Citation Nr: 21022406 Decision Date: 04/15/21 Archive Date: 04/15/21 DOCKET NO. 17-44 959 DATE: April 15, 2021 ORDER Service connection for a left knee disorder, claimed as secondary to service-connected right knee arthritis, is denied. FINDING OF FACT A left knee disorder is not shown to be causally or etiologically related to any service-connected right knee arthritis. CONCLUSION OF LAW The criteria for service connection for a left knee disorder have not been met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2020). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had active service in the United States Marine Corps from June 2002 to November 2012. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a November 2016 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). The Board remanded this matter on several occasions, the most recent being in February 2021, for further development. The requested development has been completed and the matter is now ready for appellate review. The Veteran maintains that he currently has left knee problems as secondary to his service-connected right knee disorder. He has not claimed that he has any current left knee disorder which is directly related to his period of service, limiting his appeal to the claimed left knee disorder being related to his service-connected right knee disorder. Moreover, the record does not demonstrate any complaints or findings of left knee problems in service or in close proximity to service. 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; Allen v. Brown, 7 Vet. App. 439, at 448 (1995) (holding that service connection on a secondary basis requires evidence sufficient to show that the current disability was caused or aggravated by a service-connected disability). To establish secondary service connection, the law states that there must be (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) nexus evidence establishing a connection between a service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). In conjunction with his claim, the Veteran was afforded a VA examination in September 2019. Following examination of the Veteran and review of the claims folder, the examiner opined that the condition claimed was less likely than not (less than 50% probability) proximately due to or the result of the Veteran's service-connected condition. The examiner indicated that right knee osteoarthritis was not an identified causative factor in the development of left knee PFS. The examiner noted that the Veteran had a physically taxing job as a mechanic. He would be repeatedly positioning himself in awkward positions to perform the duties of his current employment. In addition, the Arthritis Foundation reported that for each pound of extra weight on your frame, you could expect the knees to withstand an extra 4 pounds of pressure. If you’re 20 pounds overweight, that’s an extra 80 pounds of weight experienced with every step. The Veteran's BMI was 36.4. It was as likely as not that the rigors of the Veteran's chosen career and the extra weight placed on his knees due to his obesity was the culprit in his left knee PFS/condition. In its September 2020 remand, the Board noted that the September 2019 examiner never addressed the Veteran’s contention that the extra weight put on his left knee due to favoring his service-connected right knee contributed to his left knee disorder. Moreover, the examiner did not offer an opinion as to whether the Veteran’s right knee disability aggravated his left knee disability as specifically directed by the Board. As such, the opinion was inadequate and an addendum opinion was necessary. VA obtained two addendum opinions in October 2020. In an October 2020 opinion, the examiner opined that the condition claimed was less likely than not (less than 50% probability) proximately due to or the result of the Veteran's service-connected condition. The examiner stated that it was at least as likely as not that any dysfunction affecting the left knee was from the left knee condition of patellofemoral pain syndrome. This was a separate and distinct condition and diagnosis, not caused by the right knee diagnosis of OA. In an October 2020 addendum opinion prepared later that month, the examiner indicated that the Veteran's claimed condition was not at least as likely as not aggravated beyond its natural progression by his service-connected right knee disorder. The examiner noted that the Veteran was claiming left knee pain due to overuse due to a right knee condition. There was no chronic history of left knee pain and he was diagnosed with patellofemoral pain syndrome during his VA exam, based on normal x-rays, normal examination, and provider observation. The examiner noted that the most common cause of PFP was overuse. “PFP appears to be multifactorial, resulting from a complex interaction among intrinsic anatomic and extrinsic training factors. Although clinicians frequently make the diagnosis of PFP, no consensus exists about its etiology or the factors most responsible for causing pain. Overuse, malalignment, and trauma are commonly cited causative factors. Of these, overuse (ie, training overload) is most common (see 'Overload' below and 'Malalignment' below and 'Trauma' below). Early sports specialization has been identified as a risk factor for the development of PFP” [Patellofemoral Pain. Francis G O'Connor, MD, MPH, FACSM, Sean W Mulvaney, MD. This topic last updated: Jan 10, 2020.] The Veteran has factor separate from and equally or more compelling that may be the cause of the left knee or aggravation to the left knee. These include the known factors of his current occupation which requires prolonged standing and repeated change of positions, right ankle fracture and obesity. The examiner opined that it was less likely than not, a less than 50% probability that the Veteran's left knee/leg condition was caused by the service- connected right knee condition. In its February 2021 remand, the Board noted that second October 2020 examiner explained that patellofemoral pain syndrome, the Veteran’s diagnosis for his left knee, “appears to be multifactorial, resulting from a complex interaction among intrinsic anatomic and extrinsic training factors,” with the most commonly cited causes, including overuse, malalignment, and trauma. They opined that because the Veteran’s physically taxing job as a mechanic, history of right ankle fracture, and his noted weight gain would cause overuse, those are known factors that are “equally or more compelling that may be the cause of aggravation to the left knee.” The Board noted that the examiner’s explanation citing the Veteran’s right ankle fracture as a likely contributing cause to his left knee condition implied that favoring his right leg would contribute to overuse of his left knee, which was a commonly cited factor in causing patellofemoral pain syndrome. The examiner did not explain why overuse from favoring the right knee would be less likely to cause aggravation of the Veteran’s left knee than overuse from favoring his right ankle. The Board indicated that a new opinion based on full review of the record and supported by stated rationale was needed to fairly resolve the Veteran’s claim. In a March 2021 addendum report, the examiner indicated that the claimed condition was not as likely as not aggravated beyond its natural progression by the service-connected right knee disorder. The examiner noted that the claims folder revealed a history of occupation as mechanic, obesity with BMI 37 and a right ankle fracture. The examiner indicated that she was unable to locate any evidence to support leg discrepancy, right leg discrepancy, altered gait/antalgic gait or alteration in stance/weightbearing. She observed that the Veteran's claims folder noted steady gait and normal gait in all available records, therefore dispelling any notion that the right ankle or knee would cause a shift in balance. There was no credible evidence in the claims folder to suggest aggravation of the left knee disability by beyond natural progression by the service-connected right knee arthritis. As to service connection under 38 C.F.R. § 3.310, the Board finds that the most probative evidence of record shows that the Veteran does not have a left knee disorder that is caused or aggravated by his service-connected right knee disorder. See 38 C.F.R. § 3.310; Allen. To the extent that the Veteran has expressed his opinion that he currently has a left knee disorder that is related to his service-connected right knee disorder, this is an assertion as to an internal medical process, which extends beyond an immediately observable cause-and-effect relationship that is of the type that the courts have found to be beyond the competence of lay witnesses. Moreover, the Board finds that diagnosing a link between any claimed left knee disorder and the service-connected right knee disorder is a determination of medical complexity and is not capable of lay observation. Therefore, since laypersons are not capable of opining on matters requiring medical knowledge, the Board finds that the Veteran's opinion that he has a left knee disorder that was caused or aggravated by a service-connected disability is not competent evidence. In contrast, the Board obtained several opinions from VA examiners as to the relationship, if any, between any left knee disorder and his service-connected right knee disorder. The examiners rendered opinions that any left knee disorder was not caused or aggravated by his service-connected right knee disorder. The opinions were based upon thorough examinations of the Veteran and a comprehensive review of the claims folder. There was no indication that the VA examiners were not fully aware of the Veteran's past medical history, citing to it in the reports, or that they misstated any relevant facts, or relied on any inaccurate facts. Moreover, the most recent opinion, with regard to aggravation, specifically addressed any possible discrepancies in the record. For the foregoing reasons, the preponderance of the evidence is against the claim for service connection for a left knee disorder. 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. K. Parakkal Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board T. S. Kelly, 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.