Citation Nr: 21076001 Decision Date: 12/22/21 Archive Date: 12/22/21 DOCKET NO. 16-56 194 DATE: December 22, 2021 ORDER Entitlement to service connection for a right knee disability is denied. Entitlement to service connection for a left knee disability is denied. Entitlement to service connection for a low back disability is denied. Entitlement to service connection for bilateral pes planus disability is denied. FINDINGS OF FACT 1. The preponderance of the evidence is against finding that the Veteran's right knee disability began during active service or is otherwise related to an in-service injury or disease. 2. The preponderance of the evidence is against finding that the Veteran's left knee disability began during active service or is otherwise related to an in-service injury or disease. 3. The preponderance of the evidence is against finding that the Veteran's low back disability began during active service or is otherwise related to an in-service injury or disease. 4. The preponderance of the evidence is against finding that the Veteran's bilateral pes planus disability began during active service or is otherwise related to an in-service injury or disease. 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, 5107 (2012); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2020). 2. The criteria for entitlement to service connection for a left knee disability have not been met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2020). 3. The criteria for entitlement to service connection for a low back disability have not been met. 38 U.S.C. §§ 1110, 1112, 1131, 1137, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2020). 4. The criteria for entitlement to service connection for bilateral pes planus have not been met. 38 U.S.C. §§ 1110, 1111 (2012); 38 C.F.R. §§ 3.303, 3.304, 3.306 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served honorably in the United States Army from July 1979 to July 1983. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a July 2013 rating decision of a Department of Veterans' Affairs (VA) Regional Office (RO). In November 2018, September 2020, and April 2021, this matter was remanded to the Agency of Original Jurisdiction (AOJ) for additional development. In August 2021, this matter was once again remanded to the AOJ for additional development and has since been returned to the Board. Service Connection Under the relevant laws and regulations, service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1110. Generally, the evidence must show: (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. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004); Caluza v. Brown, 7 Vet. App. 498, 505 (1995). Regulations also provide that service connection may be granted for a disability diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability is due to disease or injury which was incurred in or aggravated by service. 38 C.F.R. § 3.303(d). Certain chronic diseases, such as arthritis, are subject to presumptive service connection if manifest to a compensable degree within one year from separation from service even though there is no evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C. §§ 1112, 1113; 38 C.F.R. §§ 3.307(a)(3), 3.309(a). An alternative method of establishing the second and third Shedden elements for disabilities identified as chronic diseases in 38 C.F.R. § 3.309(a) is through a demonstration of continuity of symptomatology. 38 C.F.R. § 3.303(b). Continuity of symptomatology may be shown if "the condition is observed during service or any applicable presumption period, continuity of symptomatology is demonstrated thereafter, and competent evidence relates the present condition to that symptomatology." Savage v. Gober, 10 Vet. App. 488, 498 (1997). VA is required to give due consideration to all pertinent medical and lay evidence in evaluating a claim for disability benefits. 38 U.S.C. § 1154(a). Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). 1. Entitlement to service connection for a right knee disability 2. Entitlement to service connection for a left knee disability The Veteran contends that he is entitled to service connection for right knee and left knee disabilities that are related to service. With regard to a present disability, the Veteran appeared for a VA examination in August 2021 where he was noted to have osteoarthritis status-post right knee replacement and degenerative joint disease of the left knee. Thus, the current disability criterion for service connection is met. See Shedden supra. Next, the Board must consider whether the Veteran sustained a disease or injury in service. Aside from a left ankle rotation injury in January 1980, the Veteran's service treatment records (STRs) do not include any complaints, findings, or diagnoses related to a right knee disability or left knee disability. See STR-Medical. However, at a VA examination in November 2020, the Veteran attributed his bilateral knee conditions to long ruck marches, runs, and intensive training while wearing full gear. See November 2020 C&P Exam. The Veteran's military occupational specialty (MOS) indicated that he served as an infantryman. See Certificate of Release or Discharge From Active Duty. Affording the Veteran the benefit of the doubt, the Board finds that the second service connection element is also met. Turning to nexus, the evidence of record does not support that the Veteran's current left knee and right knee disabilities are etiologically related to his active service. In November 2020, the Veteran was afforded a VA examination. There, the Veteran attributed his knee conditions to long ruck marches, runs, and intensive training while wearing full gear. Upon examination, the Veteran had abnormal range of motion in his knees bilaterally, had mild tenderness with palpation bilaterally, and was noted to use a cane regularly. The VA examiner opined that it was less likely than not (less than 50 percent probability) that the Veteran's left knee and right knee were incurred in or caused by the claimed in-service injury, event, or illness, as there was a lack of documentation of any incident while in service. The VA examiner noted that there was no documentation of any injury or complaint of any knee pain while in service, that the Veteran had arthroplasty done in 2008 due to osteoarthritis, and that the Veteran had degenerative arthritis of the left knee in the early 2000's. Pursuant to a Board remand, in May 2021, the Veteran was afforded another VA examination. There, the VA examiner opined that the Veteran's right knee and left knee were less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness, as service treatment records were silent for a right knee and left knee injuries during active duty. The VA examiner noted that an acute back strain nor a rotation of the left ankle results in the degenerative joint disease of the right knee or the left knee. The VA examiner also noted that service treatment records and post-separation files were silent for knee conditions for at least ten years after discharge. The VA examiner noted that a gap of ten or more of years without complaints supports the in-service conditions (ankle rotation and acute low back pain) resolved and intercurrent injury/disease cannot be ruled out as etiology for the knee condition. The VA examiner noted that a condition of suggested severity would have certainly required medical attention from the 1980s until early 2000 and, per review of records, there was no evidence of knee complaints for greater than ten years after separation from service. Pursuant to a Board remand, the Veteran was afforded a VA examination in August 2021 for an addendum opinion. The VA examiner considered the Veteran's available records as well as the Veteran's lay statements from the November 2020 VA examination where he attributed his various conditions due to prolonged standing, long runs, long marches, carrying heavy ruck sacks during marches, and intensive training while wearing full gear. The VA examiner opined that the Veteran's knee conditions were less likely than not due to military related MOS and physical training. The VA examiner noted that the Veteran's military records were silent, that primary osteoarthritis is age appropriate at the age of 45 and above, and that this is secondary to any trauma to the knees. The VA examiner noted that if the Veteran had bilateral knee injury, the arthritis would manifest under age 45 years old and be called secondary or traumatic arthritis due to prior trauma; however, the Veteran's records were silent for this. After careful review, the Board finds that the preponderance of the evidence is against a finding that the Veteran's current left knee and right knee disabilities were incurred in active service or are otherwise related to active service. Unfortunately, there is simply no competent evidence establishing that the Veteran's left knee and right knee disabilities had its onset in service or manifested within one year of service. In this regard, the Board finds the VA examination opinions from May 2021 and August 2021 to be the most probative evidence of record, as they accurately characterized the Veteran's service treatment records, considered relevant post-service medical records, and took into account of the Veteran's lay contentions regarding the onset of his symptoms. The Board notes that, even accepting the Veteran's descriptions of his symptomatology and his contentions as to the causes of his right knee and left knee disabilities, the evidence does not demonstrate onset of knee disabilities in service or within one year of separation from service. In fact, the Veteran did not report any issues in his knees until the early 2000's, which is over ten years after his discharge. The VA examiners' negative nexus opinions were based on a detailed and factually accurate analysis of the Veteran's symptoms, addressed the Veteran's contentions of the onset of knee pain due to military related MOS and physical training, and addressed the gap of the Veteran's reports of knee pain. The only evidence in support of the Veteran's claim consists of the Veteran's lay statements where he attributed his bilateral knee pain to long ruck marches, runs, and intensive training while wearing full gear. In this regard, the Veteran is competent to relate symptoms within the realm of his personal knowledge, just as he is competent to relate what he has been told by an examiner. Layno v. Brown, 6 Vet. App. 465, 469-70 (1994); Jandreau, 492 F.3d at 1377. The Board does not doubt that the Veteran experienced knee pain due to long ruck marches, runs, and intensive training while wearing full gear. However, the Board is unable to find that they are sufficient to establish in-service incurrence of osteoarthritis of the right knee, status-post right knee replacement, and degenerative joint disease of the left knee. The Veteran is not considered competent to offer opinions on complex medical questions regarding specialized knowledge, such as the physiological causes of his bilateral knee disabilities. See Jandreau, supra. Accordingly, the Board finds that the weight of the evidence is against finding the Veteran's osteoarthritis of the right knee, status-post right knee replacement in 2010, and degenerative joint disease of the left knee are related to service. 38 U.S.C. § 1131; 38 C.F.R. § 3.303, 3.310. As the preponderance of the evidence is against the claim, further application of the benefit-of-the-doubt doctrine is not warranted. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. 3. Entitlement to service connection for a bilateral pes planus disability The Veteran contends that he is entitled to service connection for bilateral pes planus that is related to service. With regard to present disability, the Veteran appeared for a VA examination in August 2021 where he was noted to have bilateral pes planus. Thus, the current disability criterion for service connection is met. See Shedden supra. Next, the Board must consider whether the Veteran sustained a disease or injury in service. Aside from a left ankle rotation injury in January 1980, the Veteran's STRs do not include any complaints, findings, or diagnoses related to a bilateral pes planus disability. See STR-Medical. However, at a VA examination in November 2020, the Veteran attributed his foot pain to prolonged standing, ruck marches, and long runs. As previously noted, the Veteran served as an infantryman. Accordingly, affording the Veteran the benefit of the doubt, the second service connection element is also met. Turning to nexus, the evidence of record does not support that the Veteran's current bilateral pes planus is etiologically related to his active service. In November 2020, the Veteran was afforded a VA examination. There, the Veteran attributed his foot pain to prolonged standing, ruck marches, and long runs. He also indicated that his bilateral foot condition is getting worse with increased pain, feels like he is walking on hot coals, and that his symptoms are worse in the morning. The VA examiner noted that the Veteran has pes planus, plantar fasciitis, degenerative arthritis of the left foot, and bilateral plantar fascial fibromatosis. Upon examination, the Veteran reported bilateral pain on use of feet, accentuated pain on use, accentuated pain on manipulation, and decreased longitudinal arch height on weight-bearing. The Veteran was noted to use arch supports and orthotics bilaterally with no relief. The Veteran was also noted to have nodules along the medial plantar fascia of bilateral feet of moderate severity. The Veteran had bilateral pain on movement, pain on weight-bearing, disturbance of locomotion, interference with standing, and a lack of endurance. The VA examiner opined that it was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness, as there was no documentation or diagnosis of any foot condition while the Veteran was in service. Pursuant to a Board remand, in May 2021, the Veteran was afforded another VA examination. There, the VA examiner opined that the Veteran's condition was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. The VA examiner's rationale noted that his service treatment records were silent for a foot injury during active duty that would result in pes planus. The VA examiner noted that an acute back strain nor does a rotation of the left ankle result in pes planus, as a review of current medical literature does not support this relationship. The VA examiner also noted that a gap of ten or more years without complaints supports that the in-service condition (ankle rotation and acute low back pain) resolved and that this would have no impact on the current foot condition. The VA examiner indicated that a pes planus of suggested severity would have certainly required medical attention from separation until 2020 and, per review of the records, there was no evidence of foot complaints for greater than ten years after separation from service. Pursuant to a Board remand, the Veteran was afforded a VA examination for an addendum opinion in August 2021. There, the VA examiner considered the Veteran's available records as well as the Veteran's lay statements from the November 2020 VA examination where he attributed his various conditions due to prolonged standing, long runs, long marches, carrying heavy ruck sacks during marches, and intensive training while wearing full gear. The VA examiner opined that the Veteran's bilateral pes planus is less likely than not caused by in-service running and serving as an infantryman. The VA examiner indicated that the Veteran's military records were silent for a foot condition, and that he had left foot mild pes planus on x-ray in 2004 with left foot complaints. The VA examiner noted the Veteran's physical activity requirements as an infantryman and noted that he had a normal foot examination per military physical. The VA examiner also noted that if his military activities gave him pes planus due to running and ruck sack marches as detailed in the remand, it would not wait for more than 20 years to be symptomatic. The VA examiner noted that the Veteran would have had symptoms at the time, which requires treatment with medications, arch support, temp, and/or permanent profile depending on the severity of symptoms. The VA examiner noted that the Veteran's diabetes and obesity are risk factors for pes planus. After careful review, the Board finds that the preponderance of the evidence is against a finding that the Veteran's current bilateral pes planus was incurred in active service or are otherwise related to active service. Unfortunately, there is simply no competent evidence establishing that the Veteran's bilateral pes planus disability had its onset in service or manifested within one year of service. In this regard, the Board finds the VA examination opinions from May 2021 and August 2021 to be the most probative evidence of record, as they accurately characterized the Veteran's service treatment records, considered relevant post-service medical records, as well as the Veteran's lay contentions regarding the onset of his symptoms. The Board notes that, even accepting the Veteran's descriptions of his symptomatology, the evidence does not demonstrate onset of bilateral pes planus in service or within one year of separation from service. In fact, the Veteran did not report any issues with pain in his feet until the early 2000's, which is over fifteen years since discharge. The VA examiners' negative nexus opinions are based on detailed and factually accurate analysis of the Veteran's symptoms, addressed the Veteran's contentions of the onset of bilateral pes planus due to military related MOS and physical training, and addressed the gap of the Veteran's reports of bilateral pes planus. The only evidence in support of the Veteran's claim consists of the Veteran's lay statements where he attributed his bilateral pes planus to prolonged standing, ruck marches, and long runs. In this regard, the Veteran is competent to relate symptoms within the realm of his personal knowledge, just as he is competent to relate what he has been told by an examiner. Layno, 6 Vet. App. at 469-70 (1994); Jandreau, 492 F.3d at 1377. The Board does not doubt that the Veteran experienced pain in his feet due to long ruck marches, runs, and intensive training while wearing full gear. However, the Board is unable to find that they are sufficient to establish in-service incurrence of bilateral pes planus. The Veteran is not considered competent to offer opinions on complex medical questions regarding specialized knowledge, such as the physiological causes of his knee disabilities. See Jandreau, supra. Accordingly, the Board finds that the weight of the evidence is against finding the Veteran's bilateral pes planus is related to service. 38 U.S.C. § 1131; 38 C.F.R. § 3.303, 3.310. As the preponderance of the evidence is against the claim, further application of the benefit-of-the-doubt doctrine is not warranted. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. 4. Entitlement to service connection for a low back disability The Veteran contends that he is entitled to service connection for a low back disability that is related to service. With regard to present disability, the Veteran appeared for a VA examination in August 2021 where he was noted to have degenerative arthritis of the spine, intervertebral disc syndrome (IVDS), and spinal stenosis. Thus, the current disability criterion for service connection is met. See Shedden supra. Next, the Board must consider whether the Veteran sustained a disease or injury in service. Aside from reports of back pain in November 1982 during treatment for tonsilitis, the Veteran's service treatment records (STRs) were silent for complaints, findings, or diagnoses related to a low back disability. See STR-Medical. However, at a VA examination in November 2020, the Veteran attributed his low back pain to carrying heavy ruck sacks and marches. The Veteran's MOS notes that he served as an infantryman. Accordingly, affording the Veteran the benefit of the doubt, the second service connection element is also met. Turning to nexus, the evidence of record does not support that the Veteran's current low back disability is etiologically related to his active service. In November 2020, the Veteran was afforded a VA examination. There, the VA examiner indicated that the Veteran has degenerative arthritis of the spine, IVDS, and spinal stenosis. The Veteran attributed his back pain to carrying heavy ruck sacks and marches. Upon examination, the Veteran exhibited abnormal range of motion with pain in all directions. The Veteran had pain with weight bearing, moderate tenderness with palpation/pressure in the central lumbar spine and paraspinal muscle groups bilaterally, decreased sensation to light touch on the right side, and was positive for straight leg raising on the right. The Veteran exhibited mild intermittent pain, mild paresthesias and/or dysesthesias, and numbness bilaterally. The VA examiner noted that there was involvement of the sciatic nerve bilaterally and mild radiculopathy bilaterally. The VA examiner opined that the Veteran's lower back conditions were less likely than not (less than 50 percent probability) incurred in or caused by the in-service injury, event, or illness due to the lack of documentation while in service of persistent back condition. The VA examiner noted that while the Veteran was seen in November 1982 for back pain while having symptoms of tonsilitis, x-rays from 2003 and 2013 revealed negative degenerative disease and an x-ray from 2018 showed stable degenerative changes. Pursuant to a Board remand, in May 2021 the Veteran was afforded another VA examination. There, the VA examiner opined that the Veteran's condition was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. The VA examiner stated that while the Veteran was seen for an acute back strain in 1982, there was no evidence that this resulted in a chronic back condition and that the Veteran's degenerative joint disease, spinal stenosis, and IVDS were unrelated to that incident. The VA examiner also noted that a gap of ten or more years without complaints supports the in-service condition resolved and intercurrent injury/disease cannot be ruled out as an etiology and a condition of suggested severity would have certainly required medical attention from 1982 until 2003. The VA examiner noted that a review of STRs and subsequent medical records showed no evidence of the diagnosis, treatment, or symptoms suggestive of IVDS, degenerative joint disease, or spinal stenosis while on active duty or within one year of separation. The VA examiner also indicated that imaging done many years after separation showed findings often found with aging. Pursuant to a Board remand, the Veteran was afforded a VA examination for an addendum opinion in August 2021. The VA examiner considered the Veteran's available records as well as the Veteran's lay statements from the November 2020 VA examination where he attributed his various conditions due to prolonged standing, long runs, long marches, carrying heavy ruck sacks during marches, and intensive training while wearing full gear. The VA examiner opined that the Veteran's low back diagnoses were less likely than not due to claimed military activities. The VA examiner indicated that the Veteran had degenerative joint disease of the lower back in 2018 with radiculopathy and spinal stenosis, but also indicated that his military records were silent for these conditions. The VA examiner noted that the Veteran's symptoms started over the age of 45 years old, which is due to age associated arthritis. The VA examiner noted that if it is due to trauma from military activities, it would manifest under the age of 45 years old and would not wait more than 20 years to manifest by symptoms and/or on x-ray. Thus, the VA examiner determined the Veteran's his low back diagnosis is from age associated arthritis. The VA examiner noted various risk factors for low back pain such as age, lack of exercise, excess weight, diseases, psychological conditions, and smoking. After careful review, the Board finds that the preponderance of the evidence is against a finding that the Veteran's current low back disability was incurred in active service or are otherwise related to active service. Unfortunately, there is simply no competent evidence establishing that the Veteran's low back disability had its onset in service or manifested within one year of service. In this regard, the Board finds the VA examination opinions from May 2021 and August 2021 to be the most probative evidence of record, as they accurately characterized the Veteran's service treatment records, and considered relevant post-service medical records along with the Veteran's lay contentions regarding the onset of his symptoms. The Board notes that, even accepting the Veteran's descriptions of his symptomatology, the evidence does not demonstrate onset of low back disability in service or within one year of separation from service. In fact, aside from the 1982 report of back pain, the Veteran did not have any reported issues until more than 20 years after his discharge. In addition, the Board finds the May 2021 VA examiner's opinion regarding the 1982 back pain report to be probative, as the VA examiner found that there was no evidence that this resulted in a chronic back condition and that the Veteran's current conditions were unrelated to that incident. Moreover, the VA examiners' negative nexus opinions are based on a detailed and factually accurate analysis of the Veteran's symptoms and addressed the Veteran's contentions of the onset of low back disability due to carrying heavy ruck sacks and marches. The only other evidence in support of the Veteran's claim consists of his lay statements where he attributed his low back disability to carrying heavy ruck sacks and marches. In this regard, the Veteran is competent to relate symptoms within the realm of his personal knowledge, just as he is competent to relate what he has been told by an examiner. Layno, 6 Vet. App. at 469-70 (1994); Jandreau, 492 F.3d at 1377. The Board does not doubt that the Veteran experienced pain in his back due to carrying heavy ruck sacks and marches. However, the Board is unable to find that the Veteran's statements are sufficient to establish in-service incurrence of a low back disability. The Veteran is not considered competent to offer opinions on complex medical questions regarding specialized knowledge, such as the physiological causes of his low back disability. See Jandreau, supra. (Continued on the next page) Accordingly, the Board finds that the weight of the evidence is against finding the Veteran's low back disability is related to service. 38 U.S.C. § 1131; 38 C.F.R. § 3.303, 3.310. As the preponderance of the evidence is against the claim, further application of the benefit-of-the-doubt doctrine is not warranted. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Nykeia F. Miller Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board C. Kim, 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.