Citation Nr: 21022137 Decision Date: 04/14/21 Archive Date: 04/14/21 DOCKET NO. 16-25 537 DATE: April 14, 2021 ORDER Service connection for a right knee disability is denied. FINDING OF FACT The evidence of record fails to show that it is at least as likely as not that the Veteran’s right knee disability was incurred in, caused by, or otherwise is etiologically related to his service, to include considerations given to his right knee injury and weight gain in service, and his service-connected fibromyalgia. CONCLUSION OF LAW The criteria for service connection for a right knee disability have not been met. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303, 3.307, 3.309, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran honorably served on active duty from July 1987 to July 1991. In an August 2014 rating decision, the Regional Office (RO) denied service connection for a right knee disability. The Veteran appealed. In February 2019, the Veteran testified at the Board’s hearing, a transcript of which is of record. In September 2019 and February 2021, the Board remanded the claim for supplemental medical opinions which have been obtained, and the appeal has returned to the Board. Upon reviewing all evidence of record viewed as a whole and in light of pertinent laws, the Board has found that service connection for a right knee disability is not warranted. Service connection generally may be granted for a disability incurred in or due to service. See 38 C.F.R. § 3.303(a). “Service connection” is a complex legal term connoting many factors, but essentially means that a particular disease or injury, shown to had been incurred in or coincident to service, has caused a post-service disability. Id. As such, service connection may not be automatically granted for every injury, disease, treatment, or complaint documented in or conceivably related to service. Rather, establishing an entitlement to service connection requires the competent evidence of record to show: (1) the existence of the claimed disability; (2) a relevant traumatic event in service, and (3) a causal link between the two. See Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). In this case, the Veteran was diagnosed with degenerative joint disease in his right knee in 2016. His service treatment records (STRs) reflect that he was involved in an accident on a dirt bike in 1989 in which he struck his right knee. The Veteran believes that this dirt bike accident led to the development of a right knee disability. Here, the Veteran is not shown to have specialized knowledge, training, or experience in such fields as medicine, epidemiology, or pathophysiology, and therefore he lacks the competency to determine whether an in-service accident caused a disease process to begin in his right knee. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). As such, the requisite causal link between the claimed current disability and service generally must be established by medical evidence. Id. This is particularly true in this case, where the claimed musculoskeletal disability is medically complex and is attenuated from service by many years. This is why the Board must rely on medical expertise and remanded the claim for the supplemental medical opinions twice. Unfortunately, the medical opinions of record (rendered in January 2021, July 2020, and December 2013) ultimately fail to link the Veteran’s right knee disability to either his service, or a service connected disability. Following an VA examination in January 2021, a VA examiner opined that it is less likely than not that the Veteran’s current right knee disability was incurred in, caused by, or otherwise is etiologically related to his service, to include an injury sustained in a dirt bike accident, weight gain in service, and fibromyalgia. The examiner explained that the medical evidence of record pointed to a post-service origin of his current right knee disability. The examiner noted that the Veteran has sustained two post-service knee injuries in 2003 and 2005. This is consistent with the Veteran’s testimony as to initially seeking treatment for his knee in early 2000s. The examiner further notes a Corvallis Clinic consultation for right knee treatment (dated 7/27/2009) which reflects the Veteran’s report that he has developed right knee pain after going up some stairs in 2003, at which time he was seen for this. There is also a second injury in 2005, when the Veteran slipped going down a wet grassy slope and had a valgus injury to the right knee with a popping sensation followed by one month of pain. A 2013 X-ray report notes the first signs of mild degenerative changes in the knee joints. The Veteran was diagnosed with a right knee degenerative joint disease in December 2016. The examiner then explained that the evidence does not support a service connection origin. The examiner acknowledged that the Veteran had sustained a right knee contusion in a dirt bike accident on August 27, 1989. Per STR note dated the next day, the bike “struck his medial knee.” At the time, he had medial joint line tenderness. That would amount to a contusion. In October 1989, the Veteran saw an orthopedist who ordered an MRI but the STRs fail to show any results. Of note, the Veteran has confirmed at his hearing that he had not obtained the ordered MRI. The examiner then notes that the Veteran also had a bicycle accident in July 1990, and he only suffered an abrasion to his right knee. There is no indication of any concern for more serious injury of the right knee, even in spite of his prior dirt bike accident. Further, the examiner notes per the Reports of Medical History (dated 2/19/1991 and 5/16/1991), the Veteran did mark “yes” to the “trick knee” question. However, given the call of the question—Have you now or have you ever had a trick knee?—the Veteran’s response is consistent with reporting having a history of knee problem(s) and is not indicative of any ongoing knee disability at the time of the examination. Moreover, on page 2 of the report, where “yes” answers are elaborated on, there is no mention of any ongoing knee condition or any other annotations by an examining physician. The examiner further notes that the STRs reflect a July 1993 letter pertaining to retention in the Naval reserves in context of ongoing ankle and back conditions, while this letter is dated two years after separation from active duty and also does not mention any knee condition. Given a one-time knee contusion and a one-time knee abrasion in service many years earlier, without any objective evidence supporting a finding of the ongoing knee problems or any residuals of the in-service right knee injury for at least two years after service, the examiner opined that the Veteran’s in-service right knee injuries have resolved and his current right knee degenerative joint disease is less likely than not to be etiologically related to his military service. In considering whether the Veteran’s right knee condition may be related to his weight gain in service, the examiner observes that the Veteran did not gain 50 pounds (as alleged) after his right knee contusion. Rather, the STRs note (dated 10/3/1989) states that he has “gained 50 pounds since joining the Navy.” Closer examination reveals a weight of 206 near his entry into service (8/11/1986), and the Veteran had already weighed 250 pounds by 4/17/1989, which is four months prior to the dirt-bike accident. Thus, he had gained 44 pounds before the dirt-bike accident and he had gained only 6 pounds by 10/3/1989, when his weight was noted at 256 pounds two months after the accident. Further, more recent private treatment records include a 4/26/2012 statement that he does fine art photography, as he hikes this way. His weight noted at 351 pounds. A 5/22/2012 note reflects the Veteran’s report that he walks 3.5 miles three times per week, notwithstanding bilateral knee pain. A 12/17/2012 note then reflects the Veteran’s weight at 358 pounds. Accordingly, the examiner opines that the Veteran’s right knee condition is not due to him gaining 50 pounds in service after his bike accident. Rather, his gained most weight prior to the accident. His further post-service weight gain of over 100 pounds is unrelated to a reported knee-related inactivity due to injury in service, nor secondary to or aggravated by fibromyalgia, as he was able to walk on hikes 3.5 miles three times per week. Further, an 8/12/2013 note reflects that he also does group hikes, while he is up and down trying to get good photos. A Corvallis treatment note (dated 7/27/2009) reflects the full squat and rise without difficulty. His most significant weight gain rendering him morbidly obese was clearly after service and related to overeating. For example, a mental health note (dated 9/16/2013) reflects the Veteran’s statement that his main vice is food. A 5/19/2004 note reflects the Veteran’s statement that he “would really not think much of sitting down and eating a whole pizza.” Based on the comprehensive data, the examiner ultimately concludes that the Veteran’s right knee disability is less likely as not etiologically related to his service. Of note, this medical opinion is wholly consistent the July 2020 and December 2013 medical opinions, albeit offering less elaborate rationale and thus warranting remand for a more detailed discussion. Ultimately, however, none of the medical evidence of record shows the requisite causal link between the Veteran’s current right knee disability and his service, which is the fundamental legal criterion for establishing an entitlement to service connection. In reaching this conclusion, the Board has considered all other conceivable basis for service connection. See 38 C.F.R. §§ 3.303(b), (d), 3.307(a), 3.309(a), 3.310. For example, service connection may be granted on a presumptive basis for certain chronic diseases, such as arthritis, provided that the evidence of record shows a manifestation of the disease to a compensable degree of at least 10 percent within one year from the date of discharge. Of particular note, however, the regulations unequivocally state that any manifestation of joint pain in service will not permit service connection of arthritis. See 38 C.F.R. § 3.303(b). Rather, a compensable rating requires an arthritis to be evidenced by x-ray findings. See 38 C.F.R. § 4.71a, DC 5003. The examiner persuasively explains that the record is devoid of any objective evidence of any residuals of in-service knee injuries for at least two years after discharge and the first documented evidence of arthritis dates no earlier than a 2013 x-ray showing for the first time mild degenerative knee joint changes, which is more than two decades after the Veteran’s discharge. The Board has carefully considered the Veteran’s testimony, to include statements that he was seen multiple times for his right knee problems during service. While the frequency of the Veteran’s complaints for right knee in service is not in dispute here, absent any evidence of the right knee arthritis within one year of discharge, service connection on a presumptive basis is not warranted. Alternatively, service connection may be granted on a secondary basis, when the evidence shows that the current disability was proximately caused or aggravated by an existing service-connected disability, such as fibromyalgia. In this causal chain, obesity may be considered as an intermediate link but must be etiologically related to a service-connected disability. On point, the case law observes that obesity itself is not a “disability” which VA may compensate. See Marcelino v. Shulkin, 29 Vet. App. 155 (2018). Rather, obesity may be considered a proximate causal step, that is, an intermediate link in the pathophysiological mechanism by which an existing service-connected disability causes or aggravates the claimed disability. However, the VA examiner unequivocally opines that this is not the case here. The Veteran has not submitted any evidence to the contrary, apart from expressing his own unsubstantiated beliefs that are outweighed by the medical professionals’ opinions. Accordingly, the weight of the evidence is against the Veteran’s claim. No other material issues have been expressly raised by the Veteran or reasonably raised by the evidence of record. Therefore, service connection for a right knee disability is denied. MATTHEW W. BLACKWELDER Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Alex Bardin, 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.