 05/01/2020 Hearing Transcript. The Veteran is in receipt of the Marine Combat Action Ribbon; therefore, an in-service injury is established as consisted with such service. See 09/12/2014 DD 214. Furthermore, at a June 2017 VA examination, the Veteran was diagnosed with TBI. 06/05/2017 C&P Exam. As such, the record shows the Veteran has a current diagnosis of TBI and an in-service incurrence. Thus, the first two elements of a claim of entitlement to service connection are established, and the sole question before the Board is whether a nexus exists between the Veteran’s TBI and his active military service. However, the Board finds that a remand is necessary because the June 2017 medical opinion is inadequate. When VA obtains a medical opinion, the duty to assist requires that VA ensure it is adequate. See Barr v. Nicolson, 21 Vet. App. 303 (2007).   Here, the VA examiner failed to consider relevant evidence of record, including evidence of the Veteran’s positive TBI screening in February 2015, where he reported memory loss, sensitivity to bright light, irritability, and sleep problems. See 05/10/2017 CAPRI at 314. Moreover, the VA examiner opined that the behavioral problems detailed in the Veteran’s wife’s June 2017 statement were “medically unlikely to be related to the Veteran’s mTBI and more medically likely related to history of severe PTSD and depression.” 06/05/2017 C&P Exam. No further explanation was given as to how the examiner reached this conclusion. Mere conclusions by a medical doctor are insufficient to allow the Board to make an informed decision as to what weight to assign the opinion. See Stefl v. Nicholson, 21 Vet. App. 120, 125 (2007) (holding that "the mere conclusion by a medical doctor is insufficient to allow the Board to make an informed decision as to what weight to assign to the doctor's opinion"). Finally, the Board notes that neuropsychological testing was not performed at the June 2017 VA examination, but the examiner provided no explanation as to why such testing was not indicated for the Veteran. On remand, the Veteran is to be provided with another VA TBI examination that includes neuropsychological testing, or the examiner is to explain why such testing is not appropriate or necessary to assess the nature and etiology of his TBI. This matter is REMANDED for the following action: Schedule the Veteran for an appropriate VA TBI examination to be conducted by one of the four designated specialists (physiatrist, psychiatrist, neurologist, or neurosurgeon) to assess the nature and etiology of the Veteran’s TBI. The entire claims file must be made available to and be reviewed by the examiner. Any indicated tests and studies should be accomplished, or an explanation provided as to why they medically appropriate or necessary. All clinical findings must be reported in detail and correlated to a specific diagnosis. An explanation for all opinions expressed must also be provided. First, the examiner must determine if the Veteran has a current diagnosis of TBI. If one is not found, the examiner must address the prior positive TBI diagnoses at the June 2017 VA examination and February 2015 positive TBI screening. See 06/05/2017 C&P Exam and 05/10/2017 CAPRI at 314. Second, if the Veteran has a present diagnosis of TBI, the examiner must provide an opinion regarding whether it is at least as likely as not (50 percent or greater probability) that the residuals of TBI had their onset in, or are otherwise related to, the Veteran’s active service. Note: An in-service event is established as consistent with the Veteran’s service and him being awarded the Marine Combat Action Ribbon. Third, the examiner must address the following: 1) the Veteran’s and his wife’s testimony at the March 2020 Board hearing; 2) the June 2017 VA examination; 3) the February 2015 TBI screening; 4) the Veteran’s February 2017 lay statement; and 5) the Veteran’s wife’s June 2017 lay statement. See 06/05/2017 C&P Exam; 05/10/2017 CAPRI at 314; 02/03/2017 Lay Statement; 06/16/2017 Lay Statement. The examiner must specifically address the Veteran’s reports of headaches, tinnitus, bilateral hearing loss, dizziness, and memory loss since service, and his wife’s reports of personality changes and behavioral problems. See 05/01/2020 Hearing Transcript. A comprehensive rationale for all opinions is to be provided. All pertinent evidence, including both lay and medical, should be considered. If an opinion cannot be given without resorting to speculation, the examiner should explain why and state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), the record (additional facts are required), or the examiner (does not have the knowledge or training). Paul Sorisio Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board T. Tremont, Law Clerk 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.