Citation Nr: 21026752 Decision Date: 05/03/21 Archive Date: 05/03/21 DOCKET NO. 15-38 851A DATE: May 3, 2021 ORDER Entitlement to service connection for a left foot disability is denied. Entitlement to service connection for a right knee disability is denied. Entitlement to service connection for a low back disability is denied. FINDINGS OF FACT 1. The Veteran's diagnosed left foot pes planus was noted at the time of his examination for entrance into active service; the preponderance of the evidence is against finding that the left foot pes planus was aggravated by service or by a service-connected disability. 2. The preponderance of the evidence is against finding that the Veteran's diagnosed right knee disability began during active service, is otherwise related to an in-service injury or disease, or is caused or aggravated by a service-connected disability. 3. The preponderance of the evidence is against finding that the Veteran's diagnosed lumbar spine disabilities began during active service, are otherwise related to an in-service injury or disease, or were caused or aggravated by a service-connected disability. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for a left foot disability have not been met. 38 U.S.C. §§ 1110, 5103, 5107A; 38 C.F.R. §§ 3.102, 3.159, 3.306, 3.310. 2. The criteria for entitlement to service connection for a right knee disability have not been met. 38 U.S.C. §§ 1110, 5103, 5107A; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310. 3. The criteria for entitlement to service connection for a low back disability have not been met. 38 U.S.C. §§ 1110, 5103, 5107A; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from April 2002 to April 2005. In February 2018, the Veteran testified at a hearing before the undersigned Veterans Law Judge. A transcript of the hearing is associated with the record. The Board remanded these issues in July 2018 and January 2021. In relevant part, the July 2018 remand directed the Agency of Original Jurisdiction (AOJ) to obtain the Veteran's updated VA treatment records, contact the Veteran to identify and authorize release of private treatment records, and afford the Veteran VA examinations as to his claimed left foot, right knee, and low back disabilities. In relevant part, the January 2021 remand directed the AOJ to obtain addendum opinions as to the Veteran's claimed left foot, right knee, and low back disabilities. Pursuant to the remands, the AOJ obtained the Veteran's updated VA treatment records; made appropriate efforts to have the Veteran identify outstanding private treatment records and then to obtain the identified records; and afforded the Veteran VA examinations and obtained VA addendum opinions that provide the information necessary to render a decision as to the issues on appeal. Accordingly, the Board finds that VA at least substantially complied with the July 2018 and January 2021 remands. See 38 U.S.C. § 5103A(b); Stegall v. West, 11 Vet. App. 268, 271 (1998); D'Aries v. Peake, 22 Vet. App. 97, 105 (2008). Neither the Veteran nor his representative has raised any issues with regard to the duty to notify or duty to assist as they pertain to the issues denied in this decision. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board . . . to search the record and address procedural arguments when the veteran fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). The analysis in this decision focuses on the most relevant evidence and on what the evidence shows or does not show with respect to the issues denied in this decision. The Veteran should not assume that evidence that is not explicitly discussed in the decision has been overlooked. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (noting that the law requires only that reasons for rejecting evidence favorable to the claimant be addressed). Service Connection 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). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). 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. A preexisting injury or disease will be considered to have been aggravated by active military, naval, or air service, where there is an increase in disability during such service, unless there is a specific finding that the increase in disability is due to the natural progress of the disease. 38 C.F.R. § 3.306. 1. Entitlement to service connection for a left foot disability The Veteran seeks entitlement to service connection for a left foot disability, which he contends was made worse by an altered gait caused by his service-connected left knee disability. His service treatment records show that he had asymptomatic severe bilateral pes planus at the time of his medical examination for entrance into active service in October 2001. His bilateral pes planus was asymptomatic in January 2003. In February 2005, he reported localized joint pain in the left knee. At that time, it was noted that the left knee pain "may be associated with worsening pes planus as his ankle joint rotates medially with weight bearing." The medical treatment records and VA examinations show that the Veteran is currently diagnosed with left foot pes planus. They do not show that he has been diagnosed with any other left foot disability during or in temporal proximity to the claim for service connection. The question for the Board is whether the Veteran's preexisting severe left foot pes planus was aggravated beyond its natural progression by his active service or by a service-connected disability. The Board finds that the preponderance of the evidence is against finding that the Veteran's left foot pes planus was aggravated by service or by a service-connected disability. In February 2021, a VA examiner opined that the evidence does not show that the Veteran's preexisting severe left foot pes planus was aggravated by his service and that it is less likely than not that the disability was aggravated by a service-connected disability. In support of that opinion, the examiner explained that at the time of an October 2020 VA examination, there was no evidence of pain with manipulation, swelling, calluses, extreme tenderness, decrease in longitudinal height, marked pronation, or inward bowing of the Achilles tendon , which would be signs of aggravation of the condition. In addition, a review of orthopedic literature provides no clear evidence that an injury to one joint would have any significant impact on another opposite uninjured limb unless the injury resulted in a major muscle or nerve damage causing partial or complete paralysis or shortening of the injured limb resulting in length discrepancy of more than 5 centimeters so that the individual's gait pattern has been altered to the extent that clinically there is obvious Trendelenburg gait. However, such a level of severity is not supported in this case based on a review of the record, the Veteran's history, or examination. In addition, it is not unusual for two joints to share properties in the same person, but one joint's disease does not spread to another or cause damage to it. The Board affords great probative weight to the February 2021 VA examiner's opinion because it is supported by appropriate rationale that provides insight into the medical aspects of the Veteran's preexisting left foot pes planus and its natural progression. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008), Barr v. Nicholson, 21 Vet. App. 303 (2007), Stefl v. Nicholson, 21 Vet. App. 120 (2007), Prejean v. West, 13 Vet. App. 444 (2000). The examiner explained that the evidence does not show that the Veteran's preexisting left foot pes planus has been aggravated, either by his active service or by a service-connected disability, because a number of signs that would indicate aggravation have not been present. She further explained that the Veteran's service-connected disabilities are not of a severity or nature that they would aggravate the preexisting left foot pes planus. The Board acknowledges the February 2005 treatment note stating that the Veteran had marked pes planus with medial shift of the ankle joint with weight bearing and that his left knee pain "may be associated with worsening pes planus" due to the ankle shift. However, that statement is equivocal and does not establish that the Veteran's preexisting left foot pes planus did actually worsen during his active service or that it was aggravated by his left knee disability. The Board therefore does not afford probative value to that treatment record, and the record does not weigh against the February 2021 VA examiner's probative opinion. The Board further acknowledges that the October 2020 VA examiner stated that "There is objective evidence in the Veteran's service medical record or post medical records of left foot pes planus aggravation due to left knee s/p ACL reconstruction." The statement was made in the context of an opinion that it is less likely than not that the Veteran's left foot pes planus was caused by a service-connected disability. Therefore, the statement likely includes a typographical error and was intended to say that there is "no" objective evidence that the Veteran's left foot pes planus was aggravated by his service-connected left knee disability. Even if the statement was written as intended, it is not supported by rationale. It is therefore not probative in showing that the Veteran's preexisting left foot pes planus was aggravated by his service-connected left knee disability. See Stefl, 21 Vet. App. at 123 (for a medical opinion to be adequate, it must be supported by a rationale and explanation for the conclusion reached). Accordingly, the statement has no probative value and does not weigh against the February 2021 VA examiner's probative opinion. Finally, the Board acknowledges the Veteran's assertions that his left foot pes planus was worsened by an altered gait due to his service-connected left knee disability. The Veteran is not considered competent to provide a nexus opinion regarding the issue because the issue is medically complex. Providing a nexus opinion in this case requires knowledge of the natural progression of medical conditions and the anatomical relationships between different body parts. Therefore, it is outside the competence of the Veteran because the record does not show that he has the skills or medical training 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). His statements are therefore not probative and also do not weigh against the February 2021 VA examiner's probative opinion. In summary, the preponderance of the evidence is against finding that the Veteran's preexisting left foot pes planus was aggravated by service or by a service-connected disability. In view of the foregoing, the Board concludes that the preponderance of the evidence is against the claim for entitlement to service connection for a left foot disability. Because the preponderance of the evidence is against the claim, the doctrine of reasonable doubt is not for application, and the claim must be denied. 38 U.S.C. § 5107(b); see also Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 2. Entitlement to service connection for a right knee disability 3. Entitlement to service connection for a low back disability The Veteran seeks entitlement to service connection for a right knee disability and for a low back disability, which he contends are due to in-service environment exposures; to wearing heavy equipment and lifting heavy objects, such as generators; or due to an altered gait caused by his service-connected left knee disability. The medical treatment records show that the Veteran's right knee was injured in September 2009 when a horse stepped on it. That same month, he twisted his right knee when he fell into a drainage ditch. He was diagnosed at that time with a right knee sprain. In March 2010, he reported a 4- to 5-month history of right knee pain since falling off a horse. An X-ray of the right knee was unremarkable. In October 2010, he reported that he heard a pop in his right quadricep when he fell on the stairs and hyperflexed the leg. He was diagnosed with a right quadricep tendon rupture, which was surgically repaired in January 2011. An October 2015 VA examiner diagnosed the Veteran with right knee strain and lumbar spine strain. A July 2019 VA examination diagnosed the Veteran with right knee strain and lumbar spine degenerative arthritis. The October 2020 VA examination diagnosed the Veteran with status-post right knee quadriceps tendon repair and lumbar spine degenerative arthritis. The question for the Board is whether any of the Veteran's current right knee or low back disabilities began during service; is at least as likely as not related to an in-service injury, event, or disease; or was caused or aggravated by a service-connected disability. Regarding the Veteran's contention that his right knee and low back disabilities are related to in-service environmental exposures, an October 2015 VA examiner opined that it is less likely than not that such an etiological relationship exists. In support of that opinion, the examiner explained that the medical literature does not support finding that exposure in southwest Asia causes pes planus, knee strains, or lumbar spine strain. Rather, a strain is an injury to a muscle and/or tendons. The Board affords great probative weight to the February 2021 VA examiner's opinion because it is supported by appropriate rationale that provides insight into the medical aspects of the Veteran's right knee and low back disabilities. Nieves-Rodriguez, 22 Vet. App. 295, Barr, 21 Vet. App. 303, Stefl, 21 Vet. App. 120, Prejean, 13 Vet. App. 444. The Veteran has not presented any evidence supporting the contention that his diagnosed right knee strain, lumbar spine strain, or lumbar spine degenerative arthritis may have been caused by unspecified exposures in southwest Asia. Regarding direct service connection, the February 2021 VA examiner opined that it is less likely than not that the Veteran's right knee and lumbar spine disabilities were in incurred in his active service or caused by an in-service injury, event, or illness. As a rationale for that opinion, the examiner explained that the Veteran's lay statements that he injured his right knee and low back during service are not consistent with the evidence, as he sought treatment in service for other conditions but not for the right knee and low back. Thus, his history is consistent with being seen for orthopedic conditions when they cause him pain or problems. As to the Veteran's contention that the current disabilities are related to wearing heavy equipment and lifting heavy objects during his active service, the examiner explained that strains typically resolve with conservative treatment in six to eight weeks. Once the Veteran separated from the military, he no longer carried heavy equipment, and the strains should not have incurred years after the equipment was no longer being carried. They would have resolved within several weeks following separation. Once aggravating factors were removed, his file remained silent for right knee or low back pain for many years. The Veteran injured his right knee in 2009 and 2010. In addition, he worked in construction after his separation from active service and had years of post-service wear and tear. The examiner attributed the current right knee and low back disabilities to the Veteran's post-service injuries and work in construction. The Board affords great probative weight to the February 2021 VA examiner's opinion because it is supported by appropriate rationale that provides insight into the medical aspects of the Veteran's right knee and low back disabilities. Nieves-Rodriguez, 22 Vet. App. 295, Barr, 21 Vet. App. 303, Stefl, 21 Vet. App. 120, Prejean, 13 Vet. App. 444. The examiner explained that the evidence does not show that the disabilities had their onset during the Veteran's active service, as Veteran medical history indicates that if the Veteran had a right knee or low back injury during service, then he would have sought treatment for it, but that the service treatment records do not show such treatment. She also explained that any strain caused by strenuous activities in service would have resolved shortly after the Veteran stopped engaging in those activities, and that the Veteran's current disabilities are more likely related to his post-service injuries and work in construction. Regarding the Veteran's contention that his current right knee and low back disabilities are due to or were aggravated by an altered gait caused by his service-connected left knee disability, the Board reiterates that the February 2021 VA examiner indicated that the right knee and low back disabilities are due to the Veteran's post-service injuries and post-service work in construction. In addition, the Board finds that the February 2021 VA examiner's opinion as to the claimed left foot disability is also applicable to the claimed right knee and low back disabilities. The examiner stated that medical literature provides no clear evidence that an injury to one joint would have any significant impact on another opposite uninjured limb unless the injury resulted in a major muscle or nerve damage causing partial or complete paralysis or shortening of the injured limb resulting in length discrepancy of more than 5 centimeters so that the individual's gait pattern has been altered to the extent that clinically there is obvious Trendelenburg gait. However, such a level of severity is not supported in this case based on a review of the record, the Veteran's history, or examination. In addition, it is not unusual for two joints to share properties in the same person, but one joint's disease does not spread to another or cause damage to it. The Board accepts the examiner's opinion as probative evidence that the Veteran's service-connected left knee disability is not of a nature or severity that would cause or aggravate an injury in another joint, such as the right knee and lumbar spine. The Board acknowledges the private medical opinion from M. Ward, D.C., dated in September 2018, which states that the Veteran's disabilities, including his chronic low back pain and knee pain, "are directly related to his active duty service." However, that opinion is not supported by rationale. It is therefore not probative. See Stefl, 21 Vet. App. at 123. Accordingly, the statement has no probative value and does not weigh against the October 2015 and February 2021 VA examiners' probative opinions. Finally, the Board acknowledges the Veteran's assertions that his right knee and low back disabilities are directly related to his active service or were caused or worsened by an altered gait due to his service-connected left knee disability. The Veteran is not considered competent to provide a nexus opinion regarding the issue because the issue is medically complex. Providing a nexus opinion in this case requires knowledge of the natural progression of medical conditions and the anatomical relationships between different body parts. Therefore, it is outside the competence of the Veteran because the record does not show that he has the skills or medical training to make such a determination. Jandreau, 492 F.3d at 1377 n.4; see also Kahana, 24. Vet. App. 428. His statements are therefore not probative and also do not weigh against the October 2015 and February 2021 VA examiners' probative opinions. In summary, the preponderance of the evidence is against finding that the Veteran's diagnosed right knee and lumbar spine disabilities began during active service, are otherwise related to an in-service injury or disease, or were caused or aggravated by a service-connected disability. In view of the foregoing, the Board concludes that the preponderance of the evidence is against the claims for entitlement to service connection for a right knee disability and for a low back disability. Because the preponderance of the evidence is against the claims, the doctrine of reasonable doubt is not for application, and the claims must be denied. 38 U.S.C. § 5107(b); see also Gilbert, 1 Vet. App. 49. MICHAEL MARTIN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board T. J. Anthony, 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.