Citation Nr: 21020978 Decision Date: 04/08/21 Archive Date: 04/08/21 DOCKET NO. 16-39 821 DATE: April 8, 2021 ORDER Service connection for a left knee disorder is denied. Service connection for a right elbow disorder, including ulnar neuropathy, is denied. FINDINGS OF FACT 1. The Veteran’s left knee disorder, including arthritis of the left knee, was not shown as chronic in service and did not manifest to a compensable degree within the applicable presumptive period; continuity of symptomatology is not established; and the disability is not otherwise etiologically related to an in-service injury or disease. 2. The Veteran’s right elbow disorder, including ulnar neuropathy, was not shown as chronic in service and did not manifest to a compensable degree within the applicable presumptive period; continuity of symptomatology is not established; and the disability is not otherwise etiologically related to an in-service injury or disease CONCLUSIONS OF LAW 1. The criteria for service connection for a left knee disorder 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 right elbow disorder, including ulnar neuropathy, 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 February 1990 to September 1991 and from October 2004 to January 2006. She had additional periods of active duty for training (ACDUTRA) and inactive duty training (INACDUTRA) for many years. In September 2019, a videoconference hearing was held before the undersigned. A transcript of the hearing is associated with the Veteran’s claims folder. In December 2019, the Board remanded the issues of residuals of an injury of the left knee, ulnar neuropathy of the right upper extremity, residuals of an injury of the right shoulder, and right ear hearing loss, for additional development. Following development, service connection was awarded for a right shoulder strain and right ear hearing loss by rating decision dated in July 2020. In November 2020, the Board remanded the issues of service connection for residuals of an injury of the left knee and ulnar neuropathy of the right upper extremity for further development. This has been accomplished and the case has been returned for further appellate consideration. Service Connection Entitlement to service connection for a left knee disorder The Veteran contends that service connection should be established for a left knee disorder. She asserts that she sustained an injury of her left knee during service and that she has chronic residuals, including degenerative joint disease. In an informal hearing conference in February 2016, she stated that she sustained an injury of the left knee while performing ACUTRA or INACDUTRA and was in the process of obtaining a line of duty determination related to this injury. During the Board hearing in September 2019, she testified that her knee constantly felt as if it “pops out.” She stated that she did not recall having had a specific injury of the knee, but that she believed that the knee disorder resulted from the cumulative effects of carrying heavy items and jumping out of tall vehicles while in service. Certain chronic diseases 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). An X-ray study dated in August 2020 shows that the Veteran has minimal medial femoral condylar marginal spurring of the left knee. This is diagnostic of arthritis. Arthritis is an enumerated condition under 38 C.F.R. § 3.309(a); Walker, 708 F.3d 1331. Review of the Veteran’s service treatment records (STRs) do not show that the Veteran was treated for pain of the left knee while on active duty or during ACUTRA or INACDUTRA. On pre-deployment physical examination in June 2004, the Veteran reported that she did not have any orthopedic or neurologic problems. On post-deployment physical examination in December 2007, her orthopedic complaints showed only an injury of the right foot and right shoulder, with arm pain. VA outpatient treatment records, dated in September 2015, show that the Veteran reported having knee pain since 2005. In 2013 she underwent an MRI examination that was negative. She reported occasional flare-ups in the lateral patella, with pain and clicking. She was referred for physical therapy in July 2014. Examination showed left knee popping that was palpable with extension. There was no knee edema and she ambulated without antalgia. No assessment of a left knee disorder was made at that time. An examination was conducted by VA in January 2020. At that time, the Veteran’s left knee examination was normal, although the Veteran did have complaints of left knee pain that were subjective. The examiner opined that the Veteran’s left knee disorder was less likely than not incurred in or caused by a claimed in-service injury, event, or illness. The rationale was that objective examination was normal with negative left knee X-rays in 2016. There was no objective evidence of a chronic treatment or care for the left knee, so a nexus had not been established. The Veteran’s medical records were reviewed by a VA examiner again in December 2020. The examiner was asked to opine as to whether the Veteran’s left knee condition was at least as likely as not incurred in or caused by an in-service injury, event, or illness. The examiner responded with a negative nexus opinion. The rationale was that the Veteran was discharged from her second time in service in 2006 and that the STRs did not note knee pain prior to that time. An X-ray in 2016 was negative and MRI of the left knee in 2020 would not “be a direct reflection of knee injury or condition in service which ended in 2006.” Therefore, no nexus was reasonable. In this case, the Veteran is not shown to have had a chronic left knee disorder while in service. Moreover, she did not manifest arthritis of the left knee to a compensable degree within the one-year presumptive period, and a knee disability was not noted in service with attributable continuity of symptomatology. Left knee pain was not noted until VA treatment records in 2013, years after her separation from service and years outside of the applicable presumptive period. While she is competent to report having experienced symptoms of knee pain since service, she is not competent to provide a diagnosis in this case or determine that these symptoms were manifestations of her current left knee disability as the Veteran has not demonstrated the necessary medical expertise. The issue is medically complex, as it requires knowledge of the interaction between multiple organ systems in the body or interpretation of complicated diagnostic medical testing. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). The Board gives more probative weight to competent medical evidence, which establishes that her current symptoms are too remote from service to be attributable to her period of active duty. For these reasons, the Board finds that a preponderance of the evidence is against the Veteran’s claim for service connection for a left knee disorder, and the claim must be denied. Because the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102. Entitlement to service connection for a right elbow disorder, including ulnar neuropathy The Veteran contends that service connection should be established for a right elbow disorder, specifically ulnar neuropathy. Alternatively, she contends that the neuropathy is related to her service-connected right shoulder disorder. The Veteran has a current diagnosis of bilateral ulnar neuropathy as evidenced by April 2008 electrodiagnostic testing. Other diseases of the nervous system are one of the enumerated conditions under 38 C.F.R. § 3.309(a); Walker, 708 F.3d 1331. In addition, service connection may be granted for disability which is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). “When aggravation of a veteran’s non-service-connected condition is proximately due to or the result of a service-connected condition, such veteran shall be compensated for the degree of disability (but only that degree) over and above the degree of disability existing prior to the aggravation.” Allen v. Brown, 7 Vet. App. 439 (1995). Review of the Veteran’s STRs shows no complaint or manifestation of a right elbow disorder or ulnar neuropathy while the Veteran was on active duty. During a post-deployment examination in connection with her reserve duty, performed in December 2007, the Veteran complained of having right shoulder and arm pain and numbness. No diagnosis was rendered at that time. As noted, electrodiagnostic testing in April 2008 was consistent with a drop in conduction velocity of the ulnar nerve across the elbows bilaterally. This was considered to be of unknown clinical significance in the setting of normal ulnar sensory nerve studies. On follow-up evaluation in May 2008 the Veteran stated that she had originally used “numbness” as an adjective to describe her symptoms, but on further questioning the term to describe the symptom was a deep aching sensation rather than a frank sensory deficit. She stated that she had no other associated symptoms in the left upper extremity. The abnormal EMG study conducted in April 2008 was noted, including the finding of undetermined clinical significance. On further inquiry, the Veteran denied any history of former or current elbow pain and there were no associated sensory symptoms in the neural anatomic distribution, including the ulnar nerve. Examination, including sensory examination, was normal to all modalities. The impression was that the Veteran had no signs or symptoms of an underlying neuropathic process. The electrodiagnostic findings of bilateral ulnar nerve slowing across the elbows were indeed incidental and of no clinical significance. Additional VA treatment records show that in September 2015, the Veteran reported that she had chronic right shoulder and elbow pain with peripheral neuropathy, status post right shoulder surgery in July 2010. An examination was conducted by VA in January 2020. At that time, the diagnosis was right arm neuropathy. The Veteran reported that she began experiencing neuropathy symptoms in her right arm following her right shoulder surgery in 2009. The examiner opined that that this condition was less likely than not incurred in or caused by a claimed in-service injury, event, or illness. The rationale was that the Veteran’s complaints of right arm neuropathy began in 2008, preceding her 2009 right shoulder surgery. The EMG study from 2008 showed evidence of a slight increased insertional activity isolated to the right abducted of unknown clinical significance and a drop of conduction velocity of the ulnar nerve across the elbows bilaterally of unknown clinical significance. The examiner went on to state that the ulnar neuropathy was not medically related to her left hip contusion and a nexus had not been established. The examiner did not render an opinion regarding secondary service connection. The Veteran’s medical records were reviewed by another VA examiner in December 2020. The examiner opined that it was less likely than not that the ulnar neuropathy of the right upper extremity was proximately due to or the result of a service-connected condition. The rationale was that the Veteran began experiencing neuropathy symptoms of the right arm, but that this was noted bilaterally in 2008. This was prior to the right shoulder surgery that she underwent in 2009 and was also bilateral, which would not be the case if the right shoulder surgery were the cause of the ulnar nerve condition. As such, no nexus was established. Regarding aggravation, the examiner stated that the May 2008 neurology consultation for right shoulder pain noted bilateral ulnar conduction delay and there was no known association of this finding with a right labral tear that eventually was surgically treated in 2009. Additionally, the current severity of the neuropathy was not greater than the baseline. (Continued on the next page)   Review of the record shows that the neurologic disability was not shown as chronic in service, did not manifest to a compensable degree within the one-year presumptive period, and was not noted in service with attributable continuity of symptomatology. VA treatment records show the Veteran was not diagnosed with neuropathy until 2008 and, at that time, it was bilateral in nature. Regarding secondary service connection, the only medical opinion in the record is to the effect that the right shoulder disorder is not a proximate cause of the neuropathy and did not aggravate the disorder. While the Veteran is competent to report having experienced symptoms of neuropathy since service, she is not competent to provide a diagnosis in this case or determine that these symptoms were manifestations of peripheral neuropathy as the Veteran has not demonstrated the necessary medical expertise. Similarly, the Veteran is not competent to opine as to the etiology of her current disability, to include determining whether it is related to a service-connected disability. Jandreau 492 F.3d at 1372. The Board gives more probative weight to competent medical evidence, which establishes that these symptoms are not attributable to service or to a service-connected disability. For these reasons, the Board finds that a preponderance of the evidence is against the Veteran’s claim for service connection for a right elbow disorder with ulnar neuropathy, and the claim must be denied. Because the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102. A. ISHIZAWAR Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Joseph P. Gervasio 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.