Citation Nr: 21063935 Decision Date: 10/18/21 Archive Date: 10/18/21 DOCKET NO. 10-09 013 DATE: October 18, 2021 ORDER Entitlement to service connection for a right knee disability, to include claimed as secondary to a service-connected disability, is granted. FINDING OF FACT Competent medical evidence establishes that the Veteran's right knee disability became manifest in (was incurred during) his active service. CONCLUSION OF LAW Service connection for a right knee disability is warranted. 38 U.S.C. §§ 1110, 1112, 1131, 1137, 5107; 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The appellant is a Veteran who served on active duty from August 1979 to July 1989 and from December 2003 to April 2005, and had additional service in the Army National Guard. This matter is before the Board on appeal from a December 2008 Department of Veterans Affairs (VA) rating decision. [The Veteran was afforded a Board hearing in November 2011. The Veterans Law Judge who conducted the hearing is no longer with the Board. The Veteran was notified of this in June 2017 and declined another Board hearing.] In April 2012, July 2015, August 2017, December 2018, and October 2020, this matter was remanded for additional development. The previous remands also addressed a claim of service connection for a right ankle disability. A June 2021 rating decision granted service connection for a right ankle disability, resolving that matter. Entitlement to service connection for a right knee disability is granted. The Veteran contends, in essence, that he has a current right knee disability that was incurred in/has persisted since service. Specifically, he asserted that his current right knee disability is a result of constant bending and twisting during service as well as a November 2004 fall. He contends that since then he has had ongoing pain, stiffness and swelling, which have worsened over time. The Veteran's STRs show that in November 2004, he fell down stairs in the dark and twisted his right knee, causing pain and swelling in the knee; the assessment was muscle sprain, right knee. On January 2009 VA treatment, the Veteran reported right knee pain since his duty in Iraq in 2005; he noted he had knee swelling in service. The assessment was degenerative joint disease (DJD), shown by X-ray. Later VA treatment records reflect ongoing treatment for right knee arthralgia. On September 2012 VA examination, the Veteran reported that he fell in 2004 and twisted his knee, and experienced gradually worsening pain since then. Following physical examination, the diagnosis was right knee arthritis. The examiner opined that the fall in service in 2004 is unlikely to cause arthritis of the knee in the absence of a definite fracture, which the Veteran did not have. The examiner opined that knee arthritis is a common condition in the general population and is the result of general wear and tear, and the Veteran's arthritis is consistent with degenerative arthritis, though the fall may have caused a temporary flare of pain. The examiner opined that the current knee pain is not related to the fall in service. On May 2016 VA examination, the Veteran related that he sustained a right knee injury in a fall in Iraq in 2004; it was treated conservatively with naproxen, and later he was given a knee brace. He reported ongoing severe pain, swelling, and stiffness. The diagnosis was right knee degenerative arthritis. The examiner opined that while the Veteran did sustain a right knee injury in service there is no documentation that there was continued care and treatment of the initial knee injury. The examiner noted that there is a 5-year gap, and it could not be confirmed that the current right knee condition is related to the right knee injury in service without resort to mere speculation. The examiner further opined that the right knee condition is unrelated to the Veteran's PTSD, and there is no evidence of permanent aggravation of the knee condition by the service-connected PTSD, as the medical literature does not support such a medical relationship. On February 2017 VA record review and advisory medical opinion, the reviewing provider opined that there is no objective medical or scientific evidence to support that lumbar spondylolisthesis causes knee arthritis, there is no clinical connection to lumbar spondylolisthesis, and they are separate conditions and are less likely than not related. The examiner opined that the Veteran's right knee arthritis is less likely as not proximately due to or the result of lumbar spondylolisthesis. On February 2018 VA examination, the examiner opined that the claimed knee condition was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner explained that although the STRs not a November 2004 right knee sprain, it was an acute incident. The examiner further opined that the knee condition is less likely than not (proximately due to, the result of, or aggravated by the service-connected disabilities, as there is no medical evidence to support that PTSD causes arthritis, and these are two separate illnesses with no direct correlation; and arthritis in one joint does not cause arthritis in another joint, and the medical literature does not support this. The examiner opined that there is not enough medical evidence or literature to support that the right knee injury is related to his service-connected lumbar disability and is associated with aggravating arthritis. On October 2019 VA examination, the examiner opined that the Veteran's right knee condition was less likely than not incurred in or caused by the claimed injury, event or illness in service. The examiner noted that the Veteran was seen during service in November 2004 for a right knee muscle strain and opined that the condition was acute only and there is no objective evidence of chronicity of care. The examiner further opined that there is no objective evidence that the right knee disability claimed was proximately due to, the result of, or aggravated beyond its natural progression by his service-connected radiculopathy of lower extremities. The examiner opined that the two conditions are not medically related, and the claimed disorder of right knee condition is a separate entity entirely from the lower extremity radiculopathy and unrelated to it. The examiner opined that no medical literature supports radiculopathy causing or aggravating a knee condition. On June 2021 VA examination, the examiner opined that the Veteran's right knee patellofemoral pain syndrome was at least as likely as not incurred in or caused by the right knee injury during active duty. The examiner noted based on a review of the complete record that the Veteran had no issues related to the right knee prior to military service, and opined that the current diagnosis of right knee patellofemoral pain syndrome is related to the right knee injury during active duty. The examiner opined that there is evidence of chronicity and a nexus has been established. Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. See 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). To substantiate a claim of service connection, there must be evidence of (1) a current disability (for which service connection is sought); (2) incurrence or aggravation of a disease or injury in service; and (3) a causal connection between the disease or injury in service and the current disability. See Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). A disease first diagnosed after discharge may be service connected if all the evidence establishes that it was incurred in service. 38 C.F.R. § 3.303(d); Combee v. Brown, 34 F.3d 1039, 1043 (Fed. Cir. 1994). Certain chronic diseases listed in 38 C.F.R. § 3.309(a) (to include arthritis) may be presumed to be service connected if manifested to a compensable degree within a specified period of time postservice (one year for arthritis). 38 U.S.C. §§ 1112, 1137. Lay evidence may be competent evidence to establish incurrence. See Davidson v. Shinseki, 581 F. 3d 1313 (Fed. Cir. 2009). Competent medical evidence is necessary where the determinative question is one requiring medical knowledge. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). There is clear documentation that the Veteran sustained a right knee injury in service. What remains necessary to substantiate this claim is evidence that he has a current right knee disability, and that the disability is related to his service/injury therein. It is not in dispute that the Veteran has a current right knee disability, as such has been consistently diagnosed on VA examinations. The June 2021 VA examiner opined that the Veteran's current right knee disability was at least as likely as not incurred in service/is related to the injury therein. The provider cited to supporting clinical data based on a review of the record (and the Board has no reason to question the VA provider's expertise, or the validity of the opinion offered). The Veteran has also submitted lay statements and hearing testimony (the credibility of which the Board finds no reason to question) supporting that his current right knee disability was first manifested in service and has persisted since. All the requirements for establishing service connection are met; service connection for a right knee disability is warranted. GEORGE R. SENYK Veterans Law Judge Board of Veterans' Appeals Attorney for the Board D. Schechner, 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.