Citation Nr: 21071625 Decision Date: 12/01/21 Archive Date: 11/30/21 DOCKET NO. 17-08 246 DATE: December 1, 2021 ORDER Entitlement to service connection for a right knee disability, diagnosed as right knee tendonitis, patellofemoral pain syndrome, and chondromalacia patella, is granted. Entitlement to service connection for a left knee disability, diagnosed as left knee meniscal degeneration/tear, is granted. Entitlement to service connection for residuals of a broken left foot 5th toe is denied. FINDINGS OF FACT 1. The evidence is in equipoise as to whether the Veteran's right knee disability was incurred in or caused by his active-duty service. 2. The evidence is in equipoise as to whether the Veteran's left knee disability was incurred in or caused by his active-duty service. 3. The preponderance of the evidence is against finding the Veteran's current left foot disabilities were incurred in or caused by residuals of his broken left foot 5th toe. CONCLUSIONS OF LAW 1. The criteria for service connection for a right knee disability, diagnosed as right knee tendonitis, patellofemoral pain syndrome, and chondromalacia patella, have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for service connection for a left knee disability, diagnosed as left knee meniscal degeneration/tear, have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 3. The criteria for service connection for residuals of a broken left foot 5th toe have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active-duty service from July 1972 to July 1974. These matters come before the Board of Veterans' Appeals (Board) from a November 2015 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). These matters were previously remanded by the Board in November 2019 in order to obtain addendum opinions regarding the nature and etiology of these disabilities. The requested development has been substantially complied with and the matters are again before the Board for additional appellate consideration. Service Connection In order to establish service connection for a claimed disability, the following three elements must be satisfied: (1) the existence of a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship (nexus) between the present disability and the disease or injury incurred or aggravated during service. Hickson v. West, 12 Vet. App. 246 (1999). 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. If a condition noted during service is not shown to be chronic, then generally a showing of continuity of symptomatology after service is required for service connection. 38 C.F.R. § 3.303(b), Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Service connection may also be granted for any disease diagnosed after discharge from service when all of the evidence, including lay evidence, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Lay statements may serve to support a claim for service connection by supporting the occurrence of lay-observable events or the present of disability or symptoms of disability subject to lay observation. 38 U.S.C. § 1153(a); 38 C.F.R. § 3.303(a); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Although lay persons are considered competent to provide opinions on some medical issues, some medical issues fall outside of the realm of common knowledge of a lay person. Kahana v. Shinseki, 24 Vet. App. 428 (2011). 1. Entitlement to service connection for a right knee disability. 2. Entitlement to service connection for a left knee disability. To promote efficiency, the issues of entitlement to service connection for right and left knee disabilities will be addressed together. In this case, the Veteran seeks service connection for right and left knee disabilities. To begin, the Veteran was afforded a VA examination to determine the nature and etiology of his right and left knee disabilities in October 2015. The examiner diagnosed the Veteran with right knee tendonitis, patellofemoral pain syndrome, and chondromalacia patella and left knee meniscal degeneration/tear. Therefore, given the evidence of a current disability, the Board finds the first element for service connection has been met. As it pertains to an in-service event or injury, the Veteran's service treatment records (STRs) contain numerous complaints of pain, instability, and treatment. X-rays of both knees was conducted and conservative treatment was rendered. Therefore, given the evidence of in-service knee pain and treatment, the Board finds the second element necessary for service connection has been met. With regard to the final element for service connection, a nexus, the Board finds it at least as likely as not that the Veteran's current right and left knee disabilities were incurred in or caused by his active-duty service. As will be explained below, the Board finds that entitlement to service connection for right and left knee disabilities is warranted. First, the Veteran's bilateral knee disabilities were not an isolated in-service issue and have required ongoing treatment. In June 1990, the Veteran described right knee discomfort and received treatment for right knee pain with diagnoses of "right jumper's knee" and chondromalacia patella. He complained of generalized discomfort, aches, and pains. In an August 1990 ortho note, it was noted that he wished to file "his injury under compensation" given the "unusually high amount of occupational stress" which the examiner found to be "reasonable." As for the left knee, in February 2002, the Veteran noted that his left knee was "clicking" and during the fall and winter months he began to notice his knee was making "grinding noises" but no pain. Further treatment and examinations in March 2002 and April 2002 suggested a tear on the posterior horn of the medial meniscus and bone contusion medial femoral condyle. At the time, the Veteran denied an arthroscopy. Second, a medical opinion was obtained in October 2015. However, given the conclusory nature of the opinion, the Board finds it to lack any probative value. The examiner offered a rationale that stated a lack of "pathologically-based" diagnoses in the Veteran's STRs. The examiner did not explain how recorded complaints were insufficient to establish causation. As such, an additional etiological opinion was obtained in November 2019. Here, the examiner opined that both knee diagnoses occurred long after the end of the Veteran's service period and are "best explained" as due to normal aging effects on the knee structures. The examiner notes the in-service notations of instability but, in their opinion, was best described as self-reported by the Veteran. The Board finds this opinion to be of little probative value given the history and ongoing treatment of the Veteran's bilateral knee disabilities. Therefore, given the evidence of multiple in-service complaints and treatment for bilateral knee pain and the ongoing nature of his bilateral knee pain, that chondromalacia patella is widely accepted as an early form of arthritis the chronic nature of which can serve as a substitute for medical nexus evidence, and that there is no direct evidence of any post-service trauma that can otherwise explain the Veterans meniscal left knee damage (the tear is also characterized as degenerative in nature), the Board finds the evidence to at least be in equipoise and will afford the benefit of the doubt as to whether his right and left knee disabilities, diagnosed as right knee tendonitis, patellofemoral pain syndrome, and chondromalacia patella and left knee meniscal degeneration/tear were caused by or related to his active-duty service. The Veteran has credibly reported the onset and continuation of symptoms, further evidenced by his ongoing treatment, and there is no evidence to directly contradict his assertions. Accordingly, based on all of the foregoing, the Board finds a nexus to service has been established and that service connection for right and left knee disabilities, diagnosed respectively as right knee tendonitis, patellofemoral pain syndrome, and chondromalacia patella and left knee meniscal degeneration/tear, is therefore warranted. 3. Entitlement to service connection for residuals of a broken left foot 5th toe. The Veteran seeks service connection for residuals of a broken left foot 5th toe. By way of history, in his July 2015 application for disability compensation, the Veteran noted he wished to apply for service connection for "left broken toe." However, in a September 2019 brief by the Veteran's representative, it is contended that an examination of both the left and right foot is necessary because the Veteran may have mistaken which foot was injured. In a November 2019 Board decision, the issue was remanded in order to obtain an addendum opinion regarding the etiology of his left broken toe residuals. As such, the characterization of the issue was that of "residuals of a left broken toe." To begin, the Veteran was afforded a VA examination in October 2015. During his examination, the examiner provided a current diagnosis of bilateral hallux valgus and non-displaced left 5th toe fracture. Furthermore, the examiner found evidence of hammer toes in the second, third, and fourth toes of both feet. The Veteran asserted that he is unable to move his left small toe following his in-service broken toe. Therefore, given the evidence of a current disability, the Board finds the first element of service connection to be met. As it pertains to an in-service event or injury, the Veteran's entrance examination contains a note discussing how he was "Unable to run long distances because of heel trouble. Began when young. Went to foot clinic. Had to wear special shoes." However, under the notation for "feet" it was marked normal. No diagnosis of a heel disability in either foot was provided. Although "heel trouble" was noted in the Veteran's entrance examination, no specific disability was noted, and thus, the Veteran's left and right feet is found to have been in sound condition at the time of his entrance to active duty. Meanwhile, his STRs indicate that he broke his small toe on the "right" foot while participating in physical training in November 1973. A December 1973 STR note discusses a "recheck" of month-old fracture of the 5th toe in the right foot. It notes partial healing. Therefore, given the evidence of an in-service right toe injury, which may have meant to refer to the left toe, the Board finds the second element necessary for service connection has been met. With regard to the final element necessary for service connection, a nexus, the Board finds the preponderance of the evidence is against find the Veteran's current left foot disability was caused by or related to his in-service broken 5th toe. First, a November 2015 medical opinion was obtained regarding the etiology of his foot disability. However, given the conclusory nature of the opinion, the Board finds it to be of little probative value. Following the Board's remand, an additional opinion was obtained in November 2019. Here, the examiner noted that the in-service records do not document any abnormal healing, deformity, or complications of the broken toe. Instead, the examiner notes the etiology to be multiple comorbidities and ubiquitous exposures in daily life, genetic predisposition, and inappropriate footwear. The examiner states that the STRs do not document any problems with the hallux or the appearance of hammer toes and states that there is no role of the fracture of the 5th (little) [toe] in the development of and/or aggravation of hallux valgus or hammer toes. The examiner states that after a review of current legitimate, evidence-based medicine resources, there is "no current relevant principles of medicine literature that would significantly (if at all) contradict my above statements." The examiner further notes that the inability of the Veteran to abduct the 5th foot digits is not a pathological or significant finding and that a large majority of the population without any history of foot or nerve injuries are unable to abduct the lesser toes. In summary, the examiner notes that this type of 5th toe disability would not do any degree of significance interfere with function of the foot. The Board finds the opinion to be of significant probative value given the citation to medical literature and discussion of how the 5th toe does not result in other foot disabilities. Therefore, given the highly probative negative nexus opinion, the Board finds the preponderance of the evidence is against a finding that the Veteran's current left foot disability is the result of residuals of a broken left foot 5th toe disability in service. As such, an entitlement to service connection is not warranted. Michael J. Skaltsounis Veterans Law Judge Board of Veterans' Appeals Attorney for the Board C. DeBoer, 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.