Citation Nr: 21062309 Decision Date: 10/06/21 Archive Date: 10/06/21 DOCKET NO. 17-52 003 DATE: October 6, 2021 ORDER Entitlement to service connection for right knee chronic tear of the medial meniscus is granted. Entitlement to service connection for left knee chronic degeneration of the medial meniscus, patellofemoral syndrome, and bursitis is granted. FINDINGS OF FACT 1. The evidence of record is at least in equipoise as to whether the Veteran's right knee disability, diagnosed as chronic tear of the medial meniscus, is at least as likely as not related to an in-service injury. 2. The Veteran's left knee disability, diagnosed as chronic degeneration of the medial meniscus, patellofemoral syndrome, and bursitis, is proximately due to the Veteran's service-connected right knee disability. CONCLUSIONS OF LAW 1. The criteria for service connection for right knee chronic tear of the medial meniscus are met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for service connection for left knee chronic degeneration of the medial meniscus, patellofemoral syndrome, and bursitis as secondary to service-connected right knee chronic tear of the medial meniscus are met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from February 1979 to April 1985. This appeal comes before the Board of Veterans' Appeals (Board) from a July 2016 rating decision issued by a Department of Veterans Affairs (VA) Regional Office. In a March 2019 decision, the Board denied the claims of entitlement to service connection for right and left knee disabilities. The Veteran appealed that decision to the Court of Appeals for Veterans Claims (Court). In a February 2020 Order, pursuant to a Joint Motion for Partial Remand (JMPR), the Court vacated the Board's March 2019 decision in part and remanded those issues to the Board for additional development consistent with the JMPR. The case was again before the Board in August 2020, at which time the Board again denied service connection for both disabilities. The Veteran appealed that decision, and in an April 2021 Order, pursuant to a Joint Motion for Remand (JMR), the Court vacated the Board's August 2020 decision and remanded the issues to the Board for readjudication consistent with the JMR. The case has now been returned to the Board. Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Service connection requires competent evidence showing: (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. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see also Caluza v. Brown, 7 Vet. App. 498 (1995). Service connection may also be granted for a disability that is proximately due to, or aggravated by, service-connected disease or injury. 38 C.F.R. § 3.310. The record shows that the Veteran has diagnoses of right knee meniscal tear and left knee degeneration of the medial meniscus and bursitis. See August 2021 Dr. A.F. Independent Medical Opinion. Service treatment records reveal that in March 1984, the Veteran was treated for right knee stiffness after jumping off the back of the truck. On examination, there was no edema or limitation of motion. There was a mild grinding sensation under the patella. The diagnosis was mild chondromalacia. In November 1984, the Veteran was treated after he fell on his right knee in the shower. On examination, there was tenderness, swelling, ecchymosis of the right patella, and mild effusion. There was good stability and there was no indication of injury to the meniscus. Magnetic resonance imaging (MRI) performed at the July 2016 VA examination showed right knee medial meniscus degenerative fraying and/or chronic tear, and left knee posterior horn medial meniscus mucoid degeneration, suprapatellar fat pad edema, and patellofemoral syndrome. The Veteran told the examiner that he had noticed an increase in pain and swelling of the anterior knees around 2013. The examiner opined that the knee conditions claimed were less likely than not incurred in or caused by an in-service injury, event, or illness. The rationale regarding the right knee was that the current diagnosis differed from the injury in service. In addition, the examiner noted that the right knee patella and anterior patella were normal on MRI and there were no findings of continued chondromalacia. The examiner added that the Veteran had worked as a painter since service and frequently had to kneel and bend in the course of his job. Regarding the left knee, the examiner stated that it was more likely that the left knee meniscus injury became a chronic problem after service. The examiner explained that the mechanism of the injury was not consistent with the injuries noted in the service treatment records. Rather, the examiner opined that it was more likely that the Veteran's current conditions were related to the Veteran's post-service employment as a painter. The rationale was that no severe chronic injury was noted in service. Both medial meniscus findings, in the examiner's opinion, were consistent with standing and turning as would occur as a painter. Finally, the examiner added that the mild and chronic degenerative changes were not uncommon in a 55-year-old veteran with his employment. Dr. A.F. submitted a medical opinion in August 2021. He recounted the Veteran's in-service injury to his right knee, noting that no imaging was performed after the Veteran's initial, March 1984 injury. Dr. A.F. noted that records indicated that the Veteran continued to report right knee pain after 1984 but was not seen by a medical provider until April 2015 when he presented to an emergency department with right knee pain. The pain was noted as constant and worsening and worse with kneeling down. No imaging was performed, and the Veteran was diagnosed with pre-patellar bursitis. Dr. A.F. initially noted that the Veteran had diagnoses of right knee chronic tear of the medial meniscus, and left knee chronic degeneration of the medial meniscus and bursitis. He opined that based on the mechanism of injuries occurring in service which included jumping off the back of a truck as well as falling in the shower, it was more likely than not that the Veteran's right knee disabilities were related to those injuries sustained in service. By way of rationale, Dr. A.F. noted that the initial diagnosis of chondromalacia made in March 1984 was made solely on the Veteran's objective complaints of grinding at the time of the injury. However, Dr. A.F. cited to medical literature which noted that the occurrence of chondromalacia in conjunction with median meniscus tear was prevalent, and that a medial meniscus tear would have presented with the same complaints and have been likely to occur with the traumatic chondromalacia with that mechanism of injury. Therefore, it was Dr. A.F.'s conclusion that the right knee meniscus tear occurred at the time of the March 1984 incident, and that the lack of appropriate testing at the time of injury overlooked the possible meniscus involvement. Dr. A.F. addressed the opposing findings of the July 2016 examiner. Specifically, Dr. A.F. pointed out that the conclusion of the VA examiner that the Veteran's knee injuries were related to his post-service employment as a painter was incorrect because if such had been the case, the same findings would have been present in both knees. However, in the Veteran's case, the medial meniscus tear was only present in the right knee. In his role as a painter, Dr. A.F. surmised that the kneeling would have been on both knees, not just the right; but since the tear only existed in the right knee, it was less likely that it was related to his painting duties. Regarding the left knee, Dr. A.F. noted that the abnormal compensation with his left knee due to his right knee pain would have placed increased biomechanical stress on the left knee which would have led to the degeneration seen in the left knee. Thus, Dr. A.F. concluded that it was more likely than not that the Veteran's left knee conditions were related to years of chronic compensation due to right knee pain and dysfunction since the 1984 in-service injuries. Dr. A.F. cited to medical literature supporting the finding that chronic changes in gait over a prolonged period of time would add abnormal stress to the meniscus; such an abnormal load over many years would cause the degenerative changes seen in the Veteran's left knee MRI from 2016. Upon review of the above, the Board finds the evidence to be at the very least in equipoise as to whether the Veteran's current right knee disability arose in service or is otherwise related to his fall injuries. The Board also finds the evidence to be in equipoise as to whether the Veteran's current left knee disabilities are proximately due to his right knee disability. The Board affords probative value to Dr. A.F.'s opinion, both as to direct and secondary service connection. Indeed, Dr. A.F. considered the Veteran's service treatment and post-service medical records and importantly, considered the Veteran's contentions as to the onset and progression of his knee conditions. The opinion contains clear conclusions with references to relevant medical literature, explaining why the Veteran's right knee disability more like than not onset in service and explaining why the Veteran's left knee disabilities more likely than not were caused by the right knee disability. The opinion reflects consideration of the Veteran's particular circumstances and individual disability picture and medical history. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). Accordingly, after resolving doubt in favor of the Veteran, the Board finds that service connection for right knee medial meniscus tear is warranted on a direct basis. Service connection for left knee chronic degeneration of the medial meniscus, patellofemoral syndrome, and bursitis is warranted based on secondary service connection (causation). 38 U.S.C. § 5107; 38 C.F.R. §§ 3.102, 3.310. V. Chiappetta Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Polly Johnson, 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.