Citation Nr: 21070438 Decision Date: 11/24/21 Archive Date: 11/24/21 DOCKET NO. 15-33 454 DATE: November 24, 2021 ORDER Service connection for a left knee disorder is denied. REMANDED Entitlement to service connection for acquired allergies is remanded. FINDING OF FACT A left knee disorder is not shown to be causally or etiologically related to any disease, injury, or incident during service, and arthritis did not manifest to a compensable degree within one year of discharge from active duty. CONCLUSION OF LAW The criteria for service connection for a left knee disorder have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1131, 1137, 5107; 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 September 1985 to October 1994 and September 2001 to September 2002, with additional service in the Air Force Reserve. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a rating decision issued in October 2013 by a Department of Veterans Affairs (VA) Regional Office (RO). In November 2016, the Veteran testified at a hearing before the undersigned Veterans Law Judge. A transcript of the hearing is associated with the record. In November 2018, the Board remanded the issues on appeal, as well as a claim for service connection for an acquired psychiatric disorder, for additional development. While on remand, a December 2020 rating decision awarded service connection for such disorder, characterized as somatic symptom disorder. As such is a full grant of the benefit sought on appeal with respect to such issue, it is no longer before the Board. Grantham v. Brown, 114 F.3d 1156 (Fed. Cir. 1977). The remaining claims now return for further appellate review. 1. Entitlement to service connection for a left knee disorder. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection may also be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Direct service connection may not be granted without evidence of a current disability; in-service incurrence or aggravation of a disease or injury; and a nexus between the claimed in-service disease or injury and the present disease or injury. Id.; see also Caluza v. Brown, 7 Vet. App. 498, 506 (1995) aff'd, 78 F.3d 604 (Fed. Cir. 1996) [(table)]. Where a veteran served for at least 90 days during a period of war or after December 31, 1946, and manifests certain chronic diseases, such as arthritis, to a degree of 10 percent within one year, from the date of termination of such service, such disease shall be presumed to have been incurred or aggravated in service, even though there is no evidence of such disease during the period of service. 38 U.S.C. §§ 1101, 1112, 1137; 38 C.F.R. §§ 3.307, 3.309. Alternatively, when a disease at 38 C.F.R. § 3.309(a) is not shown to be chronic during service or the one-year presumptive period, service connection may also be established by showing continuity of symptomatology after service. 38 C.F.R. § 3.303(b). However, the use of continuity of symptoms to establish service connection is limited only to those diseases listed at 38 C.F.R. § 3.309(a) and does not apply to other disabilities which might be considered chronic from a medical standpoint. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). The Veteran contends that she has a left knee disorder related to her military service. In this regard, she claims that the wear and tear of military service, to include standing and marching for prolonged periods with heavy equipment, and hard falls on her knees therein caused or accelerated the degeneration of her left knee, leading to a total knee replacement. Further, while she reported that she also injured her left knee when she fell on a cactus, her service treatment records (STRs) reflect that such was the right knee as documented in July 2000. Further, in an October 2016 statement, the Veteran's spouse reported that he recalled the Veteran experiencing left knee symptoms in service, which resulted in an inability to walk long distances, use the stairs, and kneel. As an initial matter, the Board finds that the evidence of record reflects that the Veteran has a current diagnosis of left knee status-post total knee replacement, which was preceded by diagnoses of chondromalacia patella and osteoarthritis, as demonstrated by post-service treatment records and an August 2013 VA examination. Additionally, while the Veteran has reported that her STRs are incomplete, there is no indication that such do not include all documented reports of complaints or treatment referable to her left knee. In this regard, such include a December 1989 record wherein the Veteran reported that she injured her right knee in a fall on the ice 10 days previously, which resulted in a contusion with complaints of pain; however, the assessment was left knee strain. Nonetheless, in February 1990, it was clarified that such injury was to the right knee. Additionally, in a January 1990 STR, the Veteran reported that she fell on both knees, but only a right knee injury was noted. An updated STR dated after May 1994 reflects the Veteran's report of having painful knees during wet weather since 1991 and arthritis since 1992; however, no correlating clinical evaluation, or imaging studies, were noted. Further, while a November 1992 STR reflects that a review of the Veteran's systems was significant for joint pain and arthralgia in the knees and she reported experiencing swollen or painful joints, arthritis, and a bone, joint, or other deformity in a May 1994 Report of Medical History, she did not specify the affected body part and, in January 1995 and August 1996 Reports of Medical History, she denied experiencing swollen or painful joints, arthritis, rheumatism, bursitis, lameness, or trick or locked knee, and associated Reports of Medical Examination reflect that her lower extremities were normal upon clinical evaluation. The Veteran's post-service treatment records reflect a diagnosis of mild osteoarthritis of the bilateral knees by X-ray in December 2004, and she was placed on a permanent no running profile for arthritis in her knees while in the Air Force Reserve as reflected in a November 2005 Medical Evaluation Board. In December 2007, the Veteran reported bilateral knee pain, worse on the left, that had been present since 1991 without incidence of trauma. Subsequent treatment records, to include in November 2008, January 2010, December 2010, and July 2011 continue to reflect the Veteran's reports of bilateral knee pain that she related to her military service, to include the physical nature of her in-service duties, which resulted in a total left knee replacement in August 2011. In connection with her claim, the Veteran underwent a VA examination in August 2013, at which time she was noted to have status post knee replacement in both knees. The examiner noted that the right knee disorder began in 1990, and the Veteran described such disorder began during combat training during which she received injuries that caused accelerated degeneration to both knees. The examiner then opined that the right knee disorder was at least as likely as not related to service; however, she did not provide an etiological opinion regarding the left knee disorder. Further, in light of the diagnosis of osteoarthritis as early as December 2004, a notation of relevant complaints in her STRs, and her report of experiencing pain in her left knee since 1990, the Board remanded the claim in order to obtain addendum opinion addressing the etiology of her left knee disorder in November 2018. In September 2020, a VA examiner reviewed the record and opined that the Veteran's left knee disorder was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. In support thereof, she noted the assessment of left knee strain in December 1989 and bilateral knee arthralgia (i.e., pain) without injury or ongoing complaint, diagnosis, or treatment in November 1992, but found that there was no medical evidence to support a finding that her osteoarthritis had its onset in service, or within one year thereof, as December 2004 and December 2007 X-rays showed only mild osteoarthritis. The examiner indicated that, while the Veteran can report symptoms, she is not competent to ascribe a diagnosis to such symptoms, and there was no medical evidence to support a finding that her left knee disorder is due to her military service. The Board affords great probative weight to the September 2020 VA examiner's opinion as such considered all of the pertinent evidence of record, to include the Veteran's statements and her relevant medical history, and provided a complete rationale, relying on and citing to the records reviewed. Moreover, the examiner offered clear conclusions with supporting data as well as reasoned medical explanations connecting the two. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008) (it is the factually accurate, fully articulated, sound reasoning for the conclusion that contributes to the probative value of a medical opinion); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A]medical opinion... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions"). Notably, there is no medical opinion to the contrary. The Board also considered the Veteran's assertions as to the etiology of her left knee disorder; however, as a lay person, she does not have the requisite training and experience necessary to address such a complex medical matter. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007) (noting general competence to testify as to symptoms but not to provide medical diagnosis). In this regard, the etiology of such disorder involves a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship. Specifically, the etiology of a knee disorder, to include chondromalacia patella and osteoarthritis, requires knowledge of the inner workings of the knee joint and consideration of the impact physical activity has on it. Thus, may not be competently addressed by lay statements. See Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (explaining that while the claimant is competent in certain situations to provide a diagnosis of a simple condition such as a broken leg or varicose veins, the claimant is not competent to provide evidence as to more complex medical questions). Accordingly, the Veteran's opinion as to the etiology of her left knee disorder is not competent evidence and, consequently, is afforded no probative weight. Additionally, the evidence of record fails to demonstrate that arthritis of the left knee manifested to a compensable degree within one year of the Veteran's separation from service in October 1994 or September 2002. In this regard, while the Veteran has reported the onset of her knee symptomatology in 1990 and a November 1992 STR reflects a report of bilateral knee arthralgia, she denied experiencing swollen or painful joints, arthritis, rheumatism, bursitis, lameness, or trick or locked knee in January 1995 and August 1996 Reports of Medical History, and associated Reports of Medical Examination reflect that her lower extremities were normal upon clinical evaluation. Moreover, osteoarthritis was not demonstrated on X-ray until December 2004, which is more than a year after separation from both periods of service, and such was only noted to be mild at such time. Additionally, as noted previously, the highly probative September 2020 VA examiner's opinion reflects that arthritis did not manifest within one year of separation from either period of service. Furthermore, whether the symptoms the Veteran reportedly experienced during or after service are in any way related to her currently diagnosed left knee disorder is a matter that also requires medical expertise to determine. See Clyburn v. West, 12 Vet. App. 296, 301 (1999) ("although the veteran is competent to testify to the pain he has experienced since his tour in the Persian Gulf, he is not competent to testify to the fact that what he experienced in service and since service is the same condition he is currently diagnosed with."). Consequently, presumptive service connection for arthritis of the left knee, to include on the basis of a continuity of symptomatology, is not warranted. Based on the foregoing, the Board finds that the Veteran's left knee disorder is not shown to be causally or etiologically related to any disease, injury, or incident during service, and arthritis did not manifest to a compensable degree within one year of service discharge. Consequently, service connection for such disorder is not warranted. In reaching this decision, the Board has considered the applicability of the benefit of the doubt doctrine. However, the preponderance of the evidence is against the Veteran's claim of entitlement to service connection for a left knee disorder. As such, that doctrine is not applicable in the instant appeal, and her claim must be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert, supra. REASONS FOR REMAND 2. Entitlement to service connection for acquired allergies. As noted in the November 2018 remand, the Veteran contends that she acquired numerous allergies due to in-service chemical and toxin exposure, to include various cleaning solvents and exhaust fumes. In this regard, the Board notes that she is currently service-connected for allergic rhinitis and sinusitis as a result of her allergies; however, she also claims that she has allergies manifested by skin symptomatology, to include eczema, urticaria, rash, and hives. Additionally, in October 1999, between her two periods of active duty service, her post-service treatment record allergic reactions that included hives. Further, during the Veteran's second period of active duty, a July 2002 STR reflects an allergy evaluation wherein she reported that she had skin testing by a civilian in 1991, which revealed that her triggers included cleaners that caused rashes. Also, post-service treatment records reflect that, in June 2004, she had experienced two recent acute urticarial reactions due to exposure to cleaning products. The Board further observes that a November 2005 Medical Evaluation Board (MEB) reflects that she had undergone an MEB in April 2000 for allergies and asthma. At such time, she reported developing a severe sensitivity to many common cleaners over the past year or longer that causes her to break out into a severe pruritic rash and, reported that, in 2002, she had such a severe reaction that required emergent treatment. The MEB diagnosed the Veteran with uncontrollable rhinitis and urticaria related to multiple allergens, common cleaners, and wool clothing. Additionally, in a July 2011 private treatment record, it was noted that, from 1994 to 1995, the Veteran reported that she developed eczema due to the use of soaps. The physician observed that the Veteran's skin symptoms included mild to moderate itching, rash, and easy bruising; and her allergy immunology symptoms included eczema. Additional records, to include those dated in January 2014, November 2019, and February 2020, reflect treatment for a rash. In order to determine the nature and etiology of the Veteran's acquired allergies, opinions were obtained in August 2020 and December 2020; however, at such time, the examiners only addressed the etiology of the Veteran's allergic rhinitis and sinusitis, which they found were related to her in-service exposure to chemicals and toxins. However, as noted previously, the Veteran has reported an additional acquired allergy manifested by skin symptomatology, to include eczema, urticaria, rash, and hives, and an etiological opinion addressing such claimed disorder has not been obtained. Accordingly, the matter is REMANDED for the following action: Forward the record, to include a copy of this remand, to appropriate VA examination so as to determine the nature and etiology of the Veteran's claimed acquired allergies, to include those involving skin symptomatology. Following a review of the record, the examiner should address the below inquiries: (A) The examiner should identify all of the Veteran's acquired allergies other than allergic rhinitis and sinusitis, to include those manifested by skin symptomatology such as eczema, urticaria, rash, and hives. (B) For each diagnosed allergy, the examiner should offer an opinion as to whether it is at least as likely as not (i.e., a 50 percent or greater probability) that such had its onset in, or is otherwise related to, the Veteran's military service, to include her reports of being exposed to chemicals and toxins such as various cleaning solvents and exhaust fumes. A rationale for any opinion offered should be provided. A. JAEGER Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Dawn A. Leung, 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.