Citation Nr: 21073708 Decision Date: 12/10/21 Archive Date: 12/10/21 DOCKET NO. 17-11 305 DATE: December 10, 2021 ORDER Entitlement to service connection for a right knee disability is denied. Entitlement to service connection for a right foot disability is denied. FINDINGS OF FACT 1. The preponderance of the evidence does not show that a right knee disability is related to military service, or that it is caused or aggravated by his service-connected left knee disability. 2. The preponderance of the evidence does not show that the Veteran's right foot disability is related to his military service, or that it is caused or aggravated by his service-connected left knee disability CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for a right knee disability have not been met. 38 U.S.C. § 1110, 1154, 5107; 38 C.F.R. §§ 3.303, 3.310. 2. The criteria for entitlement to service connection for a right foot disability have not been met. 38 U.S.C. § 1110, 5107; 38 C.F.R. § 3.102, 3.303, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from July 1968 to March 1969. This appeal comes to the Board of Veterans' Appeals (Board) from a June 2017 rating decision of the Department of Veterans' Affairs (VA) regional office (RO). In March 2019 and April 2021, the Board remanded the instant matters for additional development. Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Service connection requires: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. See Shedden v. Principi, 381 F.3d 1163, 1166-1167 (Fed. Cir. 2004). Service connection may also be granted for a disability that is proximately due to, or aggravated by, service-connected disease or injury. 38 C.F.R. § 3.310. Entitlement to service connection for a right knee disability The Veteran contends he has a right knee disability that is related to his active service or, alternately, is caused or aggravated by his service-connected left knee disability. In April 2017 the Veteran was afforded a VA examination. The examiner notes there was a "claimed right knee strain." The Veteran reported having functional loss which affects walking, standing, and sitting. The examiner noted normal range of motion (ROM), evidence of pain with weight bearing, no localized tenderness or pain on palpation of the joint, and no evidence of crepitus. The examiner was able to perform a repetitive test using at least three repetitions, and no additional functional loss or ROM was noted. Joint stability testing and strength testing were normal, and the Veteran did not report a history of instability, effusion, or recurrent subluxation. The Veteran reported daily bilateral knee pain, use of bilateral knee braces, and managing pain with Tylenol and naproxen. The examiner reviewed August 2016 x-ray of the bilateral knees showed "unremarkable weight-bearing views." She found the right knee to be uninjured and normal. See April 2017 C&P Examination. The examiner opined the Veteran's "claimed right knee strain is less likely than not secondary to his left knee injury, with normal 2016 right knee x-rays, normal right knee exam on this visit." Essentially, she found no current right knee disability. The Board finds this opinion probative because it is consistent with evidence of the record, and provided a clear conclusion with supporting data, and reasoned medical explanations connecting the two. Stefl v. Nicholson, 21 Vet. App. 120, 124-25 (2007); Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). In May 2017 VA requested a medical addendum from the April 2017 VA examiner to address a March 2014 x-ray which noted osteoarthritis in the right knee. She was asked to clarify whether the Veteran currently had right knee osteoarthritis. She was also asked to answer three specific questions pursuant to Correia v. McDonald, 28 Vet. App. 158 (2016). She cited to the relevant findings for the August 2016 right knee x-ray findings: "No acute fracture, subluxation or dislocation. No suspicious erosions. Joint spaces are maintained. No joint effusions. Soft tissues are unremarkable." The April 2017 examiner stated her opinion was unchanged: the Veteran's claimed right knee strain is less likely than not secondary to his left knee injury, based on the April 2016 normal x-ray for the right knee and her normal examination of the knee in April 2017. In addition to finding no disability of the right knee, she provided a rationale for no secondary causation as there was no evidence of gait abnormalities, no showing of internal derangement of the left knee, and no evidence of left knee osteoarthritis in the April 2017 MRI. See May 2017 Addendum. The Board finds that this addendum is probative on the question of secondary causation as it is consistent with evidence of the record, and provided a clear conclusion with supporting data, and reasoned medical explanations connecting the two. Stefl, 21 Vet. App. 120, 124-25 (2007); Nieves-Rodriguez, 22 Vet. App. 295, 304 (2008). The Board remanded the appeal in March 2019 to obtain an aggravation opinion and address new lay evidence of a right knee injury in service requiring a cast with pain continuing to the present. The Board noted that service treatment records (STRs) only showed a left knee injury with cast and stated that the remand would give the Veteran the opportunity to clarify if he was actually referring to the left knee. In February 2020 the Veteran was afforded a VA examination. The examiner was asked to provide an opinion as to the nature and etiology of any right knee disability. The Veteran stated that his "right knee pain started around 3 yrs ago, with no history of trauma. States pain in occasional and mild. Also states he has not complained and has not been diagnosed with a right knee condition during service." The examiner observed that this conflicts with the statement in the August 2018 VA Form 9 where he reported a right knee injury in service requiring a cast, but on review of the STRs found only the left knee injury with cast. A bilateral knee x-ray was performed in conjunction with the February 2020 VA examination and it was negative. The "[r]adiologist noted that there is no explanation for [the Veteran's] complaint of bilateral knee pains." The examiner also observed that while the Veteran is service-connected for a left knee osteoarthritis, this finding "is contrary to all x-rays and MRI results available." While the examiner stated that the Veteran was diagnosed with right knee strain in April 2017 VA examination, the record shows that this was not a diagnosis but only a report of the disability claimed by the Veteran at that time. The February 2020 examiner found that the current diagnosis was "subjective complaint of pain. No objective findings for a right knee condition." The Veteran did not report flare-ups or any functional loss or functional impairment, including with repetitive use testing. No pain was noted on examination, and there was no evidence of pain with weight-bearing, localized tenderness or pain on palpation, and no crepitus. ROM, strength, and stability testing were normal. Based on this evidence, the examiner found that a direct service connection opinion was not necessary because there were no reports of complaints, diagnosis, or treatment for a right knee condition during military service. He also provided an aggravation opinion, finding it is less likely as not that any right knee disability is aggravated by a left knee disability, as the evidence showed a completely normal right knee by x-ray and on examination, with normal ROM without pain. The evidence showed no evidence of aggravation of any kind. Finally, the examiner answered the Correia questions in the negative. In June 2021, per a Board remand, a medical addendum opinion was obtained from the 2020 examiner regarding the nature and etiology of the Veteran's claimed right knee disability. The examiner reiterated the history of normal x-ray and no injury in service, but based on the subjective complaint of pain provided a diagnosis of "Patello-Femoral Pain Syndrome (PFPS) which started three years ago (2017) as per history obtained in 2020." The examiner opined the Veteran's right knee disability was less likely than not caused by an in-service injury, event, or disease. The examiner explained the Veteran's STRs are silent to complaints, diagnosis, or treatment for a right knee condition. It is also noted the Veteran's separation examination in February 1969 does not indicate any issue with the Veteran's knees. In fact, the knee was checked off as normal. The examiner further explained that per the Veteran's own statements during the February 2020 C&P examination, he did not experience right knee pain until 2017, which is 49 years after he left service. The examiner stated an over 40-year time interval negates the possibility of the Veteran's knee disability being directly related to his active service. The examiner acknowledged the single report of a right knee injury in service but relied on the contemporaneous records and the Veteran's subsequent report of onset in 2017. The examiner also opined it was less likely than not the right knee disability was caused by or related to his service-connected left knee disability. He reiterated that on examination in April 2017 and February 2020 examinations showed completely normal right knee ROM without pain and only a mild reduction in ROM on the left knee. Likewise, there was no evidence of instability on the left knee on both these exams. These findings signif[y] that the left knee could not have affected the mechanics of the right knee. Furthermore, same VA exams did not show any gait abnormality on the left leg, which if present could also have affected the right knee mechanics. It is also important to point out that as noted on the separation exam dated 6 Feb 1969, note states left knee injury (Oct 1968) of hematoma was "resolving w/o any sequelae or residual dysfunction", therefore, in my opinion, the left knee could not have affected the function of the right knee. The examiner also opined it was less likely than not the Veteran's right knee condition was aggravated beyond natural progression by his left knee condition. The examiner explained the February 2020 C&P examination showed completely normal ROM, without any pain. The normal exam does not indicate aggravation of any type to the right knee by any factor, including the left knee. He reiterated that "the mild left knee findings, w[ith]o[ut] any instability and gait abnormality which in my opinion could not have aggravated the contralateral knee." The Board finds these detailed and thorough opinions to be extremely persuasive. They provided a clear conclusion with supporting data, and a reasoned medical explanation connecting the two. They specifically consider the medical evidence of record and apply this evidence to known medical principles. Stefl, 21 Vet. App. at 124-25; Nieves-Rodriguez, 22 Vet. App. at 304. The Board also finds that the examiner provided unique rationales to support both causation and aggravation opinions, as required by Atencio v. O'Rourke, 30 Vet. App. 74 (2018). The Board notes the Veteran's contentions that he had a right knee injury in service and wore a cast for that injury. See, August 3, 2019 Form 9. However, upon review of the record of whole, there is no evidence of a right knee injury during service. The examiner believes the Veteran misstated which knee was injured in service because the Veteran did suffer a left knee injury. See February 2020 C&P Examination. The Board finds this conclusion reasonable because the record does show a left knee injury in service, and because the Veteran later stated that his right knee pain began around 2017 with no history of trauma. For this reason, the Board gives more probative weight to the evidence supporting an onset of right knee symptoms in 2017. The Board does acknowledge the Veteran's assertions that his right knee disability is due to his left knee disability. While lay evidence may be competent on a variety of matters concerning the nature and cause of disability, etiology of dysfunctions and disorders is a medical determination and generally must be established by medical findings and opinion. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007); see also Colantonio v. Shinseki, 606 F.3d 1378, 1382 (Fed. Cir. 2010) (recognizing that in some cases lay testimony "falls short" in proving an issue that requires expert medical knowledge). Here, the Veteran is a lay person without the required medical training and expertise to make a competent etiological conclusion regarding the cause of his current disability. The VA examiners, on the other hand, are qualified to provide such opinions and have made conclusions to the contrary. There is no competent nexus evidence in favor of the Veteran's claim. The Board finds that the preponderance of the competent, probative evidence establishes that the Veteran's right knee PFPS did not have its onset in service and was not caused or aggravated by his service-connected left knee disability. As such entitlement to service connection for a right knee disability is denied. Entitlement to service connection for a right foot disability The Veteran contends his right foot disability is related to his active service or, alternately, that it is caused or aggravated by his service-connected left knee disability. In his original claim, he stated that the condition was caused by his left knee disability. In his October 2017 NOD, he stated, "I have had this condition since service[;] this come from a lot of marching. This condition got worse over the pas[t] ten years." In his August 2018 VA Form 9, he wrote, "My plantar fasciitis (right foot) problem is due to the injury to my knee." A March 2017 VA neurology treatment record reflects complaint of right foot plantar pain when walking. The Veteran reported seeing a podiatrist and being given orthotics and steroidal cream to relieve the pain. The neurologist made a note to "discuss plantar fasciitis." The April 2017 VA examiner noted a diagnosis of right foot plantar fasciitis made in 2017. The Veteran reported pain in his right foot and functional impairment, which impacts his walking and standing. The examiner noted he has extreme tenderness of plantar surfaces on his right foot. The examiner concluded it is less likely than not proximately due to or the result of the Veteran's service-connected condition. The examiner explained the Veteran's right foot plantar fascitis is less likely than not secondary to his left knee injury, and that there are no known causative correlations between a left knee injury and right foot plantar fasciitis. The examiner explained the 2016 MRI of the left knee showed no abnormalities, a normal gait on exam, and no known causative correlation between the left knee injury and the right foot plantar fascitis. See, April 2017 C&P Examination. The Board finds this opinion probative as to secondary causation, as it provided a clear conclusion with supporting data, and reasoned medical explanations connecting the two. Stefl, 21 Vet. App. at 124-25; Nieves-Rodriguez, 22 Vet. App. at 304. The Board remanded the appeal in March 2019 to obtain an aggravation opinion and address the lay evidence of marching in service with pain continuing to the present. During the April 2017 VA examination, the Veteran reported being seen by a private podiatrist. In March 2019 the Board remand included a directive to ask the Veteran to complete a VA Form 21-4142 in order to obtain any relevant private treatment records. The RO completed this directive by letter to the Veteran dated in October 2019 and the Veteran returned the VA Form 21-4142 but did not identify any private providers relevant to his foot disability. The Board finds that the duty to assist has been satisfied with respect to the identified private treatment records, and that there has been substantial compliance with the relevant 2019 remand directive. In February 2020 the Veteran was afforded a VA examination. The examiner noted diagnoses of both pes planus (flat foot) and plantar fasciitis made in 2017, and that the Veteran's record shows bilateral foot x-rays done in June 2017 that show mild bilateral pes planus. The Veteran told the examiner he was first diagnosed with plantar fasciitis around 2017. He also stated he never complained of or was treated for this condition during service. In keeping with the Board remand directives, the examiner acknowledged the lay assertions made in the NOD and Form 9 but also noted the conflicting report of onset in 2017 and that the Veteran's STRs do not contain any complaints, diagnosis, or treatment of pes planus or plantar fasciitis during service or immediately after service. STRs show at separation the Veteran denied any foot symptoms and the clinical foot examination was normal. On examination at the February 2020 examination, palpation of the plantar arch and heel showed no pain or tenderness and no evidence for plantar fasciitis. Examination did confirm a borderline diagnosis for pes planus in the right foot at 19 degrees calcaneal pitch measurement. The Veteran did report pain on prolonged walking and standing. He denied flare-ups and functional loss. Based on this evidence, the examiner opined it was less likely than not the Veteran's current disability was caused or related to his active service. With respect to plantar fasciitis, the examiner explained that it is a recurring condition and so while it was not present during her 2020 examination, it does not mean the Veteran does not suffer from that condition. However, he went on to find that even if there is plantar fasciitis that comes and goes, there is no objective evidence showing the condition existed during or shortly after separation from service. As to pes planus, he stated that because the Veteran denied foot symptoms at separation and the clinical exam of his feet was normal, and there is no evidence it existed during or shortly after service, the pes planus is an acquired condition (fallen arches) that occurred after he was separated from service. The examiner also opined the Veteran's current condition was not aggravated beyond its natural progression by his service-connected left knee disability. The examiner explained that the current exam of his right foot did not show pain or tenderness on deep palpation of the plantar arch or heel area. Further, the right foot pes planus did not show a deformity or defect that could be ascribed to aggravation beyond natural progression, such as marked pronation, inward bowing of achilles tendon and rigid hindfoot. In short, there is no aggravation beyond the natural progression of the disability to attribute. The Board finds these opinions highly probative, as they provide clear conclusions with supporting data, and reasoned medical explanations connecting the two. Stefl, 21 Vet. App. at 124-25; Nieves-Rodriguez, 22 Vet. App. at 304. To the extent the examiner rejected the Veteran's statement in his NOD of foot symptoms since service due to marching, the Board finds this conclusion reasonable. The examiner explained the basis for doing so, pointing to the conflicting reports of onset in 2017 which is significantly more consistent with the evidence of record. For the same reason, the Board also finds the report of foot symptoms beginning in service and continuing to the present to be less credible and gives them no probative weight. In June 2021, per a Board remand, a medical addendum opinion was obtained from the 2020 examiner regarding the nature and etiology of the Veteran's claimed right foot disability. The examiner essentially reiterated his opinions but added clarifications. For direct service connection, he clarified that while his February 2020 examination did not contain a diagnosis of plantar fasciitis, that does not imply that the 2017 examination which did find plantar fasciitis was incorrect. The examiner explained plantar fasciitis is a condition that waxes and wanes and could be symptomatic at one point and asymptomatic at another. However, due to the 49 years between separation from service and credibly reported symptoms, paired with the normal examination and denial of symptoms or a history of symptoms at separation, his negative direct service connection opinion remained. For secondary causation, he clarified: While there may[ ]be some etiopathogenic connection or relationship between knee mechanics and foot mechanics on the same extremity, this is not so in this patient since the knee pathology is on the left side while the foot disability is on the right side. Furthermore, it is also important to point out that the current left knee disability is mild which has no effect on the mechanical functioning of any joint except the knee joint itself. For aggravation, in addition to the clarification noted above regarding interplay between the left knee and right foot, he clarified: Exam of bilateral pes planus (Feb 2020) shows it to be mild with no specific defect or deformity that could be ascribed to aggravation beyond natural progression. Exam (Feb 2020) of the right foot plantar fasciitis shows it to be negative for the condition, signifying that most likely condition has resolved or is on remission. In my opinion, both conditions affecting the right foot shows natural progression of the disease rather than aggravation beyond natural progression. The Board also finds these addendum opinions to be extremely probative, given their great attention to detail and thorough rationales which cite to the evidence of record and provide medical and logical reasoning. Stefl; Nieves-Rodriguez. The Board does acknowledge the Veteran's assertions that his right foot disability is related to an in-service injury and that it persisted in service. See, October 6, 2017 NOD. However, as discussed above, the Board does not find this assertion credible in light of the contradictory evidence of record. The Board acknowledges the Veteran's assertion that his right foot disability is secondary to his service-connected left knee disability. However, while lay evidence may be competent on a variety of matters concerning the nature and cause of disability, etiology of dysfunctions and disorders is a medical determination and generally must be established by medical findings and opinion. Jandreau. Here, the Veteran is a lay person without medical training and expertise, and thus, is not competent to make an etiological conclusion regarding the cause of his current disability. The only competent, probative evidence of record weighs against the claim. As such, service connection for a right foot disability is denied. LAURA E. COLLINS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Brewer, 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.