Citation Nr: 21010208 Decision Date: 02/24/21 Archive Date: 02/24/21 DOCKET NO. 15-27 596A DATE: February 24, 2021 ORDER Entitlement to service connection for sarcoidosis is denied. Entitlement to service connection for right knee status post medial meniscectomy is denied. Entitlement to service connection for a left knee disability, to included degenerative arthritis, is denied. FINDINGS OF FACT 1. The Veteran’s current sarcoidosis was not caused by his exposure to chlorine and other chemicals during his period of active service. 2. The Veteran’s bilateral knee disabilities were not incurred during his period of active service; any current bilateral knee disabilities are unrelated to service. CONCLUSIONS OF LAW 1. The criteria for service connection for sarcoidosis are not met. 38 U.S.C. §§ 1110, 1131, 5107 (2018); 38 C.F.R. §§ 3.102, 3.303 (2021). 2. The criteria for service connection for right knee status post medial meniscectomy are not met. 38 U.S.C. §§ 1110, 1131, 5107 (2018); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2021). 3. The criteria for service connection for a left knee disability, to included degenerative arthritis, are not met. 38 U.S.C. §§ 1110, 1131, 5107 (2018); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2021). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty with the United States Air Force from January 1984 to January 1988. The Veteran also has active duty service in the United States Army National Guard. In October 2018, the Veteran and his spouse testified before the undersigned at a Board hearing held via videoconference. A transcript of that hearing is of record. The Veteran’s appeal was previously before the Board in May 2019 but was remanded to the Agency of Original Jurisdiction for further development. Specifically, the appeal was remanded with directives to obtain VA examinations and medical opinions regarding etiology of the Veteran’s sarcoidosis and bilateral knee disabilities. The required examinations were completed and medical opinions obtained in November 2019. The VA examinations were adequate because they were based upon consideration of the Veteran’s pertinent medical history, his lay assertions and current complaints, and the examiners provided rationales for their opinions. A July 2020 VA addendum medical opinion was obtained regarding the etiology of the Veteran’s bilateral knee disabilities was also obtained and associated with the claims file. Accordingly, the Board finds there has been substantial compliance with the remand instructions. See Stegall v. West, 11 Vet. App. 268, 271 (1998); see also D’Aries v. Peake, 22 Vet. App. 97, 105 (2008). The Board must determine the value of all evidence submitted, including lay and medical evidence. Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). The evaluation of evidence generally involves a three-step inquiry. First, the Board must determine whether the evidence comes from a “competent” source. The Board must then determine if the evidence is credible, or worthy of belief. Barr v. Nicholson, 21 Vet. App. 303, 308 (2007). The third step of this inquiry requires the Board to weigh the probative value of the evidence in light of the entirety of the record. Neither the Veteran nor his representative have raised any issues with the duty to notify or duty to assist. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that “the Board’s obligation to read filings in a liberal manner does not require the Board . . . to search the record and address procedural arguments when the veteran fails to raise them before the Board.”); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). 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, 1131; 38 C.F.R. § 3.303. That an injury or disease occurred in service is not enough; there must be chronic disability resulting from that injury or disease. In order to prevail on the issue of service connection there must be competent evidence of a current disability; medical evidence, or in certain circumstances, lay evidence of in-service occurrence or aggravation of a disease or injury; and competent evidence of a nexus between an in-service injury or disease and the current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999); Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). In addition, where a veteran asserts entitlement to a chronic disease but there is insufficient evidence of a diagnosis in service, service connection may be established under 38 C.F.R. § 3.303(b) by demonstrating a continuity of symptomatology since service, but only if the chronic disease is listed under 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). When a chronic disease manifests to a degree of 10 percent or more within 1 year from the date of separation from service, that disease is presumptively service-connected. 38 C.F.R. §§ 3.303 (b), 3.307(a)(3). The Veteran's left knee degenerative arthritis is a chronic diseases as defined by 38 C.F.R. § 3.309(a). When a disease is first diagnosed after service, service connection is warranted for that condition if the competent evidence shows it was incurred in service. 38 C.F.R. § 3.303(d). 1. Entitlement to service connection for sarcoidosis The Veteran contends that exposure to chlorine and other chemicals during his active duty service as an environmental support specialist in the United States Air Force caused his current sarcoidosis. The Veteran does not contend, and the record does not establish that his sarcoidosis was incurred during his period of active service. VA treatment records, including a November 2019 disability benefits questionnaire (DBQ), confirm the Veteran’s current diagnosis of sarcoidosis, originally diagnosed in January 2013. The Veteran’s military personnel records establish his active duty service as an environment support specialist. In an October 2018 hearing, the Veteran testified that his private medical physician stated that the Veteran’s exposure to chlorine and other chemicals during active service may have caused the current sarcoidosis. The Board finds the Veteran’s testimony to be competent and credible. At issue in the present case is whether the Veteran’s current sarcoidosis was caused by his exposure to chlorine and other chemicals during his period of active duty service. In November 2019, the Veteran completed a VA infectious diseases examination. After completing the November 2019 examination, the examiner concluded that it was less likely than not that the Veteran’s current sarcoidosis was caused by his exposure to chlorine and other chemicals during his period of active service. The examiner noted that medical literature does not support the claim that exposure to chlorine causes sarcoidosis. The Board notes that the November 2019 examination included an in-person examination of the Veteran and review of the Veteran’s prior medical history. The examiner’s conclusion is well-reasoned and is highly probative evidence against the Veteran’s claim for service connection. Finally, in an October 2018 hearing before the undersigned, the Veteran testified that since his completion of active service he has been employed in occupations that exposed him to hazardous chemicals. The Board acknowledges the Veteran’s testimony that during this employment he was issued protective gear when exposed to hazardous chemicals. Although the Veteran believes that his sarcoidosis is due to his period of military service, he is not competent to provide such an opinion. Determining the etiology of the Veteran’s sarcoidosis requires medical inquiry into biological processes and pathology. Such internal physical processes are not readily observable and are not within the competence of the Veteran in this case, who has not been shown by the evidence of record to have medical training or skills. At the hearing, the Veteran also testified that his private physician informed him that his current sarcoidosis could have been caused by exposure to chlorine and other chemical during active service. Although the Veteran stated that his physician told him that that his sarcoidosis may have been caused by his exposures during service, the claims file is absent for a probative positive opinion from the medical professional who provided this statement. Even assuming that the Veteran is a reliable historian and accurately asserts that such an opinion was provided, because it is not of record, the Board cannot assess the probative value of such a medical opinion. Specifically, the Board is unable to determine the factual basis or rationale supporting the reported opinion. The Veteran’s report that his physician provided a favorable opinion carries little probative weight and is not sufficiently persuasive to outweigh the findings of the VA examiner, who reviewed the record, examined the Veteran, and provided a complete rationale for her findings. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). Based on the most probative medical evidence of record, which is the VA examination report, the Board finds that it is less likely than not that the Veteran’s sarcoidosis was incurred during or caused by his period of active service. Accordingly, entitlement to service connection is not warranted. The Board concludes that the preponderance of the evidence is against the claim for service connection for the Veteran’s sarcoidosis. The benefit of the doubt rule therefore does not apply, and service connection for this disability is not warranted. 2. Entitlement to service connection for bilateral knee disabilities, to include right knee status post medial meniscectomy The Veteran contends that a motor vehicle accident during his active service in the United State Air Force, and significant stress put on his knees during active service caused his current bilateral knee disabilities. VA treatment records establish the Veteran’s current bilateral knee pain and a right knee surgery. In an October 2018 hearing, the Veteran testified that a motor vehicle accident during his active service with the United States Air Force may have resulted in his current bilateral knee pain. He further testified that during his active service he engaged in lifting heavy equipment, climbing, bending, and jumping from vehicles that also may have resulted in his current bilateral knee pain. Finally, the Veteran testified that his knee pain began during his period of active service with the United States Air Force. The Board finds the Veteran’s testimony regarding a motor vehicle accident and complaints of knee pain to be credible and competent evidence of an in-service event or injury. At issue in the present case is whether the Veteran’s current bilateral knee disabilities were incurred during his period of active service. In November 2019, the Veteran completed a VA knee and lower leg conditions examination. At examination, the Veteran’s was diagnosed with degenerative arthritis of the left knee, originally diagnosed in with x-ray in November 2013, and right knee status post medial meniscectomy, originally diagnosed in January 2010. Following an in-person examination of the Veteran and review of the Veteran’s medical history, the examiner found it was less likely than not that the Veteran’s bilateral knee disabilities were incurred during or caused by his period of active service. The November 2019 examiner’s opinion did not provide an adequate rationale for the stated opinion and therefore the opinion carries little probative weight. In July 2020 an addendum medical opinion regarding the etiology of the Veteran’s bilateral knee disabilities was obtained and associated with the medical evidence of record. The July 2020 opinion reasoned that the Veteran’s service treatment records were silent for complaints of bilateral knee pain during active service or a diagnosis of bilateral knee disabilities. The examiner opined: Based on the above, it is less likely than not that [the Veteran’s] left knee disability (minimal DJD) began during active service, or is related to any incident of service. There is no mention of any left knee condition in service, nor within one year of separation. His "minimal" degree of DJD is age-appropriate and is most likely due to aging and intercurrent activities. Based on the above, it is less likely than not that [the Veteran’s] right knee disability (minimal DJD, medial meniscal tear) began during active service, or is related to any incident of service. There is no mention of any right knee condition in service, nor within one year of separation. His "minimal" degree of DJD is age appropriate and is most likely due to aging and intercurrent activities. Moreover, the 2009/2010 notes indicate a clear onset of right knee symptoms, likely the occurrence of the medial meniscal tear, 3 months prior to the 11/2009 orthopedic note, while jogging. Veteran was 44 years old at that time, and it is not uncommon for a meniscal tear tow occur during such activities past the age of 40. The examiner further noted that the Veteran had a normal physical examination in February 1987, denied knee pain or stiffness in a March 1987 supplemental medical history, and had a normal physical examination in April 1987. The Board finds that the examiner’s opinion is thorough and well-reasoned and is highly probative evidence against the Veteran’s claim for service connection. Accordingly, entitlement to service connection is for bilateral knee disabilities is not warranted. The Board acknowledges the Veteran’s contention that his current bilateral knee disabilities were not incurred during or caused by his period of active service. Lay persons are competent to provide opinions on some medical issues. See Jandreau v. Nicholson, 492 F.3d 1372, 1376 -77 (Fed. Cir. 2007); see also Kahana v. Shinseki, 24 Vet. App. 428 (2011). However, determining the etiology of the Veteran’s current bilateral knee disabilities requires medical inquiry into the Veteran’s anatomical and physiological functioning. With regard to the specific issue in this case, whether his bilateral knee disabilities were caused by his period of active service, falls outside the realm of knowledge of the Veteran in this case. See Jandreau, 492 F.3d at 1377 n.4. Such internal processes are not readily observable and are not within the competence of the Veteran in this case, who has not been shown by the evidence of record to have medical training or skills. As a result, the probative value of his lay assertions is low. The July 2020 medical opinion is of significantly more probative value. Finally, the probative evidence of record does not establish that the Veteran’s bilateral knee disabilities were diagnosed within a year of his completion of service. As noted above, the Veteran’s right knee disability was not diagnosed until January 2010 and left knee disability was not diagnosed until November 2013. Additionally, the probative medical evidence does not establish a continuity of symptomatology for his current bilateral knee disabilities. Accordingly, the provisions of presumptive service connection do not apply. See 38 C.F.R. § 3.303(b), (c). The Board concludes that the preponderance of the evidence is against the claim for service connection for the Veteran’s bilateral knee disabilities. The benefit of the doubt rule therefore does not apply, and service connection for these disabilities is not warranted. D. Martz Ames Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board B. Riordan, 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.