Citation Nr: 21021259 Decision Date: 04/12/21 Archive Date: 04/12/21 DOCKET NO. 13-26 207 DATE: April 12, 2021 ORDER Entitlement to service connection for left knee disability, to include as secondary to service-connected post-operative residuals, right ankle resection with sural nerve entrapment and foot drop, resection tender angioma (right ankle disability), is denied. FINDING OF FACT The Veteran’s left knee disability did not have its onset in service, did not manifest to a compensable degree within the first post-service year, is not otherwise related to an in-service injury or disease, and is not caused or aggravated by her service-connected right ankle disability. CONCLUSION OF LAW The criteria for service connection for left knee disability due to service or a service-connected right ankle disability are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from June 1964 to September 1970. This matter initially came before the Board of Veterans’ Appeals (Board) from a May 2010 rating decision. The Board notes that on the Veteran’s August 2013 VA Form 9, she indicated that she wanted a Board hearing at a local VA office. However, in May 2016 correspondence, the Veteran indicated that she wished to withdraw this request. As such, the Board has deemed the Veteran’s request for a Board hearing withdrawn. This appeal was previously before the Board in June 2017, September 2018, and October 2020 at which time it was remanded for further development. Specifically, the Board instructed the agency of original jurisdiction (AOJ) to ask the Veteran to identify any outstanding treatment records and to complete the appropriate authorization form to allow VA to obtain any outstanding private medical records, obtain all outstanding VA treatment records, afford the Veteran a VA knee examination, and obtain medical opinions as to whether her left knee disability is related to service. Pursuant to the Board’s remands, the Veteran was asked to identify any outstanding treatment records and to complete the appropriate authorization form to allow VA to obtain any outstanding private medical records by way of a July 2019 letter. Copies of the authorization forms (VA Forms 21-4142a and 21-4142) were included with the letter. Moreover, all outstanding VA treatment records were obtained and associated with the claims file, a VA knee examination was conducted in August 2017, and a medical opinion as to whether the Veteran’s left knee disability is related to service was most recently obtained in December 2020. As explained below, the Board finds the December 2020 opinion to be adequate and of substantial probative value. Therefore, the AOJ substantially complied with the Board’s remand instructions. See Dyment v. West, 13 Vet. App. 141, 146-47 (1999); Stegall v. West, 11 Vet. App. 268 (1998). As for characterization of the issue on appeal, in light of the Veteran’s reported symptoms and contentions, and to encompass all disorders that are reasonably raised by the record, the Board has re-characterized the claim of service connection for left knee total replacement as a claim of service connection for left knee disability. Clemons v. Shinseki, 23 Vet. App. 1, 4-5 (2009) (in determining the scope of a claim, the Board must consider the claimant’s description of the claim, the symptoms described, and the information submitted or developed in support of the claim; a claim should not be limited to the disorder as characterized by the Veteran, but must be characterized and addressed based on the reasonable expectations of the non-expert claimant and the evidence in processing the claim). Entitlement to service connection for left knee disability, to include as secondary to service-connected right ankle disability. The Veteran asserts that she injured her left knee when falling down steps of her barracks while on active service. See February 2013 Statement in Support of Claim. Alternatively, she contends that her service-connected right ankle disability proximately caused or aggravated her claimed left knee disability. See July 2009 Statement in Support of Claim. 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) 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). Pursuant to 38 C.F.R. § 3.303(b), where a chronic disease is shown as such in service, subsequent manifestations of the same chronic disease are generally service connected; if a chronic disease is noted in service but chronicity in service is not adequately supported, a showing of continuity of symptomatology after separation is required. Entitlement to service connection based on chronicity or continuity of symptomatology pursuant to 38 C.F.R. § 3.303(b) applies only when the disability for which the Veteran is claiming compensation is due to a disease enumerated on the list of chronic diseases in 38 U.S.C. § 1101(3) or 38 C.F.R. § 3.309(a) (e.g., arthritis). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). In addition, such chronic diseases are presumed to have been incurred in service if they manifested to a compensable degree within one year of separation from service. 38 U.S.C. §§ 1101(3), 1112(a)(1), 1113; 38 C.F.R. §§ 3.307(a), 3.309(a). Although entitlement to service connection may not be established on the presumptive basis noted above, a veteran is not precluded from establishing service connection on a direct basis. See 38 U.S.C. § 1113 (b); 38 C.F.R. § 3.303 (d) (the availability of service connection on a presumptive basis does not preclude consideration of service connection on a direct basis). Alternately, service connection may be granted for disability that is proximately due to, or aggravated by, service-connected disease or injury. 38 C.F.R. § 3.310. The questions before for the Board are: (1) whether the Veteran has current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease; or (2) whether the Veteran has current disability that is proximately due to or the result of, or is aggravated beyond its natural progression, by service-connected disability. First, addressing direct service connection, the Board concludes that, while the Veteran has current left knee disability, the preponderance of the evidence is against finding that it began during active service, or is otherwise related to an in-service injury, event, or disease, including the asserted knee injury resulting from a fall in-service. The report of an August 2017 VA knee examination reveals that the Veteran experiences left knee osteoarthritis, status post total left knee replacement. Thus, current left knee disability is demonstrated. While the Veteran is competent to report that she tore cartilage in her left knee that required casting for 6 weeks after she fell down her barracks steps, her reports are largely not credible due to internal inconsistency and inconsistency with other evidence in the record. The Board notes that the Veteran initially asserted that her left knee disability was caused by an altered gait and weight shifting due to her service-connected right ankle disability. See July 2009 Statement in Support of Claim. Upon VA examination in December 2009, the Veteran reported no history of trauma to her left knee and indicated that aching and stabbing pain inferior to the left patella began in 2004. However, VA treatment records reveal that the Veteran fractured her left patella post-service in 1978. The Veteran first asserted an in-service left knee injury in a February 2013 statement. She reported that, in August 1963 while at Fort Jackson, South Carolina, for advanced individual training (AIT), she fell down the barracks steps and tore cartilage in her left knee and was placed in a cast for six weeks. However, upon VA examination in August 2017, the Veteran reported that her knee injury occurred in 1967 – the same year as her service-connected ankle injury – rather than in 1963 as she had previously reported. Moreover, the Veteran reported on a September 1970 report of medical history form completed for purposes of separation from service that she was neither experiencing, nor had she ever experienced, any “trick or locked knee.” She did not report a history of any other knee problems at the time of her separation from service. Unfortunately, the VA examiner who conducted the August 2017 knee examination and provided November 2019, May 2020, June 2020, and July 2020 addendum opinions based his negative nexus opinion regarding direct service connection solely on the absence of a left knee injury documented in the Veteran’s service treatment records, without providing additional rationale. Accordingly, the Board affords these opinions little probative value. In a December 2020 VA medical opinion, a VA physician opined that the Veteran’s left knee disability was less likely than not related to an in-service injury, event, or disease. The physician stated that there was no evidence of an in-service knee injury. Further, he indicated that the Veteran’s description of how the alleged 1967 left knee injury occurred was the same as her explanation of the service-connected 1967 right ankle injury, and service treatment records did not support the Veteran’s claim that a left knee injury requiring casting occurred at that or any time in service. The physician opined that the post-service treatment records unequivocally established that the Veteran suffered a left patellar fracture while working in 1978 and that it was more likely than not that the Veteran’s current left knee disability was due to this 1978 work-related injury rather than the asserted in-service injury. The December 2020 opinion is based upon a review of the Veteran’s treatment records and consideration of her reported history, and it is accompanied by a specific rationale that is consistent with the evidence of record. Therefore, the December 2020 opinion is adequate and entitled to substantial probative weight. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (most of the probative value of a medical opinion comes from its reasoning; threshold considerations are whether the person opining is suitably qualified and sufficiently informed). While the Veteran believes her left knee disability is related to an in-service left knee injury, the Board reiterates that the preponderance of the evidence weighs against findings that such in-service injury occurred or that the current left knee disability was present in service or in the year or years immediately after service. Turning to the Veteran’s claim for secondary service connection, the Board concludes that the preponderance of the evidence is against finding that the Veteran’s left knee disability is proximately due to or the result of, or aggravated beyond its natural progression, by her service-connected right ankle disability. 38 U.S.C. §§ 1110, 1131; Allen v. Brown, 7 Vet. App. 439 (1995) (en banc); 38 C.F.R. § 3.310(a). The Veteran was afforded a VA examination in December 2009 and VA medical opinions were obtained in December 2009, July 2013, and December 2020. Unfortunately, the December 2009 VA examiner provided no rationale to support his conclusion that the Veteran’s left knee disability was less likely than not proximately due to or a result of her service-connected ankle disability. Accordingly, the Board affords the December 2009 opinion little probative value. In the July 2013 VA medical opinion, a VA physician opined that the Veteran’s left knee disability was less likely than not caused by or aggravated by her service-connected right ankle disability. The physician noted that the Veteran’s left knee disability began more than thirty years after service, which he opined strongly favored a separate problem affecting the left knee rather than a relationship between the left knee and right ankle, as this would have presented much earlier. Further, the VA physician reported that medical literature did not support that a lower extremity condition would cause adverse effects on or aggravate the opposite unaffected lower extremity as there was no actual extra weight shift that occurred. He, instead, opined that the Veteran’s left knee disability was more likely than not proximately due chronic wear and tear of many years, as the knee is a weight bearing joint. With regard to aggravation, the VA physician separately reasoned that during the December 2009 VA knee examination, there was no dislocation or subluxation episodes, no constitutional symptoms of or incapacitating episodes of arthritis, no need for gait assistive devices, no other evidence for abnormal weight bearing other than right foot drop and a left limp, no knee joint instability, no knee grinding, no crepitation, no mass behind the knee, no meniscal abnormalities, no abnormal tendons or bursae, and no joint ankylosis that was apparent, but should have been had there been an association with the service-connected right ankle/foot disabilities. Consequently, the post-operative residuals, right ankle resection with sural nerve entrapment and foot drop, resection of the tender angioma, would not give rise to an aggravation of the left knee when it does not exist. In the December 2020 VA medical opinion, the physician opined that it was less likely than not that the Veteran’s left knee disability was proximately due to or aggravated by her service-connected right ankle disability. The physician stated that medical knowledge and practice supported that a condition of the right ankle would not cause degenerative joint disease (DJD) of the left knee. Further, he opined that any gait change caused by the Veteran’s service-connected right ankle disability was not expected to cause DJD of the left knee. The examiner opined that the Veteran’s left knee disability had its nexus in her work-related injury in 1978, eight years post service. The Board affords the July 2013 and December 2020 VA opinions great probative value as they are based on a review of the Veteran’s treatment records and an accurate medical history; and each of the VA physicians provided an explanation that contained clear conclusions and supporting rationale. Nieves-Rodriguez, 22 Vet. App. at 304; Barr v. Nicholson, 21 Vet. App. 303 (2007); Jones v. Shinseki, 23 Vet. App. 382 (2010); Swann v. Brown, 5 Vet. App. 229, 233 (1993); Reonal v. Brown, 5 Vet. App. 458, 461 (1993). There are no contrary competent medical opinions of record. The Veteran believes that her left knee disability is proximately due to or aggravated beyond its natural progression by her service-connected right ankle disability. The Veteran in this case is not competent to provide a nexus opinion regarding this issue. The issue is medically complex, as it requires knowledge of the interaction between multiple anatomical relationships. Therefore, it is outside the competence of the Veteran in this case because the record does not show that she has the skills or medical training to make such a determination. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007); see also Kahana v. Shinseki, 24. Vet. App. 428 (2011). Consequently, the Board gives more probative weight to the competent medical opinions of record. (CONTINUED ON NEXT PAGE) There is no other evidence of a relationship between the Veteran’s current left knee disability and service, and neither she nor her representative have alluded to the existence of any such evidence. Thus, the preponderance of the evidence is against a finding that the Veteran’s left knee disability had its onset in service or within the first post-service year, that it is otherwise related to service, or that it is caused or aggravated by service-connected disability. For the foregoing reasons, the preponderance of the evidence is against the claim. The benefit-of-the-doubt doctrine is therefore not for application, and service connection for left knee disability is not warranted. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. Brian J. Elwood Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board L. Bristow Williams, 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.