Citation Nr: 21009959 Decision Date: 02/23/21 Archive Date: 02/23/21 DOCKET NO. 10-16 471 DATE: February 23, 2021 ORDER Entitlement to service connection for a left knee disability, to include arthritis and as secondary to service-connected degenerative joint disease and instability of the right knee, is denied. FINDING OF FACT The left knee disability was not incurred in service, manifested within one year following service discharge, or is otherwise due to service and is not caused or aggravated by the service-connected degenerative joint disease and instability of the right knee. CONCLUSION OF LAW The criteria for entitlement to service connection for a left knee disability, to include arthritis and as secondary to service-connected degenerative joint disease and instability of the right knee, have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1131, 1137, 5107; 38 C.F.R. §§ 3.303, 3.304, 3.309, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty in the United States Air Force from March 1980 to August 1992. The Veteran testified before the undersigned Veterans Law Judge via videoconference in April 2018. A transcript of the hearing is included in the claims file. In a July 2018 decision, the Board, in pertinent part, denied the claim for service connection for a left knee disability. The Veteran appealed the Board’s decision to the United States Court of Appeals for Veterans Claims (Court). In a December 2019 Memorandum Decision, the Court set aside the Board’s decision and remanded the claim for further proceedings consistent with the decision. In August 2020, the Board remanded this claim for additional development. Specifically, the Board remanded the claim for an addendum opinion about the possible relationship between the left knee disability and the service-connected right knee disabilities. The Board finds there has been substantial compliance with the Board directives. The case has been returned to the Board for further appellate review. Entitlement to service connection for a left knee disability, to include arthritis and as secondary to service-connected degenerative joint disease and instability of the right knee The Veteran contends that his left knee disability is caused or aggravated by the service-connected right knee disability. The Veteran stated that his right knee disability caused him to favor his left leg and changed his gait and weight distribution, which lead to his left knee problem. The Veteran testified at the April 2018 Board hearing that his left knee began bothering him around 2007, about a year or two after his left hip began bothering him. He stated that he performed 17 jumps out of an airplane while on active duty and that contributed to his left knee disability. Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by service. See 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). To establish a right to compensation for a present disability, a veteran 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. Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Additionally, where a veteran served 90 days or more of active service, and certain chronic diseases, such as arthritis, become manifest to a degree of 10 percent or more within one year after the date of separation from such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. While the disease need not be diagnosed within the presumption period, it must be shown, by acceptable lay or medical evidence, that there were characteristic manifestations of the disease to the required degree during that time. However, where the evidence does not warrant presumptive service connection, a veteran is not precluded from establishing service connection with proof of direct causation. Service connection is also warranted for a disability which is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Such secondary service connection is warranted for any increase in severity of a nonservice-connected disability that is proximately due to or the result of a service-connected disability. 38 C.F.R. § 3.310(b). In deciding claims, it is the Board’s responsibility to evaluate the entire record on appeal. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss each and every piece of evidence submitted by the Veteran or on his behalf. Rather, the Board’s analysis below will focus specifically on what evidence is needed to substantiate the claim and what the evidence in the claims file shows, or fails to show, with respect to the claim. The Board has carefully reviewed the evidence of record and finds that the preponderance of the evidence is against the claim for service connection for a left knee disability, to include arthritis and as secondary to degenerative joint disease of the right knee. The reasons follow. As to evidence of a current disability, the November 2018 VA examination report shows that the Veteran was diagnosed with left knee degenerative arthritis. Therefore, the facts establish that the first element of a service-connection claim is met. As to evidence of an in-service disease or injury, the service treatment records do not show that the Veteran sustained a disease or injury to the left knee during service. For example, the service treatment records show that in the June 1979 Report of Medical History completed prior to the Veteran’s induction into service, the Veteran denied ever having or having arthritis, rheumatism, or bursitis; bone, joint, or other deformity; lameness; and “trick” or locked knee. The June 1979 Report of Medical Examination shows that clinical evaluation of the lower extremities was normal. Additionally, October 1983 and November 1988 Reports of Medical Examination show that clinical evaluations of the lower extremities were normal. In the June 1992 Report of Medical History completed at service discharge, the Veteran denied ever having or having then arthritis, rheumatism, or bursitis; bone, joint, or other deformity; lameness; or “trick” or locked knee. Within this report, it was documented that the Veteran had undergone right knee surgery in 1973 and had sprained that knee six times with a report that the right knee would “sometimes gives out.” The July 1992 Report of Medical Examination from service discharge shows that clinical evaluation of the lower extremities was normal. The examiner documented that the right knee had a surgical scar and that both knees had full range of motion and strength. As the Veteran did not complain of pain or seek treatment for his left knee in service, the Board finds the preponderance of the evidence is against a finding of a left knee disease or injury occurred during service. This finding is supported by the September 2020 VA opinion. The examiner noted the Veteran’s contention that he performed 17 jumps out of an airplane (parachute jumps) while on active duty that may have contributed to his left knee disability, but found that the service treatment records did not support this assertion, and the DD Form 214 is absent for attendance to Airborne Training and Parachutist Badge. Regardless, the examiner wrote that parachute injuries occur throughout all phases of the jump, but that ground impact is the primary event associated with injury. The examiner stated that the most recent imaging studies on the Veteran’s bilateral knees was obtained in December 2018; demonstrating that there were degenerative changes that were greater in the right knee than in the left knee. The examiner stated that findings that would be suggestive of post-traumatic arthritis were absent, which the examiner wrote would be found if the Veteran had sustained trauma to his knees while on active duty. The examiner wrote that a review of the current medical literature and general medical consensus shows that military service, without any known trauma (for example: fracture, meniscus tear, gunshot wound, etc.), is not a factor in the development of osteoarthritis of the knees, or other weight-bearing joints of the body. The examiner noted there is no medical evidence that supports the claim that “running, jumping, and bending” in the line of military service increases the risk for developing osteoarthritis in weight-bearing joints of the body. Thus, while the examiner doubted whether the Veteran performed 17 parachute jumps during service, the examiner still considered the Veteran’s contention when addressing whether the Veteran sustained an injury to his left knee during service and found that the evidence did not support that allegation. The Board also notes that in looking at the Veteran’s service treatment records and service personnel records, including the DD Form 214, there is no indication that he performed parachute jumps, nor is there documentation in his personnel records to reflect that this training would have been required for someone in his military specialty such that the Board could infer such experience. The examiner was correct in noting that the DD Form 214 does not show airborne training or a parachute badge. Regardless, the examiner considered this fact when concluding that a disease or injury involving the left knee was not shown in service. The Board finds that the September 2020 opinion is highly probative, as the examiner reviewed the file and provided a detailed discussion to support the finding that the Veteran did not have a disease or injury involving the left knee during service. The Veteran’s primary contention is that the left knee has been caused or aggravated by the right knee. Without evidence of a disease or injury in service, direct service connection for a left knee disability is not warranted. There is also no competent evidence that the left knee osteoarthritis manifested within one year following service discharge. For example, a March 2006 VA x-ray of the left knee was found to be normal, which is affirmative evidence that arthritis was not manifested within one year following service discharge. Thus, service connection for the left knee disability on a presumptive basis involving a chronic disease is not warranted. As to secondary service connection, as noted above, the Veteran’s primary assertion is that the left knee disability is caused or aggravated by the service-connected degenerative joint disease and instability of the right knee. There is evidence of a current left knee disability and the Veteran is service connected for degenerative joint disease and instability of the right knee. Thus, the facts establish that the first and second elements of a secondary service-connection claim are met. As to evidence of a nexus between the Veteran’s left knee disability and the service-connected right knee disability, the Board finds that the preponderance of the evidence is against a nexus. For example, the September 2020 VA examiner concluded that it was less likely than not (less than 50 percent probability) that the Veteran’s left knee disability is a result of or caused by the service-connected right knee instability with degenerative joint disease. Additionally, the examiner stated that it is less likely than not (less than 50 percent probability) that the Veteran’s left knee disability was aggravated beyond its natural progression by the service-connected right knee instability with degenerative joint disease. The examiner explained that the Veteran’s left knee diagnosis is degenerative arthritis. He stated that degenerative changes most often occur as a chronic process from “wear and tear” and is also part of the normal aging process of the joints. The examiner went on to say osteoarthritis is a degenerative type of arthritis that occurs most often in people 50 years of age and older, though the examiner noted it may occur in younger people as well. The examiner noted that osteoarthritis of the knee causes pain and stiffness; and can make it hard to do everyday activities like squatting to tie a shoe, rising from a chair, or taking a short walk. The examiner acknowledged the Veteran is service connected for right knee instability with degenerative joint disease and contends that due to this disability, he has subsequently developed a left knee disability. The examiner explained that the mechanics of limping and having an antalgic gait are poorly documented in the Orthopedic literature with no clear scientific basis for this line of thought. The examiner wrote that the available evidence indicates that an injury or condition in a joint on one lower extremity rarely causes a major problem in the contralateral extremity except when damage to the injured extremity results in a major displacement of the center of gravity of the body while walking. The examiner explained most people have some sort of a leg length discrepancy (one leg shorter than the other leg), which generally goes unnoticeable because the discrepancy is less than four or five centimeters, which does not displace the body’s center of gravity. The examiner concluded that for the Veteran to have developed a left knee condition due to having a right knee disability (right knee instability with degenerative joint disease), the condition in his right knee would have had to be so substantial that it significantly displaced the center of gravity of his body while walking. The examiner explained for the Veteran’s right knee disability to have significantly affected his left knee, the Veteran would had to have sustained major muscle or nerve damage causing partial or complete paralysis in his right lower extremity, and/or shortening of the injured leg resulting in a limb length discrepancy of more than four or five centimeters so that the Veteran’s gait pattern had been altered to the extent that clinically there is an obvious lurching-type gait (a significant limp). The examiner was stating that the Veteran did not have major displacement of the center of gravity while walking to establish that the service-connected right knee disability had caused or aggravated the left knee disability. This finding is supported by the record, as the Veteran’s gait has not been described as being indicative of a major displacement of the center of gravity. For example, the Veteran’s gait has been variously described throughout the appeal process as normal, slight limp, mild antalgic gait, antalgic gait, normal cadence, arm swing, and stride without assistive device and having a steady balance with full use of the lower extremities. The examiner also reviewed an article written by Dr. Ian J. Harrington “Limping and Back Pain.” This discussion paper was prepared for The Workplace Safety and Insurance Appeals Tribunal in March 2004 and revised August 2013. The examiner noted the paper discusses limping and the effects on the contralateral extremity and lower back. Dr. Harrington discussed that most clinicians believe that limping results in more pressure being applied on the contralateral lateral extremity and the spine to transmit increased loads while walking. The examiner wrote that what Dr. Harrington discussed with clarity is that it is not the limping that created problems in the contralateral extremity (hip and/or knee) and spine, but rather the biomechanical effects of limping that is the problem. For limping to cause a musculoskeletal disorder, it must shift or displace the center of gravity of the body. The examiner explained Dr. Harrington went on to discuss “scientific data obtained to date from clinical, x-ray, gait, and biomechanical studies; however, has not clearly defined the magnitude of leg length discrepancy necessary to generate increased force transmission by the normal leg. From a purely biomechanical perspective, a discrepancy of less than 3 or 4 centimeters would unlikely affect the back, hip, or knee.” The examiner wrote Dr. Harrington also stated that “from a biomechanical perspective, limping can cause back pain and aggravate pre-existing back pain, however, clinical data of the effects from limping on the musculoskeletal system was limited and inconclusive.” The Board accords the September 2020 VA medical opinion high probative value because the examiner reviewed the file and provided opinions with a detailed discussion to support the opinions made, including addressing the specific facts of the case and citation to medical literature. There is no competent and probative evidence to weigh against the September 2020 VA medical opinion. While the Veteran is competent to report symptoms that he has experienced in service and since service, he is not competent to directly link the current left knee disability to service or a service-connected disability, as medical expertise is required. In this regard, the question of causation involves a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship. As such, the question of etiology in this case may not be competently addressed by lay evidence, and the Veteran’s own opinion is nonprobative evidence. For the reasons described above, the Board finds the preponderance of the evidence is against the Veteran’s claim for service connection for a left knee disability, to include arthritis and as secondary to service-connected degenerative joint disease and instability of the right knee. There is no reasonable doubt to be resolved, and the claim for service connection on direct, presumptive, and secondary bases is denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. A. P. SIMPSON Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board N. Griffin, 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.