Citation Nr: 21076098 Decision Date: 12/22/21 Archive Date: 12/22/21 DOCKET NO. 15-00 307A DATE: December 22, 2021 ORDER Entitlement to service connection for a right knee disability, to include as secondary to service-connected right calf disability, is denied. FINDING OF FACT The preponderance of the evidence is against finding that the Veteran's right knee disability had its onset during service, is otherwise related to it, or was caused or worsened beyond natural progression by the service-connected right calf disability. CONCLUSION OF LAW The criteria to establish service connection for a right knee disability, to include as secondary to the service-connected right calf disability, are not met. 38 U.S.C. §§ 1131, 5107 (2012), 38 C.F.R. §§ 3.102, 3.303, 3.310 (2020). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from November 1976 to November 1979. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a November 2012 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). In October 2018, the Veteran testified before the undersigned Veterans Law Judge via videoconference hearing. A copy of the hearing transcript is of record and has been reviewed. In June 2019, the Board remanded the appeal for further development. In July 2021, the Board denied service connection for a digestive disability and a skin rash, as well as denied increased rating claims for hearing loss and finger scar. Additionally, the Board remanded the right knee claim for further development, and it has since returned for further appellate consideration. 1. Entitlement to service connection for a right knee disability, to include as secondary to service-connected right calf disability, Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active service. 38 U.S.C. § 1131; 38 C.F.R. § 3.303(a). Service connection may also be granted for any injury or disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303(d). Establishing service connection generally requires competent evidence of three things: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship, i.e., a nexus, between the claimed in-service disease or injury and the current disability. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009). Service connection may alternatively be established on a secondary basis for a disability which is proximately due to, or the result of, a service-connected disability. 38 C.F.R. § 3.310(a). Secondary service connection may also be established for a disorder which is aggravated by a service-connected disability. See 38 C.F.R. § 3.310(b) (2017); Allen v. Brown, 8 Vet. App. 374 (1995). The Board must analyze the credibility and probative value of the evidence, account for the evidence that it finds persuasive or unpersuasive and provide the reasons for its rejection of any material evidence favorable to the claimant. Kahana v. Shinseki, 24 Vet. App. 428, 433 (2011). This includes weighing the credibility and probative value of lay evidence against the remaining evidence of record. See King v. Shinseki, 700 F.3d 1339 (Fed. Cir. 2012); Kahana, 24 Vet. App. at 433-34. A veteran bears the evidentiary burden to establish all elements of a service connection claim, including the nexus requirement. Fagan v. Shinseki, 573 F.3d 1282, 1287 (Fed. Cir. 2009). In making its ultimate determination, the Board must give a veteran the benefit of the doubt on any issue material to the claim when there is an approximate balance of positive and negative evidence. Id. at 1287 (quoting 38 U.S.C. § 5107(b)). The Veteran seeks service connection for a right knee disability. The Veteran contends that his right knee disability is a result of an injury to his right calf in service. The Veteran also contends that his right knee disability is due to the rigors of service, to include running during physical training and walking from his position as a correctional officer. The Veteran has a current diagnosis of postoperative residuals of a right knee meniscectomy. See e.g., August 15, 2013 VA treatment record; December 2020 VA knee and lower leg examination report. Upon review of all the evidence, lay and medical, the Board finds that the evidence is against finding that the Veteran's right knee disability had its onset during service or is otherwise related to it. A review of the Veteran' service treatment records (STRs) show no evidence of complaints, treatment, or diagnosis of a right knee disability. The Veteran was treated for a contusion to his right calf in October 1979. He reported the symptoms occurred one and a half weeks earlier. The assessment was muscular contusion with intramuscular hematoma formation. He was given a profile of no running for 10 days. At his separation examination ten days later, clinical examination of the lower extremities was normal. A VA treatment record to establish care, dated August 2013, notes the Veteran gave a history of bilateral knee meniscectomy, one in the mid 1990's and the last in 2002. At a VA examination of the knees and lower leg in February 2016, the Veteran reported tenderness of the right calf that began in 1979. He also reported flareups of his right knee involving muscle cramps and a tingling sensation. The examiner noted that Veteran had surgery on his knee and also noted no past meniscus tear or surgery. The examiner noted that there were no diagnoses related to the calf and that the claims file had not been reviewed. At the October 2018 Board videoconference hearing, the Veteran testified that his right knee disability was due to the rigors of physical training, to include running. He testified that, as a correctional officer, he had a lot of prolonged standing and walking, including walking up and down flights of stairs. He also reported tearing his meniscus due to the weakness in his knee, about 1992, when he was a police officer, that it required surgery. He reported that he had no treatment for his knee following service until the meniscus surgery. His kneecap is constantly sore and his leg and calf twitch. In its June 2019 remand, the Board found the 2016 VA examination inadequate as the examination focused on the right calf and was conflicting with respect to reporting the Veteran's past meniscectomy. The Veteran was afforded a VA compensation examination in December 2020. The examiner confirmed a current diagnosis of residuals of bilateral knee meniscectomy. The examiner considered the Veteran's report that his knee gave way in service about 1978 during a physical training test and that his calf tensed up and he was ordered to bedrest for three days. The examiner also considered the Veteran's statements that he had right knee meniscus surgery repair due to an injury which occurred when he was arresting someone in 1987. The Veteran reported intermittent pain, weakness, giving way of the right knee. The examiner opined that the Veteran's right knee disability was less likely than not related to service or to the Veteran's service-connected right calf disability. The examiner reasoned that there was no evidence of injury to the Veteran's knee in service and noted that the right calf injury records were detailed and did not mention any trauma to the right knee. The examiner reasoned that the right knee disability was more likely than not due to the physical altercation that occurred when he arrested a subject in 1987 when he was a police officer. The examiner also noted that the Veteran had no treatment for knee disabilities between his separation from service in 1979 and meniscal injury in 1987. Additionally, the examiner noted that calf injuries by themselves, not involving the Achilles tendon, do not lead to chronic knee conditions. In its July 2021 remand, the Board found the 2020 opinion inadequate only to the extent that the examiner did not offer an opinion regarding aggravation of the right knee disability by the service-connected right calf disability. Therefore, an additional addendum was obtained in September 2021. The reviewing examiner opined that the Veteran's right knee disability was less likely than not aggravated by the Veteran's service-connected right calf disability. The examiner noted the current diagnosis of status post meniscal tear with subjective pain. The examiner noted that the natural course of the current diagnosis might involve progression and development of degenerative joint disease which was unlikely to be impacted by chronic gastrocnemius strain. The examiner reasoned that one would anticipate less activity due to a calf strain, which would cause less strain or stress on the right knee. Furthermore, the examiner noted that any right calf accomodation would favor the right side, causing less impact to the right knee, rather than more impact. The Board finds the December 2020 VA examiner's medical opinion to be adequate, competent, and highly probative. The opinion is supported by adequate rationale based on the Veteran's lay assertions, medical history, and medical evidence in this case. Importantly, there is no competent evidence of record linking the Veteran's current right knee disability to service. The only evidence of record supporting the contention that the Veteran's right knee disability is etiologically related to active service is lay evidence submitted by the Veteran. His lay statements however are not competent because the question of etiology of a knee disorder is a complex medical question and, as a layperson, the Veteran is not competent to provide an opinion relating it to service. See Kahana at 437 (2011). An opinion of etiology would require knowledge of the complexities of the musculoskeletal system, and would involve objective clinical testing and expertise that the Veteran is not competent to perform. On the contrary, the VA examiner possesses expertise and training in the medical field and has provided a competent and probative medical opinion in this case. The December 2020 VA etiology opinion outweighs the lay evidence as to etiology in this case. In addition, the evidence is against finding that the Veteran's right knee disability was caused or worsened beyond its normal progression by the service-connected right calf disability. Evidence in support of the claim based on secondary service connection includes the Veteran's assertions regarding the etiology of his right knee disability, that it developed as a result of the right calf injury. See December 10, 2012, VA 21-4138 Statement in Support of Claim. Evidence weighing against the claim includes December 2020 and September 2021 medical opinions which the Board finds to be competent, credible, and probative. The examiners reviewed the Veteran's claims file and medical records and were familiar with the Veteran's assertions, symptoms, and diagnoses of his right knee disability. Moreover, the opinions contain clear conclusions supported by a reasoned medical explanation. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). Regarding causation, the December 2020 VA examiner explained that a calf injury which did not involve the Achilles tendon would not lead to a chronic knee disability. The September 2021 VA examiner explained that the normal progression of the Veteran's post-operative meniscectomy, including the development of degenerative joint disease, would not be impacted by gastrocnemius strain, and also noted that favoring the right calf would actually lead to less impact on the right knee. Notably, there are no medical opinions or other competent medical evidence of record that contradict the December 2020 and September 2021 opinions. Accordingly, the Board finds the VA medical opinions highly probative, competent, and persuasive medical evidence in this case. The Board recognizes the Veteran's belief that his right knee disability is due to the right calf disability; however, as noted above, as a lay person, he is not competent to link the two as he is not shown to possess the medical training to do so. In sum, the Board finds that the weight of the competent and credible evidence is against finding that the Veteran's right knee disability was casually or etiologically related to service or caused or worsened beyond normal progression by the service-connected right calf disability. Because the preponderance of the evidence is against the claim for service connection, the benefit of the doubt doctrine is not for application. See 38 U.S.C. § 5107, 38 C.F.R. § 3.102. S. B. MAYS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Beach, Julia M. 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.