Citation Nr: 21071115 Decision Date: 11/29/21 Archive Date: 11/29/21 DOCKET NO. 17-65 728 DATE: November 29, 2021 ORDER Entitlement to service connection for a right knee disability is denied. Entitlement to service connection for a left knee disability is denied. REMANDED Entitlement to service connection for sleep apnea, to include as secondary to service-connected posttraumatic stress disorder (PTSD), or in the alternative, service-connected traumatic brain injury (TBI), is remanded. Entitlement to service connection for a mouth lesion is remanded. Entitlement to service connection for a right hand middle finger injury is remanded. Entitlement to service connection for a right hand ring finger disability is remanded. Entitlement to service connection for a right hand pinky finger disability is remanded. FINDINGS OF FACT 1. The record indicates that the evidence is insufficient to establish a nexus between the Veteran's in-service complaints and his current right knee disability. 2. The record indicates that the evidence is insufficient to establish a nexus between the Veteran's in-service complaints and his current left knee disability. CONCLUSIONS OF LAW 1. The criteria for service connection for a right knee disability have not been met. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. 2. The criteria for service connection for a left knee disability have not been met. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served active duty in the United States Army from October 2000 to March 2001, and from October 2004 to December 2005. In April 2021, the Veteran testified before the undersigned Veterans Law Judge at a Virtual hearing. A copy of the transcript has been associated with the claims file. In July 2021, the Board remanded the appeal for further development. SERVICE CONNECTION 1. Service connection for a right knee disability 2. Service connection for a left knee disability The Veteran contends that his right and left knee disabilities are due to his period of service. The Board finds that, while the Veteran has a current diagnosis of patellofemoral pain syndrome and his service treatment records indicate complaint of knee pain, the evidence is insufficient to establish that the Veteran's current left and right knee disabilities are related to his period of service. The Veteran's VA examinations confirm current right and left knee diagnoses. An October 2004 service treatment record noted the Veteran's report of mild knee issues that did not affect his military occupational specialty (MOS). A March 2005 service treatment record indicates report of current concerns for knees. Likewise, in a November 2005 Post-Deployment Assessment, the Veteran reported having knee pain during his deployment. The Board notes that a March 2014 VA medical opinion gave a negative nexus opinion. In a July 2021 Board decision, the Board found the opinion inadequate for the purpose of adjudicating the claims. Therefore, no further analysis of this evidence is necessary. In an August 2021 VA medical opinion, the examiner opined that it is less likely than not that the Veteran's current left and right knee disabilities are due to his period of service. The examiner noted the October 2004 pre-deployment service treatment record regarding the Veteran's complaint of mild knee pain and the November 2005 post-deployment health assessment's report of knee pain during deployment. The examiner then noted that in the Veteran's separation assessment, which was performed less than a month later, there was no mention of knee-related issues. The examiner went on to note that it was not until 2014 that the Veteran was diagnosed with suspected patellofemoral pain syndrome. The examiner stated that, as the remaining treatment records lack additional complaints from 2005 onward, it is less likely than not that the Veteran's suspected patellofemoral pain syndrome is a direct result of military service events. The Board finds the examiner's use of the Veteran's medical history and knowledge of the diagnosis of patellofemoral pain syndrome to be adequate for the purpose of adjudicating the claim. Moreover, the Board finds the opinion to be highly probative in determining whether there is a nexus between the Veteran's period of service and his current patellofemoral pain syndrome due to the detailed history and explanation given. After review of the record, the Board finds that the evidence is insufficient to establish service connection for right and left knee disabilities. The probative medical opinion of record did not find a nexus between the Veteran's in-service knee complaints and his current patellofemoral pain syndrome. As such, service connection for right and left knee disabilities is not warranted. While the Veteran believes that his right and left knee disabilities are related to his period of service, he is only competent to report symptoms and is not competent to opine on the etiology of right and left knee disabilities, as this is a medically complex question. See Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011). In this regard, while the Veteran can competently report observed symptoms, any opinion regarding whether his condition was related to his period of service requires medical expertise that the Veteran has not demonstrated. See Jandreau v. Nicholson, 492 F. 3d 1372, 1376 (2007). Therefore, the Veteran's statements regarding etiology hold no probative value. As the probative medical evidence does not establish a nexus, the criteria for service connection have not been met. REASONS FOR REMAND 1. Service connection for sleep apnea, to include as secondary to service-connected PTSD, or in the alternative, service-connected TBI, is remanded. The Veteran contends that his sleep apnea is due to his period of service, to include as due to his service-connected PTSD or, in the alternative, his service-connected TBI. In an August 2021 VA medical opinion, the examiner opined that it was not at least as likely as not that the Veteran's sleep apnea was aggravated beyond natural progression by the Veteran's PTSD. However, in the rationale, the examiner stated that there are case reports showing improved PTSD symptoms in patients being treated for obstructive sleep apnea. The examiner went on to state that, as such, it can be said that the Veteran's PTSD contributed to aggravating the Veteran's obstructive sleep apnea. The Board finds this opinion to be unclear in that the rationale conflicts with the conclusion. Moreover, the rationale itself is vague as to whether the case reports show treatment for obstructive sleep apnea resulting in improved PTSD, which does not establish aggravation for the purposes of service connection of sleep apnea, or that worsened PTSD symptoms aggravated obstructive sleep apnea, which would establish aggravation for the purpose of service connection. Therefore, the Board finds the opinion inadequate for the purpose of adjudication of the claim. Moreover, though the issue was raised by the Veteran and in the provided general treatises, there is no opinion of record regarding whether the Veteran's sleep apnea is secondary to his service-connected TBI. Therefore, a remand is necessary. 2. Service connection for a mouth lesion is remanded. The Veteran contends that his mouth lesion is due to his period of service. In a July 2021 Board remand, the Board directed that an addendum opinion be given regarding the Veteran's mouth lesion. Specifically, as the previous medical opinion did not consider evidence of an in-service record of an oral lesion, the Board instructed that the examiner consider and discuss the October 2004 service treatment record, in which a dental examiner noted that the Veteran has curious lesion. In an August 2021 VA medical opinion, the examiner opined that it was less likely than not that the Veteran's mouth lesion was related to his period of service. The rationale did not address the October 2004 service treatment record. Moreover, in listing the reviewed documents for the oral lesion medical opinion, the examiner did not list the aforementioned service treatment record. As the prior directives were not followed and it is not clear that this record was considered in rendering this opinion, a remand is necessary. 3. Service connection for a right hand middle finger injury is remanded. 4. Service connection for a right hand ring finger disability is remanded. 5. Service connection for a right hand pinky finger disability is remanded. The Veteran contends that his right hand middle finger disability, right hand ring finger disability and right hand pinky finger disability are due to his period of service. In a July 2021 Board decision, the Board noted that the Veteran reported finger pain that caused limitation of motion and painful motion. The Board noted that where pain causes functional impairment, a disability for VA compensation purposes exists, even if there is no underlying diagnosis. Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018). The Board remanded the claims and directed that the examiner determine whether it is at least as likely as not (a 50 percent probability or greater) that the Veteran's right middle finger, ring finger, and pinky finger disabilities are such that they cause functional impairment of earning capacity. If so, the examiner was asked to opine as to whether it is at least as likely as not that they were manifested in, caused by, or are otherwise etiologically related to his period of active duty service. In an August 2021 VA medical opinion, the examiner opined that it was less likely than not that the Veteran's finger disabilities were due to his period of service. The examiner stated that the prior VA examinations did not establish right hand conditions and a reply discussing its functional impairment on the Veteran's earning capacity would be mere speculation. The Board notes that the rationale of the August 2021 medical opinion relies on the previous VA opinions that found no named diagnoses. The Board notes that these opinions were found inadequate to adjudicate the claims. Moreover, the opinion does not indicate consideration of the Veteran's description of current functional impairment. Therefore, a remand is necessary. The matters are REMANDED for the following action: 1. Send the Veteran's file to an appropriate examiner(s) for addendum opinions to determine the nature and etiology of the Veteran's sleep apnea and mouth lesion. Schedule an examination if the examiner deems it necessary. The claims file, to include this remand, should be made available and reviewed by the examiner. After review of the record, the examiner(s) is asked to offer an opinion on the following: 2. a. Determine whether it is at least as likely as not (a 50 percent probability or greater) that the Veteran's sleep apnea is manifested in, caused by, or is otherwise etiologically related to his active duty service or, in the alternative, whether his sleep apnea was proximately due to or aggravated by his service-connected traumatic brain injury. The examiner is also asked to determine whether it is at least as likely as not that the Veteran's sleep apnea is aggravated by his service-connected PTSD. In making this determination, the examiner should consider and discuss the article submitted by the Veteran in April 2021 regarding TBI, PTSD and sleep apnea. b. Determine whether it is at least as likely as not (a 50 percent probability or greater) that the Veteran's mouth lesion is manifested in, caused by, or is otherwise etiologically related to his active duty service. In making this determination, the examiner MUST consider and discuss the October 2004 service treatment dental record noting lesion. 3. Schedule the Veteran with an appropriate examiner to determine the nature and etiology of the Veteran's claimed right middle finger, ring finger, and pinky finger disabilities. The claims file, to include this remand, should be made available and reviewed by the examiner in conjunction with conducting the examination. After examination and review of the record, the examiner is asked to offer an opinion on the following: Determine whether it is at least as likely as not (a 50 percent probability or greater) that the Veteran's right middle finger, ring finger, and pinky finger conditions are such that they cause functional impairment or impact on employment. In making this determination, the examiner should consider the physical examination and the Veteran's lay statements. If so, is it at least as likely as not that they were manifested in, caused by, or are otherwise etiologically related to his period of active duty service? In making this determination, the Veteran's reported fall should be considered and discussed as an in-service incurrence. JENNIFER HWA Veterans Law Judge Board of Veterans' Appeals Attorney for the Board C. Ford 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.