Citation Nr: 21030733 Decision Date: 05/19/21 Archive Date: 05/19/21 DOCKET NO. 16-14 486 DATE: May 19, 2021 ORDER Service connection for a left knee disability is granted. Service connection for a back disability is granted. FINDINGS OF FACT 1. The preponderance of the evidence weighs for finding that the Veteran's left knee DJD is causally related to service. 2. The preponderance of the evidence weighs for finding that the Veteran's back disability is secondary to a service-connected psychiatric disability. CONCLUSIONS OF LAW 1. The criteria for service connection for a left knee disability have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for service connection for a back disability have been met. 38 U.S.C. §§ 1110, 1131, 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 August 1979 to September 1983. These matters are before the Board of Veterans Appeals (Board) on appeal from a September 2015 rating decision. These matters were previously remanded by the Board in January 2019 and August 2020 for further evidentiary development. The Board finds that there has been substantial compliance with those remand directives. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (holding that a remand by the Board confers upon the Veteran, as a matter of law, the right to compliance with its remand instructions, and imposes upon VA a concomitant duty to insure compliance with the terms of the remand); see also D'Aries v. Peake, 22 Vet. App. 97, 105 (2008) (holding that only substantial rather than strict compliance with the Board's remand directives is required under Stegall). Service Connection Service connection means that a veteran has a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303 (a). Service connection may be granted for any disease diagnosed after discharge when the evidence shows that the disease was incurred in service. 38 C.F.R. § 3.303 (d). Entitlement to service connection is established when the following elements are satisfied: (1) the existence of a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship or "medical nexus" between the current disability and the disease or injury incurred or aggravated during service. Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004); see 38 C.F.R. § 3.303 (a). Service connection may also be established on a secondary basis for a disability that is proximately due to, the result of, or aggravated by a service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires: (1) competent evidence of current disability; (2) evidence of a service-connected disability; and (3) competent evidence that the current disability was either: (a) caused by; or (b) aggravated by a service-connected disability. 38 C.F.R. § 3.310 (a); see Allen v. Brown, 7 Vet. App. 439 (1995). 1. Service connection for a left knee disability Factual Background & Analysis The Veteran's contention is that he incurred a left knee injury during service which has persisted to the present day. He has communicated that he was unable to seek care for this disability for a period following service due to his homelessness. The Veteran's service treatment records (STRs) reveal that he stepped in a hole and twisted his left knee and heard a "pop" during service. In October 2020 the Veteran underwent a VA knee examination and was diagnosed with degenerative joint disease (DJD) of the left knee. The examiner opined that it is at least as likely as not that this disability is related to the claimed left knee injury during service. The examiner explained there is evidence of chronicity of care and in this case the Veteran's arthritis is post-traumatic, meaning it can manifest over 10 years after the initial injury. Moreover, the examiner stated that the Veteran's injury during service was a first degree MCL sprain and individuals with a history of joint trauma are three to six times more likely to develop knee osteoarthritis based on a National Institute of Health (NIH) study. In October 2020, the Agency of Original Jurisdiction (AOJ) requested an addendum VA medical opinion to reconcile the findings of the October 2019 VA knee examiner, who opined that the Veteran's current left DJD was caused by the natural aging process and therefore is less likely than not related to events during service, with the positive nexus opinion of the October 2020 VA examiner. The January 2021 VA addendum opinion agreed with the findings of the October 2019 VA examiner and stated that the Veteran's left knee injury during service was acute in nature and that current left knee DJD is due to the natural aging process. The examiner also noted that July 2015 left knee x-rays were normal. After a review of the probative medical evidence the Board finds that the evidence is in relative equipoise as to whether the Veteran's current left knee DJD is causally related to his service. Critically, the October 2019 and January 2021 VA medical opinions did not cite to any pertinent medical literature in formulating their opinions. The October 2020 positive VA nexus opinion cites to a peer-reviewed study regarding the increased likelihood of arthritis in individuals with a history of joint trauma such as the Veteran who suffered an MCL sprain during service. A claimant is entitled to the benefit of the doubt when there is an approximate balance of positive and negative evidence on any issue material to the claim. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102 (providing, in pertinent part, that reasonable doubt will be resolved in favor of the claimant). When the evidence supports the claim, or is in relative equipoise, the claim will be granted. See Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990); see also Wise v. Shinseki, 26 Vet. App. 517, 532 (2014). Based on the above, the Board finds that there is at least an approximate balance of positive and negative evidence regarding whether the Veteran's left knee DJD is causally related to his service and the claim is granted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 2. Service connection for a back disability Factual Background & Analysis The October 2019 VA spine examination report reflects diagnoses for degenerative arthritis of the spine, intervertebral disc syndrome (IVDS) and spinal stenosis. The Veteran communicated that he has had progressively increasing lower back pain. He related this disability to a motor vehicle accident (MVA) during service where he was driving a truck that overturned while stationed at Fort Riley. The October 2019 VA examiner opined that is less likely than not that the Veteran has a back disability that is causally related to service. The examiner explained that there is no documentation of an MVA accident during service and that the Veteran was not diagnosed with any back disabilities until 2018. Moreover, there is a gap in treatment for any back disabilities from 1983 to 2006. The examiner also discussed the Veteran's report of homelessness for a 6-year period in the 2010s noting that he had access to VA medical services while living in a Veteran's shelter. The Board has carefully reviewed the lay and medical evidence of record and finds that the most probative medical evidence is weighted against finding that direct service connection for the Veteran's current back disabilities is warranted. Here, the October 2019 VA examiner considered the Veteran's lay contentions regarding the etiology of his back disabilities. Based on their medical training and a review of the medical evidence, they determined it to be less likely than not that any back disabilities were incurred during service or are causally related to events during service. Further, there is otherwise no opinion or treatment record authored by a competent medical professional which supports the Veteran's contention that his back disabilities are related to events during service. The Board acknowledges the Veteran's lay contentions regarding an etiological relationship between his back disabilities and events during service. Certainly, the Veteran is competent to describe experiencing symptoms and his medical treatment records corroborate at least to some extent the Veteran's history of symptoms. Nevertheless, as a lay person, the Veteran does not have the training or expertise to render a competent nexus opinion regarding the etiology of complex musculoskeletal disabilities that is more probative than the VA examiner's opinion on this issue because this is a medical determination that is complex and requires specific medical training and expertise. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007); Barr v. Nicholson, 21 Vet. App. 303, 309 (2007); Layno v. Brown, 6 Vet. App. 465, 469-71 (1994)). Consequently, the Board finds that the Veteran's lay contentions regarding the etiology of his back disabilities are outweighed by the competent opinion of the VA examiner of record. See Id.; see also King v. Shinseki, 700 F.3d 1339, 1345 (Fed. Cir. 2012). Accordingly, the preponderance of the evidence is against granting service connection for a back disability under a direct service connection theory of entitlement. 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). The Board remanded this matter in August 2020 for a VA medical opinion to address a possible relationship between any current back disabilities and the Veteran's service-connected psychiatric disability. An October 2020 VA medical opinion from a qualified clinician reflects that a baseline level of severity of the Veteran's back disabilities could not be established. The examiner opined however that it is at least as likely as not that the Veteran's back disabilities have been aggravated beyond there natural progression by a service-connected psychiatric disability. The examiner cited to medical literature which substantiates that severe musculoskeletal injuries and surgeries are positively correlated and associated with symptoms of common mental disorders. Moreover, myalgias can be caused by multiple conditions including psychiatric disabilities. In October 2020, the AOJ requested an addendum VA medical opinion to elaborate on the October 2020 VA medical examiner's findings. A different clinician provided a January 2021 VA addendum opinion which states that it is less likely than not that any current back disabilities were aggravated by a service-connected psychiatric disability. The given rationale was that there is "no medical relationship" between any current back disabilities and a service-connected psychiatric disability therefore aggravation "is not plausible." Initially, the Board finds this rationale to be conclusory as it is unsupported by any facts, data, or medical literature. Further, its assertion that there is no medical relationship between the Veteran's back disabilities and a service-connected psychiatric disability is contradicted by the medical literature cited to by the October 2020 VA examiner. This opinion therefore is entitled to minimal probative value. Consequently, the Board finds that the preponderance of the evidence is in favor of granting service connection for a back disability as secondary to a service-connected psychiatric disability. 38 C.F.R. § 3.310(a). Jennifer White Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Kyle McKone 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.