Citation Nr: 21028320 Decision Date: 05/11/21 Archive Date: 05/11/21 DOCKET NO. 16-50 491 DATE: May 11, 2021 ORDER Entitlement to service connection for a left knee disability is denied. FINDING OF FACT The Veteran's left knee disability is not related to service. CONCLUSION OF LAW The criteria for entitlement to service connection for a left knee disability are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from July 1973 to July 1995. This appeal is before the Board of Veterans' Appeals (Board) from a January 2012 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). This matter was previously before the Board in December 2020. The claim was remanded for the RO to obtain an addendum opinion. In January 2021an addendum for the left knee was completed. Thus, the Board finds that the RO substantially complied with the December 2020 Board remand directive and that the matter has been properly returned to the Board for appellate consideration. Stegall v. West, 11 Vet. App. 268 (1998). The Veteran claims his left knee disability is related to service. Specifically, he alleges he injured his knee in service after he was pushed from a truck. For the reasons discussed below, the Board finds the evidence weighs against a finding that the Veteran's current disability is related to service. Therefore, service connection is not warranted. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection requires: (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. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see also Caluza v. Brown, 7 Vet. App. 498 (1995). Service connection may also be granted for any disease diagnosed after discharge when the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). In addition, for certain chronic diseases, a presumption of service connection arises if the disease is manifested to a degree of 10 percent within one year following discharge from service. 38 C.F.R. §§ 3.307, 3.309(a). When a chronic disease is not shown within one year after service, under 38 C.F.R. § 3.303(b) 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. When the fact of chronicity in service is not adequately supported, a showing of continuity after discharge is required to support a claim for such diseases; however, such continuity of symptomatology may only support a claim for those chronic diseases listed under 38 C.F.R. §§ 3.303(b), 3.309(a); see Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination, the benefit of the doubt is afforded the claimant. Turning to the evidence, service treatment records (STRs) in May 1974 reflect treatment for knee pain after the Veteran fell off a truck. In June 1975 the Veteran was treated for the right knee. A February 1995 retirement report of medical history indicated the Veteran suffered from swollen or painful joints. Post service, in December 2005 the Veteran reported a one-month history of left medial knee pain with no apparent injury. He indicated there was no history of previous trauma or surgery related to the knee. After X-ray views of the left knee, an assessment indicated the Veteran suffered from acute left knee pain with possible internal derangement. In January 2006 private treatment records, an MRI suggested the Veteran suffered from a medial meniscus tear of the left knee as well as proliferative syndrome. The doctor indicated the left symptoms are possibly related to pigmented villonodular synovitis (PVNS). In March 2015 private treatment records, an assessment indicated the Veteran suffered from left knee ostearthritis. In December 2015, the Veteran submitted a medical nexus opinion from S.O., M.D., indicating the Veteran's left knee meniscal tear is more than likely related to his military service. No rational was provided. In January 2020, the Veteran submitted a Residual Functional Capacity Questionnaire and etiology opinion from M.J., M.D. The doctor opined the Veteran's left knee osteoarthritis is more than likely related to his military service. No rationale was provided. A July 2020 VA examination report indicated review of the Veteran's claims file, recounted the Veteran's history, and recited his complaints. He was diagnosed with a left knee meniscal tear and left knee joint osteoarthritis. He reported the condition began in 1975 after he was pushed from a truck. The pain was sharp and more medial than lateral, and he was seen in sick call for the condition. The examiner opined the left knee condition is less likely than not related to an in-service injury, event, or illness. It was reasoned, there are no records of the in-service fall or the sick call for the left knee. The examiner noted "the major injury that the Veteran has is a meniscal tear which was first noted remotely from his discharged from active service. The knee arthritis is a progressive condition. Which is not supported by records reviewed as having started during service." A January 2021 VA examination report indicated review of the Veteran's claims file and recounted the Veteran's history. The examiner opined the left knee condition is less likely than not related to an in-service injury, event, or illness. It was reasoned, There is no evidence of the accident cited by the veteran as a fall from a truck in 1974. Even if conceded, it is unlikely the veteran's current conditions are due to or incurred in that event. There is no evidence of a chronic condition while in service. If events occurring in 1974 had become chronic, it is unlikely the veteran could have served an additional 20 years without seeking care. A meniscus tear is an acute, painful event. The separation exam is negative for acute or chronic knee conditions while in service. This includes the veteran-answered questionnaire, specifically negative for "trick knee." These exams are notably thorough, and it is unlikely a significant knee injury/condition would have gone unnoted or unreported. There is no evidence of a condition arising proximate to service or until late 2005 and the meniscectomy in February 2006. The veteran was noted to have pigmented villonodular synovitis (PVNS) on the preoperative MRI, which was confirmed at surgery. PVNS is a proliferative disorder and it is likely to have had its onset along with the meniscal injury in or around 2005. The MRI in 2017 suggests a recurrent meniscal tear, as well as the continued presence of PVNS and DJD. In summary, there is no evidence of the claimed injury in service, but clearly no evidence of a chronic condition, as the veteran is unlikely to have been able to complete 20 years of service with a torn meniscus. It is more likely than not that the meniscal injury and the PVNS had their onset well after the claimed event in 1974 and a decade post-service. DJD is considered a natural aging process, to which the PVNS likely contributed. Therefore, it is less likely than not that the veteran's torn meniscus, PVNS and DJD had their onset in service, including the undocumented, claimed events in 1974. The January 2021 VA examiner provided an addendum clarifying the opinion, as the examiner incorrectly found there was no evidence of the 1974 in-service fall from a truck. In the addendum the examiner opined the claimed condition was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. It was reasoned, The prior opinion is unchanged. The opinion above included concession of the complaints of a fall from the truck. Documents do confirm the May 1974 knee pain and noted the fall again in 1975. Nonetheless, the rationale still applies. There is no evidence of a chronic condition while in service, though the veteran did have an episode of acute pain due to the fall from the vehicle in 1974. The veteran served an additional 20 years in service without evidence of a chronic knee condition. The veteran-answered questionnaire was negative for "trick knee", etc. at the time of the separation exam. Separation exam[ination] are notably thorough and it is highly unlikely a significant knee condition would have gone unreported or unnoted. The meniscal tear in or around 2005 and the PVNS clearly arose post-service. Therefore, it is still less likely than not that the veteran's fall with knee pain occurring in 1974 is the nexus for the veteran's currently claimed conditions, including DJD. It is less likely than not that the current conditions are due to or incurred in service, including the fall from the vehicle. The pain in service appears to have been acute and self-limited and clearly was not present at separation or until in or around 2005. DJD is a naturally occurring condition and is age related due to normal wear and tear on the weight-bearing joint. The Board has reviewed all of the lay and medical evidence of record in conjunction with the applicable laws and regulations and finds the current disability is not related to service. In this regard, the Board finds that the January 2021 VA opinion and addendum, discussed above, is the most probative evidence of record. The examiner found the disability was not related to service. It is supported by an adequate rationale, noting although the Veteran had an episode of acute pain due to the fall from the vehicle in 1974, he served an additional 20 years in service without evidence of a chronic knee condition. The opinion is supported by the December 2005 treatment records as the Veteran reported a one-month history of left medial knee pain with no apparent injury. Furthermore, in January 2006 private treatment records, the doctor indicated the Veteran's medial meniscus tear of the left knee was possibly related to pigmented villonodular synovitis. Therefore, the Board finds the January 2021 VA opinion and addendum is the most probative evidence. To the contrary the Board acknowledges the December 2015 opinion from S.O., M.D., and the January 2020 opinion from M.J., M.D finding the left knee condition is related to the Veteran's service. However, no rationales were provided for these opinions. The Court 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). Moreover, the preponderance of the evidence demonstrates that symptoms of the left knee disability has not been continuous or recurrent since separation from active service in July 1995. In December 2005 the Veteran reported a one-month history of left medial knee pain with no apparent injury. He indicated there was no history of previous trauma or surgery related to the knee. After X-ray views of the left knee, an assessment indicated the Veteran suffered from acute left knee pain with possible internal derangement. The Board finds the evidence does not reflect continuous or recurrent left knee pain as that notion is inconsistent with the Veteran's reports to a medical examiner while seeking treatment for the left knee. See Harvey v. Brown, 6 Vet. App. 390, 394 (1994) (Board decision properly assigned more probative value to a private hospital record that included lay history that was made for treatment purposes than to subsequent statements made for compensation purposes); Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006) (in analyzing credibility, the Board is justified in taking into account multiple factors, including lack of contemporaneous medical evidence, possible bias, and inconsistencies within the record); Pond v. West, 12 Vet. App. 341, 345 (1999) (while the Board is not free to ignore a claimant's assertion as to any matter on which he is competent to offer an opinion, it may properly consider the personal interest a claimant has in his or her own case). The only other evidence relating the Veteran's left knee disability to an in-service injury are the Veteran's lay statements. However, these statements alone do not establish a medical nexus. Indeed, while the Veteran is competent to provide evidence regarding matters that can be perceived by the senses, he is not shown to be competent to render medical opinions on questions of etiology. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007); see also Barr v. Nicholson, 21 Vet. App. 303 (2007) (lay testimony is competent to establish the presence of observable symptomatology). As such, as a lay person, he is without the appropriate medical training and expertise to offer an opinion on a medical matter, including the diagnosis, etiology, or causation of a specific disability. The question of diagnosis and causation, in this case, involves complex medical issues that the Veteran is not competent to address. The Board acknowledges that the evidence established that an event or injury occurred in service. As described above, the STRs document an isolated occurrence of what appears to be trauma to at least one knee. However, as noted above there are no other STRs related to the knees, and the service separation examination did not identify any knee complaints or pathology. As such, any in-service injury to the knees appears to have been acute and transitory and resolved prior to discharge. Indeed, the record does not reflect treatment for a left knee disability until 2005, 10 years post service. This lapse of time is a factor for consideration in deciding a service connection claim, as discussed in the analysis above. Maxson v. Gober, 230 F.3rd 1330, 1333 (Fed. Cir. 2000). Accordingly, service connection for a left knee disability is denied. As the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not applicable. See 38 U.S.C.§5107(b); 38 C.F.R.§ 3.102; see also Gilbert, 1 Vet. App.at 53-56. JONATHAN B. KRAMER Veterans Law Judge Board of Veterans' Appeals Attorney for the Board B. Jackman, Associate 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.