Citation Nr: 21024146 Decision Date: 04/22/21 Archive Date: 04/22/21 DOCKET NO. 15-25 290 DATE: April 22, 2021 ORDER Service connection for a left knee disorder, claimed as secondary to service-connected right knee disability, is denied. FINDING OF FACT A left knee disorder is not shown to be caused or aggravated by service-connected right knee disability. CONCLUSION OF LAW The criteria for service connection for a left knee disorder, claimed as secondary to service-connected right knee disability, have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty form January 1969 to January 1972. This matter comes to the Board of Veterans’ Appeals (Board) on appeal from a rating decision issued in December 2013 by a Department of Veterans Affairs (VA) Regional Office. In June 2018, the Veteran testified at a Board hearing before the undersigned Veterans Law Judge. A transcript of the hearing is associated with the record. In November 2018, January 2020, and December 2020, the Board remanded the case for additional development and it now returns for further appellate review. Entitlement to service connection for a left knee disorder, claimed as secondary to service-connected right knee disability. As an initial matter, the Board notes that the Veteran does not allege, nor does the record reflect, that he first manifested a left knee disorder, to include arthritis, during service or within one year of his separation from service, or that such disorder is otherwise related to his military service on a direct or presumptive basis. See Robinson v. Shinseki, 557 F.3d 1355, 1361 (2008) (claims which have no support in the record need not be considered by the Board as the Board is not obligated to consider “all possible” substantive theories of recovery. Where a fully developed record is presented to the Board with no evidentiary support for a particular theory of recovery, there is no reason for the Board to address or consider such a theory). Rather, the Veteran claims that his left knee disorder is secondary to his service-connected right knee disability. Specifically, he alleges that his osteoarthritis of the right knee spread to his other joints, resulted in an altered gait and stature, and/or caused numerous falls, thereby negatively impacting his left knee. In this regard, service connection may be established on a secondary basis for a disability which is proximately due to or the result of service-connected disease or injury. 38 U.S.C. § 1110; 38 C.F.R. § 3.310 (a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). Further, service connection may not be awarded on the basis of aggravation without establishing a pre-aggravation baseline level of disability and comparing it to the current level of disability. 38 C.F.R. § 3.310 (b). As an initial matter, the Board observes that the record reflects that the Veteran has a current diagnosis of osteoarthritis of the left knee. In this regard, the Board notes that it was originally suggested he had rheumatoid arthritis; however, a September 2019 VA examiner reported that she could not confirm a diagnosis of rheumatoid arthritis of the left knee based on objective testing; rather, she found that the evidence supported a diagnosis of osteoarthritis or degenerative joint disease of the left knee. Such diagnosis was further confirmed at a February 2020 VA examination and by a third VA examiner in December 2020. The Veteran is also service-connected for a total right knee replacement, which was previously characterized as osteoarthritis. Thus, the remaining inquiry is whether the Veteran’s left knee disorder is caused or aggravated by his service-connected right knee disability, to include as a result of an altered gait. In this regard, at a May 2013 VA examination, it was noted that the Veteran used a cane and brace, and favored the left knee. Additionally, a November 2014 VA record reflected a finding of an impaired gait and ambulation with an antalgic pattern while using a rolling walker. However, in September 2019, a VA physician opined that the Veteran’s right knee osteoarthritis did not spread to his other joints, and there was no documentation of an altered gait and stature and/or that such resulted in numerous falls, so as to negatively impact his left knee. In this regard, the VA physician cited to a May 2013 VA examination report, which she reported “showed no major issued with left knee and no documentation of abnormal gait.” She further opined the service-connected right knee disability is not associated with the development of any arthritis or osteoarthritis in any remote joints, and the Veteran’s left knee disorder is not affected by his right knee disability. Per medical literature, right knee osteoarthritis cannot spread to the other joints as it is a degenerative disease of cartilage and results in overgrowth of bone underneath the cartilage. According to the VA physician, a traumatic joint injury in some people can lead to osteoarthritis, while in others, genetics may play a role. The disease usually begins with a single large joint, such as a hip or knee. Finally, she found that the evidence indicates that an injury in one extremity rarely causes a major problem in the opposite or uninjured extremity except when damage to the leg results in a major displacement of the centre of gravity of the body while walking, significant shortening of the injured limb, and an abnormal gait pattern present for an extended period of time. In the January 2020 Board remand, it was noted that the VA physician relied, at least in part, on the absence of evidence of an altered gait and stature at the May 2013 VA examination. However, as noted previously, the examination report indicated that the Veteran used a cane and brace, and favored the left knee. Further, such did not specifically comment on his gait. Additionally, the aforementioned November 2014 VA treatment record reflected an impaired gait and ambulation with an antalgic pattern while using a rolling walker. Therefore, the Board found a remand necessary in order to obtain an addendum opinion that considered such evidence. Accordingly, in February 2020, the Veteran underwent an additional VA examination and an addendum opinion was rendered. Specifically, the examiner opined that his left knee disorder is less likely than not proximately due to or the result of his service-connected right knee disability. In this regard, she noted that the evidence indicates that an injury in one extremity rarely causes a major problem in the opposite or uninjured extremity except when damage to the leg results in major displacement or the center of gravity of the body while walking, significant shortening of the injured limb, and abnormal gait pattern has been present for an extended period of time. Additionally, in the July 2020 addendum opinion, the examiner opined that it is less likely that a right knee condition would aggravate a left knee condition given the absence of major displacement of the center of gravity or shortening of a limb. As noted in the December 2020 remand, the Board found the February 2020 and July 2020 opinions to be inadequate as the examiner simply restated the same rationale as provided in the September 2019 opinion and did not consider aforementioned May 2013 and November 2014 records indicating an altered gait. Thus, the Board again remanded the claim in order to obtain an addendum opinion. In December 2020, a VA examiner opined that the Veteran’s left knee disorder, which clearly and unmistakably existed prior to service, was clearly and unmistakably not aggravated beyond its natural progression by an in-service injury, event, or illness. In this regard, while such standard pertains to disorders that existed prior to service, which is not the case here, the Board notes that the examiner merely checked the box addressing aggravation by service, rather than aggravation by a service-connected disability. Nonetheless, the totality of the opinion provided, as described further herein, indicates the examiner’s determination that the Veteran’s left knee disorder was not caused or aggravated by his right knee disability. In this regard, a medical examination report must be read as a whole in determining its adequacy, and the Board is permitted to draw inferences based on the overall report so long as the inference does not result in a medical determination. Acevedo v. Shinseki, 25 Vet. App. 286, 294 (2012)(citing Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011)). In this regard, the December 2020 VA examiner determined that the Veteran’s diagnosed left knee disorder, identified as osteoarthritis, is very common in the general population for his age group, and is caused by genetics and age-related wear and tear. He further indicated that he agreed with the September 2019 VA examiner’s assessment an injury in one extremity rarely causes a major problem in the opposite or undamaged extremity except when damage to the leg results in a major displacement of the center of gravity of the body while walking, significant shortening of the injured limb, and an abnormal gait pattern present for an extended period of time. In further support of the foregoing determination, the examiner cited relevant medical literature for the proposition that there was no clear evidence to suggest that an injury to one lower extremity would have any significant impact on the opposite uninjured limb unless the injury resulted in major muscle or nerve damage causing partial or complete paralysis of the damaged leg and/or shortening of the injured lower extremity resulting in a limb length discrepancy of more than four or five centimeters so that the individual’s gait pattern has been altered ot the extent that clinically there is an obvious lurching type gait (a significant limp). Such literature also indicated that, in order for such type of gait to have an impact on the opposite or uninjured leg, it is likely that the abnormal gait or limp would need to be present over an extended period of time, i.e., years. Further, it was noted that a temporary abnormality in gait, e.g., a limp over a relatively short period of time of weeks or months is unlikely to have any effect on the opposite leg. Finally, it was observed that the use of a cast, cane, and crutches are also unlikely to have any major impact on the stress borne by the uninjured limb. In regard to the use of crutches, the examiner noted that crutches are used either to completely unload the injured extremity or to partially unload it. When completely unloading the extremity, the injured leg dangles in the air in permanent swing phase and the weight borne is not enough to cause a strain. In the case of partial unloading the injured extremity, the injured leg is on the ground and body weight is borne by the arms through the crutches. Thus, there is no change in the weight born by the normal leg and there is no change in the rhythm of gait. In regard to the May 2013 VA examination report, which indicates that the Veteran used a cane and brace, the examiner referenced the above medical literature and reported that there is no evidence that using a cane or brace put significant stress on his left leg or shifted his weight to the left. Rather, it simply meant that the Veteran treated his left knee gently. With respect to the November 2014 VA treatment record, which shows that the Veteran had an impaired gait and ambulated with antalgic pattern while using a rolling walker, the examiner reported that there is no evidence that the abnormal gait was severe and lasted for years so as to have an impact on the left leg, especially as it was noted that strength, gait, and function were expected to improve following his November 2014 right knee replacement. Further, there was no evidence of abnormal gait at the February 2020 VA examination. Thus, the examiner found that, even with the history of impaired gait, using a cane, crutches, or walker, it is unlikely that the Veteran’s right knee disability had a major impact on his left leg. The Board affords great probative weight to the VA examiner’s December 2020 opinions as such considered all of the pertinent evidence of record, to include the Veteran’s medical history and a provided a complete rationale, relying on and citing to the records reviewed. Moreover, the examiner offered clear conclusions with supporting data as reasoned medical explanations connecting the two. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). Notably, there is no medical opinion to the contrary. The Board has considered the Veteran’s statements that his left knee disorder is related to his service-connected right knee disability; however, as a lay person, he does not have the specialized training sufficient to render such an opinion. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007) (noting general competence to testify as to symptoms but not to provide medical diagnosis). In this regard, the etiology of such disorders is a matter not capable of lay observation and requires medical expertise to determine. Specifically, the question of etiology of such disorder involves a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship as it requires knowledge of the musculoskeletal system and the impact of one joint on another. See Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (explaining that while the claimant is competent in certain situations to provide a diagnosis of a simple condition such as a broken leg or varicose veins, the claimant is not competent to provide evidence as to more complex medical questions). Accordingly, the Veteran’s opinion as to the etiology of his left knee disorder is not competent evidence and, consequently, is afforded no probative weight. Consequently, the Board finds that a left knee disorder is not shown to be caused or aggravated by his service-connected right knee disability. Thus, service connection for such disorder is not warranted. In reaching such conclusion, the Board has considered the applicability of the benefit-of-the doubt doctrine. However, as the preponderance of the evidence is against the Veteran’s claim for service connection for a left knee disorder, that doctrine is not applicable, and the claim must be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). A. JAEGER Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Waite 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.