Citation Nr: 20056789 Decision Date: 08/27/20 Archive Date: 08/27/20 DOCKET NO. 14-41 115A DATE: August 27, 2020 ORDER Entitlement to service connection for bilateral knee degenerative joint disease is denied. FINDING OF FACT The Veteran’s bilateral knee degenerative joint disease (DJD) did not begin during active service or is not otherwise related to an in-service injury or disease. CONCLUSION OF LAW The criteria for service connection for bilateral knee DJD are not met. 38 U.S.C. §§ 1110, 1112, 1113, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from April 1975 to November 1976. This matter comes before the Board of Veterans’ Appeals (the Board) on appeal from an August 2011 rating decision of the Department of Veterans’ Affairs (VA) Regional Office (RO). This case was previously before the Board. The Veteran testified before the undersigned at a hearing in April 2018. A transcript of the hearing is of record. In July 2018, the Board remanded this case to in order to add Social Security Administration (SSA) documents to the record. Those documents, as well as private treatment records from Atrium Health, have been added to the file. The RO readjudicated the matter in light of this new evidence and denied the Veteran’s claim in an April 2020 Supplemental Statement of the Case (SSOC). The case was recertified to the Board in May 2020. The Veteran’s representative filed an appellate brief in August 2020. 1. Entitlement to service connection for bilateral knee DJD. The Veteran contends that his bilateral knee DJD began with injuries in basic training at Lackland Air Force Base in 1975. Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). Certain chronic diseases, including arthritis, will be presumed related to service if they: were shown as chronic in service; manifested to a compensable degree within a presumptive period following separation from service; or were noted in service (or within an applicable presumptive period) with continuity of symptomatology since service that is attributable to the chronic disease. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.303, 3.307, 3.309; Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2013). Arlington Orthopedics diagnosed the Veteran with left knee DJD in June 2004 and then with bilateral knee DJD in October 2004. He received pain management from primary provider E.J.T. at Atrium Health for his knee disability as recently as April 2019. As the Veteran has a current knee disability, the first element for service connection is met. The Veteran’s service treatment records (STRs) reflect knee injuries and treatment for weight management. He entered service in April 1975. In June 1975, he sought treatment for painful knees when running and was diagnosed with chondromalacia. Shortly after that, he was referred to a weight management program. He suffered a second knee injury and was enrolled in physical therapy on 18 February 1976. He completed treatment on 27 February 1976. In his final physical therapy record, the Veteran was identified as a 22 year old moderately obese male who made “good progress” with physical therapy. There are no further knee treatments or complaints in the Veteran’s STRs. He was discharged in November 1976. The Veteran was given the opportunity to report medical issues in his October 1976 separation report of medical history. He denied joint problems and trick or locked knee. His report of physical examination at separation in October 1976 documents normal clinical evaluation of his lower extremities. The Veteran was separated from service in November 1976. Therefore, the first question before the Board is whether there is a causal relationship between the current disability and in-service events. On review, the record does not contain reports of continued knee injury or treatment immediately following military separation. The Veteran testified that his first treatment for knee pain outside of the military occurred sometime in 1981. His first treatment after service, of record, is from Raleigh Orthopedics regarding a right knee injury playing football in November 1980. The Veteran’s wife provided an August 2009 statement that the Veteran had ceased waterskiing, hiking, and other sports due to knee and ankle pain when they met in April 1982. He returned to Raleigh Orthopedics for knee treatment in November 1984 after a fall and in March 1985 after twisting his leg. The first evidence of a chronic knee condition is a follow-up x-ray report in June 1985 noting “some osteoarthritic changes” in his right knee. The Veteran continued treatment with Cumberland Orthopaedic Associates, reporting acute injuries related to falls in January 1990 and March 1992. In February 1992, he returned to them for general knee pain that he attributed to old football injuries. There is no mention of military service or military service injuries. The Board notes that the treatment records from Raleigh Orthopedics and Cumberland Orthopaedic do not provide an opinion on or basis to establish a nexus. None of these records mention his time in service or injuries in the military. Rather, they all involve specific, acute injuries to the knee, generally citing weight as a relevant factor in injury and treatment. Although they are medical notes regarding bilateral knee treatment, they are not probative to the question at hand. The record also contains conflicting medical opinions regarding the Veteran’s current disability and its relationship with his active service. There is a March 2010 VA examination that found no relationship. However, there are two private provider notes that opine in favor of a connection between the in-service injuries, and the Veteran’s current disability. The probative value of medical opinion evidence is based on the medical expert’s personal examination of the patient, the physician’s knowledge and skill in analyzing the data, and the medical conclusion that the physician reaches. Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993). Whether a physician provides a basis for a medical opinion goes to the weight or credibility of the evidence in the adjudication of the merits. See Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998). Other factors for assessing the probative value of a medical opinion are the physician’s access to the claims folder and the thoroughness and detail of the opinion. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000); Nieves-Rodriguez, 22 Vet. App. 295 (2008); Prejean v. West, 13 Vet. App. 444, 448-9 (2000). The March 2010 VA examiner did not find a nexus after reviewing the Veteran’s STRs, private medical records, and performing a physical examination of the Veteran. He concluded that the Veteran’s current disability was less likely due to his in-service injury, and more likely due to his current obesity. He noted that the Veteran’s separation physical contained no mention of joint problems and there were no treatment records for bilateral knee DJD prior to 2005. The Veteran submitted two statements regarding nexus from private providers. In May 2012, orthopedist P.W.G. stated that there are several factors, including in-service injuries, age, and weight, that contribute to the Veteran’s current disability. There is no indication that P.W.G. reviewed the Veteran’s STRs before making that statement, no rationale explaining the finding, and no further clarification on which factors are more significant than others. However, P.W.G. also opined for the Veteran in regards to his SSA claim in January 2010. In that opinion, P.W.G. stated that the Veteran had degenerative arthritis "severely aggravated by tremendous weight." His SSA opinion does not mention the Veteran’s military injury or service. In July 2018, physician assistant R.T. filled out a VA knee examination form and medical opinion form concluding that the Veteran’s current disability was more likely than not caused by his in-service injuries. R.T. marked “no records reviewed,” on the VA examination form, indicating he did not review the Veteran’s record in any manner prior to offering his opinion. Notably, the Veteran also submitted a June 2018 memorandum from primary care physician E.J.T. That provider acknowledged that the Veteran’s in-service knee injuries happened and stated that the Veteran’s current knee problems affect his obesity. He does not provide an opinion regarding nexus but suggests that the two conditions may aggravate each other. There is also no evidence that E.J.T. reviewed the Veteran’s case file or STRs before making his assertion. As such, the Board does not consider this memorandum to be probative to question of causality because it does not directly address that issue. The Board finds that the medical opinions from P.W.G. and R.T. less probative than the VA examiner’s opinion because they do not reference the Veteran’s case file and their rationales are less thorough. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008); Reonal v. Brown, 5 Vet. App. 458, 460-61 (1993). The VA examiner reviewed the Veteran’s case file, medical records, and provided a rationale for his findings. P.W.G.’s access to the case file is unknown, and R.T. stated that he made no records review. Neither private opinion articulates a rationale for finding a favorable nexus. P.W.G.’s memorandum notes that age and weight also contribute to the Veteran’s disability, but his January 2010 SSA statement makes clear that the Veteran’s weight is a major aggravating factor. As such, the evidence against a nexus is more probative than the evidence supporting one. The Board finds a preponderance of the evidence weighs against finding that the Veteran’s diagnosis of bilateral knee DJD began during service or is otherwise related to an in-service injury, event, or disease. Therefore, the second question before the Board is whether the Veteran’s bilateral knee DJD manifested to a compensable degree within one year of discharge from service, or was noted in service (or within an applicable presumptive period) with continuity of symptomatology since service that is attributable to the chronic disease. The Board finds that the Veteran’s disability was not shown as chronic in service, did not manifest to a compensable degree within a presumptive period, and was not noted in service with attributable continuity of symptomatology. The Veteran had knee injuries in service, but he received and completed treatment. He did not mention any residual pain or lasting impairment in his separation examination. He was not diagnosed with any form of arthritis until June 1985, nearly a decade after discharge. Between separation and his arthritis diagnosis, he was treated for multiple acute knee injuries. His treatment notes do not reflect any complaints regarding service or injuries in service. His current disability was diagnosed in October 2004, twenty-eight years after military separation. The Board recognizes that the Veteran testified to knee pain since basic training, and that the Veteran is competent to report evidence within his personal knowledge, such as pain and symptom onset. See Charles v. Principi, 16 Vet. App. 370, 374-75 (2002); Layno v. Brown, 6 Vet. App. 465, 469 (1994). However, the Board finds the reports of continuity of symptomatology not credible. The Veteran's reports are inconsistent with his statements in contemporaneous treatment records, which report football, falls, and other causes for knee pain, without any mention of military service. This is particularly notable in the medical notes from the early 1980s, close to when the Veteran separated from service. While the Veteran believes his bilateral knee DJD is related to an in-service injury, event, or disease, he is not competent to provide a nexus opinion in this case. The issue is medically complex, as it requires knowledge of pathology absent an immediate cause-and-effect relationship. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). Consequently, the Board gives more probative weight to the competent medical evidence. For the reasons stated above, the Board finds that the preponderance of evidence is against the Veteran's claim of entitlement to service connection for bilateral knee DJD and his appeal must be denied. There is no reasonable doubt to be resolved as to this issue. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. 49. JAMES G. REINHART Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board W. Stearns, 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.