Citation Nr: 21026144 Decision Date: 04/29/21 Archive Date: 04/29/21 DOCKET NO. 14-10 409 DATE: April 29, 2021 ORDER Service connection for a left knee disorder is denied. Service connection for a left shoulder disorder is denied. Service connection for a left foot disorder is denied. FINDINGS OF FACT 1. A left knee disorder is not shown to be causally or etiologically related to any disease, injury, or incident during service, and is not caused or aggravated by a service-connected disability. 2. A left shoulder disorder is not shown to be causally or etiologically related to any disease, injury, or incident during service. 3. A left shoulder disorder is not shown to be causally or etiologically related to any disease, injury, or incident during service, and is not caused or aggravated by a service-connected disability. CONCLUSIONS OF LAW 1. The criteria for service connection for a left knee disorder have not been met. 38 U.S.C. §§ 1110, 1154(b), 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 2. The criteria for service connection for a left shoulder disorder have not been met. 38 U.S.C. §§ 1110, 1154(b), 5107; 38 C.F.R. §§ 3.102, 3.303. 3. The criteria for service connection for a left foot disorder have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from September 1999 to December 2003. This matter comes before the Board of Veterans’ Appeals (Board) from rating decisions issued in September 2012 and May 2013 by a Department of Veterans Affairs (VA) Regional Office. In July 2017, the Veteran testified at a Board hearing before the undersigned Veterans Law Judge. A transcript of the hearing is of record. In May 2018 and April 2020, the Board remanded the instant claims, as well as a claim for service connection for erectile dysfunction for additional development. While on remand, an August 2020 rating decision granted service connection for erectile dysfunction. As such is a full grant of the benefit sought on appeal with respect to such issue, it is no longer before the Board. Grantham v. Brown, 114 F.3d 1156, 1159 (Fed. Cir. 1997). The case now returns for further appellate review. Service Connection Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Service connection may also be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Direct service connection may not be granted without evidence of a current disability; in-service incurrence or aggravation of a disease or injury; and a nexus between the claimed in-service disease or injury and the present disease or injury. Id.; see also Caluza v. Brown, 7 Vet. App. 498, 506 (1995) aff’d, 78 F.3d 604 (Fed. Cir. 1996) [(table)]. Service connection may also be established on a secondary basis for a disability which is proximately due to or the result of service-connected disease or injury. 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). 1. Entitlement to service connection for left knee disorder, to include as secondary to service-connected left ankle strain with old avulsion and calcaneal spur and/or service-connected posttraumatic stress disorder (PTSD). When initiating his claim, the Veteran contended that he started to experience left knee swelling and pain subsequent to the injury to his service-connected left ankle disability during service. Thus, he claimed that his left knee disorder is directly related to his military service, or is caused or aggravated by his service-connected left ankle strain with old avulsion and calcaneal spur. He also alleged, in the alternative, that such disorder is caused or aggravated by his service-connected PTSD, but did not offer a basis for such theory of entitlement. The Veteran’s service treatment records (STRs) reveal a complaint of unspecified knee pain after playing soccer in July 2003. His separation examination only reveals complaints of prior right knee injury, accompanied with symptoms of swelling and popping. After service, in August 2004, the Veteran reported bilateral knee pain; however, only an X-ray of the right knee was performed. In October 2012, the Veteran underwent a VA examination at which time he reported the onset of left knee symptoms in 1999 from carrying heavy gear. The examiner provided a diagnosis of left knee patellofemoral pain syndrome, and opined that such disorder was less likely than not incurred in or caused by the claimed in-service injury, event, illness. In this regard, he noted the Veteran’s STRs did not include any complaints specific to the left knee and, based on the evidence of record, the findings on examination, and the known etiology/progression of the condition involved, his left knee disorder was less likely than not related to service. At a February 2019 VA examination, the examiner found that the Veteran’s left knee pain was not consistent with patellofemoral pain syndrome; rather, he diagnosed left knee strain. Following a review of the record, an interview with the Veteran, wherein he alleged, for the first time, that his left knee disorder resulted from being tossed to the ground by a rocket propelled grenade (RPG) blast in April 2003; and a physical examination, the examiner opined that his left knee disorder was less likely than not aggravated by the Veteran’s left ankle strain or PTSD. He further found that there are no records to establish a left knee condition during service. In this regard, while a July 2003 service treatment record referenced pain of an unspecified knee while playing soccer, his separation examination only noted twisting injury of the right knee. Further, there was a significant lack of evidence that the Veteran had any sort of established left knee condition that already existed and was aggravated by the aforementioned service-connected disabilities. However, in the April 2020 remand, the Board observed that the Veteran is in receipt of the Army Commendation Medal with Combat Valor Device “V,” which denotes combat. Thus, he is entitled to the presumptions afforded combat veterans in 38 U.S.C. § 1154(b), which provides that, in any case where a veteran is engaged in combat during active service, lay or other evidence of service incurrence of a combat related disease or injury will be considered sufficient proof of service connection if consistent with the circumstances, conditions, or hardships of service, notwithstanding the fact that there is no official record of such incurrence during service. In this regard, the Board notes that the presumption found in § 1154(b) applies not only to the potential cause of a disability, but also to whether a disability itself was incurred while in service. See Reeves v. Shinseki, 682 F.3d 988, 999 (Fed. Cir. 2012). However, the combat presumption, does not alleviate the requirement that the evidence show current disabilities attributable to the past in-service disorders. See generally Clyburn v. West, 12 Vet. App. 296, 303 (1999). Therefore, the Board found it was necessary to obtain an opinion that addressing whether the Veteran’s left knee disorder is related to his acknowledged that the RPG blast. Additionally, as the February 2019 VA examiner did not address whether his left knee disorder is caused by his left ankle disability or PTSD, and did not provide a rationale for his opinion that such disorder was not aggravated by such service-connected disabilities, the Board likewise found that an addendum opinion addressing such aspects of his claim was necessary. Accordingly, in August 2020, a VA examiner reviewed the record and opined that the Veteran’s left knee disorder was less likely than not incurred in or caused by his military service. In this regard, it was noted that the Veteran was diagnosed with patellofemoral pain syndrome and knee strain during the appeal period. The examiner explained that patellofemoral pain syndrome results from overuse, injury, problems of alignment and tracking, and muscle imbalances, and a strain occurs when there is injury that causes stretching of the ligaments or muscles associated with the joint. However, there is no evidence of record that shows a chronic strain occurred from a traumatic injury in service and such was not related to his history of patellofemoral pain syndrome. The examiner further opined that the Veteran’s left knee disorder is less likely than not proximately due to, the result of, or aggravated by his service-connected left ankle strain or service-connected PTSD. Specifically, she noted that there is no evidence of contralateral joint involvement of offloading in the Veteran’s record, there is no association between a mental health condition, such as PTSD, and a knee joint condition. The Board affords great probative weight to the February 2019 and August 2020 VA examiners’ opinions as such considered all of the pertinent evidence of record, to include the Veteran’s statements and treatment records, and a provided a complete rationale, relying on and citing to the records reviewed. Moreover, they offered clear conclusions with supporting data as well as reasoned medical explanations connecting the two. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008) (it is the factually accurate, fully articulated, sound reasoning for the conclusion that contributes to the probative value of a medical opinion); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) (“[A]medical opinion... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions”). Notably, there is no medical opinion to the contrary. The Board also considered the Veteran’s assertion as to the etiology of his left knee disorder; however, as a lay person, he does not have the requisite training and experience necessary to address such a complex medical matter. 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 disorder involves a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship. Specifically, such requires knowledge of the inner workings of the knee joint, and the resulting impact of his reported in-service injury and/or service-connected disabilities on such joint. Thus, such matter may not be competently addressed by lay statements. 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). Moreover, whether the symptoms the Veteran reportedly experienced during or after service are in any way related to his currently diagnosed left knee disorder is a matter that also requires medical expertise to determine. Clyburn, supra, at 301 (“although the veteran is competent to testify to the pain he has experienced since his tour in the Persian Gulf, he is not competent to testify to the fact that what he experienced in service and since service is the same condition he is currently diagnosed with.”). Accordingly, the Veteran’s opinion as to the onset and etiology of his left knee disorder is not competent and, consequently, is afforded no probative weight. Therefore, the Board finds that a left knee disorder is not shown to be causally or etiologically related to any disease, injury, or incident during service, and is not caused or aggravated by a service-connected disability. Thus, service connection for such disorder is not warranted. In reaching such determination, the Board has considered the applicability of the benefit of the doubt doctrine. However, the preponderance of the evidence is against the Veteran’s claim for service connection for a left knee disorder. As such, that doctrine is not applicable in the instant appeal, and his claim must be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 2. Entitlement to service connection for left shoulder disorder. The Veteran asserts that he has a left shoulder disorder as a result of the aforementioned in-service injury when an RPG struck near him and sent him flying through the air while in Iraq in 2003. The Veteran’s STRs are silent as to any complaints, treatment, or diagnoses referrable to a left shoulder disorder; however, as noted previously, due to his combat service, his reported injury related to the RPG blast is acknowledged. Post-service treatment records reveal the Veteran complained of shoulder pain in August 2004; however, an X-ray performed at the time revealed no abnormalities. A June 2014 private treatment record reflects an assessment of partial tear of rotator cuff, and a November 2017 VA treatment record indicates the Veteran had left shoulder pain from rotator cuff impingement and bicipital tendonitis. The Veteran underwent a VA examination in February 2019, at which time a diagnosis of rotator cuff tendonitis was confirmed. However, the examiner opined that such disorder was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. In this regard, he noted that there were no records or service treatment records validating any sort of shoulder condition in service and the Veteran’s separation examination was silent as to such a condition. Thus, the examiner found that there were no records to establish that the Veteran’s left shoulder condition occurred in service, to include as due to an RPG explosion. He further indicated that there were also no medical records within close proximity of a few years of exiting service. However, in the April 2020 remand, the Board noted that, in light of the Veteran’s combat service, his report of incurring a left shoulder injury coincident with an RPG blast is accepted as having occurred despite the lack of documentation in his STRs. Thus, an addendum opinion was requested to address the acknowledged in-service injury, along with the August 2004 VA treatment record, which reflects complaints of shoulder pain within a year of separation. Thereafter, in August 2020, a VA examiner reviewed the record and opined that the Veteran’s left shoulder disorder was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. In this regard, she noted that VA treatment records dated in March 2018 and April 2018 reflect the Veteran’s report that he is a warehouse worker and his left shoulder pain is worse from lifting his arm, and found that his rotator cuff tendonitis is consistent with complaints of overhead movement and lifting heavy boxes at work. Additionally, the examiner found that there was no evidence of traumatic arthritis or injury of the left shoulder. Thus, she concluded that the Veteran’s left shoulder disorder is less likely than not incurred in or caused by the aforementioned in-service RPG explosion. The Board affords great probative weight to the August 2020 VA examiner’s opinion as such considered all of the pertinent evidence of record, to include the Veteran’s statements and medical records, and provided a complete rationale, relying on and citing to the records reviewed. Moreover, she offered clear conclusions with supporting data as well as reasoned medical explanations connecting the two. See Nieves-Rodriguez, supra; Stefl, supra. Notably there is no medical opinion to the contrary. The Board also considered the Veteran’s assertion as to the etiology of his left shoulder disorder; however, as a lay person, he does not have the requisite training and experience necessary to address such a complex medical matter. Jandreau, supra. this regard, the etiology of such disorder involves a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship. Specifically, such requires knowledge of the inner workings of the shoulder joint, and the resulting impact of his reported in-service injury on such joint. Thus, such matter may not be competently addressed by lay statements. Woehlaert, supra. Moreover, whether the symptoms the Veteran reportedly experienced during or after service are in any way related to his currently diagnosed left shoulder disorder is a matter that also requires medical expertise to determine. Clyburn, supra, at 301 Accordingly, the Veteran’s opinion as to the onset and etiology of his left shoulder disorder is not competent and, consequently, is afforded no probative weight. Therefore, the Board finds that a left shoulder disorder is not shown to be causally or etiologically related to any disease, injury, or incident during service. Thus, service connection for such disorder is not warranted. In reaching such determination, the Board has considered the applicability of the benefit of the doubt doctrine. However, the preponderance of the evidence is against the Veteran’s claim for service connection for a left shoulder disorder. As such, that doctrine is not applicable in the instant appeal, and his claim must be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert, supra. 3. Entitlement to service connection for left foot disorder, to include as secondary to service-connected left ankle strain with old avulsion and calcaneal spur. The Veteran contends that he has a current left foot disorder as the result of wearing boots while marching during service or, in the alternative, that such is caused or aggravated by his service-connected left ankle strain with old avulsion and calcaneal spur. While the Veteran’s STRs were negative for any complaints, treatment, or diagnosis of a left foot disorder, a September 1999 entrance examination revealed a notation of moderate pes planus. Post-service treatment records reflect a diagnosis of left foot plantar fasciitis in December 2017. Thus, in May 2018, the Board remanded the claim in order to afford the Veteran a VA examination so as to determine the nature and etiology of his left foot disorder. Thereafter, the Veteran underwent a VA examination in February 2019, at which time only a diagnosis of plantar fasciitis was rendered. In this regard, the examiner found that, upon review of the record and contemporaneous examination, the Veteran did not have a current diagnosis of pes planus. He further opined that such disorder was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. In this regard, he indicated that plantar fasciitis developed from being repeatedly on the feet; however, there were no medical records or STRs to establish such foot condition. Further, there was no record of a foot condition prior to 2012, which was 8 years after service. The examiner further opined that the Veteran’s left foot disorder was not aggravated by his left ankle disability. In this regard, he found that his baseline of such disorder was assumed to be asymptomatic, which also indicated that no prior condition existed. Thus, the examiner determined that such did not meet the criteria to determine aggravation since, as prior to the Veteran experiencing pain, he did not have plantar fasciitis. However, as such opinion did not address whether the Veteran’s left foot disorder is related to wearing boots while marching, or caused by his left ankle disability, the Board remanded the claim in April 2020 in order to obtain an addendum opinion addressing such matters. Thereafter, in August 2020, a VA examiner reviewed the record and opined that it was less likely than not that the Veteran’s left foot disorder was incurred in or caused by the claimed in-service injury, event, or illness, or proximately due or the result of his service-connected left ankle disability. In this regard, she noted that the Veteran had pes planus, which is a congenital or acquired postural deformity relating to the collapse or flattening of the medial longitudinal arch, at the time of enlistment. The examiner explained that flat feet progress slowly as one increases the feet’s exposure to weight-bearing activities, and the two most common progressions from flat feet were foot deformities and bony stress injuries. In this regard, the examiner explained that plantar fasciitis can develop as a result of the altered arch biomechanics and increasing midfoot pronation. She indicated that the plantar fascia is loaded excessively while trying to compensate for the continuing loss of arch integrity. Thus, the examiner found that the Veteran’s pre-existing plantar fasciitis followed its natural progression to plantar fasciitis. While she acknowledged that increased weight-bearing activity can lead to stress on the plantar fascia with altered biomechanics of hyperpronation, there is no causal relationship between wearing boots and the development of plantar fasciitis in the Veteran’s case. Thus, based on the foregoing, the examiner found that it was less likely than not that the Veteran’s plantar fasciitis was incurred in or caused by marching in boots or any other in-service injury or event. The Board affords great probative weight to the February 2019 and August 2020 VA examiners’ opinions as such considered all of the pertinent evidence of record, to include the Veteran’s statements and medical records, and provided a complete rationale, relying on and citing to the records reviewed. Moreover, they offered clear conclusions with supporting data as well as reasoned medical explanations connecting the two. See Nieves-Rodriguez, supra; Stefl, supra. Notably there is no medical opinion to the contrary. The Board also considered the Veteran’s assertion as to the etiology of his left foot disorder; however, as a lay person, he does not have the requisite training and experience necessary to address such a complex medical matter. Jandreau, supra. this regard, the etiology of such disorder involves a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship. Specifically, such requires knowledge of the inner workings of the foot, to include the fascia, and the resulting impact of wearing boots while marching in service and/or service-connected left ankle disability on such joint and its tissue. Thus, such matter may not be competently addressed by lay statements. Woehlaert, supra. Moreover, whether the symptoms the Veteran reportedly experienced during or after service are in any way related to his currently diagnosed left foot disorder is a matter that also requires medical expertise to determine. Clyburn, supra, at 301 Accordingly, the Veteran’s opinion as to the onset and etiology of his left foot disorder is not competent and, consequently, is afforded no probative weight. Therefore, the Board finds that a left foot disorder is not shown to be causally or etiologically related to any disease, injury, or incident during service, and is not caused or aggravated by a service-connected disability. Thus, service connection for such disorder is not warranted. In reaching such determination, the Board has considered the applicability of the benefit of the doubt doctrine. However, the preponderance of the evidence is against the Veteran’s claim for service connection for a left foot disorder. As such, that doctrine is not applicable in the instant appeal, and his claim must be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert, supra. 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.