Citation Nr: 21009831 Decision Date: 02/23/21 Archive Date: 02/23/21 DOCKET NO. 11-26 822 DATE: February 23, 2021 ORDER Entitlement to service connection for left lower extremity disorder, diagnosed as left knee osteoarthritis, is granted. FINDING OF FACT Resolving reasonable doubt in the Veteran’s favor, left lower extremity disorder, diagnosed as left knee osteoarthritis, is at least as likely as not related to active service. CONCLUSION OF LAW The criteria for service connection for left lower extremity disorder, diagnosed as left knee osteoarthritis, are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from January 1987 to May 1987 and from November 1990 to May 1991. This matter is before the Board of Veterans’ Appeals (Board) on appeal of March 2010 and July 2010 rating decisions of a Department of Veterans Affairs (VA) Regional Office (RO). This case was previously remanded by the Board in September 2017. In December 2018, the Board denied entitlement to service connection for left lower extremity and right knee disorders. The Veteran appealed the Board’s decision to the United States Court of Appeals for Veterans Claims (Court). In an October 2019 Order, the Court granted a Joint Motion for Remand (JMR) of the Veteran and the Secretary of Veterans Affairs (the Parties) to vacate and remand the portion of the Board’s December 2018 decision that denied entitlement to service connection for left lower extremity and right knee disorder. Specifically, the JMR found that the Board erred in relying on the October 2017 VA examination, which was inadequate. Subsequently, the Board remanded these issues in April 2020 for compliance with the JMR. Thereafter, in the August 2020 rating decision, service connection was awarded for the Veteran’s right knee disorders; representing a full grant of the benefit sought on appeal. The Board also finds that with respect to the remaining issue on appeal, there has been substantial compliance with the prior remand directives. See Stegall v. West, 11 Vet. App. 268 (1998). Entitlement to service connection for left lower extremity disorder, diagnosed as left knee osteoarthritis, The Veteran contends that she is entitled to service connection for a left lower extremity disability, to include osteoarthritis. She alleges that she injured her left leg in physical training after slicing it open on a piece of rebar steel while deployed. The Board notes that a May 1987 service treatment record shows a report of left knee pain following a physical training test. Further, in April 1991, the Veteran’s service treatment records indicate that she sliced her left leg on rebar while deployed and had an anterior left tibial scar. The service treatment records did not note any further injury or need for treatment. The Board concludes that the Veteran has a current disability that is related to active service. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a). Initially, the Board notes that the Veteran has been diagnosed with left knee osteoarthritis as found in the October 2017 VA examination and private treatment records. Moreover, with respect to any other disabilities of the left lower extremity, the Board observes that the Veteran has already been awarded service connection for the residual scar from when her left leg was sliced on a rebar. Moreover, the issue of service connection for left lower extremity sciatica associated with low back disability is currently on appeal, but not yet before the Board and will be addressed in a future decision if necessary. Further, the Board finds that the preponderance of the evidence is against finding that the Veteran has any other disabilities of the left lower extremity. In this regard, after examining the Veteran and reviewing the claims file, the July 2020 VA examiner clearly found that the Veteran did not suffer from a left lower extremity muscle injury. The examiner found that there were no left lower muscle extremity weakness or deformities, or loss of muscle mass noted on examination. Based on the examiner’s findings, there exists no basis for finding that a threshold of functional impairment of earning capacity has been met. Absent such evidence, there can be no finding of a disability. See Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018). Thus, the question becomes whether the current left knee osteoarthritis is related to service. On this question there are probative opinions in favor of and against the claim. The evidence against the claim includes a November 2020 opinion where the examiner found that it is less likely than not (50 percent or lesser probability) that the Veteran’s current left lower leg condition is related to the physical demands of active duty service. The examiner rationalized that considering all evidence, there are limited medical objective evidences to show diagnosis and treatment for the left leg while in active duty. Additionally, from separation in 1991, which is unremarkable for knee or lower leg condition, interim periods until 2008, which is a 17 year health care gap, were silent for chronic left lower leg complains. The Veteran was able to gain employment without left knee or lower leg complaints. It was in 2010 where she began to report bilateral knee pain along with stiffness associated with prolonged sitting. She continued to report chronic bilateral knee pain from overuse. Thereafter, x-ray of the knee was negative. During that time, the Veteran was found working for three years (2009 to April of 2012) until she broke her foot and was laid off. She then worked since July of 2012 as a warehouse associate at which she is mostly on her feet. The Veteran was also found to be obese with BMI of 36-37.0 at that time. She began physical therapy in 2011 and reports “daily her knees hurt as a result of the job on her feet.” The Veteran’s private treatment records indicate that in July 2015 she was diagnosed with bilateral knee osteoarthritis. Muscle Injuries Disability Benefits Questionnaire dated July 2020 reports negative findings for muscle group of foot and leg. The Veteran was seen and examined at the recent Knee and Lower leg examination and showed physical examination findings consistent with bilateral patellofemoral pain syndrome knee meniscal tear right and degenerative arthritis of the right knee. Obesity and post military employment have likely caused her current knee conditions. There is a lack of medical objective evidence to show high impact as well as continuity and chronicity of symptom in relation to service. However, in contrast, the evidence in favor of the claim includes the July 2020 opinion. Although the examiner was primarily opining as to the etiology of the Veteran’s right knee disability, the examiner also indicated that the Veteran’s left knee disability was related to service. In this regard, after reviewing the claims file, the examiner rationalized that the Veteran had reported onset of knee pain in April 2008. In 2011, the Veteran was diagnosed with chondromalacia and chronic knee pain, in 2015 degenerative arthritis was noted on x ray. The Veteran was diagnosed with osteoarthritis in 2014 with an outside orthopedist. Bilateral knee x -rays in 2015 show mild joint space narrowing. Thus, the examiner opined that the Veteran's prior military service and military occupational specialty in flight operations and physical training could have at least 50% contributed to the development of the knee conditions. The other factors of obesity and aging, which were previously discussed as the contributing factors of the degenerative arthritis certainly contributed. The examiner continued that the Veteran’s military service contributed to the onset of arthritis. Review of literature supports the claim that increased load bearing in the large joints, especially knees and hips during military service can contribute to microtrauma and set up for inflammatory changes that contribute to the development of arthritis. The examiner concluded that occupations that involve heavy physical workloads increase the risk of developing lower limb osteoarthritis. Heavy lifting, squatting, knee bending, kneeling, and climbing may all increase the risk of developing osteoarthritis in both the knees and hips. Efforts to reduce exposure to these tasks, reducing joint injuries, optimizing bodyweight may reduce the risks of lower limb osteoarthritis for occupations which are physically demanding. The Board also finds it significant that the July 2020 examiner’s findings are also supported by an April 2016 private opinion. The private examiner indicated that if the Veteran was doing a lot of running, jumping and hiking throughout her military career, then in the examiner’s opinion, the Veteran’s military career contributed to the onset of her arthritis. The Board is thus faced with a conflicting record as to whether the Veteran’s left knee disability is related to service. Both of the VA examiners have been identified as medical professionals, were aware of the Veteran’s medical history, and offered rationales for their opinions. Importantly, the July 2020 opinion is also supported by the April 2016 private opinion. As such, the Board finds the evidence to at least be in equipoise as to whether the Veteran’s current left knee osteoarthritis is related to service. Accordingly, after resolving all doubt in favor of the Veteran, the Board finds that service connection for left lower extremity disorder, diagnosed as left   knee osteoarthritis is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. L. M. BARNARD Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J.N. Moats 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.