Citation Nr: 21030134 Decision Date: 05/17/21 Archive Date: 05/17/21 DOCKET NO. 16-35 390 DATE: May 17, 2021 ORDER Entitlement to service connection for right knee osteoarthritis, retro-patellofemoral pain syndrome, strain, degenerative joint disease, and chondromalacia patellae is granted. Entitlement to service connection for left knee osteoarthritis, retro-patellofemoral pain syndrome, strain, degenerative joint disease, and chondromalacia patellae is granted. REMANDED Entitlement to service connection for left hip pain is remanded. Entitlement to service connection for right hip pain is remanded. Entitlement to service connection for a left ankle condition is remanded. FINDINGS OF FACT 1. The evidence is at least in equipoise that the Veteran's right knee osteoarthritis, retro-patellofemoral pain syndrome, strain, degenerative joint disease, and chondromalacia patellae are etiologically related to her service and/or service-connected lumbar spine arthritis. 2. The evidence is at least in equipoise that the Veteran's left knee osteoarthritis, retro-patellofemoral pain syndrome, strain, degenerative joint disease, and chondromalacia patellae are etiologically related to her service and/or service-connected lumbar spine arthritis. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for right knee osteoarthritis, retro-patellofemoral pain syndrome, strain, degenerative joint disease, and chondromalacia patellae have been met. 38 U.S.C. §§ 1110, 1112, 5107; 38 C.F.R. §§ 3.303, 3.310. 2. The criteria for entitlement to service connection for left knee osteoarthritis, retro-patellofemoral pain syndrome, strain, degenerative joint disease, and chondromalacia patellae have been met. 38 U.S.C. §§ 1110, 1112, 5107; 38 C.F.R. §§ 3.303, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from August 1993 to March 2001. This matter comes to the Board of Veterans' Appeals (Board) on appeal from an October 2014 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Baltimore, Maryland. In relevant part, service connection was denied for a left ankle condition in a December 2018 Board decision. The Board remanded claims for service connection for hips, knees, lumbar spine, chronic pelvic pain, urinary stress incontinence, and gastroenteritis for further development. The gastroenteritis claim was specifically remanded for the issuance of a statement of the case and to allow for perfection of the Veteran's appeal. In October 2019, the United States Court of Appeals for Veterans Claims (Court) vacated in part the December 2018 Board decision and remanded these matters for further development. In February 2020 and January 2021, the Board remanded the claim for a left ankle condition for further development. See Manlincon v. West, 12 Vet. App. 238 (1999). While pending remand, in January 2021, the RO granted service connection for endometriosis with bladder symptoms and hysterectomy and removal of both ovaries (claimed as chronic pelvic pain and urinary stress incontinence), degenerative arthritis of the thoracolumbar spine (claimed as low back pain), and lumbar bilateral lower extremity radiculopathy. The Board considers the above to be a full grant of the benefits sought for the pelvic, lower back, and urinary claims. See Grantham v. Brown, 114 F.3d. 1156 (Fed. Cir. 1997). The RO also issued a January 2021 statement of the case, addressing entitlement to service connection for gastroenteritis. The Veteran did not timely appeal this decision. As a result, the Board does not retain jurisdiction. Service Connection Under the relevant laws and regulations, service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1110. Generally, the evidence 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. Shedden v. Principi, 381 F.3d 1163, 1166-67(Fed. Cir. 2004). 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(a). Lay evidence may be competent evidence to establish incurrence. See Davidson v. Shinseki, 581 F. 3d 1313 (Fed. Cir. 2009). Competent medical evidence is necessary where the determinative question is one requiring medical knowledge. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). 1. Entitlement to service connection for a right knee disability. 2. Entitlement to service connection for a left knee disability. The Veteran asserts that her bilateral knee disabilities are etiologically related to service and/or her service-connected lumbar spine arthritis. Following consideration of the evidence, the Board finds the issue to be in equipoise such that service connection is warranted. Treatment medical and examination records confirm diagnosed disabilities of the right and left knee to include osteoarthritis, retro-patellofemoral pain syndrome, strain, degenerative joint disease, and chondromalacia patellae. Service treatment records confirm repeat treatment for knee injuries/pain as well as spine pain and right leg shortening. The Veteran is service connected for thoracolumbar degenerative arthritis. What remains is ascertaining nexus. In September 2015, the Veteran submitted positive opinions from Advanced Registered Nurse Practitioner, G.U., correlating her current disabilities to service and to her service-connected lumbar spine disability. G.U. opined that the collective record supported on-going disability since service. Essentially, the Veteran's service treatment records document injury and diagnosis with associated pain which the Veteran credibly/competently reported as continuing until the present. G.U. explained that such reports were supported by findings within treatment medical records and were characteristic of the Veteran's diagnosed conditions per medical literature. G.U. also opined that service connection was warranted on a secondary basis. G.U. cited to in-service records that documented "low back pain," "right leg shortening " ( a 1.25 cm comparative difference ), and "sacral base unleveling." G.U. explained these findings/symptoms were indicative of the Veteran experiencing sacroiliac joint dysfunction (SIJD) in-service. Importantly, per medical literature, SIJD is known to cause not only low back pain but also biomechanical misalignment which results in leg length inequality (LLI). G.U. explained that the Veteran's SIJD when paired with LLI placed undue mechanical stress and strain on the Veteran's knees which overtime led to his current progressive knee disabilities, to include osteoarthritis. The Board finds the above opinions to be highly probative, as they were based on consideration of the service treatment records, treatment medical records, and radiologic testing results as well as relevant current literature. Service connection is warranted. The Board acknowledges the record contains negative opinions. However, no examiner has considered or addressed the specific findings of G.U. or the medical treatise/in-service medical records used to support those findings. The negative opinions are also silent for direct consideration or analysis of the Veteran's most recently submitted February 2021 arguments with associated treatise, treatment records, and lay records. Given these omissions, the Board finds these negative opinions to have significantly limited probative value. The Board has considered whether a remand is warranted to address these inadequacies. However, a remand is not warranted as the positive findings of record are competent, well rationalized, and predicated on extensive review of the record and relevant medical treatise. Thus, resolving doubt in the Veteran's favor, the Board finds the Veteran's bilateral knee disabilities are caused by her service-connected lumbar spine disability and service. As such, service connection for bilateral osteoarthritis, retro-patellofemoral pain syndrome, strain, degenerative joint disease, and chondromalacia patellae of the knees is granted. REASONS FOR REMAND 1. Entitlement to service connection for left hip pain is remanded. 2. Entitlement to service connection for right hip pain is remanded. 3. Entitlement to service connection for a left ankle condition is remanded. VA examination opinions for the Veteran's bilateral hip and left ankle disabilities were obtained in October 2020 and March 2021. An addendum opinion is required. Neither examiner address the findings of G.U., ARNP. Although an opinion as to hip and ankle etiology was not specifically provided by G.U., the submitted evidence is nonetheless suggestive that service connection might be warranted for these conditions. Moreover, between December 2020 and February 2021, the Veteran submitted argument with adjoining treatise evidence, treatment medical evidence, and lay/ buddy statements in support of her claims. The treatise evidence appears to support the proposition that her ankle and hip disabilities are intertwined with her now service-connected knee disabilities as well as service connected low back disability. This evidence was not considered by the October 2020 examiner and its relevance was not specifically addressed by the March 2021 examiner. Moreover, as service connection for bilateral knee disability is now established, an opinion addressing secondary service connection is needed. The matters are REMANDED for the following action: 1. Obtain an addendum opinion as to the nature and etiology of the Veteran's bilateral hip and left ankle conditions. The clinician is asked to opine: (a.) Whether it is at least as likely as not (i.e. probability of 50 percent or greater) that the Veteran's bilateral hip, or left ankle disabilities are related to her active duty service, to include the Veteran's lay statements that her hip, and/or ankle pain began in-service and have continued ever since. Note, the Veteran has submitted lay correspondence from her former spouse attesting to on-going ankle pain, and the use of over-the-counter treatment since service. Note, the Veteran has resubmitted treatment medical records from November 2001 that show hip pain and back pain immediately post service. These records and the Veteran's reports of on-going symptoms must be addressed. (b.) Whether the Veteran's bilateral hip, and/or left ankle disabilities are at least as likely as not caused by her service-connected lumbar spine, bilateral knee, and/or radiculopathy disabilities. (c.) Whether the Veteran's bilateral hip, and/or left ankle disabilities are at least as likely as not aggravated by her service-connected bilateral knee, lumbar spine, and/or radiculopathy disabilities. Note: aggravation means any incremental increase in disability in non-service-connected disabilities (i.e., any additional impairment of earning capacity) resulting from service-connected conditions. Note: the Veteran has submitted treatise evidence suggesting a correlation between her claimed conditions and her lumbar spine/knee disabilities. These treatises, submitted in February 2021, must be considered. Additionally, this treatise must be addressed in relation to the Veteran's arguments submitted in February 2021 and those of her representative in April 2021. Note: the examiner must address the Veteran's former husband's December 2020 statements regarding her ankle injury and symptomatology. Note: the examiner must address the positive September 2015 opinions of G.U., ARNP. These collective opinions and adjoining treatise are suggestive that the Veteran's hips and ankle could be biomechanically linked with, and/or impacted by, her service-connected spine and knee disabilities, as well as her conceded in-service leg shortening in 2000. (The RO must ensure the examiner has copies of all the Veteran's records, including April-December 2000 service treatment records documenting said leg length discrepancy diagnosis. The October 2020 examiner indicated being unable to access these records). The examiner is asked to provide the underlying reasons for all opinions expressed, and is reminded that the term "as likely as not" does not mean "within the realm of medical possibility," but rather that the evidence of record is so evenly divided that, in the examiner's expert opinion, it is as medically sound to find in favor of the proposition as against it. MICHAEL A. HERMAN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. L. Burroughs, 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.