Citation Nr: 21010296 Decision Date: 02/24/21 Archive Date: 02/24/21 DOCKET NO. 14-23 856 DATE: February 24, 2021 ORDER Entitlement to service connection for status post total left knee replacement is denied. FINDING OF FACT A left knee disability, including status post total left knee replacement, was not present during active duty, did not manifest to a compensable degree within one year of separation from active duty, continuity of symptomatology is not established, and the Veteran’s current status post total left knee replacement disability is not otherwise causally related to active service. CONCLUSION OF LAW The criteria for service connection for status post total left knee replacement are not met. 38 U.S.C. §§ 1110, 1112, 1113, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty in the U.S. Navy from February 1969 to December 1970. This matter comes to the Board of Veterans’ Appeals (Board) on appeal from an October 2013 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO), which denied service connection for a left knee condition, including status post total replacement. The Veteran filed a timely notice of disagreement received by VA in January 2014. In May 2014, the RO issued a statement of the case. The Veteran’s substantive appeal was received by VA in June 2014. In March 2018, July 2019, and August 2020, the Board remanded the matter for further development. Entitlement to service connection for status post total left knee replacement. The Veteran contends that he frequently climbed up and down and banged his knees while using ladders on board a Navy vessel during his active service and that the frequent use and injury caused his current status post total left knee replacement disability. See, e.g., January 2014 Notice of Disagreement. Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166–67 (Fed. Cir. 2004). Certain specifically enumerated chronic diseases, including arthritis, will be presumed related to service, absent an intercurrent cause, if they were shown as chronic in service; or, if they manifested to a compensable degree within a presumptive period following separation from service (a year following separation for arthritis); or, if they were noted in service (or within an applicable presumptive period) with continuity of symptomatology since service that is attributable to the chronic disease. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.303, 3.307, 3.309; Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2013). In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence that it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. Gabrielson v. Brown, 7 Vet. App. 36, 39–40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). “When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter,” the benefit of the doubt shall be given to the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. The question is whether the evidence supports the claim or is in relative equipoise, with the claimant prevailing in either event, or whether a fair preponderance of the evidence is against the claim, in which event the claim must be denied. Gilbert, 1 Vet. App. at 54. At the Veteran’s January 1969 enlistment examination, his musculoskeletal system and lower extremities were examined and determined to be normal. The Veteran also completed a report of medical history in connection with the examination on which he denied having or ever having had swollen or painful joints and a trick or locked knee. The Veteran’s in-service treatment records are silent for complaints or findings of a left knee symptoms or disability, including degenerative joint disease (DJD). At the Veteran’s October 1970 separation examination, his lower extremities and musculoskeletal system were examined and again determined to be normal. In pertinent part, the post-service record on appeal reflects that the Veteran worked as a machinist in a factory from 1984 to 2000 spending eight hours per day walking, standing, climbing, kneeling, crouching, crawling, and handling large objects, and additional duties involving frequent lifting of 50 pounds or more. See, e.g., Social Security Administration Records. Post-service VA treatment records show, in pertinent part, that in May 2007, the Veteran had an initial visit to a VA clinic. At that time, he reported a history of a left knee arthroscopy in 2000. See May 2007 VA Primary Care Initial Visit Note. Subsequent VA clinical records show continued complaints of knee pain. Imaging studies in December 2007 showed tricompartmental DJD with joint space narrowing, marginal osteophytes, and eburnation. There was bilateral suprapatellar effusion. In July 2009, the Veteran was admitted for a total left knee replacement procedure. In August 2013 VA received the Veteran’s claim of entitlement to service connection for total left knee replacement. In a statement accompanying the claim, the Veteran’s representative indicated that the Veteran’s only treatment for his knee condition was through VA and he did not have any private medical treatment. In August 2013, VA also received lay statements from several family members of the Veteran. Taken together, these statements indicated that when the Veteran returned from active service, his walking was slower than normal and he complained about pain in both knees—particularly his left knee—when walking, sitting for a prolonged period, or standing up. In January 2014 the Veteran submitted to VA excerpts from a medical journal article entitled Knee Kinematics and Kinetics during Descent of a Navy Ship Ladder. The article described a study noting the presence of higher knee moments on naval ship ladders compared to traditional stairs and concluded, “if traditional stairs have the potential to cause knee disorders” (a point for which another study was cited), “sailors who spend time on hard deck surfaces and Navy ship ladders also have the potential to be at greater risk for similar knee disorders.” In August 2018 the Veteran was afforded a VA examination in connection with his claim. The VA examiner diagnosed the Veteran as having a status post left knee arthroplasty. The Veteran reported that he had sustained multiple injuries to the left knee while climbing ladders and steps during his active service. The Veteran stated that his left knee symptoms had persisted since that time. The examiner opined that the Veteran’s current left knee disability was less likely than not incurred in or caused by the claimed in-service injury, event, or illness because the Veteran’s claims file was negative for any treatment or diagnosis of a left knee condition or injury during service or during the year following service. Pursuant to the Board’s remand instructions, in February 2020 the Veteran was afforded another VA examination. The Veteran told the examiner that he had performed manual labor after his active service. The examiner opined that the Veteran’s status post total left knee replacement was less likely than not incurred in or caused by an in-service injury, event, or illness. The examiner noted that service treatment records were silent for knee problems, as was the examination at the Veteran’s separation from active service. The post-service VA treatment records showed that in December 2008 the Veteran complained of knee pain only for several years and did not report a history of injury. The examiner reasoned that there was no indication that climbing ladders contributes to knee degeneration. The examiner further opined that the Veteran’s post-service manual labor may have been a contributing factor to the Veteran’s status post total left knee replacement. In October 2020 VA obtained an addendum medical opinion in this matter. The VA clinician opined that the Veteran’s status post total left knee replacement disability was less likely than not incurred in or caused by an in-service injury, event, or illness. The clinician indicated that she had reviewed the Veteran’s enlistment examination, service treatment records, separation examination, post-service treatment records, SSA records, the lay statements of record, and the medical article submitted by the Veteran. The clinician explained that the Veteran’s left knee disability did not manifest in service or proximate to service, and that x-rays from 2008 showed bilateral DJD of the type that develops slowly over time—not from climbing, carrying weight, or banging knees. The clinician also stated that because the medical study submitted by the Veteran did not include a control group, did not document any crepitus or patellofemoral syndrome actually developing, did not include significant p values or variables accounted for as contributing to the study, or any statistical analysis, the article carried no weight. Based on these factors and the onset of the Veteran’s knee condition long after service, the clinician concluded that it was more likely than not that the Veteran’s knee condition was related to the post-service occupation carrying weight and performing manual labor for 15 years, rather than the less than two years in service. Viewing the evidence of record in light of the applicable legal criteria set for above, the Board finds that the preponderance of the evidence is against awarding service connection for a status post total left knee replacement disability. As a preliminary matter, the Board finds that the most probative evidence reflects that left knee DJD was not present during active service nor was it manifest to a compensable degree within one year of separation. As set forth above, the Veteran’s service treatment records contain no notation of left knee arthritis or other pathology; moreover, at his October 1970 separation examination, the Veteran’s lower extremities and musculoskeletal system were examined and affirmatively found to be normal. The Board also notes that in the October 2020 VA opinion discussed above, the examiner explained that X-ray studies from 2008, performed 38 years after the Veteran’s separation from service, reflected pathology which was of the type which developed slowly over time. Coupled with the normal findings at separation, the Board finds that this VA medical opinion lends further support to the conclusion that left knee arthritis was not present during active duty or within the first post-service year. In reaching this determination, the Board has considered lay statements submitted by the Veteran and his family members to the effect that the Veteran had knee pain beginning in service and continuing thereafter. As laypersons, however, the Veteran and his family members are not competent to attribute the Veteran’s reported knee pain to DJD because that would involve medical inquiry into biological processes, anatomical relationships, and physiological functioning. 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 had medical training or skills. See Jandreau v. Nicholson, 492 F.3d 1372, 1376–77 (Fed. Cir. 2007). Thus, even though the Veteran states that he experienced knee pain during service and in the year after service, this does not demonstrate the presence of DJD at that time, particularly given the normal findings at separation and the nature of the pathology demonstrated on 2008 imaging studies. For these reasons, the preponderance of the evidence is against finding that the Veteran’s left knee DJD, which led to his current status post total left knee replacement, had its inception during active duty, was manifest to a compensable degree within one year of separation, or was present on a continuous basis since service. The Board also finds that the preponderance of the evidence shows that the Veteran’s current status post total left knee replacement disability is not otherwise causally related to an in-service disease or injury. As set forth above, the Veteran has competently stated that during his active service, his duties required that he frequently ascend and descent ship ladders and that on multiple occasions he banged his knee on those ladders. Despite these reported injuries, however, the Board finds that the most probative evidence reflects that the current left knee disability is not the result of those reported injuries and activities. In this regard, the Board considers the October 2020 VA medical opinion highly probative. As detailed above, the VA examiner based her opinion on a review of the record on appeal as well as the Veteran’s reported history and provided a detailed rationale for her conclusion, explaining that given the type of pathology shown on December 2008 VA imaging studies, as well as the Veteran’s service treatment records and his post service occupational history, it was less likely than not that the Veteran’s current left knee disability had been caused by the reported in-service injuries and activities. The Board has also considered the journal article submitted by the Veteran, but finds that—both for the reasons given by the October 2020 VA clinician and because the study lacks sufficient information to provide any probability of a nexus under the particular facts of this case—the study is entitled to less probative weight. Similarly, the Board has considered the Veteran’s contentions to the effect that frequent use of naval ladders and injuries on those ladder caused his current status post total left knee replacement disability. As explained, however, the Veteran is not competent to provide an opinion on the etiology of the current disability because it would involve medical inquiry into biological processes, anatomical relationships, and physiological functioning. Such internal physical processes are not readily observable and are not within the competence of the Veteran. See Jandreau, 492 F.3d at 1376–77. Questions of competency notwithstanding, the Board assigns more probative weight to the findings of the VA clinician given the clinical expertise and the rationale supporting that opinion. For the foregoing reasons and bases, the Board concludes that the preponderance of the evidence is against the claim of service connection for status post total left knee replacement. Under these circumstances, the benefit-of-the-doubt rule does not apply. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). K. Conner Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board C. Hillan Sosa, 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.