Citation Nr: 21004090 Decision Date: 01/26/21 Archive Date: 01/26/21 DOCKET NO. 17-51 785 DATE: January 26, 2021 ORDER Entitlement to service connection for right knee degenerative arthritis, to include as secondary to the service-connected disability of lumbar spine degenerative disc disease and scoliosis is denied. FINDING OF FACT The evidence fails to establish that the Veteran’s right knee degenerative arthritis was caused or aggravated by the service-connected disability of lumbar spine degenerative disc disease and scoliosis. CONCLUSION OF LAW The criteria for service connection for right knee degenerative arthritis, to include as secondary to lumbar spine degenerative disc disease and scoliosis, have not been met. 38 U.S.C. § 1131; 38 C.F.R. §§ 3.303, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from July 1964 to July 1968. This matter is before the Board of Veterans’ Appeals (Board) on appeal from an August 2017 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). This case was previously before the Board in March 2019 when it was remanded for additional development to include a VA medical opinion to address the nature and etiology of his claimed back condition. The Board notes that, to the full extent possible, VA complied with all prior remand instruction requests, and there exist no deficiencies in VA’s duties to notify and assist in that regard. See Stegall v. West, 11 Vet. App. 268 (1998); but see D’Aries v. Peake, 22 Vet. App. 97, 104 (2008). The matter has returned to the Board for appellate review. The Veteran asserts entitlement to service connection for a right knee disability secondary to his already service-connected low back disability. The Board notes that neither the Veteran nor his representative have asserted, nor does the record reflect, that the claimed right knee condition first manifested during service or was directly related to his active duty service. Rather, the Veteran has claimed that the right knee disability is secondary to the service-connected low back disability. See October 2017 Substantive Appeal. Thus, the Board will address only whether the Veteran is entitled to service connection for his claimed right knee disability on a secondary basis. See Robinson v. Peake, 21 Vet. App. 545, 552-56 (2008), aff’d sub nom. Robinson v. Shinseki, 557 F.3d 1355 (Fed. Cir. 2009). In general, service connection may be granted if the evidence demonstrates that a current disability resulted from an injury or a disease incurred or aggravated in the line of duty during active military service. This means that the facts establish that a particular injury or disease resulting in disability was incurred coincident with service in the Armed Forces or, if preexisting such service, was aggravated therein. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the disease or injury in service and the current disability. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). Secondary service connection may be granted for a disability that is proximately due to, or aggravated by, a service-connected disease or injury. 38 C.F.R. § 3.310. However, VA will not concede aggravation unless the baseline level of severity of the non-service-connected disease is established by medical evidence. 38 C.F.R. § 3.310(b). In order to prevail on the issue of entitlement to secondary service connection, there must be (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) nexus evidence establishing a connection between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). Determinations as to service connection will be based on review of the entire evidence of record, to include all pertinent medical evidence. VA must also consider all favorable lay evidence of record. See 38 U.S.C. § 5107(b). A Veteran is competent to report on that of which he has actually observed and is within the realm of his personal knowledge. Layno v. Brown, 6 Vet. App. 465 (1994). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. See Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). The Board acknowledges that the Veteran has a current diagnosis of right knee degenerative arthritis. See July 2017 VA knee and lower leg conditions examination. Therefore, the question for the Board is whether the current disability is proximately due to, or aggravated by, his service-connected low back disability. Post-service treatment records include a September 2009 VA nursing telehealth record that noted the Veteran complained about continuing right leg, knee and ankle swelling after a recent fall. The same record noted that the Veteran reported X-rays and was informed that there were no fractures. A September 2009 VA primary care record noted the Veteran fell backwards watching a game and sprained his right knee. A separate September 2009 VA orthopedic surgery consult noted the Veteran fell backwards over a curb in early September and landed with his leg fully flexed under him. He was evaluated for a possible quadriceps tear. Symptoms included an inability to pick up the distal part of his leg and difficulty bearing weight. An October 2009 VA surgical operation report that noted a pre-operative diagnosis of right knee quadriceps tendon tear, a post-operative diagnosis of the same, and a right quadriceps tendon surgical repair using bone tunnel. The same record noted that the Veteran was stepping off a curb and felt immediate pain in his right knee. A January 2010 VA physical therapy record noted the Veteran tripped and fell backward over a curb while getting out of the car and had a knee flexion injury with a snap. Tendon repair in October 2009 and he wears a hinged knee brace full-time. The Veteran also reports he feels like his knees want to buckle sometimes. There are additional VA physical therapy treatment records from April and May 2009. The Board notes that the Veteran denied back, hip, or knee pain in March 2015, August 2015, and May 2016 VA primary care treatment records. The claims file includes a July 2017 VA knee and lower leg conditions examination wherein the examiner confirmed a diagnosis of right knee degenerative arthritis. The examiner noted the 2009 tendon repair surgery. The Veteran reported flare-ups. All range of motion (ROM) results were normal. In an attached medical opinion, the examiner opined the Veteran’s right knee condition is less likely than not (less than 50 percent probability) proximately due to or the result of the Veteran’s service-connected low back condition. As a rationale, the examiner noted the Veteran’s report that back pain was so intense that it caused him to trip and fall and tear his quadriceps tendon. The examiner noted that the Veteran is obese with a body mass index (BMI) of 33 and he worked as a machinist after separation from active duty. Additionally, the claim is subjective, with no evidence to support his assertion that his back condition caused him to fall and tear his quadriceps tendon. Medical records show the Veteran reported he stepped off a curb and felt an immediate pain in his right knee and was subsequently diagnosed with a quadriceps tendon rupture. The Veteran has reported improvement since the October 2009 surgery but still sometimes feels that his right knee has begun to give way. The examiner noted that the treatment records do not establish the Veteran has sought treatment for this complaint. Clinical examination was negative for laxity of his anterior cruciate ligament (ACL), and the examination was entirely normal. Right knee X-rays show osteo arthritis (OA). Therefore, the examiner noted it is less likely than not that the quadriceps injury was due to his service-connected low back condition. The examiner concluded it was more likely than not that the Veteran had a spontaneous rupture of his quadriceps tendon and has right knee OA due to the combination of being overweight and spending many years on his feet working as a machinist. Following the March 2019 Board REMAND, the RO requested and obtained an October 2019 VA medical opinion to address secondary service connection under an aggravation theory. 38 C.F.R. § 3.310(b). The reviewer opined that it was less likely than not (less than 50 percent probability) that the Veteran’s right knee condition of torn right quadriceps tendon status post (s/p) surgical repair with the incidental finding of age-related right knee degenerative arthritis was caused by or related to or permanently aggravated beyond the normal progression of the condition by the service-connected lumbar spine degenerative disc disease and scoliosis. As a rationale, the reviewer acknowledged the Veteran’s injury and surgical history as noted above. The reviewer also observed the Veteran’s claim of service connection for his right knee/quadriceps tendon condition as due to the service-connected lumbar spine degenerative disc disease and scoliosis. Specifically, the reviewer acknowledged the Veteran’s assertion that sharp low back pain caused him to fall. The reviewer noted that the medical evidence is negative for a nexus between the Veteran’s service-connected back condition and his right quadriceps tendon tear and was not noted in the claims file until the Veteran raised his claim of service connection for his right knee condition as being due to his back condition. The reviewer noted the Veteran’s consistent description of his right knee injury as being that he tripped and fell. The only difference between his described history over time is that he initially reported that he tripped backward over a curb and later indicated that sharp back pain caused him to fall backward with no mention of a curb being involved. The reviewer indicated that the weight of medical literature supports that sudden onset of sharp low back pain leads to a guarding of movement to the point of freezing in place while spasms subside. The medical literature does not support that assertion that the sudden onset of sharp low back pain leads to falling backward. The reviewer acknowledged this potentiality could occur if a leg gave way, however, he noted nothing in the evidence of record shows this. Thus, common sense agrees with the available medical records, that the Veteran tripped backwards over a curb, and this mechanism of injury is consistent with the torn quadriceps tendon. Additionally, the reviewer addressed the July 2017 examiner’s diagnosis of right knee arthritis without rendering a diagnosis of torn right quadriceps tendon s/p surgery. The reviewer noted the diagnosis of right knee arthritis is medically correct and supported by a radiological finding. However, the reviewer asserted the diagnosis is not helpful to the claim, as the Veteran is not and has not been claiming arthritis developed due to the fall. Instead, the diagnosis of right knee arthritis is an incidental diagnosis that took the examiner into a tangent, as the July 2017 medical opinion noted the most likely etiology of the right knee arthritis as being due to obesity and a long history of standing while working. The reviewer noted this has nothing to do with the etiology of the Veteran’s torn right quadriceps tendon s/p surgical repair. The reviewer noted that the correct diagnosis is a torn right quadriceps tendon s/p surgical repair with the incidental finding of age-related right knee degenerative arthritis. As noted above, neither the medical evidence nor common sense provides a nexus between the Veteran’s service-connected lumbar spine degenerative disc disease and scoliosis and his torn right quadriceps tendon s/p surgical repair or age-related right knee degenerative arthritis. Based on the same rationale noted above, the examiner also opined that it is less likely than not (less than 50 percent probability) that the Veteran’s condition of torn right quadriceps tendon s/p surgical repair with the incidental finding of age-related right knee degenerative arthritis was caused by or related to or permanently aggravated beyond the normal progression of the condition by any event during military service. There are no additional etiology opinions related to the Veteran’s right knee condition. The Board is aware of the Veteran’s contentions, as described above, but he lacks the training and credentials to provide a competent opinion as to a medical diagnosis or etiology. His lay opinion accordingly does not constitute competent and probative evidence. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). In short, the preponderance of the evidence is against the Veteran’s claim, and the claim must be denied. In reaching the above conclusion, the Board has considered the applicability of the benefit of the doubt doctrine. As the preponderance of the evidence is against the Veteran’s claim, that doctrine is not applicable in the instant appeal. See Gilbert, supra. Entitlement to service connection for right knee degenerative arthritis, to include as secondary to the service-connected disability of lumbar spine degenerative disc disease and scoliosis is denied. A. C. MACKENZIE Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board B. Banks, 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.