Citation Nr: 21028279 Decision Date: 05/10/21 Archive Date: 05/10/21 DOCKET NO. 09-06 445 DATE: May 10, 2021 ORDER Service connection for a left knee condition, to include as secondary to service-connected disabilities, is denied. FINDING OF FACT The preponderance of the evidence is against finding that the Veteran's left knee condition began during active service or is otherwise related to an in-service injury or disease, to include service-connected disabilities. CONCLUSION OF LAW The criteria for establishing service connection for a left knee condition are not met. 38 U.S.C. §§ 1110, 1112, 1113, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.3.10. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from September 1989 to March 1992. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an August 2007 rating decision. Following several remands, in which the Board requested additional development, in March 2017, the Board issued a decision denying service connection for a left knee disability, finding the Veteran did not have a current left knee disability. The Veteran appealed that decision to the United States Court of Appeals for Veterans Claims (Court). In November 2017, the Court issued an Order that vacated the Board's March 2017 decision and remanded the matter on appeal for adjudication consistent with the instructions outlined in a Joint Motion for Remand (JMR) by the parties. See November 2017 JMR. In July 2018, the Board issued another decision which again denied service connection for a left knee condition. The Veteran appealed that decision to the Court and in May 2019, the Court issued an Order that vacated the Board's July 2018 decision and remanded the matter on appeal for adjudication consistent with the instructions outlined in a JMR by the parties. See May 2019 JMR. In October 2019 and in September 2020, the Board remanded the case for further development. Service Connection Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). To establish service connection, a veteran must show: (1) the existence of a present disability; (2) 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. Holton v. Shinseki, 557 F.3d 1362 (Fed. Cir. 2010); Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). Another theory of entitlement to service connection is secondary service connection. Disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. 38 C.F.R. § 3.310. When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. Id. The phrase "due to or the result of" encompasses disability caused by or aggravated by the service-connected disease or injury. See Allen v. Brown, 7 Vet. App. 439 (1995). VA will not concede that a nonservice-connected disease or injury was aggravated by a service-connected disease or injury unless there is medical evidence showing the baseline level of severity of the nonservice-connected disease or injury before such was worsened beyond its natural progress by the service-connected disease or injury. 38 C.F.R. § 3.310(b). In rendering a decision on appeal the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive and provide the reasons for its rejection of any material evidence favorable to the claimant. Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). A lay person is competent to report on the onset and reoccurrence of current symptomatology. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a veteran is competent to report on that of which he or she has personal knowledge). The Board must determine, on a case by case basis, whether a veteran's particular disability is the type of disability for which lay evidence may be competent. See Kahana v. Shinseki, 24 Vet. App. 428 (2011). Generally, the degree of probative value which may be attributed to a medical opinion issued by a VA or private treatment provider considers such factors as its thoroughness and degree of detail, and whether there was review of the claims file. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000). Also significant is whether the examining medical provider had a sufficiently clear and well-reasoned rationale, as well as a basis in objective supporting clinical data. See Bloom v. West, 12 Vet. App. 185, 187 (1999). The United States Court of Appeals for Veterans Claims has held that a bare conclusion, even one reached by a health care professional, is not probative without a factual predicate in the record. Miller v. West, 11 Vet. App. 345, 348 (1998). When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. When all of the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event, or whether a fair preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). Entitlement to service connection for left knee condition, to include as secondary to service-connected disabilities The Veteran contends he suffers from a left knee condition as a result of his military service, or in the alternative, he contends his left knee condition has been compromised by overcompensating for his service-connected right knee and bilateral ankle strains. See January 2016 VA Form 21-4138; see July 2017 VA Form 21-4138. The question for the Board is whether the Veteran has a current diagnosis of a left knee condition that 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 his service-connected disabilities, including right knee disability, bilateral ankle disability, a lumbar spine disability, an intercostal muscle strain, and bilateral lower extremity radiculopathies. The Board concludes that, while the Veteran has been diagnosed with a left knee condition, the preponderance of the evidence is against finding that it began during active service, or is otherwise related to an in-service injury, event or disease, including his service-connected disabilities. At the outset, the Board acknowledges based on the lengthy procedural history, the record includes several VA medical examinations and opinions which have evaluated the nature and etiology of Veteran's left knee and addressed the theories of causation he has advanced. In fact, the Veteran underwent VA examinations on his left knee in February 2013, October 2015, October 2016, March 2020, January 2021 and again in February 2021. Through these examinations, it is established that the Veteran has a current left knee condition. However, the Veteran's service treatment records (STRs) are silent for any signs, symptoms or diagnoses relating to his left knee condition. Notably, the Veteran's Report of Medical Examination for purposes of separation in January 1992 reported a well-healed scar on the left knee but the clinical evaluation of the knee itself was normal. Additionally, in the associated Report of Medical History, while the Veteran reported having a "trick" or locked knee, this was clarified to be intermittent pain and stiffness in the right knee. The Veteran did not report having any left knee symptoms despite having an opportunity to do so and also reporting symptoms related to the right knee. See STRs. Furthermore, VA examinations performed in February 2013 and October 2015 addressed the Veteran's direct theory of causation between his left knee and his service and both examinations found a negative nexus. See February 2013 VA examination and See October 2015 VA examination. In fact, the February 2013 VA examination concluded that the Veteran's knee pain was most likely due to normal progression with aging and the Veteran's physical employment working with a road crew and the October 2015 VA examination noted there was no evidence of a chronic left knee injury with any chronic sequelae. The examination also noted the Veteran had an unrelated left knee work injury in 1996 that resulted in surgery. Without competent evidence to the contrary, service connection for left knee condition on the theory of direct onset is not established. 38 C.F.R. § 3.303(a). While service connection on a direct basis cannot be established, the Veteran has also advanced secondary theories of causation between his service-connected disabilities, including right knee disability, bilateral ankle disability, a lumbar spine disability, an intercostal muscle strain and bilateral lower extremity radiculopathies and his left knee condition. See Allen v. Brown, 7 Vet. App. 439 (1995); 38 C.F.R. § 3.310(b). The October 2016 VA medical opinion was the first medical opinion to address the Veteran's secondary theory of causation claims. See October 2016 VA Medical Opinion. Ultimately, the examiner determined it was less likely than not that the left knee condition was caused or aggravated by service, or a service-connected disability, to include the right knee and right ankle conditions. In support of that conclusion, the examiner noted that the Veteran's STRs documented a self-limiting right knee and right ankle sprain injuries from playing basketball and stated that these conditions are shown to have resolved without residuals. As such, these injuries could not have caused or aggravated any type of left knee condition. The examiner said that the finding was bolstered by the fact that the Veteran's STRs did not contain any complaints or medical encounters concerning the left knee. Moreover, the examiner noted that after the Veteran's separation from service in March 1992, he had a left knee medial meniscus tear resulting in a workers' compensation injury, which later required surgery, in 1996. The examiner noted that the medical record was silent for any left knee problems or treatment between separation from service and the 1996 work injury. To this extent, the examiner acknowledged the Veteran' lay statements, especially the December 2013 statement where he reported he continued to suffer from left knee symptoms since service, however, the examiner indicated that this was not borne in the objective medical record. Significantly, the examiner indicated that the Veteran's assertions that he "self-treated his left knee because he could not always afford to go to the doctor until it became critical" to be medically non-persuasive. Ultimately, the examiner concluded that all current left knee problems or residuals were more likely than not secondary to the Veteran's workers' compensation injury. Thus, a negative nexus medical opinion was provided. Most recently, and pursuant to the Board's September 2020 remand, VA medical addendum opinions were obtained in January 2021. These opinions collectively, and separately, address the Veteran's secondary service-connected arguments. In the collective opinion, which summarizes the individual opinions, the examiner indicated there was no clear evidence of orthopedic literature to suggest that an injury to one joint would have any significant impact on another or opposite uninjured joint or 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 individuals gait pattern would be altered to the extent that clinically there was no obvious Trendelenburg gait. The examiner then stated that this level of severity was not supported based on record review, history, or examination. The examiner further stated that it was not unusual for two joints to share properties in the same person, but one joint's disease did not spread to another or cause damage to it. The examiner concluded that the Veteran's left knee condition was less likely than not related to the other service-connected conditions. See January 2021 VA medical addendum opinion. While the January 2021 VA medical opinion provided a negative nexus regarding secondary causation of the Veteran's left knee condition, the opinion fell short in addressing possible aggravation of the condition. Therefore, VA medical addendum opinions were obtained in February 2021 which again collectively, and separately, addressed the possible aggravation of the Veteran's left knee by his secondary service-connected disabilities. See February 2021 VA medical opinion. Again, following a review of the Veteran's entire record, the VA examiner opined it was less likely than not that the Veteran's left knee disorder was caused or aggravated beyond its natural progression by his service-connected disabilities, to include his bilateral ankle disabilities, right knee disability, lumbar spine disability, intercostal muscle strain, and bilateral lower extremity radiculopathies. In support of that opinion, the examiner indicated the claimed conditions were not medically related. For rationale, the examiner stated there was no credible evidence to suggest that an injury or disease of the spine or lower extremity (to include Veteran's service-connected lumbar strain with degenerative arthritis and bilateral lower extremity radiculopathy, right knee strain and bilateral chronic ankle sprain) would have any significant impact on another lower extremity joint (claimed as left knee), unless the injury of the resulted in significant deformity of the leg or major muscle or nerve damage causing partial or complete paralysis of the lower extremity, and/or shortening of a lower extremity resulting in a limb length discrepancy of more than four or five centimeters so that the individual's gait pattern would be altered to the extent that clinically there was an obvious lurching type gait (a very significant limp). The examiner then indicated that none of the Veteran's service-connected conditions were of the severity to exact any effect on the claimed left knee. See February 2021 VA medical opinion. Pertaining to the Veteran's claim that his left knee disorder was caused or aggravated by his service-connected intercostal muscle strain, claimed as a rib condition, the VA examiner also provided a negative nexus opinion. In support of the negative opinion, the examiner indicated there was no documented evidence of continued intercostal muscle strain. The examiner explained that muscle strains were an acute condition that resolved over time, and the medical records were negative for continued symptoms/complaints of the condition, which indicated the muscle strain had resolved. The examiner concluded that because there was no current diagnosis of intercostal muscle strain, an aggravation opinion was not appropriate. See February 2021 VA medical opinion. Notably, the Veteran has not advanced any specific theory of causation or aggravation based on this service-connected disability throughout the period at issue. Based on the foregoing medical evidence, taken together, it is not shown that the Veteran's left knee condition had its onset in service or is otherwise related to his military service; it is also not shown that the Veteran's left knee condition was caused or aggravated by his service-connected disabilities. The Board recognizes the Veteran's continued argument that his left knee condition was caused or aggravated by at least one of his service-connected disabilities. He has advanced several different theories as to how his service-connected disabilities has impacted his left knee condition. Most specifically, the Board acknowledges the Veteran's argument that despite the fact he injured his left knee in 1996 (which was not the subject of a worker's compensation claim as mistakenly reported by the October 2016 VA examiner), post service, this injury should not be considered a work injury. Instead, he argues the fact that his left knee popped during his injury actually supports his argument that his left knee was weakened by compensating for his right knee. He states his knee could have popped in a similar way at any time because he was merely bending down when the injury occurred. Ultimately, he argues his left knee "took up the strain" for his service-connected bilateral ankle and right knee injuries and eventually gave out requiring surgery. He also states his work did not cause the injury, it was a simple activity of bending down which caused it, supporting his contention that his left knee was weakened by the strain of compensating for his other injuries. See January 2017 Statement in Support of the Claim. Furthermore, the Board also acknowledges the Veteran's earlier December 2013 statement that he has had continuous left knee symptoms since service, and stated that "he self-treated his left knee because he could not always afford to go to the doctor until it became critical." See December 2013 Veteran's Statement. Ultimately, while the Board understands and is sympathetic to the Veteran's belief that his left knee condition was caused or aggravated his service-connected disabilities, either collectively or individually, he is not competent as a lay person to opine as to whether his current left knee disability is related to his service-connected disabilities. He is also not competent to state whether the symptoms he has experienced since service are related to his current left knee disability. The questions involved in this case are medically complex and require specialized knowledge and the ability to interpret complicated diagnostic medical testing. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). Consequently, the Board gives more probative weight to the competent medical evidence. In this regard, the VA examiners thoroughly reviewed the claims file, and based on the medical training and experience, the examiners found that the Veteran's left knee condition were less likely than not caused or aggravated by his service-connected lumbar strain with degenerative arthritis and bilateral lower extremity radiculopathy, right knee strain intercostal muscle strain and bilateral chronic ankle sprain and provided sound rationale based on medical research. The examiners' reasoning clearly explains the Veteran's left knee condition is a separate condition than his service-connected disabilities and are not medically related. Furthermore, for aggravation to have occurred between his left knee condition and his service-connected disabilities in the way the Veteran argues, evidence of increased severity in the Veteran's service-connected disabilities would have been present in the record. Because such severity is not present with his service-connected disabilities, the examiner indicated aggravation of the left knee condition was not supported. Therefore, his service-connected conditions did not cause his left knee to "pop" as a result of overcompensation and cause his post-service injury. Thus, the Veteran's statements, to the extent that they are to be accorded some probative value regarding his post-service injury to his left knee, are far outweighed by the more thoroughly explained and detailed opinion from the VA medical professional. Notably, while previous medical examinations of record may have been incomplete or had legal deficiencies, none of the opinions contradict the most recent October 2016, January 2021 and February 2021 VA examiners' conclusions. (Continued on the next page) For these reasons, the Board finds that the preponderance of the evidence is against the claim for service connection left knee condition, to include as secondary to service-connected disabilities, and there is no reasonable doubt to be resolved. 38 U.S.C. § 5107(b). A. ISHIZAWAR Veterans Law Judge Board of Veterans' Appeals Attorney for the Board K. Churchwell, 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.