Citation Nr: 21011126 Decision Date: 03/01/21 Archive Date: 03/01/21 DOCKET NO. 16-50 840 DATE: March 1, 2021 ORDER Entitlement to service connection for a left knee disability is denied. Entitlement to service connection for a right knee disability is denied. Entitlement to a 10 percent rating based on multiple, noncompensable service-connected disabilities is denied. FINDINGS OF FACT 1. The Veteran did not exhibit a left knee disability in service; arthritis of the left knee did not manifest to a compensable degree within one year after discharge from service; and a left knee disability is not otherwise shown to be associated with service.  2. The Veteran did not exhibit a right knee disability in service; arthritis of the right knee did not manifest to a compensable degree within one year after discharge from service; and a right knee disability is not otherwise shown to be associated with service.  3. The Veteran’s left varicocele and residuals of urethral meatal stenosis are not of such character as clearly to interfere with normal employability. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for a left knee disability have not been met. 38 U.S.C. §§ 1110, 1112, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309(a).  2. The criteria for entitlement to service connection for a right knee disability have not been met. 38 U.S.C. §§ 1110, 1112, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309(a).  3. The criteria for entitlement to a 10 percent rating based on multiple, noncompensable service-connected disabilities have not been met. 38 C.F.R. §§ 3.324. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from February 1972 to February 1974. This matter comes before the Board on appeal from February 2013 and September 2015 Regional Office (RO) rating decisions. In May 2019, the Veteran testified at a hearing before the undersigned Veterans Law Judge. Service Connection 1. Entitlement to service connection for a left knee disability is denied. 2. Entitlement to service connection for a right knee disability is denied. Service connection is warranted where the evidence of record establishes that an injury or disease resulting in disability was incurred in the line of duty in the active military service or, if pre-existing such service, was aggravated thereby. 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, or nexus, between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may also be granted for listed chronic diseases, such as arthritis, if such were shown as chronic in service; manifested to a compensable degree within a presumptive period (usually one year) after separation from service; or were noted in service with continuity of symptomatology since service. 38 U.S.C. §§ 1112, 1113; Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013); 38 C.F.R. §§ 3.303(b), 3.307, 3.309(a). The Veteran has claimed entitlement to service connection for disabilities of the left and right knees. He testified at his May 2019 Board hearing that his knees have bothered him since service. Specifically, he noted that he “was a machine gunner” and “carried my machine gun full pack. We did forced marches and we just walked and walked and walked. I have walked until my legs were just … gone.” (See Board hearing transcript, page 7.) He noted that he “had no feeling in my knees at all and then when I got out of service.” (See Board hearing transcript, page 8.) He noted that his knees never bothered him until after he came out of service, but that “all that walking we did and force[d] marches” resulted in disability to both knees. (See Board hearing transcript, page 8.) The Veteran’s DD Form 214 reflects that his military occupational specialty (MOS) was machine gunner. The Veteran’s service treatment records reflect that his lower extremities were clinically normal when examined at the time of his January 1972 entrance examination and his January 1974 release from active duty examination. He expressly denied any history of, or current, trick or locked knee on his January 1972 entrance medical history report. Otherwise, the Veteran’s service treatment records reflect that he neither complained of nor sought treatment for symptoms that have been associated with a knee disability. The Veteran underwent a VA examination in December 2019. Based on review of the record and interview and examination of the Veteran, the examiner diagnosed left and right knee degenerative arthritis, left and right knee chondromalacia, and left knee effusion. It was noted that these disabilities were diagnosed in 2014. The examiner noted that the Veteran reported that his knee condition began in 1972. He reported that he was a machine gunner and had to carry guns and heavy equipment and walked over 20 miles and that this is when his knee pain began. He reported that he sought medical attention during service and was given pain pills, which helped for a while. He did not recall having imaging or other treatments for his knees during service. He reported that his symptoms continued, and he sought medical treatment after service in the 1970s. He reported that he was given pain pills but was unable to recall any specific diagnosis or treatment. He reported that his knee symptoms worsened over the years and that he sought medical attention two or three years ago. He reported that he was given muscle relaxants and a knee brace which helped a little. He reported that surgery has been recommended but that he is not interested in surgery. He has tried physical therapy which helped his mobility but not his pain. He reported having “daily sharp pain in both knees, right and left knee-gives out while standing, occasional swelling, worse with activity.” The examiner opined that the Veteran’s left and right knee disabilities were less likely than not incurred in or caused by the claimed in-service injury, event, or illness. In her rationale, the examiner noted the Veteran’s dates of service and personal statements regarding in-service experiences and symptoms. She noted that the Veteran had “noted that his knees never bothered him until after he came out of service.” She noted that “There is no evidence of a diagnosis or chronicity of care … during or following his active duty service.” She concluded that it is unlikely that the Veteran’s current left and right knee disabilities, which were diagnosed in March 2014 (40 years after service), had their onset in service or are otherwise related to service. Therefore, a nexus has not been established. The Board remanded this claim to obtain an opinion that corrects two deficiencies in the December 2019 opinion. First, the Board noted that its remand had requested that the examiner’s opinion “specifically include a discussion of whether any current left or right knee disability is consistent with the mechanism of injury that was described by the Veteran at his May 2019 Board hearing.” The Board observed that, while the December 2019 opinion includes the Veteran’s description of the in-service activities that he believes led to his current knee disabilities, the examiner’s opinion did not actually “include a discussion of whether any current left or right knee disability is consistent with the mechanism of injury that was described by the Veteran at his May 2019 Board hearing.” Therefore, a remand for an addendum opinion was necessary. Second, the Board noted that the December 2019 VA examiner estimated knee disability diagnoses dates of 2014. However, the VA medical records contain a May 2003 primary care nursing note that specifically lists complaints of knee pain. The examiner was directed to discuss whether this earlier notation of knee pain affects her opinion. A new VA examiner reviewed the record and provided opinions and rationales in October 2020. The examiner opined that the claimed left and right knee disabilities were less likely than not incurred in or caused by service. The examiner noted that, “While the veteran notes serving as a machine gunner and walking 20 miles at a time, this may cause acute knee complaints.” The examiner noted that the separation examination noted normal lower extremities. With respect to the left knee, the examiner noted that “The veteran was noted to have knee pain in 2003 with additional diagnosis rendered in 2014.” With respect to the right knee, the examiner noted that “The veteran was noted to have knee pain in 2003 without laterality specified. Additional diagnosis rendered in 2014 of chondrocalcinosis and [degenerative joint disease].” The examiner opined that “The veteran’s left knee conditions are less likely as not due to [active duty] service and were not diagnosed within one year of separation from service. A nexus is not established.” The examiner opined that “The veteran’s right knee conditions are less likely as not due to [active duty] service to include marches and gunner status and were not diagnosed within one year of separation from service. A nexus is not established.” The Board finds this opinion to be highly probative, as it was authored by an individual who possesses the necessary education, training, or experience to provide competent medical evidence under 38 C.F.R. § 3.159 (a)(1). See Cox v. Nicholson, 20 Vet. App. 563 (2007). It is based on review of the record, including the findings of the December 2019 VA examiner. It contains a rationale that cites to the facts of the case. It also responds to the concerns raised in the August 2020 Board remand, specifically acknowledging the 2003 report of knee pain and noting that the in-service activities that were described by the Veteran would produce acute knee complaints and therefore not a chronic disability that has persisted ever since service. The only remaining contrary opinion comes from the Veteran himself. The Board recognizes that there are instances in which a layperson may be competent to offer testimony on medical matters, such as describing symptoms observable to the naked eye or even diagnosing simple conditions. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). The Board finds, however, that the question posed by this claim, whether the Veteran’s current left and right knee disabilities are related to in-service activities that had occurred decades earlier, is of such complexity as to require that individuals who provide competent medical evidence on this matter possess a level of expertise that a layperson simply does not possess. In addition, as noted by the October 2020 VA examiner, arthritis did not manifest in either knee in service or within one year of his separation from service. There is no persuasive medical evidence or persuasive credible lay evidence that the Veteran's claimed disorder manifested to a compensable degree within a year of his separation from service or had its onset in service and continued ever since service. The Veteran's lay belief that symptoms he has experienced over the years are manifestations of a chronic continuous disease process that had its onset in service rather than separate and distinct responses to post-service events is unfounded according to the medical expert. Therefore, service connection based on presumptive service connection for a chronic disease or based on a theory of continuity of symptomatology is not warranted. In short, the Board finds that entitlement to service connection for disabilities of the left and right knees on a direct basis or on a presumptive basis based on chronic disability is not warranted. The Board has considered the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claims, the claims are not in equipoise. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). Accordingly, the claims must be denied. 3. Entitlement to a 10 percent rating based on multiple, noncompensable service-connected disabilities is denied. Whenever a Veteran is suffering from two or more separate permanent service-connected disabilities of such character as clearly to interfere with normal employability, even though none of the disabilities may be of compensable degree under the 1945 Schedule for Rating Disabilities, the rating agency is authorized to apply a 10-percent rating, but not in combination with any other rating. 38 C.F.R. § 3.324. In the case at hand, the Veteran is in receipt of 0 percent (noncompensable ratings) for (1) left varicocele, and (2) residuals of urethral meatal stenosis. Service connection is not in effect for any other disability. The Veteran underwent a VA male reproductive system conditions examination in April 2015. The examiner opined that the Veteran’s meatal stenosis and left varicocele do not impact his ability to work. The Veteran provided testimony with respect to this claim at his Board hearing. He noted that he had to be taken off of driving his 18-wheeler cross country because “I started falling asleep behind the wheel.” (See Board hearing transcript, page 26.) He also testified that he had to stop driving a school bus because “you can’t be falling asleep and you got them kids on the bus.” (See Board hearing transcript, page 26.) He then stated “And then my kidneys hit me. My kidneys got so bad I had to stop on the side of the road and start urinating.” (See Board hearing transcript, page 26.) He also noted that “the headache hit me and I got pulled over. So, that caused me to stop driving school buses.” (See Board hearing transcript, page 27.) Finally, he stated that “And then on security, I can’t be security and walking around when my knees [are] messing me up and I’m falling asleep, so the answer to that is yes. I can’t do security falling asleep and walking.” (See Board hearing transcript, page 27.) Based on the above, the Board finds that entitlement to a 10 percent rating based on multiple, noncompensable service-connected disabilities is not warranted. As noted above, the April 2015 VA examiner expressly found that the Veteran’s service-connected disabilities do not impact his ability to work. In addition, the Veteran expressly testified at his Board hearing that his ability to work is impacted solely by nonservice-connected disabilities. There is no contradictory information of record. The Board has considered the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, the claim is not in equipoise. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). Accordingly, the claim must be denied. TANYA SMITH Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Elizabeth Jalley, 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.