Citation Nr: 21071215 Decision Date: 11/30/21 Archive Date: 11/30/21 DOCKET NO. 16-15 612A DATE: November 30, 2021 ORDER Service connection for a right knee disability is denied. FINDING OF FACT The preponderance of the evidence is against finding that a right knee disability began during active service or is otherwise related to an in-service injury or disease and is not secondary to a service-connected disability and is not otherwise related to an in-service injury or disease. CONCLUSION OF LAW The criteria for service connection for a right knee disability have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had active service from October 1979 to October 1982 and from February 1991 to April 1991, as well as service in the United States Army Reserves. The Veteran asserts that she has a right knee disability due to service and/or due to her service-connected pes planus, right foot (0% 07/30/2010; 10% 12/05/2016). See 03/28/2019 Correspondence. The Veteran asserts that she injured her right knee in 2000 while preparing for a physical training test when her right knee popped out of joint. See 08/10/2011 VA Examination. At the Board hearing, the Veteran reported having problems with her knee during service due to running in boots and marching in boots for long periods of time. 08/14/2019 Hearing Transcript at 2. 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). Active service includes any period of active duty for training (ACDUTRA) during which the individual was disabled from a disease, or an injury incurred in the line of duty, or a period of inactive duty training (IDT) during which the veteran was disabled from an injury incurred in the line of duty. 38 U.S.C. § 101(24); 38 C.F.R. § 3.6(a). Service connection may be granted for a disability that is proximately due to, or aggravated by, service-connected disease or injury. 38 C.F.R. § 3.310. The question for the Board is whether the Veteran has a current right knee disability that began during service or is at least as likely as not related to an in-service injury, event, or disease or due to or aggravated by a service-connected disability. The Board concludes that, while the Veteran has a current diagnosis of degenerative joint disease of the right knee and evidence shows that she had in-service complaints, the preponderance of the evidence weighs against finding that the Veteran's diagnosis of degenerative joint disease of the right knee began during service (to include during a period of ACDUTRA or IDT) or is otherwise related to an in-service injury, event, or disease nor does the evidence support that it is proximately due to or the result of, or aggravated beyond its natural progression by service-connected disability. 38 U.S.C. §§ 1110, 1131; Allen v. Brown, 7 Vet. App. 439 (1995) (en banc); 38 C.F.R. § 3.310(a). Service treatment records reflect that in June 1979 the Veteran reported a 1976 injury to the left leg while playing basketball. 08/02/2010 STR-Medical at 161. In June 1982 she complained of her right leg cramping in the knee joint, and in September 1982 she complained that her knee ached sometimes. 08/01/1988 STR at 3, 23. A July 1996 Report of Medical History reflects reports of right knee pain from three days prior. 08/02/2010 STR-Medical at 58. An April 1988 Report of Medical History reflects that she incurred a right knee injury playing basketball in junior high with no sequelae. Id. at 14. Service treatment records reflect that in March 2004 she sustained a knee sprain and was put on a physical profile. 08/01/1988 STR at 17. The Veteran asserts that she injured her right knee in 2000 while preparing for a physical training test, stating that her right knee popped out of joint. See 08/10/2011 VA Examination. At the August 2019 Board hearing, the Veteran reported having problems with her knee during service due to running in boots and marching in boots for long periods of time. 08/14/2019 Hearing Transcript at 2. Correspondence dated in February 2015 from a VA physician reflects that the Veteran complained of right knee pain while on active duty and her knee complaints have continued to the present time. The examiner opined that it is more likely than not that the Veteran's right knee condition began while she was on active duty. 05/15/2015 Correspondence. In August 2015, the same examiner provided a positive opinion. The examiner noted a diagnosis of degenerative joint disease of the knee. The examiner stated that while on active duty in the mid-1980s she first complained of right knee pain and discomfort. Her complaints have continued to the present day. The examiner noted a review of a limited portion of her service treatment records and her VA medical records. The examiner stated that there is an underlying assumption that the physical demands placed on her knee joint while on active duty, which directly lead to her current degenerative joint disease of the knee. The examiner stated that degenerative joint disease often begins with continued repetitive use of a joint as would be expected from the military PT requirements. These would include but not be limited to long marches and jogging on hard surfaces while carrying in excess of 25 pounds of gear. 08/26/2015 Third Party Correspondence. In January 2020, the Veteran underwent a C&P examination wherein the examiner opined that it is less likely than not that the Veteran's right knee degenerative joint disease is due to military service. The examiner noted that medical records indicate an isolated occurrence of muscular strain in 1982 and 1996 and there are no records indicating a continuity of symptoms immediately after discharge from service which establish a longitudinal association with present findings. There is no evidence of a persistent disability that originated from military service. In formulating the opinion, however, the examiner did not acknowledge the March 2004 physical profile after she sustained a knee sprain. 08/01/1988 STR at 17-22. The examiner also did not address the positive etiological opinion which relates her right knee disability to the "physical demands placed on her knee joint" and "long marches and jogging on hard surfaces while carrying in excess of 25 pounds of gear" during active service. Thus, an addendum opinion was sought. In April 2021, another C&P examiner reviewed the claims folder. The examiner stated that reports of medical history and examination on 5/18/1986, 3/29/1991, and 2/3/2003 did not reveal history or physical exam findings for ongoing acute or chronic treatment of right knee joint condition. A January 2020 C&P examination documents a diagnosis of right knee degenerative joint disease. Medical record review did not reveal continuous ongoing medical treatment or aggravation of acute or chronic right knee joint condition during time of discharge from active military service to present day. The examiner stated that right knee degenerative joint disease is secondary to joint aging and chronic overuse of the right knee joint over duration of many years and is independent from the claimant's active military career. The examiner opined that a right knee disability was less likely than not related to an in-service injury, event, or disease, to include during active service, active duty for training, or inactive duty for training. In April 2021, an addendum opinion was requested, in which the examiner was asked to consider the 2004 service treatment record. The written opinion does not appear to contain any further comments from the examiner, to include acknowledgement or comment pertaining to the 2004 service treatment record. See 04/14/2021 C&P Exam. Moreover, it is not clear that the examiner considered the February 2015 and August 2015 opinions of record as instructed in the December 2020 Board Remand. Thus, the issue was remanded for a further opinion. A September 2021 C&P examiner reviewed the claims folder and opined that her right knee disability was less likely than not due to service. With regard to the February 2015 and August 2015 statements by the VA physician the C&P examiner stated the following: It is a statement made by a doctor who is being asked by his patient to make a statement. When I am in the same position, under the pressure by my patient to make a statement, I will make a similar statement. In that statement, it just elaborate[s] what the patient said, and within timeline given, the possibility of the problem exist[ing] during the time is valid. But it is all merely speculation. As an example, during my residency program I have to walk from my apartment to the hospital everyday, and during that time I start having knee pain, can I blame my program making that issue when I have DJD right now? Is it possible I have an injury outside my working time, how about my wear and tear after my residency, how about my aging factor or I do not care for my knee pain and make it worse. Because by literature without any significant structural damage that can prove as the cause, it is merely speculation. The examiner acknowledged the April 1988 Report of Medical History in which she incurred a right knee injury playing basketball in junior high with no sequelae and that in March 2004 she sustained a knee sprain and was put on physical profile. The examiner acknowledged a December 2018 examination which did not indicate a worsening of symptoms and no x-ray evidence of worsening as x-ray without degenerative changes, spurring or other abnormalities. The examiner acknowledged the reports of medical history and exams in May 1986, March 1991 and February 2003 which did not reveal a history or physical exam findings for ongoing acute or chronic treatment of the right knee joint condition. A January 2020 examination documents a diagnosis of right knee degenerative joint disease. The examiner acknowledged a November 2010 x-ray which showed mild degenerative change affecting the right knee without acute fracture or subluxation, and an April 2018 x-ray which showed mild degenerative change of the right knee. The examiner explained that osteoarthritis occurs when the cartilage that cushions the ends of bones in your joints gradually deteriorates. Cartilage is a firm, slippery tissue that enables nearly frictionless joint motion. Eventually, if the cartilage wears down completely, bone will rub on bone. Osteoarthritis has often been referred to as a wear and tear disease. But besides the breakdown of cartilage, osteoarthritis affects the entire joint. It causes changes in the bone and deterioration of the connective tissues that hold the joint together and attach muscle to bone. It also causes inflammation of the joint lining. Factors that can increase your risk of osteoarthritis include old age and gender, as women are more likely to develop osteoarthritis, though it is not clear why. The examiner also noted that obesity, carrying extra body weight contributes to osteoarthritis in several ways, and the more you weigh, the greater your risk. Increased weight adds stress to weight-bearing joints, such as your hips and knees. Also, fat tissue produces proteins that can cause harmful inflammation in and around your joints. Joint injuries, such as those that occur when playing sports or from an accident, can increase the risk of osteoarthritis. Even injuries that occurred many years ago and seemingly healed can increase your risk of osteoarthritis. Repeated stress on the joint, if your job or a sport you play places repetitive stress on a joint, that joint might eventually develop osteoarthritis. Some people inherit a tendency to develop osteoarthritis. Some people are born with malformed joints or defective cartilage. Certain metabolic diseases, including diabetes and a condition in which your body has too much iron, can cause osteoarthritis. The examiner noted that the Veteran's active duty was for 4 years (1979-82 and 1991) and the significant finding of knee imaging as degenerative is in 2018 (36-year gap), even though recognized that the Veteran had multiple subjective complaints regarding the knee pain. The degenerative joints are known to cause wear and tear disease, with no particular significant injury and time gap. The examiner opined that her right leg disability is less likely than not due to service. As detailed, while service treatment records do reflect complaints related to the right leg/knee a knee sprain during a period of ACDUTRA/IDT, the records are negative for a chronic right knee disability which manifested during active service or due to an injury during ACDUTRA or IDT. Mild degenerative changes affecting the right knee without acute fracture or subluxation are shown in November 2010, thus many years after separation from active service and over 6 years after the March 2004 knee sprain. Moreover, based on the in-service complaints and the Veteran's lay assertions, opinions were sought which were negative. As detailed above, the September 2021 C&P examiner reviewed and acknowledged the entirety of the evidence of record, including the service treatment records, 2015 medical opinions, and post-service medical evidence of record and concluded that her right knee disability is not due to service. This opinion is probative, because it is based on an accurate medical history and provides an explanation that contains clear conclusions and supporting data. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). While acknowledging the 2015 positive opinions, the Board finds that such opinions are less probative than the September 2021 C&P examiner's opinion. Initially, it is noted that the Veteran did not have active duty service in the mid-1980s; she had active service in the late 1970s and early 1980s and in 1991. It is also not clear which records the examiner relied on as he indicated that he reviewed a "limited portion" of her service treatment records. Thus, it is not clear that the examiner had the benefit of review of the pertinent medical evidence in the claims file. Instead, the opinion appears to be based on a combination of the Veteran's lay assertions, review of a "limited portion" of service treatment records, and physical examination. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008); Reonal v. Brown, 5 Vet. App. 458, 460-61 (1993). As discussed by the September 2021 C&P examiner, the 2015 opinions of the VA examiner were speculative in nature as the statements just elaborated what the Veteran was saying and provided a possibility of the problem existing during the times asserted by the Veteran. For these reasons, the Board assigns less probative weight to the 2015 opinions of record. With regard to service connection on a secondary basis, the April 2021 examiner opined that the Veteran's right knee disability is not due to or aggravated by his pes planus, right foot. Specifically, the examiner stated that medical records do not indicate significant sequelae from pes planus to warrant a cause effect relationship between these two conditions. Likewise, there is no documented medical record data provided by a specialist to support or add merit to this claim. In addition, there is no direct pathophysiologic correlation between the two conditions to substantiate a cause-and-effect relationship without resulting to mere speculation. The examiner opined that the Veteran's right knee has not been aggravated beyond its natural progression by pes planus. There is no association between pes planus and right knee changes is not established based on medical records provided. There is no specialist documentation or other documentation in the medical records which established a cause effect relationship between the two condition beyond mere speculation. A December 2018 C&P examination does not indicate a worsening of symptoms and no x-ray evidence of worsening as X-ray without degenerative changes, spurring or other abnormalities. The September 2021 C&P examiner commented that with regard to a secondary relationship the article (https://www.mayoclinic.org/diseases-conditions/osteoarthritis/symptoms-causes/syc-20351925) indicates that pes planus is not even as a risk factor for this wear and tear disease. The examiner opined that pes planus does not aggravate the knee condition as there is no pathophysiological relationship. Regardless of an established baseline, the Veteran's right knee condition is less likely as not aggravated beyond its natural progression by right foot pes planus. Based on the in-service assertions of the Veteran regarding a secondary relationship to her service-connected pes planus, right foot, opinions were sought. As detailed, both the April and September 2021 C&P examiners reviewed the evidence of record and concluded that her right knee disability is not due to or aggravated by her pes planus. The collective opinions are probative because they are based on an accurate medical history and provides an explanation that contains clear conclusions and supporting data. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). There is no contrary opinion of record. The Board acknowledges the Veteran's belief that she has a right knee disability due to service and/or due to a service-connected disability. The Veteran, however, is not competent to provide a nexus opinion regarding these issues. The issue is medically complex, as it requires knowledge of the interaction between multiple organ systems in the body and their anatomical relationships and pathology, as well as interpretation of complicated diagnostic medical testing. Therefore, it is outside the competence of the Veteran in this case because the record does not show that she has the medical training or credentials to make such a determination. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007); see also Kahana v. Shinseki, 24. Vet. App. 428 (2011). Consequently, the Board gives more probative weight to the September 2021 C&P examiner on a direct basis, and the April 2021 and September 2021 opinions on a secondary basis as such examiners are trained medical professionals. Eric S. Leboff Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M.W. Kreindler, 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.