Citation Nr: 21003606 Decision Date: 01/22/21 Archive Date: 01/22/21 DOCKET NO. 10-28 150 DATE: January 22, 2021 ORDER Entitlement to an increased rating in excess of 10 percent for tendonitis of the right wrist is denied. Entitlement to service connection for a right knee disability, to include patellofemoral syndrome, is denied. Entitlement to service connection for a left knee disability, to include patellofemoral syndrome, is denied. FINDINGS OF FACT 1. The Veteran’s right wrist tendonitis manifests with pain and weakness but does not cause ankylosis. 2. The Veteran’s current right knee disability, to include patellofemoral syndrome and superior patellar enthesopathy, did not onset in service is not etiologically related to service. 3. The Veteran’s current left knee disability, to include patellofemoral syndrome and superior patellar enthesopathy, did not onset in service is not etiologically related to service. CONCLUSIONS OF LAW 1. The criteria for entitlement to an increased rating in excess of 10 percent for tendonitis of the right wrist have not been met. 38 U.S.C. § 1155, 5107; 38 C.F.R. §§ 3.321, 4.1, 4.40, 4.45, 4.71a, Diagnostic Code 5024. 2. The criteria for entitlement to service connection for a right knee disability have not been met. 38 U.S.C. §§ 1110, 1131, 5103A, 5107; 38 C.F.R. §§ 3.159, 3.303, 3.304, 3.307, 3.309. 3. The criteria for entitlement to service connection for a left knee disability have not been met. 38 U.S.C. §§ 1110, 1131, 5103A, 5107; 38 C.F.R. §§ 3.159, 3.303, 3.304, 3.307, 3.309. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from September 1977 to September 1979 and August 1981 to September 1996. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a July 2008 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Indianapolis, Indiana. In February 2018, the Board reopened the Veteran’s claim for service connection for a right and left knee disability and remanded her service connection claim and her claim for an increased rating for her right wrist disability for additional development. The claim has since been returned to the Board for further appellate action. The Board is satisfied there was substantial compliance with its remand orders. See Dyment v. West, 13 Vet. App. 141, 146-47 (1999); Stegall v. West, 11 Vet. App. 268, 271 (1998). 1. Entitlement to an increased rating in excess of 10 percent for tendonitis of the right wrist Disability evaluations are determined by evaluating the extent to which a Veteran’s service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities. The percentage ratings represent as far as can practicably be determined the average impairment in earning capacity resulting from such diseases and injuries and the residual conditions in civilian occupations. Generally, the degree of disabilities specified are considered adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the several grades of disability. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities and the criteria for specific ratings. If two disability evaluations are potentially applicable, the higher evaluation will be assigned to the disability picture that more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability will be resolved in favor of the Veteran. 38 C.F.R. § 4.3. However, the evaluation of the same disability under various diagnoses, known as pyramiding, is to be avoided. 38 C.F.R. § 4.14. The Veteran currently has a 10 percent rating for right wrist tendonitis under Diagnostic Code 5024. Diagnostic Code 5024 for tenosynovitis instructs that the condition should be rated as limitation of motion of the affected part, as arthritis under Diagnostic Code 5003. 38 C.F.R. § 4.71a. Under Diagnostic Code 5003, degenerative arthritis established by X-ray findings is rated based on limitation of motion under the appropriate diagnostic code for the joint or joints involved. If limitation of motion is noncompensable, a 10 percent rating may be assigned for each major joint or group of minor joints affected by limitation of motion, to be combined, not added. Without limitation of motion, a 10 percent rating applies where there is X-ray evidence of the involvement of two or more major joints or minor joint groups. A 20 percent rating applies where there is X-ray evidence of the involvement of two or more major joints or minor joint groups, with occasional incapacitating exacerbations. 38 U.S.C. § 4.71a, Diagnostic Code 5003. Note (2) instructs, however, that the 20 percent and 10 percent ratings based on X-ray findings, above, will not be utilized in rating conditions listed under diagnostic codes 5013 to 5024, inclusive. Id. Diagnostic Code 5215 pertains to limitation of motion of the wrist. A maximum 10 percent rating is provided for limited palmar flexion and limited dorsiflexion of the wrist. As the Veteran is already in receipt of a 10 percent rating, a higher evaluation is not possible under this code. Higher ratings are possible under Diagnostic Code 5214 for ankylosis of the wrist, but the record clearly shows that the Veteran’s right wrist is not ankylosed. On VA examination in July 2012 the Veteran reported pain in her right wrist when she lifts something. She reported weakness that prevents her from picking up heavy objects. Range of motion testing was normal as was muscle strength on flexion and extension. Upper extremity nerve testing was normal. Imaging was unremarkable. At a May 2018 Board hearing the Veteran reported that she has weakness in her right wrist and cannot lift heavy objects like a pot. On VA examination in April 2019, the examiner indicated no loss of range of motion with palmar flexion, dorsiflexion, or radial deviation, but stated that ulnar deviation was limited to 30 degrees on testing. No pain was noted on examination, and the Veteran was noted to report no wrist pain associated with movement. The Veteran reported weakness in her wrist preventing her from lifting anything more than 10 pounds. The Board acknowledges the pain and difficulties lifting heavy objects reported by the Veteran but finds that a rating in excess of 10 percent is not warranted. The Board finds that the functional loss reported by the Veteran and shown by the evidence is contemplated by the 10 percent rating assigned. Even factoring pain and flare-ups, the evidence does not reflect the condition more nearly approximates ankylosis. Therefore, entitlement to a rating in excess of 10 percent for right wrist tendonitis is denied. Service Connection 2. Entitlement to service connection for a right knee disability, to include patellofemoral syndrome 3. Entitlement to service connection for a left knee disability, to include patellofemoral syndrome The Veteran contends that her current right and left knee disabilities were caused by her service. Specifically, she has alleged that her current knee conditions are due to marching and running while on active duty. 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 evidence of: (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). The question for the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. The Board concludes that, while the Veteran has a current diagnosis of patellofemoral syndrome and superior patellar enthesopathy, and evidence shows that she strained both knees in service, the preponderance of the evidence weighs against finding that the Veteran’s current knee disability began during service or is otherwise related to an in-service injury, event, or disease. The Veteran has alleged that her knee pain started in service and has continued since. She has specifically cited to knee pain after long marches in 1993 and 1995. The Veteran’s service treatment records include a March 1990 report of left knee trauma that reflects a normal knee X-ray. On report of medical history forms in July 1990 and March 1991 she denied having a trick or locked knee and the accompanying medical examinations indicate normal lower extremities. There is a record of a September 1993 complaint of bilateral knee pain that worsened in training. She was diagnosed with “overuse syndrome.” The Veteran’s September 1996 separation examination indicates normal lower extremities. An accompanying medical history report discusses a variety of medical conditions but does not note any knee problems. She checked that she did not have a trick or locked knee on the medical history form. At a January 1997 compensation and pension examination the Veteran reported knee pain and numbness. The examiner indicated no objective findings and no diagnosis was made. In August 2001 she underwent an X-ray after reporting bilateral knee pain. The radiograph was read to be normal. In October 2004, a treatment record suggests that her knee pain could be due to patellofemoral syndrome. At a May 2008 compensation and pension examination she reported sharp, tingling knee pain. A May 2009 right knee X-ray was ready not to show any acute abnormality, although a 7-millimeter quadriceps tendon enthesophyte was noted. The Veteran was afforded a compensation and pension examination in connection with her current claim in April 2019. The examiner indicated a diagnosis of knee strain in 1990 for the left knee and 1993 for the right knee as well as a diagnosis of patellofemoral syndrome in both knees in 2004. The examiner also stated that a 2009 X-ray showed a right knee enthesophyte and current X-rays show bilateral superior patellar enthesopathy. The examiner opined that the Veteran’s current knee conditions were less likely than not incurred in or otherwise related to the Veteran’s service. The examiner explained that in service the Veteran strained her left knee in 1990 playing basketball and her right knee in 1993 after resuming running after a 30-day profile. The examiner opined that those strains resolved in service. Subsequently, eight years after service, the Veteran was diagnosed with patellofemoral syndrome and 13 years after service she was diagnosed with a right knee enthesopathy. The examiner opined that neither condition is related to the Veteran’s resolved in-service knee strains. The Board finds that the etiology opinion of the April 2019 VA examiner is the most probative in this case. The examiner’s opinion is probative because it is based on an accurate medical history and provides an explanation that contains clear conclusions and supporting data. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). The Board acknowledges the Veteran’s own etiology opinion but finds that it has little probative value. While the Veteran is competent to report experiencing knee pain, she is not competent to provide a diagnosis in this case or determine that knee symptoms she experienced in service were manifestations of her currently diagnosed knee disability. The issue is medically complex, as it requires knowledge of the musculoskeletal and interpretation of complicated diagnostic medical testing. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). Therefore, it is outside the competence of the Veteran in this case because the record does not show that she has the medical training or credentials 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 opinion of the April 2019 VA examiner. Based on the forgoing, the Board finds that a preponderance of the evidence is against finding that the Veteran’s current right or left knee disability onset in service or is causally related to her service. Therefore, the benefit of the doubt doctrine does not apply, and the claim must be denied. H. SEESEL Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board A. Christensen 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.