Citation Nr: 21023493 Decision Date: 04/20/21 Archive Date: 04/20/21 DOCKET NO. 14-07 823 DATE: April 20, 2021 ORDER Service connection for left knee disability, to include as secondary to service-connected low back disability, is denied. Service connection for right knee disability, to include as secondary to service-connected low back disability, is denied. Service connection for left hand disability, to include as secondary to service-connected right hand disability, is denied. Service connection for hypertension is denied. FINDINGS OF FACT 1. The Veteran’s left knee disability was not manifested in service or in the first post-service year; and is not shown to be related to his service or secondary to a service-connected disability. 2. The Veteran’s right knee disability was not manifested in service or in the first post-service year; and is not shown to be related to his service or secondary to a service-connected disability. 3. The Veteran’s left hand disability was not manifested in service or in the first post-service year; and is not shown to be related to his service or secondary to a service-connected disability. 4. The Veteran’s hypertension was not manifested in service or in the first post-service year, and is not shown to be related to his service. CONCLUSIONS OF LAW 1. The criteria for service connection for left knee disability, to include as secondary to service-connected low back disability, 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, 3.310. 2. The criteria for service connection for right knee disability, to include as secondary to service-connected low back disability, 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, 3.310. 3. The criteria for service connection for left hand disability, to include as secondary to service-connected right hand disability, 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, 3.310. 4. The criteria for service connection for hypertension 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 June 1972 to June 1974. The Veteran testified before the undersigned Veterans Law Judge during a November 2018 hearing. A transcript of the hearing is in the record before the Board. In August 2019, the Board remanded the claims on appeal, along with the claim of entitlement to service connection for headaches. A September 2020 rating decision granted service connection for migraine headaches. As a result, the headache claim is no longer before the Board. The Board remanded the claims on appeal again in November 2020 for additional development. Significantly, the Board found that August 2020 VA Medical Opinions were inadequate. They provided medical opinions for the Veteran’s knees and hypertension that were difficult to understand and a medical opinion for the Veteran’s left hand that was based on an inaccurate medical history. There has been substantial compliance with the November 2020 remand and the Board will proceed with adjudication. Stegall v. West, 11 Vet. App. 268 (1998). Service Connection In general, 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) a 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). Certain chronic diseases, including arthritis and hypertension, 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 one-year 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). Service connection may also be granted for a disability that is proximately due to, or aggravated by, service-connected disease or injury. 38 C.F.R. § 3.310. 1. Service connection for left knee disability, to include as secondary to service-connected low back disability. 2. Service connection for right knee disability, to include as secondary to service-connected low back disability. The Veteran contends that his left and right knee disabilities are due to active duty, or his service-connected residuals of low back injury. During a March 2018 VA examination, he stated that an in-service laceration several inches above the right knee resulted in a current right knee disability. A March 2018 VA examination report provides a diagnosis of right knee patellofemoral syndrome and relates that each knee has arthritis. The question for the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. The Board concludes that, while the Veteran has current left and right knee diagnoses, the preponderance of the evidence is against a finding that his left knee disability or right knee disability first manifested in service or manifested to a compensable degree within the first post-service year, are otherwise related to service, or are proximately due to, or aggravated by, service-connected disease or injury. The Veteran's service treatment records are negative for relevant complaints, symptoms, findings or diagnoses other than an August 1972 swollen left knee from an infected insect bite. The post-service medical records are negative for a left or right knee disability, to include arthritis, for many years after the Veteran’s separation from service. A significant lapse in time between service and post-service medical treatment may be considered as part of the analysis of a service connection claim. Maxson v. Gober, 230 F.3d 1330 (Fed. Cir. 2000). A March 2018 VA Medical Opinion specifically indicates that the Veteran’s right patellofemoral syndrome was less likely than not proximately due to or the result of the Veteran’s service-connected low back disability. The rationale section provides that the Veteran’s right knee patellofemoral syndrome was not related to service on a direct basis. The examiner pointed out that neither the right knee laceration nor a right knee problem could be confirmed in the Veteran's service treatment records. An x-ray that day did not even show arthritis. One would suspect that if the low back had been such a problem to the knee for this many decades there would at least be some arthritis. The examiner observed that the Veteran worked physical jobs (standing and walking) after leaving service until 2003. This too would likely cause patellofemoral syndrome. The Veteran was overweight and had been so for many years. Simple aging could contribute to patellofemoral syndrome and arthritis. With all of these factors, it would appear that there was not enough medical evidence to make a nexus either directly to service or secondary to the Veteran's low back disability. Other factors were more medically likely to be the main cause of the Veteran's right knee patellofemoral syndrome. An April 2018 VA Medical Opinion specifically indicates that the Veteran's left knee mild arthritis and some patellofemoral syndrome were less likely than not proximately due to or the result of the Veteran's service-connected low back disability. The rationale section provides that the Veteran's left knee mild arthritis and some patellofemoral syndrome were not related to service on a direct basis. The examiner pointed out that there was no evidence of any ongoing left knee chronic condition upon the Veteran leaving the service. There were no records showing any significant knee condition until the last couple of years. The Veteran was overweight, aging and did a standing job for many years. Therefore, there was not enough medical evidence to make a nexus either directly to service or secondary to his low back disability. In addition, the treatment for an infected insect bite in 1972 would not be medically related or relevant to his current left knee disability either. A December 2020 VA Medical Opinion provides that there was no evidence supporting the Veteran's contentions that his right or left knee arthritis or patellofemoral syndrome were aggravated by his service-connected low back disability. As a rationale, the examiner reviewed an August 2017 VA examination report regarding the Veteran's post-service jobs, and March 2018 and February 2020 VA examination reports regarding current findings. The examiner found that the knee examinations in 2018 and 2020 did not indicate that the back condition was affecting the bilateral knee condition. The Board finds that the foregoing evidence does not show that the Veteran's left knee disability or right knee disability first manifested in service or manifested to a compensable degree within the first post-service year, are otherwise related to service, or are proximately due to, or aggravated by, service-connected disease or injury. The Board recognizes that a February 2020 VA Medical Opinion provides a medical opinion linking the Veteran's left knee disability to service based on the rational that the Veteran had “severe STS of the left knee in 1972 and cont to note knee pain throughout the service and since d/c.” Further, the February 2020 opinion provider linked the Veteran's right knee disability to his left knee disability. However, the left knee opinion is based on an incorrect review of the Veteran's service treatment records. The service treatment records do not show continued notations of knee pain throughout service. There is no documentation of knee pain following the August 1972 insect bite which was noted to have caused effusion of the knee. A June 1974 separation examination noted clinical examination of the lower extremities was normal; an August 1974 reenlistment examination also noted normal lower extremities and the Veteran denied having a trick or locked knee or arthritis in his report of medical history. The Veteran also made similar denials of knee problems in a January 1976 report of medical history. Accordingly, the Board finds the February 2020 opinions were based on an inaccurate factual premise and are without probative value. The Board also recognizes the Veteran's own assertions in support of his claims. However, the Veteran himself is not competent to provide medical opinions that his knee disabilities are related to active duty or were caused or aggravated by his service-connected low back disability. These issues are medically complex and require specialized medical training and expertise. Therefore, they are outside the competence of the Veteran in this case because the record does not show that he has the medical training or credentials 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). Further, to the extent the Veteran asserts continuity of symptomatology, such assertions lack credibility as they are inconsistent with his assertions at the time of his service examinations and/or reports of medical history in June 1974, August 1974, and January 1976. In light of the foregoing, service connection for left knee disability, to include as secondary to service-connected low back disability, and right knee disability, to include as secondary to service-connected low back disability, is denied. In reaching this decision, the Board has considered the applicability of the benefit of the doubt doctrine. However, the preponderance of the evidence is against the claims. 38 U.S.C. § 5107. 3. Service connection for left hand disability, to include as secondary to service-connected right hand disability. The Veteran contends that his left hand disability is due to active duty, or his service-connected residual of fracture, proximal tip of the right 4th metacarpal. An August 2017 VA examination report provides a diagnosis of left hand degenerative arthritis. The question for the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. The Board concludes that, while the Veteran has a current left hand diagnosis, the preponderance of the evidence is against a finding that his left hand disability first manifested in service or manifested to a compensable degree within the first post-service year, is otherwise related to service, or is proximately due to, or aggravated by, service-connected disease or injury. The Veteran’s service treatment records include a November 1972 record of a one inch laceration of the distal left middle finger which required 2 sutures and the follow-up was noted as return in a week for suture removal. The June 1974 separation examination and an August 1974 reenlistment examination noted clinical examination of the upper extremities was normal. The post-service medical records are negative for a left hand disability, to include arthritis, for many years after the Veteran’s separation from service. A significant lapse in time between service and post-service medical treatment may be considered as part of the analysis of a service connection claim. Maxson, supra. An August 2017 VA Medical Opinion specifically indicates that the Veteran’s left hand disability was less likely than not proximately due to or the result of the Veteran’s service-connected right hand disability. The rationale section provides that the Veteran’s left hand disability was not related to service on a direct basis. The examiner observed that when asked, the Veteran denied having a chronic disabling left hand disability. The examiner pointed out that the Veteran only complained of numbness in the fingers of the left hand and based on the available history this was at least as likely as not due to radiculopathy. While the Veteran had degenerative changes of his hand and wrist, no chronically disabling condition of the left hand was noted or resulted from the in-service fracture of the right 4th metacarpal. The Veteran's degenerative changes of both hands were very similar and would be consistent with normal wear and tear from his post-military work for 31 years setting up machines and being a molding fitter. A December 2020 VA Medical Opinion provides that there was no evidence supporting the Veteran’s contentions that his left hand arthritis was aggravated by his service-connected right hand 4th metacarpal fracture. As a rationale, the examiner reviewed August 2017 and February 2020 VA examination reports regarding current findings. She stated that it “IS at least as likely as not the Veteran's post military physical labor for 30 years as well as his self-reported history of polypsoriatic arthritis IS the etiology of his left hand arthritis and it is NOT at least as likely as not related to or aggravated by his well healed right hand 4th metacarpal fracture in 1973.” (emphasis in original) The Board finds that the preponderance of evidence is against a finding that the Veteran's left hand disability first manifested in service or manifested to a compensable degree within the first post-service year, is otherwise related to service, or is proximately due to, or aggravated by, service-connected disease or injury. The Board recognizes that a February 2020 VA Medical Opinion provides a medical opinion linking the Veteran’s left hand disability to service. However, the opinion is based on an incorrect review of the Veteran’s service treatment records. The opinion provider’s rationale for the positive opinion was that the Veteran “injred his left hand after striking it on a gate of a truck in 1973” and “after cont c/o pain for 1 month xrays dx a chip fx of the 4th MCP.” , and accordingly it does not support the Veteran’s claim. However, this history is accurate with respect to the service-connected right hand injury, as reflected in the STRs, but not the left. Accordingly, this opinion is afforded no probative weight. The Board also recognizes the Veteran’s own assertions in support of his claim. However, the Veteran himself is not competent to provide a medical opinion that his left hand disability is related to active duty or was caused or aggravated by his service-connected right hand disability. This issue is medically complex and requires specialized medical training and expertise. Therefore, it is outside the competence of the Veteran in this case because the record does not show that he has the medical training or credentials to make such a determination. Jandreau, supra; see also Kahana, supra. Further, to the extent the Veteran asserts continuity of symptomatology, such assertions lack credibility as they are inconsistent with his assertions at the time of his service examinations and/or reports of medical history in June 1974, August 1974, and January 1976 at which times he denied a bone or joint deformity and arthritis, rheumatism or bursitis. In light of the foregoing, service connection for left hand disability, to include as secondary to service-connected right hand disability, is denied. In reaching this decision, the Board has considered the applicability of the benefit of the doubt doctrine. However, the preponderance of the evidence is against the claim. 38 U.S.C. § 5107. 4. Service connection for hypertension. The Veteran contends that his hypertension is due to active duty. VA CAPRI records provide a diagnosis of essential hypertension. The question for the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. The Board concludes that, while the Veteran has a current hypertension diagnosis, the preponderance of the evidence is against a finding that his hypertension first manifested in service or manifested to a compensable degree within the first post-service year, is otherwise related to service. The Veteran’s service treatment records are negative for diagnoses of hypertension. He had a blood pressure reading of 138/82 at entrance. His blood pressure reading was 138/102 on service discharge examination in June 1974, prompting serial blood pressure readings of 142/98, 150/76, 148/80 and 148/88, after which it was concluded that no treatment was required. Subsequent reenlistment examination reports show blood pressure readings of 110/72 and 130/88 on the same date in August 1974, a blood pressure reading of 130/88 in January 1976, and that the Veteran reported that he was on no medication and was in good health. A December 2020 VA Medical Opinion provides that the Veteran's hypertension was less likely than not incurred in or aggravated by service. As a rationale, the examiner reviewed the blood pressure readings in the Veteran's service treatment records. She noted that shortly after his entrance, the Veteran denied having or having had high blood pressure. His blood pressure reading at separation was slightly higher than his enlistment blood pressure but not enough to give him a diagnosis of hypertension at the time or currently for compensation purposes according to the VA Hypertension DBQ, which required a blood pressure reading predominantly 160 systolic or 90 diastolic. His blood pressure readings on his 1974 and 1976 reenlistment examinations were not significantly different than his enlistment blood pressure. Therefore, there was no evidence that the Veteran's current hypertension disorder was incurred in or aggravated by service. The Board finds that the preponderance of the evidence is against a finding that the Veteran's hypertension first manifested in service or manifested to a compensable degree within the first post-service year, or is otherwise related to service. The Board also recognizes the Veteran’s own assertions in support of his claim. However, the Veteran himself is not competent to provide a medical opinion that his hypertension is related to active duty. This issue is medically complex and requires specialized medical training and expertise. Therefore, it is outside the competence of the Veteran in this case because the record does not show that he has the medical training or credentials to make such a determination. Jandreau, supra; see also Kahana, supra. In light of the foregoing, service connection for hypertension is denied. In reaching this decision, the Board has considered the applicability of the benefit of the doubt doctrine. However, the preponderance of the evidence is against the claim. 38 U.S.C. § 5107. M. C. GRAHAM Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Davitian, 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.