Citation Nr: 21023382 Decision Date: 04/20/21 Archive Date: 04/20/21 DOCKET NO. 16-23 639 DATE: April 20, 2021 ORDER Entitlement to service connection for a left knee disability is granted. Entitlement to service connection for vertigo, to include as secondary to service-connected hypertension, is granted. FINDINGS OF FACT 1. Resolving all reasonable doubt in favor of the Veteran, his left knee disability is related to his active service. 2. Resolving all reasonable doubt in favor of the Veteran, his vertigo is related to his active service. CONCLUSIONS OF LAW 1. The criteria for service connection for a left knee disability have been met. 38 U.S.C. §§ 1110, 5107 (2018); 38 C.F.R. §§ 3.102, 3.303 (2020). 2. The criteria for service connection for vertigo have been met. 38 U.S.C. §§ 1110, 5107 (2018); 38 C.F.R. §§ 3.102, 3.303 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active naval service from April 1991 to April 1999. This case comes before the Board of Veterans’ Appeals (Board) on appeal of a February 2012 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). This case was previously before the Board in September 2018, at which time the issues on appeal were remanded for additional development. This case has been returned to the Board for further appellate action. Service Connection Left Knee Disability The Veteran asserts that his left knee disability is related to his active service. Specifically, the Veteran asserts that he injured his left knee during active service and has had dislocation, popping, and swelling since that time. The Veteran’s service treatment records (STRs) reveal that he was assessed as having infrapatellar bursitis and abrasion of the left knee, after presenting with complaints of swelling, in August 1991. Later in August 1991, the Veteran was assessed as having unresolved infrapatellar bursitis and left knee tendonitis with persistent discomfort. At that time, an x-ray revealed persistent infrapatellar bursitis and soft tissue swelling present over the lower pole of the patella and narrowing of the medial joint space. In an October 1991 report of medical history, it was noted that the Veteran’s infrapatellar bursitis had not resolved initially but, at that time, had resolved and did not cause any more problems. The Veteran did not indicate any knee issues on his January 1999 separation examination report. In a September 2010 statement, the Veteran reported that he messed up his left knee while in California. In June 2011, the Veteran was afforded a VA examination for joints. At that time, the Veteran reported that he had pain and swelling after physical training (PT) and was diagnosed with bursitis. The Veteran also reported that he had inflammation and pain in his knee in 1999 and increased problems with pain, popping and bending of his knee since that time. An x-ray revealed a normal left knee. The VA examiner diagnosed the Veteran with patella femoral syndrome and bursitis of the left knee. However, the VA examiner opined that the Veteran’s left knee disability was not caused by or the result of in-service treatment for patella femoral syndrome. The VA examiner reasoned that pain may represent unusually benign or extremely pathological conditions, a local condition, or be the result of referred symptoms. The VA examiner further stated that local pain, subjectively, may represent different or unrelated etiologies and that pain was not reliable as a diagnostic or prognostic indicator. The Board finds that the June 2011 VA examination is inadequate for adjudication purposes. The VA examiner failed to adequately incorporate the Veteran’s lay statements pertaining continuity of his symptoms such as swelling, which was present at his initial in-service diagnosis. Additionally, the VA examiner used speculative language (i.e. “may”) to identify possible sources of the Veteran’s pain without offering a medical explanation of how those sources were relevant to his complaints. See Swann v. Brown, 5 Vet. App. 229, 232 (1993). Additionally, the Board notes that the medical evidence of record supports that the Veteran was diagnosed with infrapatellar bursitis during his active service, and that he has reported continued symptoms since that time. Heuer v. Brown, 7 Vet. App. 379 (1995); Falzone v. Brown, 8 Vet. App. 398 (1995); Caldwell v. Derwinski, 1 Vet. App. 466 (1991). Moreover, the Board finds the Veteran to be credible in that respect. Further, the Board notes that lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. In fact, competent medical evidence is not necessarily required when the determinative issue involves either medical etiology or a medical diagnosis. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 1372); Buchanan v. Nicholson, 451 F.3d. 1331 (Fed. Cir. 2006). Here, as noted above, the Veteran is competent to identify the symptoms of his infrapatellar bursitis and has been found credible in that respect. In sum, the Veteran has competently and credibly reported that his symptoms of swelling and pain have continued since active service. STRs confirm complaints, treatment and diagnosis of infrapatellar bursitis, and the June 2011 VA examination confirms that diagnosis. Therefore, the Board finds that the evidence is at least in equipoise. Accordingly, resolving all reasonable doubt in the Veteran’s favor, the Board finds that entitlement to service connection for a left knee disability is warranted. 38 U.S.C. § 5107(b) (2018); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Vertigo The Veteran asserts that his vertigo is related to his active service. Specifically, he claims that his first bad episode of vertigo began during service and that his episodes of vertigo have continued since that time. The Veteran’s STRs reveal that in December 1995 he complained of dizziness and headaches for four days. At that time, the Veteran stated that if he stood up or turned around too fast, he felt like he was going to fall down and that he had a loss of balance. In December 1998, the Veteran was seen for complaints that the room was spinning and that his episode of vertigo was not controlled with Meclizine. In January 1999, the Veteran was noted as having a history of vertigo. The Veteran’s January 1999 separation report noted that he had been evaluated for vertigo but that it had resolved. However, in February 1999, it was noted that the Veteran had an episode of vertigo. In another March 1999 treatment note, the Veteran stated that his vertigo and dizziness began when he was working under a truck, lasted for approximately 10 minutes, and was associated with nausea. At that time, the Veteran also stated that his next episode was several months later and lasted for hours over a period of two to three days, and that his symptoms had resolved for two years until December 1998. In September 2010, the Veteran was afforded a VA audiological examination. At that time, the Veteran stated that his balance problems with vertigo began in 1994 and 1995 during his military service. The Veteran also noted that his balance problems occurred daily at irregular intervals and lasted for seconds to minutes. The Veteran described the dizziness as lightheadedness, unsteadiness and spinning, that occur with head movements, lying down, standing and a squatting position on elevators. The VA examiner deferred the medical opinion, pertaining to vertigo, to an ear, nose and throat (ENT) physician. Later in September 2010, the Veteran was afforded a VA examination for ear disease. The Veteran reported that the onset of his vestibular problem was 1994 when he experienced a sensation of dizziness. The VA examiner noted that the Veteran’s vestibular problem was recurrent and that he had significant difficulties with vertigo from 1994 until 1998, at which time his vertigo subsided. Additionally, the Veteran stated that the severity of his episodes was less but that the frequency of his recurrent episodes resulted in multiple emergency room visits over the years. The VA examiner noted that the Veteran had a current diagnosis of vertigo. However, the VA examiner opined that the Veteran’s vertigo was less likely than not caused by an otologic disorder that occurred during his military service. The VA examiner reasoned that the Veteran’s military records, audiometric and videonystagmography (VNG) evaluation, and history and physical examination did not support an otologic explanation for the Veteran’s complaint of vertigo. The VA examiner also noted that the Veteran’s dizziness and vertigo during his military service were associated with parallel episodes of dehydration and markedly abnormal blood pressures. In June 2011, the Veteran was afforded a VA audiological examination. At that time, the Veteran reported that he had chronic dizziness and lightheadedness that began in 1995. The Veteran also reported that his episodes occurred every few days for a couple of minutes and that he sat down to get them under control. The VA examiner noted that the Veteran had a diagnosis tinnitus and vertigo. However, the VA examiner deferred the medical opinion, pertaining to vertigo, to an ENT physician. In a June 2011 addendum opinion, a VA examiner opined that the Veteran’s vertigo was less likely than not caused by an otologic disorder that occurred during military service. The VA examiner noted that the Veteran had one abstracted episode of a three-day period of vertigo, resulting in a diagnosis of vestibular neuritis, that was the only condition that impressed him as being otologic, in regard to dizziness. Additionally, the VA examiner stated that the vestibular neuritis was a self-limiting condition over a short time and was not typical to recur. The VA examiner noted that a symptom of the Veteran’s dehydration could have been dizziness. However, the VA examiner did not provide a formal opinion due to a lack of expertise and referred the medical opinion to a practitioner who managed hypertension. In September 2012 treatment note, the Veteran was noted as having dizziness and gait difficulty with staggering. In a May 2016 statement, the Veteran stated that his first bad vertigo spell was in December 1995 which lasted for several days. The Veteran also stated that he had subsequent episodes of vertigo in May 1998, December 1998, January 1999, and February 1999, and that he was diagnosed with episodic vertigo in February 1999. Additionally, the Veteran stated that he dealt with vertigo for 15 years before going to a civilian neurologist, Dr. L.V., who assessed that he had ongoing chronic vertigo and tinnitus. In March 2019, the Veteran reported that he began to have more frequent episodes of severe vertigo in October 2018. In a June 2019 VA addendum opinion, the VA examiner assessed that the medical knowledge to determine the precise natural progression of the Veteran’s vertigo did not exist. The VA examiner also assessed that there was no evidence to support worsening of vertigo beyond its natural progression by the Veteran’s service-connected hypertension. In an August 2019 VA addendum opinion, the VA examiner opined that the Veteran’s vertigo was less likely than not proximately due to or the result of the Veteran’s service-connected hypertension. The VA examiner provided no supporting rationale for that conclusion. The VA examiner also opined that the Veteran’s claimed vertigo was not aggravated by his service-connected hypertension. The VA examiner reasoned that there was no objective evidence of aggravation by his service-connected hypertension found. Additionally, the VA examiner noted that the Veteran’s complaints of vertigo were not supported by repetitive audiologic testing. At the outset, the Board finds that the September 2010, June 2011, and August 2019 VA opinions are inadequate for adjudication purposes. The September 2010 VA examiner failed to provide medical support for her conclusion that there was no otologic explanation for the Veteran’s vertigo. The September 2010 VA examiner also associated the Veteran’s vertigo with his service-connected hypertension but failed to provide an opinion pertaining to aggravation. Additionally, the June 2011 VA examiner noted that the Veteran had an otologic event but then provided speculative language (“not typical”) that failed to even address whether the event could recur in the Veteran, in particular. Finally, the August 2019 VA examiner failed to provide rationale for the direct-service opinion and based the secondary opinion on an inaccurate premise, as the September 2010 VA examiner noted, objectively, that the Veteran’s episodes of vertigo could be associated with significantly elevated blood pressure. Therefore, as those VA opinions are inadequate, they are afforded no probative value. The Board notes that the medical evidence of record supports that the Veteran was diagnosed with vertigo in-service and he has reported that his symptoms have continued since that time. Heuer v. Brown, 7 Vet. App. 379 (1995); Falzone v. Brown, 8 Vet. App. 398 (1995); Caldwell v. Derwinski, 1 Vet. App. 466 (1991). Moreover, the Board finds the Veteran to be credible in that respect. The Board also notes that the Veteran is competent to identify the onset and continued symptoms of his vertigo, and has been found credible in that respect. Jandreau, 492 F.3d at 1372; Buchanan, 451 F.3d. at 1331. In sum, the Veteran’s STRs document complaint of, treatment for, and diagnosis of vertigo. The Veteran has a competently and credibly reported that symptoms of his vertigo have continued since his in-service diagnosis of vertigo, and his post-service treatment records contain a current diagnosis of vertigo. Additionally, the VA medical opinions of record are not adequate and of no probative value. Accordingly, the Board finds that the evidence for and against the claim is at least in equipoise. Therefore, reasonable doubt must be resolved in favor of the Veteran and entitlement to service connection for vertigo is warranted. 38 U.S.C. § 5107 (2018); Gilbert, 1 Vet. App. at 49. Roya Bahrami Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board A. Byrd, 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.