Citation Nr: 21062451 Decision Date: 10/07/21 Archive Date: 10/07/21 DOCKET NO. 19-03 030A DATE: October 7, 2021 ORDER Service connection for a left knee disability is denied. FINDING OF FACT The Veteran's left knee disability is not attributable to injury sustained during his period of service and left knee arthritis was not manifest during service or within one year of separation. CONCLUSION OF LAW The criteria to establish service connection for a left knee disability have not been met. 38 U.S.C. §§ 1110, 1112, 1113, 1154 (2012); 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 June 1963 to May 1967. This matter came before the Board of Veterans' Appeals (Board) on appeal from an April 2016 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). In June 2021, the Board remanded the appeal for further development of the record. In pertinent part, the Board instructed the RO to schedule the Veteran for VA examination to determine the etiology of his claimed left knee disability. The Veteran received a responsive examination in July 2021. The requested development was completed and the case is returned to the Board for appellate disposition. This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c). 38 U.S.C. § 7107(a)(2) (2012). 1. Entitlement to service connection for a left knee disability Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active military service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Establishing service connection generally requires (1) evidence of a current disability; (2) evidence of in-service incurrence or aggravation of a disease or injury; and (3) evidence of a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see also Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996) (table); 38 C.F.R. § 3.303. In addition, for Veterans who have served 90 days or more of active service during a war period or after December 31, 1946, certain chronic disabilities, including arthritis, are presumed to have been incurred in service if they manifested to a compensable degree within one year of separation from service. 38 U.S.C. §§ 1101, 1112, 1113, 1131, 1137; 38 C.F.R. §§ 3.307, 3.309. That an injury or disease occurred in service is not enough; there must be chronic disability resulting from that injury or disease. If there is no showing of a resulting chronic condition during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity. 38 C.F.R. §§ 3.303(b), 3.309; Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). As noted, arthritis is a chronic disease. 38 U.S.C. § 1101. Therefore, section 3.303(b) is potentially applicable. Service connection may also be granted for any injury or disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303(d). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107(b). An April 1964 service treatment record hospital admission reflects that the Veteran was admitted for treatment for pain and swelling of the left knee following a fall in which he struck his left knee against a ladder rung and sustained a left knee contusion. On physical examination, he had tenderness of the patella with a small joint effusion. There was no ligamentous instability. X-ray findings were negative and the Veteran was placed on bed rest and whirlpool baths (4 times per day). He showed resolution of the effusion and decrease in tenderness over the patella. He was discharged to light duty. The April 1967 separation examination documents that the lower extremities clinical evaluation was normal. After service, a January 1972 VA examination report reflects that the Veteran has a history of fracture of either the right or left patella during service in 1963 when he fell. He was placed on bedrest for 6 weeks and received physiotherapy. He had no residual complaints since then. Examination was negative for abnormal findings. An October 1979 treatment record documents the Veteran's report that he sustained injury to his left knee during service. He complained that his left knee had been giving away for the past 2 to 3 days and he would lose his balance and fall. He reported that occasionally, his left knee was very sore and stiff. On examination, he had full range of motion of the left knee and no swelling, warmth or deformity, crepitus, or instability. An October 2015 VA treatment record documents the Veteran's report that during service he fell from a ladder from the third deck to the seventh deck and fractured his patella. He complained of intermittent left knee pain and occasional give way weakness since that injury. November 2015 VA x-ray findings of the left knee showed moderate cartilage space narrowing in the medial compartment; bony ossicle at the medial aspect of the joint space, likely an osseous loose body; heterotopic ossification in the region of the proximal medial collateral ligament (MCL), consistent with prior injury; and slight diffuse marginal osteophyte formation in all 3 compartments. The Veteran was advised that his left knee x-ray findings showed a moderate amount of arthritis, especially involving the medial aspect of the knee joint. A December 2015 VA physical therapy treatment record reflects that the Veteran complained of chronic left knee pain and intermittent giveaway weakness after a patella fracture in 1964. The Veteran reported that he picked a heavy case of water up approximately a month and a half earlier and felt left knee pain that caused him to stumble but not fall. He also reported that 2 to 3 weeks earlier his left knee buckled and caused him to fall. The March 2016 VA examination report documents that the Veteran received treatment for a left knee contusion (sustained when he hit his left leg on a ladder rung) during his period of service. In-service x-ray findings did not show any fracture. The Veteran was treated with rest, medication, and light duty for several days. There was no evidence of any persistent chronic or recurring left knee complaints. The physician noted that there were no knee complaints until 2015 when x-ray findings showed arthritis. The physician stated that other unknown, intercurrent events may have transpired after service that could have contributed to his current left knee disability. The physician also noted that the Veteran had gained approximately 60 pounds since his separation from service and reported significant weight gain can contribute to the development of arthritis, especially in weight bearing joints. Thus, the physician opined that it was less likely than not that the Veteran's current left knee disability onset due to the left contusion sustained during his period of service. The July 2021 VA knee and lower leg examination report documents diagnosis of left knee strain. The examiner noted that the Veteran received treatment for a left knee disorder (left knee contusion) in service, sustained when he struck his left knee against a ladder rung. Tenderness of the patella was noted but x-ray findings were negative for any fracture. The examiner noted that the Veteran returned to duty a week after sustaining the left knee contusion and he had no further left knee complaints during the remainder of his period of service. The examiner reported that a 2015 treatment record documented that the Veteran injured his knee while trying to pick up a case of water and reiterated there was no evidence of a fracture in 1972 or in 2015. The examiner opined that the left knee disability was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner explained that the service treatment records were reviewed and showed that the Veteran injured his left knee (bruised after hitting a ladder rung) in 1964; however, x-ray findings were negative and he was returned to light duty. He had no further complaints about his left knee for the remainder of his period of service. However, the examiner reiterated that the Veteran twisted his knee in 2015 while lifting a case of water and had complained of intermittent pain since then. The examiner found that it was unlikely that a 57-year-old, one-time, acute injury was the cause of the Veteran's current knee disability. Rather, the examiner explained that it was more likely that the Veteran's current knee disability was due to more recent events. Thus, the examiner concluded that it was less likely than not that the Veteran's current left knee disability onset due to injury sustained during his period of service. Though the Veteran has a current left knee disability, the preponderance of the evidence is against a finding of a linkage between the onset of the current left disability and injury sustained during a period of service. The evidence clearly shows that the Veteran sustained an in-service injury; however, the evidence shows that it was unlikely that a 57-year-old, one-time, acute injury was the cause of the Veteran's current knee disability. Rather, it was more likely that the Veteran's current knee disability was due to more recent events (i.e., injury sustained while lifting a case of water in 2015) (See July 2021 VA examination report). Further, it was less likely that the Veteran's current left knee disability onset due to injury (left knee contusion) sustained in service because he gained a significant amount of weight after service that could have contributed to the development of his current left knee disability (left knee arthritis) (See March 2016 VA examination report). Accordingly, the claim of service connection for a left knee disability will be denied. This conclusion is probative as it is based on facts presented by both the service treatment records and the assertions made by the Veteran at the time of the VA examination. Also, notably, there is no competent or credible evidence or opinion that suggests that there exists a medical relationship, or nexus, between the current left knee disability and a period of the Veteran's service. Additionally, there is no evidence of left knee arthritis in service. To determine that a chronic disease was shown in service, the disease identity must be established. 38 C.F.R. § 3.303(b); Walker, 708 F.3d at 1339. No examiner in service, or since, has established chronicity or an underlying chronic disease process in service. In sum, characteristic manifestations sufficient to identify the disease (arthritis) entity were not noted. As the service treatment records lack the documentation of the combination of manifestations sufficient to identify left knee arthritis and sufficient observation to establish chronicity during service, then a showing of continuity of symptomatology is another way to establish service connection. 38 C.F.R. §§ 3.303(b), 3.309; Walker, supra. However, the Board does not find the Veteran's statements as to continuity of symptomatology credible. There is no corroborating evidence to support the Veteran's claim that he has experienced chronic left knee pain and intermittent giveaway weakness since sustaining a patella fracture in service in 1964. Indeed, the April 1964 service hospitalization records document that x-ray findings were negative (i.e., there was no patella fracture). The March 2016 and July 2021 VA examination reports confirm there was no in-service left knee patella fracture. Further, the January 1972 VA examination report documents that the Veteran had no residual left knee complaints since the April 1964 in-service injury and objective examination (in January 1972) was negative for abnormal findings. The October 1979 treatment record documents the Veteran's report that he had been experiencing left knee giving way for the past 2 to 3 days and occasionally, his left knee was very sore and stiff. Moreover, the December 2015 VA physical therapy treatment record reflects that the Veteran sustained a left knee injury a month and a half earlier (approximately October/November 2015) while trying to pick up a heavy case of water. Here, the post-service record is silent as to complaints, treatment, or diagnoses of any left knee disability until, at the earliest, October 1979, over a decade after separation from service. Thus, the Veteran's statements as to continuity of symptomatology since service are not credible and are thus afforded little probative value. For these reasons, service connection for left knee arthritis cannot be awarded on a presumptive basis. 38 U.S.C. § 1101, 1110, 1112, 1113, 1131, 1137; 38 C.F.R. § 3.303(b), 3.307, 3.309. The Veteran is not competent to link his current left knee disability to a period of service. Competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159. Lay evidence may be competent and sufficient to establish a diagnosis of a condition when: (1) a layperson is competent to identify the medical condition (i.e., when the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer); (2) the layperson is reporting a contemporaneous medical diagnosis, or; (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007); see also Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009) (where widow seeking service connection for cause of death of her husband, the Veteran, the Court holding that medical opinion not required to prove nexus between service-connected mental disorder and drowning which caused Veteran's death). The Veteran is a lay person and is not competent to establish that his current left knee disability onset because of an injury sustained during a period of service or offer an opinion as to etiology of any current left knee disability. The question regarding the etiology of such a disability is a complex medical issue that cannot be addressed by a layperson. For these reasons, his allegations are no more than conjecture and do not rise to the type of evidence addressed by Jandreau. The claim of entitlement to service connection for a left knee disability must be denied. The preponderance of the evidence is against the claim and the benefit-of-the-doubt doctrine is not applicable. See 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). Vito A. Clementi Veterans Law Judge Board of Veterans' Appeals Attorney for the Board G. Jackson The Board's decision is only binding on this case. This action is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.