Citation Nr: 21010376 Decision Date: 02/24/21 Archive Date: 02/24/21 DOCKET NO. 19-22 362A DATE: February 24, 2021 ORDER Entitlement to service connection for a left knee condition is denied. Entitlement to service connection for posttraumatic stress disorder (PTSD) is denied. REMANDED Entitlement to service connection for an acquired psychiatric disorder other than PTSD, to include an adjustment disorder, is remanded. FINDINGS OF FACT 1. The preponderance of the competent medical evidence weighs against a determination that the Veteran incurred a left knee injury while in combat that has led to his development of left knee osteoarthritis, first diagnosed many years after service. 2. The competent evidence does not demonstrate that the Veteran currently has diagnosable PTSD, nor has he experienced such a condition during the pendency of the appeal or recent to the filing of the claim.  CONCLUSIONS OF LAW 1. The criteria for service connection for a left knee condition have not been met. 38 U.S.C. §§ 1110, 1131, 1112, 1116, 1137; 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309. 2. Service connection for PTSD is not warranted. 38 U.S.C. §§ 1110, 1112, 1113, 5107; 38 C.F.R. § 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from May 1967 to May 1969, with verified service in the Republic of Vietnam during the Vietnam Era. This matter was last before the Board in October 2020, whereupon it was remanded to the Agency of Original Jurisdiction (AOJ) for further development of the record. Following the issuance of a December 2020 supplemental statement of the case continuing the denial of the claims at issue, the case was returned to the Board for its adjudication. The Board notes that the Veteran testified at an August 2020 videoconference hearing before the undersigned Veterans Law Judge. The Board further notes that it previously remanded to the AOJ the issue of entitlement to service connection for an acquired psychiatric disorder, to include PTSD. In the resulting November 2020 VA examination detailed below, the VA examined declined to diagnose PTSD, and instead set forth a diagnosis of adjustment disorder with features of anxiety. In view of these facts, and to provide broader consideration on appeal, the Board has bifurcated the prior claim of entitlement to service connection for PTSD from the claim of service connection for an acquired psychiatric disorder other than PTSD. These claims are addressed separately below. Service Connection Entitlement to service connection requires evidence of three elements: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship or nexus between the current disability and the disease or injury incurred or aggravated during active service.  Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004).  If the Veteran engaged in combat with the enemy, and it is claimed that a disease or injury was incurred in such combat, VA shall accept as sufficient proof of service connection satisfactory lay or other evidence of service incurrence, if the lay or other evidence is consistent with the circumstances, conditions, or hardships of such service. 38 U.S.C. § 1154(b); 38 C.F.R. § 3.304(d). Even where the combat presumption applies, however, a veteran must still show that a causal relationship exists between the present disability and the in-service injury or disease. Reeves v. Shinseki, 682 F.3d 988, 999 (Fed. Cir. 2012). Every reasonable doubt must be resolved in the Veteran’s favor, and service connection of injuries or diseases linked to combat may be rebutted only by clear and convincing evidence. 38 U.S.C. § 1154(b). 1. Left Knee Condition The Veteran contends that he has a diagnosable left knee condition that he incurred while in combat in the Republic of Vietnam. In the alternative, he asserts generally that his left knee condition was incurred in service or is otherwise attributable to service. At the outset, the Board accepts that the Veteran did engage in combat while in service as evidenced by his receipt of the Combat Infantryman Badge, which is shown on his certificate of discharge on DD Form 214. Therefore, the first question for the Board is whether the Veteran’s contentions regarding his incurring a left knee injury while in combat during service is consistent with the circumstances of his service, and furthermore whether there is a causal relationship between the purported in-combat left knee injury and his current left knee condition. If the criteria for application of the combat presumption are not met, the question remaining for the Board is whether the Veteran has a left knee condition that began during service or is at least as likely as not related to an in-service injury, event, or disease. With regard to the question of whether the combat presumption applies, the Board notes that during the August 2020 hearing the Veteran detailed that he injured his knee when he jumped out of a helicopter during a combat mission. According to the Veteran, he was not able to seek medical attention for the injury while in service; however, he asserted that he began to experience left knee symptomatology intermittently in service that continued to the present day. This notwithstanding, the evidence must fulfill the above-detailed criteria before the Board can grant service connection of this basis. 38 U.S.C. § 1154(b); 38 C.F.R. § 3.304(d). In reviewing the Veteran’s service treatment records, the Board highlights that there is no record of the Veteran having experienced a left knee injury in service or having sought treatment for left knee symptomatology in service. No lower extremity abnormality was noted on his April 1969 separation examination, and the Veteran also did not report any history of left knee symptomatology on the corresponding April 1969 Report of Medical History. Pursuant to the Board’s October 2020 remand instructions, the Veteran was scheduled for a VA knee examination in December 2020, during which he reported his history of left knee injury in service. He also related that he had been experiencing a “trick knee” ever since service and that he was told he had arthritis in his left knee when he sought treatment from an orthopedist two years prior. After an in-person examination and a review of the claims file, the examiner endorsed a diagnosis of left knee osteoarthritis, and opined that the condition was less likely than not incurred in or otherwise attributable to service. In support thereof, the examiner noted the lack of documentation of in-service left knee symptomatology as well as the Veteran’s dismissal of any history of left knee symptomatology at the time of his discharge and the lack of medical evidence showing treatment for the left knee for several years after service. In addition, the examiner noted that the Veteran’s osteoarthritis was a condition caused by chronic wear and tear and aging as opposed to being the result of an injury. As the examiner thoroughly reviewed the claims file and relied on medical expertise in setting forth his opinion, the Board finds that opinion to be highly probative. Sklar v. Brown, 5 Vet. App. 140 (1993). A review of available post-service medical records does not reflect any documented treatment for left knee symptomatology. Although the Veteran has asserted that he was diagnosed with probable arthritis by a private orthopedist, there is no copy of any such treatment record in the file. The Board accepts the Veteran’s reports of a left knee injury in service, notably in view of his participation in combat with the enemy. That said, the Board finds that the competent evidence of record does not support a causal link between his current disability and a disease or injury incurred in service. As detailed, he expressly denied any history of left knee symptomatology at the time of his discharge from service, and there is no documentation of the Veteran experiencing any left knee symptomatology or seeking treatment for the same until the statements during the August 2020 hearing. Indeed, left knee osteoarthritis was only diagnosed during the December 2020 VA examination. The Board concludes that, while the Veteran has left knee osteoarthritis, which is a chronic disease under the appropriate regulations, it did not manifest to a compensable degree in service or within a presumptive period, and continuity of symptomatology is not established.  38 U.S.C. §§ 1101(3), 1112, 1113, 1137; 38 C.F.R. §§ 3.303(b), 3.307, 3.309(a). Specifically, the Board notes the lack of in-service treatment as well as the lack of any documented treatment for or diagnosis of a left knee condition until the Veteran reported such during the August 2020 hearing, over 50 years after his discharge from service. As a chronic left knee condition did not manifest within the applicable one-year presumptive period, service connection on a presumptive basis as a chronic disease is denied.  38 C.F.R. § 3.307(a)(3). The Veteran may still be entitled to service connection for a left knee condition if all of the evidence establishes that the condition is otherwise attributable to an in-service occurrence. 38 C.F.R. § 3.303(d). As stated above, however, the Veteran has presented no objective medical evidence to support a determination that the left knee condition is attributable to service, and the probative October 2020 examiner’s opinion refutes this assertion. The Board further notes that there is no evidence in the record showing that the Veteran has the medical training, credentials, or other expertise to competently conclude that his left knee condition is attributable to physical activity in service. Jandreau v. Nicholson, 491 F.3d 1372 (Fed. Cir. 2007). Moreover, as discussed, there is no documentation of treatment for or a diagnosis of a left knee condition for over 50 years after the Veteran’s discharge from service, which further weighs against a determination that the left knee condition is otherwise attributable to service. Buchanan v. Nicholson, 451 F.3d 1331, 1335 (Fed. Cir. 2006). Ultimately, the Board finds that the August 2020 VA examiner’s opinion substantially outweighs the lay evidence of record. The competent medical evidence weighs against a determination that the Veteran incurred a left knee injury while in combat that has led to his development of left knee osteoarthritis, first diagnosed many years after service. Therefore, the preponderance of the evidence is against the claim for service connection for a left knee condition. Consequently, the benefit of the doubt rule does not apply, and the claim is denied.  38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). 2. PTSD The Veteran contends that he has diagnosable PTSD which is presumptively attributable to his exposure to combat while serving in the Republic of Vietnam during the Vietnam War era. Without delving into the question of the potential etiology of this condition, the Board finds that the preponderance of the evidence is against a determination that the Veteran has diagnosable PTSD; as such, entitlement to service connection must be denied.  The Veteran was first afforded a VA examination to evaluate the nature of his claimed PTSD in August 2016, during which he reported being in a good relationship with his wife of over 30 years. After administering a PTSD screening test and review the claims file, the VA examiner declined to endorse a diagnosis of PTSD or any other diagnosable psychiatric disorder. The Veteran submitted copies of treatment notes from his therapy sessions through VA in July 2020. These treatment notes show that PTSD was listed as an active problem as early as November 2019 and continued to be listed as an active problem through April 2020. That being said, a review of available VA medical records does not show any actual diagnosis of or treatment for PTSD. During the August 2020 hearing, the Veteran asserted generally that he had PTSD and that he was being treated for the condition through his medical treatment providers. Pursuant to the Board’s October 2020 remand instructions, the Veteran was scheduled for a November 2020 VA PTSD examination, during which he reported experiencing symptomatology that he attributed to traumatic occurrences in service, to include avoidant behavior, flashbacks, nightmares, and acting overly cautious. After administering a PTSD screening test and reviewing the claims file, the VA examiner declined to endorse a diagnosis of PTSD, finding that the Veteran’s symptomatology was not significantly disruptive and did not last for more than one month at a time. Instead, the examiner set forth a diagnosis of adjustment disorder with features of anxiety, and detailed that the only symptom was difficulty in establishing and maintaining effective work and social relationships. After reviewing the record, the Board finds that the preponderance of the evidence is against a determination that the Veteran has diagnosable PTSD for VA compensation purposes. While the Board acknowledges that the Veteran has asserted that he is receiving treatment for diagnosed PTSD, and submitted therapy records showing that PTSD was listed as an active problem since November 2019, this diagnosis is not substantiated by medical evidence which shows that it was made in conformity with DSM-IV or DSM-V criteria as is necessary under the relevant guidelines. Indeed, all of the psychiatrists and medical professionals of record who have evaluated the Veteran have declined a diagnosis of PTSD, to specifically include the two VA examiners of record. The Board finds both of these examinations to be highly probative of the question of whether the Veteran has diagnosable PTSD as both examiners thoroughly reviewed the claims file and reported the results of diagnostic testing. Sklar v. Brown, 5 Vet. App. 140 (1993). Accordingly, without supporting records of sufficient objective and probative value, the Board concludes that the Veteran does not have diagnosable PTSD and has not had such a condition during the appeal period.  The Veteran himself does not have the medical training or credentials to offer an opinion as to a diagnosis or its etiology.  Jandreau, supra.  Service connection is denied. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992).  As the preponderance of the evidence is against the Veteran’s claim, the benefit-of-the-doubt standard of proof does not apply. 38 U.S.C. § 5107(b).  REASONS FOR REMAND Entitlement to service connection for an acquired psychiatric disorder other than PTSD is remanded. The Board in its October 2020 remand instructed the AOJ to secure an examination to evaluate the nature and likely etiology of any diagnosable acquired psychiatric disorder. In a November 2020 VA examination, a VA physician declined a diagnosis of PTSD and alternatively diagnosed an adjustment disorder with features of anxiety, finding that this condition accounted for all of the Veteran’s mental health symptomatology. However, rather than set forth a clear opinion as to the likely etiology of the diagnosed adjustment disorder, the examiner appeared to reiterate the Board’s remand instructions repeatedly. It is wholly undiscernible whether the examiner found it at least as likely or less likely than not that the adjustment disorder was incurred in or otherwise attributable to service. As such, remand is necessary in order to secure an addendum opinion as to the likely etiology of the diagnosed adjustment disorder. Stegall v. West, 11 Vet. App. 268 (1998). The matters are REMANDED for the following action: Provide the claims file to the individual who administered the November 2020 VA PTSD examination, or to another qualified medical professional if that individual is not available, for the purpose of eliciting an addendum opinion as to the likely etiology of the diagnosed adjustment disorder with anxiety features. The entire claims file, to include a copy of this REMAND, must be provided to the examiner and reviewed in full. The examiner is asked to opine as to whether it is at least as likely as not (a 50 percent probability or higher) that any diagnosed psychiatric disorder other than PTSD had its onset during service or is otherwise related to service. The examiner must provide any and all opinions as to etiology in the form of a probability and must provide a complete rationale for any opinion expressed. A. C. MACKENZIE Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Christopher M. Collins, 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.