Citation Nr: 21063326 Decision Date: 10/13/21 Archive Date: 10/13/21 DOCKET NO. 18-42 799A DATE: October 13, 2021 ORDER Entitlement to service connection for left knee patellofemoral pain syndrome with osteoarthritis is granted. REMANDED Entitlement to an initial disability rating in excess of 20 percent for lumbosacral strain is remanded. Entitlement to an initial disability rating in excess of 50 percent for left hip status post joint replacement is remanded. FINDING OF FACT Resolving reasonable doubt in the Veteran's favor, his left knee patellofemoral pain syndrome with osteoarthritis is at least as likely as not related to his active military service. CONCLUSION OF LAW The criteria for service connection for left knee patellofemoral pain syndrome with osteoarthritis are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty in the United States Army from February 1975 until his honorable retirement in October 1995. This case comes before the Board of Veterans' Appeals (Board) on appeal from May 2017 and June 2017 decisions by a Regional Office of the United States Department of Veterans Affairs (VA). In May 2011, the Veteran testified at a Board hearing before the undersigned Veterans Law Judge. Evidentiary Standards In deciding claims, it is the Board's responsibility to evaluate the entire record on appeal. VA is required to give due consideration to all pertinent medical and lay evidence in evaluating a claim for disability benefits. 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. 38 U.S.C. § 5107(b). To deny a claim on its merits, the preponderance of the evidence must be against the claim. See Alemany v. Brown, 9 Vet. App. 518, 519 (1996). The law requires the Board address its reasons for rejecting evidence favorable to the Veteran. Timberlake v. Gober, 14 Vet. App. 122, 12829 (2000). The Board must review the entire record but does not have to discuss each piece of evidence. Gonzales v. West, 218 F.3d 1378, 1381 (Fed. Cir. 2000). The analysis below focuses on the most salient and relevant evidence within the period on appeal and on what this evidence shows, or fails to show, on the claims. Service Connection VA provides compensation for a disability resulting from disease or injury incurred in or aggravated by service. This is referred to as a "service connection." 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. Regulations also provide that service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. § 3.303(d). Generally, in order to be entitled to service connection there must be competent, credible evidence of (1) a current disability, (2) an in-service incurrence or aggravation of an injury or disease, and (3) a nexus, or link, between the current disability and the in-service disease or injury. See, e.g., Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Pond v. West, 12 Vet. App. 341 (1999). When these elements are satisfied, service connection may be granted on a direct basis. Analysis The claim for service connection for left knee patellofemoral pain syndrome with osteoarthritis, claimed as left knee fracture, is granted. First element: A current disability According to an April 28, 2017, VA-contracted examination, the Veteran is diagnosed with left knee patellofemoral pain syndrome and osteoarthritis. Therefore, the first element is satisfied. Second element: An in-service event, injury, or illness, or aggravation thereof During his April 2017 VA-contracted examination, the Veteran reported experiencing an onset of symptoms in 1988. He stated that his symptoms progressed to the point that he needed to use joint supplements. During his July 1995 separation examination, the Veteran endorsed joint pain. He asserted his symptoms stemmed from parachute jumps during active military service. The Board observes that the Veteran received a Master Parachutists Badge. DD Form 214. The Board finds the Veteran's statements credible and probative. Therefore, the second element is satisfied. Third element: A causal link The April 2017 VA-contracted examiner opined that the Veterans' left knee disability was at least as likely as not incurred in or caused by his active military service. The examiner reasoned, "It is well-documented that parachute jumping results in significant trauma to the knees which can result in injuries that will last chronically and may progress to osteoarthritis." Yet, the VA Regional Office requested an addendum opinion to address the question, whether "it is at least as likely as not that the Veteran's left knee osteoarthritis occurred in or was caused solely due to the parachute activities while the Veteran was on active duty" in light of evidence that the Veteran suffered a "severely comminuted intra-articular fracture for the proximal tibia with soft tissue injury, fracture of the proximal fibula left knee and underwent open reduction internal fixation surgery" in 2004. The examiner concluded that it was "at least as likely as not the current knee problems are secondary to the severely comminuted intra-articular fracture for the proximate tibia." The examiner stated that the "[i]njuries to the joint have been well-documented to lead to degenerative processes[.]" The VA-contracted examiner's addendum opinion stated it was at least as likely as not that the Veteran's left knee disability was due to his fracture in 2004, but the examiner did not withdraw or contradict his initial opinion that the Veteran's left knee disability was at least as likely as not due to his active military service. In this regard, the evidence related to establishing a nexus is at least in relative equipoise. Therefore, affording the Veteran the benefit of reasonable doubt, the Board concludes there is sufficient evidence to establish a nexus between the Veteran's left knee disability and active military service. Therefore, the third element is satisfied. Accordingly, service connection for a left knee disability, to include patellofemoral pain syndrome with osteoarthritis, is granted. In granting service connection, while the Board finds that some portion of the Veteran's left knee disability is due to his active military service, the assignment of the initial disability rating will be made by his local VA Regional Office. REASONS FOR REMAND The Veteran's representative asserted that the Veteran is entitled to additional disability ratings for radicular symptoms stemming from his lumbar surgery on his L4-S1 vertebrae, which is part of his service-connected lumbosacral strain. See September 2018 VA Form 9 (Substantive Appeal to Board); May 2021 Board Hearing Transcript, at 23. His lumbosacral strain is rated under 38 C.F.R. § 4.71a, Diagnostic Code 5237, which uses the "General Rating Formula for Diseases and Injuries of the Spine." Note (1) of the General Rating Formula instructs, "Evaluate any associated objective neurologic abnormalities, . . . separately, under an appropriate diagnostic code." (Emphasis added). The Veteran has credibly testified about his subjective neurologic symptoms, and his medical records document objective neurologic symptoms. See, e.g., July 2021 OrthoCarolina Progress Note (documenting that lateral recess stenosis at L4-L5 and recording that the Veteran reported that a podiatrist informed him that his bilateral feet numbness, tingling, and swelling were caused by his back issues). Yet, no VA medical examination has been offered to the Veteran to identify his specific neurologic symptoms and associated severity. In addition, the Veteran's Board testimony generally indicates a potential worsening of symptoms associated with his service-connected lumbosacral strain and left hip disability since his most recent examination in April 2017. Accordingly, remand is required to fulfill VA's duty to assist by affording the Veteran an updated VA examination to address his lumbosacral strain and left hip disability and an examination to addresses any associated neurologic symptoms. 38 U.S.C. § 5103A(d); 38 C.F.R. § 3.159(c)(4); McLendon v. Nicholson, 20 Vet. App. 79 (2006). Accordingly, the matters are REMANDED for the following actions: 1. Obtain any of the Veteran's outstanding VA medical records and associate them with the claims file. 2. Send appropriate correspondence to the Veteran asking him to identify and authorize release of any relevant medical records from: (a.) Ortho Carolina; (b.) Any private podiatry medical records, as his July 2021 Progress Note from Ortho Carolina indicates he received medical treatment from a private podiatrist; and (c.) Any other private treatment received for his disabilities. Reasonable attempts must be made to obtain relevant private medical records. 3. After any additional records are associated with the claims file, obtain a new VA examination from an appropriately qualified clinician as to the current severity of the Veteran's service-connected lumbosacral strain and left hip disabilities. The entire claims file must be made available to and be reviewed by the examiner, including a copy of this REMAND order. (Continued on the next page) (a.) As to the Veteran's lumbosacral disability, please assess any objective neurological abnormalities (under the appropriate diagnostic code) associated with the Veteran's lumbar spine disability, to include numbness, tingling, and swelling of the Veteran's feet as indicated in the July 2021 Ortho Carolina Progress Note. See 38 C.F.R. § 4.71a, Diagnostic Code 5237, Note (1). M. Tenner Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. F. Sawka, 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.