Citation Nr: 21015205 Decision Date: 03/16/21 Archive Date: 03/16/21 DOCKET NO. 15-35 274 DATE: March 16, 2021 ORDER Entitlement to service connection for right knee disability, variously diagnosed as right knee strain, right knee meniscal tear, right knee chondromalacia of the medial femoral condyle and patellofemoral joint, right knee loose body, and right knee synovitis, is granted. FINDING OF FACT The Veteran’s current right knee disability, as likely as not, had its onset during active service, with disability continuing since separation. CONCLUSION OF LAW The criteria for entitlement to service connection for a right knee disability have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty in the United States Air Force from October 1997 to December 2004 and from September 2006 to December 2006. Additionally, the Veteran had several periods of active duty for training (ACDUTRA) during inactive service with the Air Force National Guard and Air Force Reserve. This appeal comes before the Board of Veterans’ Appeals (Board) from a May 2013 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO) which, in pertinent part, denied service connection for a right knee condition. The Veteran’s notice of disagreement (NOD) was received in May 2014. The RO issued the statement of the case (SOC) in July 2015, and the Veteran’s VA Form 9, substantive appeal was received in September 2015. In April 2019 the Board remanded the case to the RO for further development and adjudicative action. In March 2020 the Board remanded the case to the RO for further development and adjudicative action. In December 2018, the Veteran testified at a videoconference Board hearing before a Veterans Law Judge who is no longer employed by the Board. The Veteran was offered a replacement hearing before another Veterans Law Judge in February 2020. The Veteran was advised that if a response was not received within 30 days, it would be assumed that he did not want another hearing and that the Board would proceed accordingly. No response has been received. As such, the appeal has been reassigned to the undersigned Veterans Law Judge and has been returned to the Board for further consideration. Service Connection Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active 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”- the so-called “nexus” requirement.” Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2010) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection for certain chronic diseases may also be established based upon a legal “presumption” by showing that the disease manifested itself to a degree of 10 percent or more within one year from the date of separation from service. 38 U.S.C. §§ 1112, 1137; 38 C.F.R. §§ 3.307, 3.309. In addition, service connection may be granted for any disease diagnosed after service when all the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection for a right knee disability, variously diagnosed as right knee strain, right knee meniscal tear, right knee chondromalacia of the medial femoral condyle and patellofemoral joint, right knee loose body, and right knee synovitis. The Veteran contends that his right knee disability is related to service. The Board concludes that the Veteran has a current disability that began during active service. 38 U.S.C. §§ 1110, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a). Service treatment records (STRs) reflect that the Veteran was seen in November 2002 for right knee complaints. He reported that he fell on his knee a year before and had pain that had progressively worsened since the initial injury. The Veteran’s knee was noted as tender to touch. In December 2002, the Veteran was provisionally diagnosed with prepatellar bursitis in the left knee. The Veteran’s knee pain was noted as being located over the kneecap and he had crepitus with extension of the right knee. No further knee problems were noted during active service. Post-service, a March 2013 private orthopedic treatment note indicates that the Veteran presented complaining of left knee pain for approximately 12 years. He stated that he initially had an injury while in active service and was told that he had messed up some cartilage. He reported being given NSAIDs for treatment. The Veteran stated that he has had occasional swelling and mild pain with weight bearing since the injury during service but stated that the occasional pain and swelling has now become persistent. The Veteran was treated with injections in his left knee. In a follow-up visit in September 2013, the Veteran also complained of similar pain and symptoms in his right knee and bilateral medial meniscus tears were suspected. In a March 2014 private orthopedic note, it was indicated that the Veteran had had several knee injections which provided only temporary relief and that he continued to report bilateral knee pain. An MRI was taken of the Veteran’s bilateral knees in April 2014. The MRI of the right knee revealed a 5.5 mm ossified loose body in the anterior aspect of the medial tibiofemoral compartment, no meniscal tear or ligament tear, grade 2 chondrosis in the patellofemoral and medial tibiofemoral compartments and low-grade proximal patellar tendinosis with no tear. There was no bone contusion or acute fracture but there was trace joint effusion. In a follow-up visit in May 2014, the Veteran reported that his right knee pain bothers him on a day-to-day basis and is worsened with walking, standing and any other weightbearing activities. The Veteran reported having had injections in his knees in the past which have provided only moderate relief. The Veteran’s right knee was noted to be tender to palpation along the medial joint line and deep to patellar tendon. The Veteran stated that the pain bothers him enough that he would like to proceed with surgery. The physician stated that the loose bodies shown on the MRI are probably causing impingement, particularly in extension. The Veteran underwent bilateral knee arthroscopies in December 2014. The Veteran was diagnosed with right knee chondromalacia of the medial femoral condyle and patellofemoral joint, right knee loose body, and right knee synovitis. The diagnoses were unchanged before and after the surgery. X-rays were taken in June 2015 which revealed no recurrence of his loose bodies, well-maintained joint spaces and “no major osteoarthritis.” However, the physician was unsure why the Veteran continued to have worsening symptoms in his left knee following his surgery after responding well initially. The physician stated that it was possible the loose bodies could have recurred and not show up on x-ray imaging if they did not contain calcification within them. In April 2016, a Line of Duty determination (LOD) was made regarding the Veteran’s left knee. It was stated that the Veteran hurt his left knee after falling on the flight line multiple times while on active duty and was seen in clinic and x-rays were taken. The Veteran was treated with NSAIDs. It was noted that the Veteran stated that treatment for his left knee pain began in approximately 1999. However, a review of the record reflects December 2002 treatment for right knee bursitis due to falls, which evidence is confirmed by the Veteran’s hearing testimony, leading the Board to conclude that the LOD determination is applicable to both knees. In December 2018, the Veteran was afforded a Board hearing before a Veterans Law Judge. It was noted that the Veteran gave a history of having knee pain for 12 years during treatment in March 2013. The Veteran stated that over the course of his active duty, around 2001 or 2002 he fell and went to see a doctor. He stated that the doctor diagnosed him with bursitis and clicking in his right knee. The Veteran stated that x-rays were taken but that they do not show soft tissue damage. He stated that the clicking was thus most likely the loose cartilage that was in his knee. The Veteran reported that he has had knee problems since the fall during service. He stated that the cartilage would occasionally get lodged in between the knee and kneecap and hurt for a while and then dislodge and the pain would go away until it got caught in between the knee and kneecap again. The Veteran reported seeking treatment again in 2006 but stated that no MRIs were taken until 2014 so no medical providers saw that he had knee damage until then. The Veteran reported falling and hitting his knees several times on the flight lines while on active duty when he was part of a fuel troop that was tasked with refilling aircraft. The Veteran underwent a VA examination for his claimed right knee disability in January 2020. The examiner diagnosed right knee strain, right knee meniscal tear, and status post right knee meniscectomy/debridement. The Veteran reported that between early 2000 through 2004, he injured his knees multiple times when he fell and experienced symptoms of pain in his knee joint and had broken and loose bodies of cartilage in his knee. The Veteran reported daily pain, swelling and locking of his right knee. X-rays taken of the Veteran’s right knee were normal and showed no abnormalities. The VA examiner opined that it is less likely than not that the Veteran has a diagnosis of a right knee condition that is caused by the right knee injury during service. The examiner’s rationale was that prepatellar bursitis does not cause the development of chronic knee strain or meniscal tear. An addendum VA medical opinion was obtained in April 2020. The Board directed the examiner to provide an opinion “for any diagnosed right knee disorder made during the pendency of the appeal, to include arthritis,” as to whether it is at least as likely as not (50 percent or greater probability) that each such disorder had its onset in service or is otherwise directly related to service. The examiner stated that the January 2020 x-ray of the right knee was normal and thus there was no evidence of arthritis and no pathology to render a diagnosis of arthritis of the right knee. The Board notes that the only suggestion of right knee arthritis in the record is a March 2014 private treatment note indicating that the Veteran was undergoing treatment by orthopedics for osteoarthritis of the knees and meniscus injury. X-rays throughout the appeal period have revealed left knee degenerative arthritis, but no specific diagnosis of right knee arthritis is of record. While the January 2020 VA examiner provided a negative nexus opinion, he only provided an opinion as to whether the Veteran’s in-service diagnosis of prepatellar bursitis could have caused his current chronic knee strain or meniscal tear. The examiner did not consider whether the diagnosed bursitis was a manifestation of an underlying right knee disability caused by the reported right knee injuries during service. In this regard, the Board finds it significant that the December 2002 STR indicates that the Veteran experienced crepitus with extension of the right leg and in May 2014 a private orthopedic physician opined that the loose bodies shown on MRI of the right knee were probably causing impingement, particularly in extension. Furthermore, a private orthopedic note dated in June 2015 indicates that such loose bodies would not show up on x-rays if they did not have calcification in them. Thus, x-rays taken prior to the first MRI of the right knee in 2014 would not necessarily have shown any such abnormality. The January 2020 VA examiner did not address the Veteran’s lay statements of experiencing continuous right knee pain since suffering multiple falls during active service. The Veteran is competent to report observable symptoms such as right knee pain. See Jandreau v. Nicholson, 492 F.3d 1372, 1376 (Fed. Cir. 2007). See also Layno v. Brown, 6 Vet. App. 465, 470 (1994). Furthermore, the examiner did not opine as to whether the documented right knee prepatellar bursitis could have contributed to or caused the Veteran’s diagnoses of right knee chondromalacia of the medial femoral condyle and patellofemoral joint, right knee loose body, and right knee synovitis which were made during the appeal period. See December 2014 private orthopedic surgical note. Given that the Veteran’s STRs show complaints and treatment for a right knee disability related to a fall during service, the Veteran’s credible assertions that he has experienced knee pain continuously since service, and objective medical evidence noting similar right knee symptoms such as crepitus on extension during the initial treatment for a right knee injury during service and post-service treatment during the appeal period, the evidence is at least in equipoise as to whether the Veteran’s current right knee disability had its onset during service. Thus, after resolving all reasonable doubt in favor of the Veteran’s claim, entitlement to service connection for a right knee disability is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. Z. SAHRAIE Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Modesto, Victor 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.