Citation Nr: 21003702 Decision Date: 01/22/21 Archive Date: 01/22/21 DOCKET NO. 17-30 441 DATE: January 22, 2021 ORDER Entitlement to service connection for a left knee disorder, to include degenerative joint disease, is denied. FINDING OF FACT Any current left knee disorder, to include degenerative joint disease, is not of service origin. CONCLUSION OF LAW The criteria for service connection for a left knee disorder, to include degenerative joint disease, have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1131, 1137, (2012); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2019). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran, who is the appellant, had active service from February 1983 to February 1987. He appeared at a hearing before the undersigned Veterans Law Judge in November 2019. A transcript of the hearing is of record. This matter was previously before the Board of Veterans Appeals (Board) in February 2020. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C. § 1131; 38 C.F.R. § 3.303(a). Service connection may be granted for any disease 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). As a general matter, service connection for a disability requires evidence of: (1) the existence of a current disability; (2) the existence of the disease or injury in service, and; (3) a relationship or nexus between the current disability and any injury or disease during service. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004); see also Hickson v. West, 12 Vet. App. 247, 253 (1999), citing Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996). Arthritis is a "chronic disease" listed under 38 C.F.R. § 3.309(a); therefore, the presumptive service connection provision of 38 C.F.R. § 3.303(b) apply to those claims. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). If a condition noted during service is not shown to be chronic, then generally a showing of continuity of symptomatology after service is required for service connection. 38 C.F.R. § 3.303(b). Service connection may be granted for any disease initially diagnosed after service when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Arthritis will be presumed to have been incurred in service if manifested to a compensable degree within the first year following separation from active duty. 38 U.S.C.§§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. It is the defined and consistently applied policy of VA to administer the law under a broad interpretation, consistent, however, with the facts shown in every case. When, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding service origin, the degree of disability, or any other point, such doubt will be resolved in favor of the claimant. 38 C.F.R. § 3.102. It is the Board's responsibility to evaluate the entire record on appeal. See 38 U.S.C. § 7104(a) (2012). In this case, the Board has thoroughly reviewed all the evidence in the Veteran's file. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, all of the evidence submitted by the Veteran or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). In evaluating the evidence in any given appeal, the Board has been charged with the duty to assess the credibility and weight given to evidence. Davidson v. Shinseki, 581 F. 3d 1313 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F. 3d. 372 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F. 3d 1331 (Fed. Cir. 2006); Klekar v. West, 12 Vet. App. 503, 507 (1999); Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). Indeed, the Court has declared that in adjudicating a claim, the Board has the responsibility to do so. Bryan v. West, 13 Vet. App. 482, 488-89 (2000); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992). The Veteran claims that his current left knee problems had their onset in service and have continued to the present day. He maintains that he entered service with no left knee problem and that his current left knee problems are a result of activities performed in service. At the time of his September 1982 service enlistment examination, the Veteran reported having no knee problems. A history of remote knee strain, not considered disabling, was noted at that time. The Veteran was seen with complaint of knee pain which he attributed to carrying his backpack. A diagnosis of knee strain was rendered at that time. In March 1983, the Veteran reported that his knees were extremely painful. In July 1983, the Veteran reported that his left knee had given way. He was found to have mild crepitus. A diagnosis of chondromalacia patella was rendered at that time. In June 1984, the Veteran was noted to have been in an auto accident three weeks earlier and to have left knee pain. The Veteran was reported to have pain with running. A diagnosis of soft tissue injury, resolving, was rendered. On his December 1986 service separation report of medical history, the Veteran checked the “no” box when asked if he had or had ever had a tricked or locked knee. He also checked the “no” boxes when asked if he had or had ever had arthritis, rheumatism, or bursitis; bone, joint or other deformity; or lameness. A history of bilateral chondromalacia was noted. At the time of the Veteran’s December 1986 service separation examination, normal findings were reported for the lower extremities. Post-service treatment records reveal that the Veteran went to the emergency room on August 23, 1987, soon after suffering an injury to the left knee while playing basketball. The Veteran could not straighten his left leg, which was swollen and tender. He was given a knee immobilizer, pain medication, and crutches and was told to use ice and elevation at home. Examination revealed that surgery would be needed. Notations of prior knee problems were made at the time. He was admitted to the hospital several days later and on August 31, 1987, had surgery which found that the injury had caused a complete rupture of the left patellar ligament with complete disruption of the extensor mechanism. Surgery repaired the patellar ligament and ruptured tendon. The Veteran underwent physical therapy on his left knee for many months thereafter. X-rays taken of the left knee in April 1991 revealed no significant abnormality of the bone joint, or adjacent soft tissues, with the examiner indicating that no significant bone or joint abnormality of the knee was present. In conjunction with this claim, the Veteran was afforded a VA examination in May 2017. Following examination, the examiner indicated that most sprains, strains, and musculoskeletal issues generally resolved without residuals. He noted that the December 1986 Report of Medical Examination (for separation) revealed a normal lower extremity examination. He observed that on the December 1986 Report of Medical History (for separation) the Veteran checked “NO” to "Trick or locked knee"; "Arthritis Rheumatism or Bursitis"; and to "bone, joint, or other deformity" He stated that there was no objective continuity of care for this Veteran’s claimed condition from time of service. He noted that the Veteran had degenerative arthritis of multiple sites of the body and had had 2 post-service injuries to the left knee/leg. He stated that degenerative arthritis of the left knee was part of the normal aging process and not secondary to inservice events. He indicated that degenerative arthritis of the left knee was part of the normal aging process and not secondary to inservice subjective complaints, objective diagnosis, and/or treatment. He opined that given the above, the Veteran’s degenerative arthritis of the left knee, diagnosed years after military service, was not incurred in or caused by, or first manifested by the signs and symptoms of the left knee noted during active duty service (to include chondromalacia patella, left knee strain, of July 1983 and June 1984). He further opined that the post-operative left knee August 1987 tear of quadriceps tendon (after discharge) was related to post service events, subjective complaints, objective diagnosis, and/or treatment. He also noted that post-operative left knee 2008 for tear of quadriceps tendon (WC case) (after discharge) was related to post-service events, subjective complaints, objective diagnosis, and/or treatment. He indicated that the subjective symptoms (Veteran’s complaints) and the objective findings (physical examination) of a degenerative arthritis of the left knee and post-operative left knee x 2 for post service injuries were similar, making the separation of the two subjective symptoms (Veteran’s complaints) and objective findings (physical examination) not possible without resort to pure speculation. In the February 2020 decision, the Board noted that further development and clarification was warranted with the May 2017 VA examination opinion. The Board observed that the May 2017 VA examiner indicated that the Veteran’s degenerative arthritis of the left knee, diagnosed years after military service, was not incurred in or caused by, or first manifested by the signs and symptoms of the left knee noted during active duty service to include chondromalacia patella, left knee strain of July 1983 and June 1984. The Board further noted that the examiner reported that the subjective symptoms (Veteran’s complaints) and the objective findings (physical examination) of a degenerative arthritis of the left knee and post-operative left knee x 2 for post service injuries were similar, making the separation of the two subjective symptoms (Veteran’s complaints) and objective findings (physical examination) not possible without resort to pure speculation. The Board noted that while the examiner provided an opinion, neither the testimony of the Veteran with regard to continuity of symptoms nor the reports of prior knee problems being noted that the time of the August 23, 1987, emergency room visit appeared to have been addressed in the rationale. The Board requested that, if available, return the file to the examiner who prepared the May 2017 opinion as to the etiology of the Veteran’s left knee disorder. Following a complete review of the record, the examiner was requested to render an opinion as to whether it was at least as likely as not (50 percent probability or greater) that any current left knee disorder had its onset in service or was otherwise related to his period of service. When rendering the opinion, the examiner was to address and discuss the Veteran’s reports of continuous symptoms of left knee problems since his period of service. The examiner was to also address the notations of prior knee problems being noted at the time of the August 23, 1987, emergency room visit, which occurred less than five months following the Veteran’s separation from service. As it related to the rendered opinion, if the examiner indicated that an opinion could not be rendered without resort to speculation, the examiner had to state whether the need to speculate was due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or that the examiner did not have the knowledge or training. If the deficiency in the record could be remedied, remedy the deficiency and have the examiner render the requested opinion. If the examiner did not have the knowledge or training to render the requested opinion, the matter was to be referred to an examiner with the required background with the examiner rendering the above requested opinion. In a March 2020 opinion, prepared by the same examiner, the prior inservice medical history was noted. The examiner indicated that there was no objective continuity of care for the Veteran’s claimed condition from time of service. The examiner noted that the Veteran sustained a left quadriceps tendon-knee injury tear in 1987 and again in 2008. (This Veteran had 2 post service injuries to the left knee/leg). It was noted that the Veteran had degenerative arthritis of multiple sites of the body. The examiner acknowledged the Veteran’s subjective reports of continuous symptoms of left knee problems since his period of service and the notations of prior knee problems being reported at the time of the August 23, 1987, emergency room visit, which occurred less than five months following the Veteran’s separation from service; however, he stated a history of an acute left strain(s) was not objective medical evidence of a chronic continuous left knee disability-diagnosis-condition, with the notation and acknowledgement of this Veteran being completely asymptomatic (no chronic complaints) at discharge, December 1986, and having a normal lower extremity examination at his discharge separation from active duty service, December 1986. The examiner stated that given the above, the Veteran’s degenerative arthritis of the left knee, diagnosed years after military service, was not incurred in or caused by, nor did it first manifest by the signs and symptoms of the left knee noted during active duty service. He indicated, given the above, there was no objective medical evidence to support the Veteran’s current left knee disability had its onset in service or was otherwise related to his period of service. After a review of all the evidence, lay and medical, the Board finds that the weight of the evidence is against the conclusion that the Veteran's current left knee disorder had its onset in service. As discussed above, the weight of the evidence demonstrates that the Veteran has been diagnosed with arthritis. While the Board notes that the Veteran was seen with complaints of left knee pain on several occasions during service, with a diagnoses of left knee strain and chondromalacia of the left knee being rendered, these problems resolved, as evidenced by the normal findings at separation and the Veteran indicating that he did not have knee problems on his service separation examination. While the Veteran was seen with left knee problems in close proximity to service in August 1987, these problems were specifically related to an injury sustained following service, which resulted in left knee surgery being performed at that time. As to the Veteran's reports that he has had knee problems since service, the Board finds that the contemporaneous evidence shows that although the Veteran was seen with left knee complaints on several occasions during service, these resolved as there were no reports or findings of left knee problems at the time of his separation from service, as evidenced by the normal findings at his separation examination and the Veteran’s notations of no knee problems on his December 1986 service separation examination. The Board does note the notation of past knee problems at the time of the August 1987 emergency room report; however, there is no indication that the knee problems were still present nor was there any indication that the knee problem he was being treated for at that time was related to his period of service. The contemporaneous evidence outweighs and is more probative than are his assertions voiced in connection with a claim for disability benefits. As to the Veteran's belief that his current left knee disorder is related to his period of service, the question of causation of a complex medical condition, such as the degenerative joint disease, extends beyond an immediately observable cause-and-effect relationship, and, as such, the Veteran is not competent to address etiology in the present case. See Jandreau v. Nicholson, supra. It has not been shown that he has the requisite training to diagnose the cause of his current degenerative joint of the knee or any other current left knee disorder. Next, service connection may be granted when the evidence establishes a nexus between active duty service and current complaints. The Veteran was afforded the opportunity to provide medical evidence and/or an opinion relating his current left knee disorder to his period of service. He has not provided either medical evidence or an opinion to support this proposition. The May 2017/March 2020 VA examiner, following a comprehensive review of the record and examination, opined that the Veteran's left knee disorder was less likely than not caused by or a result of an incident in service or to have begun in active service. The Board is placing greater weight on this opinion as it was rendered after a thorough review of the record with detailed rationale being set forth to support the opinion. There was no indication that the VA examiner was not fully aware of the Veteran's past medical history or that he misstated any relevant fact. The examiner cited to specific findings in the record and noted and addressed the Veteran’s subjective complaints when rendering his opinions. The Board does note that the Veteran’s representative has cited to the examiner’s most recent opinion as insufficient. He has indicated that in the opinion, the VA examiner noted the appellant as having multiple left knee strains in service, to include a remote sprain for enlistment, which was not supported by review of the file; the representative also stated that records reflected that the Veteran reported right knee pain over a month after his enlistment. The representative further noted that the Veteran complained of joint pain on his separation exam and that service treatment records confirmed that the Veteran informed doctors that his left knee would give out during his time in service. The representative stated that the opinion demonstrated that a thorough review was not performed in providing an addendum to the previous opinion due to critical noted complaints not being referenced in the rendered opinion. The representative stated that they supported the Veteran’s position that service connection for his left knee condition should be granted, or, at a minimum, remanded once more for a more thorough review of the file with an adequate opinion to satisfy the request on this appeal. In this regard, the Board notes that with each opinion that has been rendered, the examiner has indicated that he reviewed the entire file. In addition, the opinions cite to specific medical records when rendering the opinion, with the original opinion noting all the inservice findings. The examiner also noted and addressed the Veteran’s reports and contentions when rendering the opinions. The Board finds the opinion of record to be adequate to properly address the issue on appeal. The weight of the competent evidence demonstrates that the current left knee disorder was neither incurred in nor related to active service. For these reasons, the Board finds that service connection for a left knee disorder, to include arthritis, is not warranted. As the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application and the claim must be denied. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102. K. Parakkal Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board T. S. Kelly, 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.