Citation Nr: 21025513 Decision Date: 04/28/21 Archive Date: 04/28/21 DOCKET NO. 16-22 343 DATE: April 28, 2021 ORDER Entitlement to service connection for traumatic right knee arthritis, status-post total knee arthroplasty, is granted. Entitlement to service connection for atrial fibrillation is granted. FINDINGS OF FACT 1. The Veteran sustained a traumatic right knee injury in service and has experienced continuity of symptomatology related to traumatic right knee arthritis since his separation from service. 2. The Veteran’s atrial fibrillation is a consequence of surgical treatment for his herein service-connected traumatic right knee arthritis. CONCLUSIONS OF LAW 1. Traumatic right knee arthritis, status-post total knee arthroplasty, was incurred in service. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. Atrial fibrillation is proximately due to or the result of service-connected disease or injury. 38 C.F.R. § 3.310(a). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from December 1977 to September 1992. The Board previously remanded the Veteran’s claims in July 2020. Service Connection 1. Entitlement to service connection for traumatic right knee arthritis status-post total knee arthroplasty The Veteran contends his right knee arthritis is due to service, including from constantly being on his feet and running, and that he has been symptomatic, albeit intermittently, since service. See January 2015 notice of disagreement. i. Applicable Law Generally, to establish service connection, a claimant must show: (1) a present disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service, the so-called “nexus” requirement. See 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303; see also Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004).  With chronic disease shown as such in service (or within the presumptive period under § 3.307) so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. This rule does not mean that any manifestation of joint pain, any abnormality of heart action or heart sounds, any urinary findings of casts, or any cough, in service will permit service connection of arthritis, disease of the heart, nephritis, or pulmonary disease, first shown as a clearcut clinical entity, at some later date. For the showing of chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word “Chronic.” When the disease identity is established (leprosy, tuberculosis, multiple sclerosis, etc.), there is no requirement of evidentiary showing of continuity. Continuity of symptomatology is required only where the condition noted during service (or in the presumptive period) is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303(b). ii. Facts and Analysis The record evidences that when the Veteran filed his claim, he had bilateral knee arthritis, and shortly after filing his claim, had right knee replacement surgery. Arthritis is an enumerated chronic disease under 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 708 F.3d 1331, 1338 (2013) (finding 38 C.F.R. § 3.303(b) is constrained by § 3.309(a)). Service treatment records show the Veteran complained of and was treated for symptoms of right knee pain in March 1988 and April 1990. In March 1988 the Veteran reported his knee had been bothering him for four months and that pain increased with activity. See March 11, 1988 service treatment record. In April 1990 the Veteran was training for a challenge competition and had being doing a lot of running and carrying heavy objects. He reported pain and “popping” in his knees. He was found to have bilateral contused medial meniscus. See April 20, 1992 service treatment record. A review of post-service treatment records reflects right knee surgery in February 2014 and complaints in the years just prior to that, including as far back as February 2011. See, e.g., VA treatment records from February 18, 2011 (pain in knees and feet) and May 17, 2011 (right knee steroid injection, but no discussion of historical symptoms). Prior to February 2011, there are limited treatment records in the Veteran’s claims file and those that do exist predominantly focus on ulcerative colitis and cancer treatment. The Veteran attended VA knee examinations in July 2014 and December 2020. The July 2014 examiner noted the Veteran was diagnosed with a contused meniscus in service, but that this diagnosis was made without evidence of an x-ray or magnetic resonance imaging (MRI). The examiner emphasized, “OF NOTE: A MRI is used to diagnose a meniscal contusion . . . this is an acute selflimiting condition, and unlike a meniscus tear, resolves by itself and does not leave residual.” See July 2014 examination report, pages 5-6. VA treatment records, not identified by either the July 2014 or December 2020 examiners, show the Veteran has multiple meniscus tears. See November 21, 2013 VA treatment record (MRI revealing multiple tears, but does not specify if new or old). The July 2014 examiner opined the Veteran’s bilateral knee osteoarthritis is less likely as not caused by or a result of intra-service events. The examiner explained that treatment records suggest his degenerative condition did not become symptomatic until many years after service, there was no direct service injury, and that post-service the Veteran had years with long hours of standing and walking at work. The Board previously considered the July 2014 examiner’s opinion, but remanded for a new examination, since the examiner did not specifically address the Veteran’s lay assertions that he had right knee pain since his multiple in-service reports of knee pain. The Veteran attended another VA examination in December 2020. The examiner likewise provided a negative nexus opinion. In support of the negative nexus opinion, the examiner stated, “During service, right knee arthritis, was acute only. There is no evidence of chronicity of care and symptoms are subjective only. A nexus has not been established.” In providing a rationale for a negative nexus opinion, the December 2020 examiner’s only reference to the Veteran’s reports of pain was to say, “symptoms are subjective only”. However, the Veteran is competent to report pain. See Miller v. Wilkie, 32 Vet. App. 249, 260 (2020). Also, the 2013 MRI revealing multiple meniscus tears is objective evidence of knee disability that was overlooked by both examiners. While there are limited treatment records from prior to 2011, the Board finds that the Veteran has continued to experience right knee symptoms since service. The Veteran is competent to report that he experienced intermittent pain since service that has worsened over the years. His statements are credible and entitled to probative weight, as they are internally consistent and consistent with other evidence of record, including his April 1990 service record that shows increased symptoms with increased use. In addition, the service records reflect an on-going issue lasting a significant length of time. Furthermore, the evidence is at least in equipoise as to whether the Veteran sustained a meniscus tear in service. As noted above, diagnostic imaging was not performed in service, and mere contusion is not expected to have residuals. Here the Veteran has had residuals of intermittent pain and popping, particularly with increased use, which has increased in frequency and severity over time. The Veteran has not reported an intercurrent right knee injury. Similarly, the limited treatment records do not reveal a post-service knee injury, and the July 2014 VA examiner, who had access to more treatment records than the Board, did note a specific post-service right knee injury. In light of the above, the Veteran has had a continuity of right knee symptomatology since service. This serves as a nexus between service and the Veteran’s current right knee disability. See Walker v. Shinseki, 708 F.3d 1331, 1338-1339 (2013). Accordingly, service connection is granted. 2. Entitlement to service connection for atrial fibrillation Upon review of the evidence of record, the Board finds the Veteran’s atrial fibrillation is proximately due to, or the result of, treatment for his herein service-connected right knee arthritis. Generally, to establish service connection, a claimant must show: (1) a present disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service, the so-called “nexus” requirement. See 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303; see also Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Except as provided in § 3.300(c), disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. 38 C.F.R. § 3.310. The Veteran was seen for a VA heart examination in December 2020, but the focus of this examination, and the opinions provided, were on an ostensible heart disability that possibly pre-existed service and whether it was aggravated by service or aggravated by surgical treatment of the Veteran’s service-connected ulcerative colitis. No medical professional has indicated the Veteran current’s atrial fibrillation is the same disability as the sinus arrythmia (tachycardia) that possibly pre-existed service and was noted at entry. To the contrary, the December 2020 VA examiner opined the Veteran did not actually have a pre-existing disability and does not have a heart disability that is directly related to service. The Veteran has reported that atrial fibrillation developed as a consequence of his right knee replacement surgery. The Veteran’s knee surgery was performed outside of VA, and records from that surgery are not contained within the Veteran’s claims file. The Veteran has consistently reported post-surgery atrial fibrillation to treatment providers, and treatment records reflect relevant treatment. Furthermore, the Veteran is competent to report being informed that blood clots and atrial fibrillation developed in relation to his knee surgery. See, e.g., May 15, 2014 VA treatment record (from chief complaint – “He recently had a knee replacement but then ended up with four blood clots, two in his lungs and had Atrial fibrillation”). VA records note the Veteran was diagnosed with atrial fibrillation (AFib) in 2014, without more specificity. Nevertheless, the Veteran’s VA records also note the Veteran developed pulmonary embolisms (PE) two days after his knee surgery, was subsequently treated for PE and AFib with anticoagulants, and continues to be treated for AFib. See VA treatment records from March 10, 2014 (pulmonary embolisms), November 18, 2014 (anticoagulation treatment for PE and AFib), and January 31, 2021 (AFib treated with anticoagulant therapy).   The evidence of record does not contain an actual medical opinion regarding the relationship between the Veteran’s knee surgery and AFib. However, in light of the competent and credible evidence of record, as discussed above, the Board finds the Veteran’s atrial fibrillation is proximately due to or the result of treatment of the Veteran’s herein service-connected knee traumatic arthritis. Therefore, service connection for atrial fibrillation is granted. H. N. SCHWARTZ Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Gregory T. Shannon, 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.