Citation Nr: 21006304 Decision Date: 02/03/21 Archive Date: 02/03/21 DOCKET NO. 18-40 342 DATE: February 3, 2021 ORDER Entitlement to service connection for a right knee condition is denied. Entitlement to service connection for erectile dysfunction is denied. REMANDED Entitlement to service connection for bilateral hearing loss is remanded. FINDINGS OF FACT 1. The preponderance of the evidence is against finding that a right knee condition began during service, or is otherwise related to an in-service injury or disease, or to a service-connected disability. 2. The preponderance of the evidence is against finding that erectile dysfunction began during service, or is otherwise related to an in-service injury or disease, or to a service-connected disability including any medication taken therefor. CONCLUSIONS OF LAW 1. The criteria for service connection for a right knee condition are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. 2. The criteria for service connection for erectile dysfunction are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from February 1968 to April 1969. These matters were previously before the Board in March 2019, May 2020, and June 2020, and return now for adjudication. 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 competent evidence showing: (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, 1167 (Fed. Cir. 2004); see also Caluza v. Brown, 7 Vet. App. 498 (1995). 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. 1. Right Knee The Veteran contends that his right knee condition is directly related to service, specifically to an injury sustained when a piece of shrapnel hit below his right knee, or alternatively, to having jumped out of helicopters with heavy gear. The record has also raised the question of whether any of the Veteran’s right knee conditions are related to his service-connected right calf condition. Medical evidence shows that the Veteran has diagnoses of right knee strain and right knee meniscal tear. See April 2018 VA examination. The Board notes that the Veteran is in receipt of service connection for a shrapnel wound to his upper right calf. Service treatment records show that the Veteran was treated in October 1968 for a shrapnel wound to the right leg. In an April 1969 separation report of medical history, the Veteran denied experiencing any knee problems and had a normal clinical evaluation of his lower extremities. The first post-service evidence of a right knee issue is in an August 2006 VA treatment note where the Veteran reported problems with his knees and noted that he had an episode a few years ago where his knees locked up. X-ray imaging at that time showed slightly prominent medial tibial spines bilaterally, without any other localizing signs of bone or soft tissue abnormality. An April 2014 VA treatment note indicates that the Veteran received cortisone shots in his right knee. In an August 2014 statement, the Veteran indicated that he had difficulty climbing and kneeling, and that he believed his knee problems to stem from the shrapnel injury to his calf in service or to having jumped out of helicopters with heavy gear in service. At an April 2018 VA knee conditions examination, a VA examiner diagnosed right knee strain and right knee meniscal tear. The examiner noted the shrapnel wound in service as well as the post-service VA treatment records noting knee pain. The Veteran explained that a right knee condition began when he was wounded in 1968 below his right knee and after jumping out of helicopters with 65 pounds of equipment. However, he also noted that the date of onset of symptoms was 2000. In a corresponding medical opinion, the examiner opined that the Veteran’s right knee condition was less likely than not related to, or aggravated by, the Veteran’s service-connected right calf condition. The rationale was that there was no evidence of complaints of right knee pain during the Veteran’s military service, or resulting from the Veteran’s shrapnel wound to the lower right soft tissue, which was healed during service without any recorded chronic complications. In an April 2019 addendum opinion, a different VA examiner opined that the Veteran’s knee problems, to include right meniscal tear, were a direct result of aging, weight, occupation, nutrition, genetic makeup, and day to day activity as in any other individual of the Veteran’s age. Specifically, the examiner noted, there was no continuity of treatment back to 1968; rather, there was overwhelming evidence that the Veteran’s profession in the construction industry as a building inspector and steel worker subjected him to prolonged periods of walking for several decades. It was the examiner’s opinion that his professional knee use and the resultant wear and tear, along with the aging process and other factors noted above, were the proximate cause of the Veteran’s knee problems, and not any issues experienced in service. The examiner added that the Veteran’s civilian physician had not noted any knee problems during treatment sessions. Because the Board concluded in a May 2020 Remand that the April 2019 examiner had not specifically considered the Veteran’s reports of jumping out of helicopters or the Veteran’s lay reports of continuity of symptomatology, an additional opinion was obtained in June 2020. Therein, a separate VA examiner indicated that a review of the Veteran’s service treatment records noted no specific complaints of right knee pain, though a 1969 report of medical history noted cramps in his legs with long walking. The examiner stated that the first post-service indication of medical treatment was in August 2006, when the Veteran established care and noted knee problems. In light of the foregoing, and the additional medical evidence reviewed, the examiner concluded that it was less likely as not that his current knee complaints were secondary to his time spent in the military as there was no direct nexus of injury, given the service treatment records which did not indicate any right knee injury. Rather, the examiner noted that it was equally as likely that the Veteran’s employment in which he had to stand for prolonged periods of time could cause knee pain. Another opinion was obtained in July 2020. Therein, yet another VA examiner opined that it was less likely as not that any current knee disability was incurred in or as a result of the Veteran’s military service, including reports of frequently jumping out of helicopters with heavy gear. The examiner noted a review of the Veteran’s service treatment records, noting that the leg cramps noted in April 1969 appeared to have resolved without residuals. Moreover, the examiner indicated, leg cramps were a multifactorial muscle condition that were temporary in duration and resolved with rest and hydration, as appeared to be the case with the Veteran. The examiner noted that the Veteran had a successful, 23-year career as a building inspector that involved extensive walking, and that at age 76, 51 years after leaving service, the Veteran was bound to experience some bilateral knee pain due to the aging process, obesity, nutritional/familial/genetic factors, and baseball, in addition to 23 years as a building inspector and steel worker prior to that. The examiner added that the Veteran actually appeared to have aged “remarkably and admirably,” without having had to undergo any surgical knee treatment. The examiner added that while the Veteran’s account of his ongoing and continuity of symptoms may be true, it was nevertheless unsupported by credible medical evidence spanning 51 years. Rather, the examiner attributed the Veteran’s right knee conditions to co-morbidities, including obesity, gout, and many decades of professional use of his knee post-service. Those factors, alone or in combination, were the proximate cause of his knee symptoms, the examiner concluded. In light of the foregoing, the Board concludes that, while the Veteran has current right knee conditions, including right knee strain and a meniscal tear, the preponderance of the evidence is against finding that either condition is proximately due to service, or the result of, or aggravated beyond its natural progression by any 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). The Board affords high probative values to the aforementioned VA opinions in combination. Indeed, the combined opinions considered the in-service and post-service medical evidence, the Veteran’s statements regarding the onset of his knee issues and his reported continuity of symptomatology, and notably, his medical and employment history which were noted to be a more likely cause of his right knee symptoms. Taken together, the opinions are based on an accurate medical history and contain explanations that contain clear conclusions and supporting data. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The opinions in combination adequately address the question of whether any right knee condition onset in service, or was otherwise caused or aggravated by the Veteran’s service-connected upper right calf disability. The Board adds that there is no medical evidence that is contrary to the findings of the VA examiners. The Board has considered the Veteran’s reports that his right knee symptoms have persisted since service, and reiterates that any symptoms stemming from his shrapnel wound have been considered in the award of service connection for shrapnel wound upper right calf. However, regarding symptoms other than those associated with his service-connected right calf disability, the Board finds the contemporaneous lay and medical evidence more probative. See Curry v. Brown, 7 Vet. App. 59, 68 (1994). In this regard, the medical evidence does not show any complaints of or treatment for any right knee symptoms until 2006 and multiple VA examiners have directly attributed his knee symptoms to a longstanding career as a building inspector, requiring prolonged periods of standing and walking, in conjunction with aging and other comorbidities. The July 2020 VA examiner specifically noted that any reports of continuity of symptoms were essentially outweighed by credible evidence spanning a more than 50-year period. While the Veteran believes that his right knee condition is related to service, or to a service-connected disability, the Board notes that the Veteran is not competent to provide a nexus opinion regarding this issue, as it is medically complex and requires specialized medical knowledge of the musculoskeletal system. Therefore, it is outside the scope of the Veteran to opine on such a causal relationship because the record does not show that he 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 combined VA opinions. For these reasons, the preponderance of the evidence is against the claim of entitlement to service connection for a right knee condition, either on a direct or a secondary basis. As the preponderance of the evidence is against the claim, the benefit-of-the-doubt rule is not for application, and the claim must be denied. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 2. Erectile Dysfunction The Veteran contends that his erectile dysfunction is either related to service, or to his service-connected PTSD, or alternatively, to medications taken for other service-connected conditions. See August 2014 Statement in Support of Claim. It is not in dispute that the Veteran has a current diagnosis of erectile dysfunction. Service treatment records, however, are silent for any complaints of, treatment for, or diagnoses of erectile dysfunction. The first post-service evidence of erectile dysfunction is in 1988 following the Veteran’s bladder cancer diagnosis. Pursuant to a March 2019 Board Remand, VA obtained a medical opinion in April 2019. Therein, a VA examiner opined that erectile dysfunction was not aggravated beyond its natural progression by the Veteran’s service-connected PTSD. Rather, the examiner stated that there was “clear-cut evidence” that the condition was due to or a direct result of bladder cancer and subsequent treatments. The examiner added that the Veteran’s erectile dysfunction predated the diagnosis of PTSD, and that there was clear evidence that erectile dysfunction was caused by chemotherapy. The examiner also noted that there was insufficient evidence that the Veteran’s erectile dysfunction was aggravated beyond its natural progression by any medications taken for any of his other service-connected disabilities. The rationale was that while the medications taken by the Veteran had some side effects that generally improved with stopping or changing medication, erectile dysfunction was a multifactorial condition related to circulatory and endocrine issues, the aging process, and other comorbidities. The examiner reiterated that erectile dysfunction was related exclusively to chemotherapy received for his bladder cancer. In a May 2020 Remand, the Board indicated that the April 2019 VA examiner did not provide a rationale in support of his opinion that erectile dysfunction was not aggravated by the Veteran’s service-connected PTSD. The Board did not note other deficiencies with the April 2019 opinion. In a June 2019 addendum opinion, a VA examiner indicated that medical evidence showed that erectile dysfunction was noted in 1988 following the Veteran’s bladder cancer diagnosis with subsequent chemotherapy. The examiner added that the Veteran also had hypertension, peripheral vascular disease, and chronic renal insufficiency, all conditions which could contribute to erectile dysfunction. Given that erectile dysfunction was a multifactorial condition, the examiner concluded that there was no evidence to suggest that the Veteran’s PTSD aggravated erectile dysfunction beyond its natural progression. In a July 2020 addendum opinion, a different VA examiner opined that it was less likely as not that the Veteran’s erectile dysfunction was caused or aggravated by the Veteran’s service-connected PTSD, to include any symptoms or manifestations thereof. The rationale was that the Veteran was diagnosed with bladder cancer in 1988 and subsequently underwent chemotherapy, at which time he complained of erectile dysfunction. The examiner indicated that was clear and unmistakable evidence that the condition was due to or a direct result of bladder cancer and treatment. The examiner continued by noting that the Veteran was 76 years old, and there was insufficient evidence that the erectile dysfunction condition had progressed beyond its natural progression by his service-connected PTSD. Indeed, aging, alcohol, comorbidities, alone or in combination, could contribute to erectile dysfunction at any age, the examiner noted, but there was insufficient evidence to conclude that PTSD had any role in the Veteran’s erectile dysfunction. In light of the foregoing, the Board concludes that, while the Veteran has a current disability of erectile dysfunction, the preponderance of the evidence is against finding that the condition is proximately due to service, 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). The Board affords high probative value to the combined opinions of the April 2019, June 2019, and July 2020 VA examiners, who each concluded that the evidence overwhelmingly supported a finding that the Veteran’s erectile dysfunction was more likely than not due to his bladder cancer and subsequent chemotherapy treatment, rather than to his service-connected PTSD or other service-connected conditions to include any medications taken therefor. Taken together, the opinions are based on an accurate medical history for the claimed condition of erectile dysfunction and contain explanations that contain clear conclusions and supporting data. See Nieves-Rodriguez v. Peake, supra. Specifically, the combined opinions recognized the Veteran’s pertinent diagnosis of bladder cancer, its subsequent treatment, and the notations that the Veteran noted the presence of erectile dysfunction at or around the time of his diagnosis, but not earlier. The combined opinions also adequately address the questions of whether erectile dysfunction was caused or aggravated by either PTSD, also noting that erectile dysfunction predated the Veteran’s PTSD diagnosis, or by any medications taken for any service-connected conditions. The Board notes that there is no medical nexus evidence that is contrary to the findings of the VA examiners. Insofar as the Veteran asserts that service connection for erectile dysfunction is warranted on a direct basis, the Board does find that the Veteran’s contentions supporting a direct theory of service connection are credible, as there is no medical evidence suggesting that the Veteran had symptoms of erectile dysfunction either during service or in the intervening years until his diagnosis of bladder cancer and resultant chemotherapy. Accordingly, the Board finds that direct service connection is also not warranted for erectile dysfunction. While the Veteran believes that his erectile dysfunction is related to service, or to a service-connected disability, or to a medication taken for a service-connected disability, the Board notes that the Veteran is not competent to provide a nexus opinion regarding this issue, as it is medically complex and requires specialized knowledge of the inner workings of the body. Therefore, it is outside the scope of the Veteran to opine on such a causal relationship because the record does not show that he has the medical training or credentials to make such a determination, as noted above. See, Jandreau, supra; see also Kahana, supra. The Board adds that in this regard, it has considered several articles submitted in support of the Veteran’s claim. Specifically, the Veteran has submitted articles discussing relationships between anxiety disorders and sexual dysfunction. However, while the articles speak to an association between PTSD and sexual dysfunction, including erectile dysfunction, they do not prove causation. Consequently, the Board gives more probative weight to the combined VA opinions, which took into account the Veteran’s specific medical circumstances, most notably, his bladder cancer and treatment. For these reasons, the preponderance of the evidence is against the claim of entitlement to service connection for erectile dysfunction, either on a direct or a secondary basis. As the preponderance of the evidence is against the claim, the benefit-of-the-doubt rule is not for application, and the claim must be denied. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). REASONS FOR REMAND While the Board sincerely regrets the additional delay, it finds that the most recent, October 2020 VA opinion is not fully responsive to the directives set forth in the Board’s May 2020 Remand. Specifically, the Board requested that a VA examiner address the Veteran’s complaint of decreased hearing in his April 1969 separation examination report of medical history as well as the relevance, if any, of the Veteran’s post-service noise exposure in the context of employment at a steel mill, as a carpenter, and as a building inspector. The October 2020 VA examiner stated that a review of the Veteran’s service records indicated that the Veteran’s hearing was within normal limits at the time of separation from service in April 1969. The examiner continued by citing to the Institute of Medicine (IOM) report from 2005 which concluded that a prolonged delay in the onset of noise-induced hearing loss was unlikely. Given that the October 2020 VA examiner did not specifically address the Veteran’s notation of decreased hearing secondary to acoustic trauma, as noted on his April 1969 separation report of medical history, the Board finds that an addendum opinion is necessary. The matters are REMANDED for the following action: 1. Obtain an addendum opinion addressing the etiology of the Veteran’s bilateral hearing loss disability. The examiner is asked to review the Veteran’s entire claims file, and then respond to the following: Indicate whether the Veteran’s bilateral hearing loss (50 percent or greater probability) had its onset in service or is otherwise related to the Veteran’s presumed in-service noise exposure. The examiner must consider and explicitly address the Veteran’s service treatment records, to specifically include the Veteran’s report of decreased hearing at separation from service. The examiner must also identify any post-service noise exposure and discuss the relevance of such. (Continued on the next page)   If relying on the IOM study, as did the October 2020 VA examiner, the examiner must explain how the qualifying and contradictory statements in the IOM report impact the examiner’s ultimate conclusion as to whether the Veteran’s hearing loss is related to service. 2. Then, readjudicate the issue on appeal. Zi-Heng Zhu Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Polly Johnson, 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.