Citation Nr: 21066586 Decision Date: 11/01/21 Archive Date: 11/01/21 DOCKET NO. 14-31 909 DATE: November 1, 2021 ORDER Entitlement to service connection for a left knee condition, to include left knee degenerative joint disease (DJD) status post total knee arthroplasty, is denied. Entitlement to service connection for a right knee condition, to include DJD, is denied. FINDINGS OF FACT The Veteran's bilateral knee disability was not shown as chronic in service and did not manifest to a compensable degree within the applicable presumptive period; continuity of symptomatology is not established; and the disability is not otherwise etiologically related to an in-service injury or disease. CONCLUSIONS OF LAW 1. The criteria for service connection for left knee condition, to include left knee DJD status post total knee arthroplasty, have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 2. The criteria for service connection for right knee condition, to include DJD, have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from June 1968 to June 1970 and from September 1970 to September 1973. This matter is before the Board of Veterans' Appeals (Board) on appeal from an October 2011 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). The Board remanded the appeal in April 2018, August 2019, July 2020, and in February 2021 for further development. There has been substantial compliance with the February 2021 remand directives. See Stegall v. West, 11 Vet. App. 268 (1998). 1. Entitlement to service connection for left knee condition, to include left knee DJD status post total knee arthroplasty, is denied. 2. Entitlement to service connection for right knee condition, to include right knee DJD, is denied. The Veteran contends that he has current diagnoses of bilateral knee conditions that are related to his active duty service. See October 2010 VA Form 21-4138. Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). Certain chronic diseases will be presumed related to service, absent an intercurrent cause, if they were shown as chronic in service; or, if they manifested to a compensable degree within a presumptive period following separation from service; or, if they were noted in service (or within an applicable presumptive period) with continuity of symptomatology since service that is attributable to the chronic disease. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.303, 3.307, 3.309. Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2013). The Veteran's VA examination reports reflect a current diagnosis of bilateral knee DJD. Thus, the question for the Board is whether the Veteran's disability began during service; or is at least as likely as not related to an in-service injury, event, or disease; or manifested within a presumptive period. The Board concludes that, while the Veteran has a bilateral knee disability, the preponderance of the evidence weighs against finding that they began during service or are otherwise related to an in-service injury, event, or disease. Further, the Board finds that, while DJD is an enumerated condition under 38 C.F.R. § 3.309(a), the disability was not shown as chronic in service, did not manifest to a compensable degree within a presumptive period, and was not noted in service with attributable continuity of symptomatology. Walker, 708 F.3d 1331. The Veteran's January 1968 enlistment exam reflects normal lower extremities. A July 1969 service treatment record noted complaint of soreness below knees without a known injury. In a March 1970 separation report of medical history, the Veteran denied swollen or painful joints; arthritis, rheumatism, or bursitis; or "trick" or locked knee. The corresponding March 1970 separation exam noted normal clinical evaluation of lower extremities. A September 1970 enlistment exam noted normal lower extremities. A December 1970 radiology exam request sprained right knee; the subsequent January 1971 radiology assessment noted "nothing abnormal seen." A January 1971 record noted pain in the right knee due to playing basketball in December 1970. The record noted the Veteran had pain in the right knee that lasted three days during high school. The Veteran was diagnosed with right knee traumatic synovitis. In the July 1973 separation report of medical history, the Veteran denied any swollen or painful joints; arthritis, rheumatism, or bursitis; or "trick" or locked knee. His July 1973 separation exam reflects normal evaluation of the lower extremities. After service, the Veteran's VA or private treatment records are silent for a knee condition until 2006. A July 2006 VA record noted history of bilateral knee tenderness. In a September 2006 VA record, the Veteran reported he was throwing a ball to his dog, and that his knees were so tender and he fell. He reported his knees are locking. He stated he is ambulating with cane and had unsteady gait. He reported pain in the knees. The assessment was "osteoarthritis, rt hip pain"; it did not indicate whether osteoarthritis pertained to his knees or right hip. A July 2007 VA record noted the Veteran had severe arthritis of the knees and bursitis of the hip, and that he is deferring knee arthroplasty until neuro workup is complete. An April 2008 VA radiology report of his left knee noted the following: severe DJD in the medial compartment; mild degree of patellofemoral DJD; and mild DJD in the lateral compartment. The right knee radiology report noted mild DJD in the medial compartment. A January 2010 VA record noted the Veteran had a knee joint replacement; it did not indicate which side. In an October 2010 VA Form 21-4138, the Veteran reported that he injured his knees during active service in Germany. He stated the knees would swell often but go down, and that he did not seek medical attention because did not think the injury was serious. He stated the condition worsened over the years. He noted he has had a knee replacement and still suffers from pain and swelling in his knees. In the September 2011 VA examination, the Veteran was diagnosed with bilateral knee DJD in 1990s, and right knee traumatic synovitis in 1971. The examiner opined that it was less likely than not that the Veteran's bilateral knee conditions were caused by an in-service event or illness. In the April 2018 remand, the Board found the September 2011 opinion inadequate as the reported bilateral knee injury was not considered, and as service treatment records suggested a pre-existing injury. The case was remanded for a new opinion. A November 2018 VA examination noted diagnoses of bilateral knee DJD and traumatic right knee synovitis that has resolved. The examiner opined that the Veteran's bilateral knee disability did not clearly and unmistakably exist prior to enlistment into military service because the 1968 entrance exam did not reveal any knee condition. The examiner went on to opine that it was less likely than not that his bilateral knee disability was caused by an in-service event, injury, or illness, finding that the bilateral knee DJD is a new and separate non-service-related condition associated with age. The examiner explained that the Veteran's knee demonstrated no symptoms in the July 1973 separation exam, which was evidence of resolution of the symptoms of the January 1971 traumatic synovitis. The examiner similarly noted that the July 1969 pain below the knees was treated conservatively with subsequent resolution. In the August 2019 remand, the Board found that the September 2011 and November 2018 examiners did not consider the Veteran's October 2010 lay statement which noted he injured his knees during service and there has been symptoms present since the injury. The case was remanded for a new examination. The remand directives also included questions on whether the Veteran's service accelerated the onset of his condition and whether the diagnosed disability was caused or aggravated by his opposite knee. In the January 2020 VA examination, the Veteran was diagnosed with DJD status post left knee arthroplasty and right knee DJD. The Veteran reported he had no knee conditions prior to enlistment. He stated he injured his right knee during active service; he could not recall any trauma, treatment, or diagnosis for his left knee. He stated that after service, he worked as a welder for 30 years and retired in 2008 due to cervical spine surgery. He reported his left knee pain had onset in 2006 after a fall. He stated he had a left knee replacement in 2009, and had to wear a knee brace since due to instability. He had a revision left total knee replacement in 2017 by Dr. D. The examiner noted VA records from 1999 to 2002 and private records from Dr. D. were unavailable for review. The examiner opined that the claimed condition was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner explained that the July 1973 separation exam was negative for a joint or knee complaint, and that the right knee traumatic synovitis was a temporary and transient condition which resolved without residuals prior to separation. The examiner noted there was no available medical documentation of an ongoing right knee condition from 1970 until the 2000s, a time span of over 30 years. The examiner further noted that the onset of the left knee condition began in 2006 after a fall. She noted the Veteran had a left total knee arthroplasty in December 2009 with post-operative left middle collateral ligament incompetence, and a revision left total knee arthroplasty in 2017. The examiner stated that given his occupational history as a welder for more than 30 years, it is more likely than not that his bilateral knee DJD was secondary to normal aging and occupational physical demands. In the July 2020 remand, the Board found that the January 2020 examiner did not opine whether the Veteran's service accelerated the onset of his condition or whether his condition was caused or aggravated by his opposite knee. The Board also found additional development was needed as the examiner stated that she was unable to review VA records from 1999 to 2002 and private records from Dr. D. An addendum VA opinion was obtained in September 2020. The examiner opined that the condition claimed was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. In October 2020, the RO requested an addendum opinion because while no response was received from the Veteran regarding Dr. D.'s records, VA records from 1999 to 2002 had been obtained and the September 2020 examiner had not had a chance to review them. As a side note, VA records from 1999 did not reveal any knee issues. In an October 2020 addendum, the examiner stated that records received did not change the medical opinion as written in September 2020. In the February 2021 remand, the Board found that the September 2020 and October 2020 rationale appeared to be based on the Veteran's documented medical history and lack of documented symptoms, and that it did not adequately address his in-service injury. The Board indicated that the September 2020 medical opinion was inadequate; an addendum opinion was requested. In August 2021, the Veteran underwent a VA contract examination. He was diagnosed with bilateral knee DJD, right knee anterior cruciate ligament tear, and left knee infection. He reported bilateral knee pain from jumping out of trucks and climbing poles during service. He stated he was treated for a right knee pain after jumping out of a work truck in 1972. He reported his left knee pain occurred after a fall in 2006, and had a left knee replacement in 2009 and a left knee revision surgery in 2017. He stated he has been nonambulatory for years due to neurologic issues. The examiner opined that it is less likely as not that the diagnosed disabilities were caused by activities or incidents in service, or that any in-service injury or event accelerated the onset of the disabilities. The examiner explained that the Veterans bilateral knee degenerative changes are non-service-related conditions associated with aging presenting 30 years after service. He stated while the Veteran was diagnosed with traumatic synovitis in January 2017, his July 1973 separation exam did not show any knee symptoms or findings. He also noted that the documented episode of knee pain in service would not have directly or indirectly led to the significant amount of degenerative changes found 30 years later in both knees. He noted that aging was a more likely cause. He also noted that the Veteran's normal service activity would not have placed him at any greater risk of development of DJD of either knee 30 years later. The examiner also opined that it is less likely as not that the diagnosed disabilities were caused or aggravated by the disability of the opposite knee. He stated that the Veteran's neurologic condition causing him to have altered gait, using assistive devices and eventually becoming wheelchair bound, would not have caused worsening of his DJD of the knees. He added that DJD of the opposite knee has no anatomic or physiologic bearing on the affected knee. After a review of the evidentiary record, the Board finds the preponderance of the evidence weighs against finding that service connection is warranted for bilateral knee conditions. Specifically, regarding DJD being an enumerated condition under 3.309(a), the Board finds service connection is not warranted on a presumptive basis. DJD was not noted in service or within a year of discharge. 38 C.F.R. §§ 3.307, 3.309(a). VA records show the Veteran was not diagnosed with such DJD until many years after separation from service. Service connection is also not warranted based on chronicity and continuity of symptomatology because DJD was not noted in service or within a year of discharge, and there is no credible showing of continued knee symptoms thereafter. The Veteran's lay statements of continuous knee pain since service are inconsistent with other evidence of record, including post-service records being silent for a knee condition until 30 years later, his statement at the September 2011 exam that his DJD developed in the 1990s, and his consistent statements that the left knee condition had onset in 2006 after a fall. Further while the Veteran would be competent to report having experienced symptoms of pain since service, he is not competent to determine that these symptoms were manifestations of his current DJD or that such manifested within the one-year presumptive period following discharge. The issue is medically complex, as it requires knowledge of the interaction between multiple organ systems in the body and interpretation of complicated diagnostic medical testing. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). Accordingly, 38 C.F.R. § 3.303(b) does not provide an avenue of service connection based on chronicity or continuity of symptomatology. The Board further finds that service connection is not warranted on a direct basis. Further, VA opinions of record establish that the Veteran's bilateral knee conditions are not at least as likely as not related to an in-service injury, event, or disease. While the Board previously found the September 2011 and September 2020 VA nexus opinions inadequate due to deficiencies in the rationale, those opinions and the ones relied on by the Board in reaching the decision herein, were not favorable on the question of causal nexus. The November 2018 examiner explained that the Veteran's knees demonstrated no symptoms at the July 1973 separation exam, which indicated resolution of the July 1969 pain below the knees and the January 1971 traumatic synovitis. The examiner added that the DJD developed in the 1990s is a new condition that was associated with aging. The January 2020 examiner noted that given the Veteran's occupational history as a welder for more than 30 years, it was more likely than not that his bilateral knee DJD was secondary to normal aging and occupational physical demands. The August 2021 examiner explained that the separation exam did not reveal any knee symptoms, and that degenerative changes in his knees 30 years later was more likely due to his age. He also explained that the Veteran's neurologic condition causing him to have altered gait, using assistive devices and eventually becoming wheelchair bound, would not have caused worsening of his DJD of the knees. He added that the opposite knee had no anatomic or physiologic bearing on the affected knee. The VA medical opinions are supported by review of the Veteran's entire claims file, and addendum opinions were obtained specifically for consideration of the Veteran's lay reports. The Board finds the supporting rationales of the VA opinions when read together are consistent with the facts found and, when considered with the other probative evidence of record, are adequate to decide the claims. The probative weight of the lay evidence is outweighed by the objective medical evidence, including the VA opinions, which are based upon consideration of the Veteran's pertinent medical history and his lay assertions. Nieves-Rodriguez, 22 Vet. App. 304. There is no competent medical opinion to the contrary. To the extent the Veteran contends his bilateral knee disabilities are related to service, the Board finds he is not competent to provide such a determination because the issues are medically complex. The Veteran has not been shown to possess the necessary skills and training to render a complex medical opinion or diagnosis. Jandreau, 492 F.3d at 1377 n.4; Kahana v. Shinseki, 24. Vet. App. 428 (2011). Consequently, the Board gives more probative weight to the VA examiners' opinions. The Board has considered the applicability of the benefit of the doubt doctrine; however, as the preponderance of the evidence is against the claims, the doctrine is not applicable. Accordingly, entitlement to service connection for bilateral knee conditions are not warranted. See 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 55-7 (1990). D. JOHNSON Veterans Law Judge Board of Veterans' Appeals Attorney for the Board B. Jake Choi, 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.