Citation Nr: 21015782 Decision Date: 03/18/21 Archive Date: 03/18/21 DOCKET NO. 16-51 836 DATE: March 18, 2021 ORDER Service connection for a right knee condition is denied. Service connection for a left knee condition is denied. FINDING OF FACT The Veteran’s bilateral knee condition (arthritis) was not shown as chronic in service and did not manifest to a compensable degree within one year of separation from service, and the disability is not otherwise etiologically related to an in-service injury or disease, including constant standing, walking, and running over a period of two decades. CONCLUSIONS OF LAW 1. The criteria for service connection for a right knee condition have not been met. 38 U.S.C. §§ 1110, 1112, 1113, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 2. The criteria for service connection for a left knee condition have not been met. 38 U.S.C. §§ 1110, 1112, 1113, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from October 1969 to October 1989. This matter comes to the Board of Veterans’ Appeals (Board) on appeal from an August 2015 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). The Board previously remanded this claim in June 2019. This appeal has been advanced on the Board’s docket pursuant to 38C.F.R. §20.900(c). 38 U.S.C. § 7107(a)(2) Service Connection 1. Service connection for a right knee condition is denied. 2. Service connection for a left knee condition is denied. The Veteran asserts that his bilateral knee conditions are due to the physical rigors of service and duties of his military occupational specialty, including constant standing, walking, and running over a period of two decades. See May 2015 VA Form 21-4138; September 2015 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 chronic diseases, such as 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; 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). The Veteran’s service treatment records include complaints relating to the left knee. In December 1975 treatment records from U-Tapao USAF Hospital, the Veteran was noted to have mild chondromalacia of the left knee with no effusion, ligament instability, or trauma. The impression section noted no restrictions. Subsequent April 1984 service treatment record noted a soft tissue injury. The Veteran last complained of a knee injury in service in an August 1984 treatment record, which noted that he had hurt his left knee while running with an impression of soft tissue injury. At separation, the Veteran’s January 1989 report of medical history was silent for related abnormalities. In fact, the Veteran denied arthritis, rheumatism, or bursitis; bone, joint, or other deformity; lameness; trick, locked knee; and swollen or painful joints. The January 1989 separation evaluation noted normal lower extremities and was otherwise silent for related conditions. Post-service treatment records indicate multiple diagnoses relating to the Veteran’s knees. June 2005, October 2005, and February 2009 imaging show the Veteran was noted to have degenerative changes and osteoarthritis of the knees. The October 2005 MRI also showed degenerative tear of the right knee meniscus with bilateral chondromalacia patella. In August 2013treatment records, osteoarthritis of the knee and acute medial meniscus tear were noted in the Veteran’s chronic problems. The Veteran has been afforded various VA examinations and opinions in relation to these claims. At a July 2015 VA examination, an examiner indicated that there was no objective medical evidence supported either a left or right knee condition. In a June 2019 remand, the Board determined this opinion was inadequate because the examiner did not reconcile this finding with the prior imaging and evidence of record. The Veteran was afforded another VA examination in August 2016. The Veteran reported onset of symptoms in service, in the 1980s, as due to flight landings. The Veteran also indicated that in-service imaging showed a torn cartilage and bilateral arthritis. The August 2016 examination report noted that imaging did not show arthritis. However, the examiner noted a January 2006 assessment of left knee internal derangement of the medial meniscus posterior horn. The examiner opined that left knee internal derangement was at least as likely as not related to service. The examiner also noted a similar January 2006 assessment of the right knee patellar chondromalacia and internal derangement of the medial meniscus posterior horn. The examiner checked the box indicating that the right knee conditions were less likely than not related to service, but then wrote the “claimed condition is at least as likely related to military service.” The rationale for both opinions was “Dr. Richard Ursone, MD 01/26/2006 cc: male with 5 yr h/o of bilateral knee pain. MRI done and found degenerative changes in his meniscus. a: internal derangement of medial meniscus posterior horn.” An addendum opinion was provided in August 2016 by a different examiner. The examiner indicated that despite prior imaging showed degenerative changes, the most recent imaging studies of the Veteran’s bilateral knees are not indicative of osteoarthritis. Thus, the examiner concluded that the studies suggest that any joint space narrowing is minimal, and the Veteran does not warrant a diagnosis of osteoarthritis at the current time. The examiner further opined that any osteoarthritis in the Veteran’s knees would not be related to his active military service. In support of this conclusion, the examiner noted that osteoarthritis is an age-related degenerative condition, which occurs with normal activities over time. Further, it is extremely common in individuals of the Veteran’s age and would not be related to and/or a result of his active military service which occurred many years ago. In June 2019, the Board remanded the appeal for an addendum opinion as the examiner did not provide an opinion regarding the prior diagnosis of internal derangement of the medial meniscus posterior horn noted in the prior VA 2016 examination report. Pursuant to the Board’s Remand, a December 2019 VA examination and opinion was obtained in December 2019. During the examination, the Veteran reported a fall onto his knees in 1981, with knee pain afterwards. The Veteran also reported that he became an instructor in 1986, and by 1988 was noticing knee pain while running. The VA examiner state that the Veteran clearly has a diagnosis of bilateral knee joint osteoarthritis and it is consistent with the internal knee derangement, as are the changes in the meniscus noted on MRI. The examiner explained that ‘internal knee derangement’ is a non-specific term to describe essentially any abnormality within the knee joint and may include arthritis. As to etiology, the December 2019 examiner provided an unfavorable opinion as to the relationship between the Veteran’s bilateral knee osteoarthritis and service. The examiner acknowledged the Veteran’s self-reported history of knee injury in service. However, the examiner noted that the in-service treatment records and the Veteran’s lay statements are inconsistent with an injury to the knees that was significant enough to have resulted in orthopedic changes later in life. Notably, the examiner indicated that such a severe injury would be expected to result in some notation of the injury, evidence of recurrent symptoms or treatment or notation of an abnormality on examination. While there were injuries noted in the service, the medical records appear to be soft tissue related. Further, a soft tissue condition is consistent with the Veteran’s own description of the injury. Finally, the examiner highlighted the comprehensive January 1989 examination and January 1989 self-reported history, which were silent for knee issues. The examiner inferred from this silence that the Veteran’s knees were either not symptomatic at that time and/or any prior injury was minor enough not to rise to the level of self-reported concern. As such, the examiner concluded that the diagnosed osteoarthritis is not related to service, including as having had onset during service. Upon review, the Board finds that service connection is not warranted. Initially, the Board notes that the Veteran’s osteoarthritis of the bilateral knees was not shown as chronic in service, did not manifest to a compensable degree within one year, and was not noted in service with attributable continuity of symptomatology. In fact, such a diagnosis was not noted in the January 1989 separation report. The Veteran himself denied such a condition in the separation report of medical history. Moreover, the post-service treatment record did not note a diagnosis of osteoarthritis for many years after service. As such, the probative evidence shows that the Veteran was not diagnosed with osteoarthritis until many years after his separation from service, outside of the presumptive period. While the Veteran is competent to report having experienced symptoms of pain during and since service, he is not competent to provide a diagnosis in this case, determine that these symptoms were manifestations of osteoarthritis, or opine as to etiology. Rather, the Veteran has not demonstrated the necessary medical expertise. The issue is medically complex, as it requires knowledge of an internal degenerative process which is not capable of being observed with the senses. Moreover, the diagnosis of the condition requires interpretation of complicated diagnostic medical testing. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). Finally, the Veteran’s assertions in August 2016 VA examination that he received a diagnosis in service of arthritis is not probative. The statements are contrary to service treatment records and the Veteran’s own statements in the report of medical history. The Board accords more probative value to the contemporaneous treatment records and statements, as opposed to the more recent statements made in furtherance of this appeal. As such, the probative evidence establishes that the Veteran was not diagnosed with osteoarthritis for many years after service. Turning to direct service connection, the December 2019 VA opinion is unfavorable on the question of causal nexus between the Veteran’s current bilateral knee disability and service. The examiner, a physician, explained that the Veteran’s disability is more likely related to his advancing age and not of service origin. The Board finds this opinion probative because it was authored by a physician with the appropriate training, expertise and knowledge to evaluate the bilateral knee disability. The examiner provided a thorough and cogent rationale for his findings and opinions, which included consideration of the Veteran’s reported service injury, and his symptoms both during and after service, and the clinical history of the disability. See Nieves-Rodriguez v. Peake, 22 Vet.App. 295, 301 (2008) ("[A] medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two."). The evidence of record contains no competent and probative opinions to the contrary. As noted previously, the Veteran has been noted to lack the medical training necessary to author a competent opinion. To the extent that the initial August 2016 VA examination report contained a favorable nexus opinion for the right knee, the rationale is inadequate and fails to clearly explain the reasoning for the examiner’s opinion. A VA medical opinion is adequate where it sufficiently inform[s] the Board of a medical expert's judgment on a medical question and the essential rationale for that opinion. See Monzingo v. Shinseki, 26 Vet.App. 97, 105 (2012); see also Ardison v. Brown, 6 Vet.App. 405,407(1994) Further, the opinion on the left knee was internally inconsistent, as discussed above. For this reason, neither nexus opinion is probative. Ultimately, the preponderance of the competent and persuasive evidence is against finding that the Veteran’s bilateral knee disabilities onset during service or for many years thereafter, or are otherwise related to an in-service injury, event or disease. As such, the benefit of the doubt doctrine does not apply, and service connection is not warranted. D. JOHNSON Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board K. Vuong, 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.