Citation Nr: 21030966 Decision Date: 05/20/21 Archive Date: 05/20/21 DOCKET NO. 17-18 334 DATE: May 20, 2021 REMANDED Entitlement to service connection for a right knee condition is remanded Entitlement to service connection for a left knee condition is remanded. REASONS FOR REMAND The Veteran served on active duty from May 1950 to September 1954, from February 1955 to August 1960, and from November 1963 to August 1974, with additional periods of active duty for training. The Veteran passed away during the pendency of the appeal, and in August 2020, the agency of original jurisdiction (AOJ) granted the appellant's request for substitution. As an initial matter, the Board expresses its condolences to the appellant for the loss of the Veteran and recognizes his valuable contribution to this country in the United States Navy. In December 2017, the Board denied the Veteran's claim for entitlement to service connection for left and right knee osteoarthritis. The Veteran appealed the December 2017decision to the United States Court of Appeals for Veterans Claims (Court). In July 2018, the Court vacated the Board's decision and remanded the claims. In February 2019, the Board remanded the matter for further development. In December 2019, the Board denied the claim. In September 2020, the Court granted a Joint Motion for Remand (JMR) that vacated the Board's December 2019 decision and remanded it for further action. Most recently, in January 2021, the Board remanded the above issues to obtain VA opinions, which were obtained in March 2021. The case has since returned to the Board for appellate review. 1. Entitlement to service connection for a right knee condition is remanded; entitlement to service connection for a left knee condition is remanded. The appellant contends that entitlement to service connection for a right and left knee condition is warranted. The Board sought additional VA opinions regarding the etiology of the Veteran's left and right knee conditions, which were obtained in March 2021. In March 2021, the VA examiner opined that it is less likely as not (less than a 50 percent or greater probability) that the Veteran's osteoarthritis of the left and right knees had their onset during active duty service. The examiner reasoned that, according to the medical record review, the Veteran's active duty service records fail to show complaint, diagnosis, or treatment of a left or right knee condition, including arthritis, in active duty service. Based on the record, a diagnosis of right knee arthritis is not noted until 2011; left knee arthritis is not noted until 2012. The objective evidence therefore fails to support development of osteoarthritis to the left and/or right knee in active duty service. The March 2021 VA examiner also opined that it is less likely as not (less than a 50 percent or greater probability) that the Veteran's osteoarthritis of the left and right knees had their onset within the first year after separation from service. The examiner reasoned that, as per the medical record review, the development of osteoarthritis of the right knee is not noted until 2011, 37 years after separation from active duty service. Regarding the left knee, the examiner noted that the objective evidence provides a diagnosis of left knee arthritis in 2012, 38 years after separation from active duty service. The objective evidence of record fails to support a complaint, diagnosis or any condition of the left or right knee including development of osteoarthritis of the left and/or right knee within a year after separation from active duty service. In the year the Veteran separated from active duty, in 1974, the examiner noted that a medical exam documents 'normal' lower extremities and the Veteran reported 'no' to arthritis, muscle pain/cramps, painful joints, lameness or weakness. The Veteran was 44 years old at the time. Considering the Veteran's active duty record and medical literature, the examiner concluded that it is likely that the Veteran had normal knees upon discharge from active duty service. The literature fails to provide objective evidence to support development of arthritis of the left or right knee within a year after separating from active duty with normal knees. The March 2021 VA examiner also opined that it is less likely as not (less than a 50 percent or greater probability) that the Veteran's osteoarthritis of the left and right knees is related to an in-service injury, disease, or event. The September 2019 VA examiner acknowledged Dr. B's July 2013 opinion noted that "'the bulk of the Veteran's time' (27 years in the Navy) was spent on Naval ships. He noted the compressive force of walking on the steel decks, stairways, and ladders of ships in the Navy over 27 years of service "positively contributed" to the onset of osteoarthritis.'" However, the examiner noted that the medical record does not support Dr. B's opinion that the Veteran spent the 'bulk' of his 27 years on ships and/or on steel decks, stairways and ladders of ships. The examiner noted that about 5+ years were spent on ships, and this was distributed throughout the course years during the Veteran's career. The examiner concluded that a review of the Veteran's work history and the literature concerning the types of activities that the Veteran participated in as storekeeper and commissioned officer fails to support prolonged 'compressive force' on the knees. Orthopedic literature provides that prolonged heavy labor may contribute to degeneration of the knee however based on the Veteran's work history and active duty medical record over the course of his time in the Navy the objective evidence fails to support prolonged heavy labor nor walking on steel decks, stairways and ladders for a prolonged period of time. Neither is there objective evidence of a complaint, diagnosis, or treatment of a knee condition, thus indicating that a knee condition was not caused by the Veteran's active duty service. According to the orthopedic literature several factors contribute to development of degenerative joint disease of the knee, including advanced age (generally over the age of 50), trauma or injury, overweight or obesity and genetic predisposition. Per the record, the Veteran's arthritis was not diagnosed for over thirty years after separation from active duty. The record shows no arthritis at discharge from active duty at the age of 44. There is a gap of over thirty years after separation during which the Veteran's medical history is not known. Whether there was injury or trauma during this period of time is not known. However, the Veteran aged during this time and increased in weight during this period of time. It is likely that these risk factors contributed to the development of degenerative joint disease of the knees. The objective evidence goes against development of degenerative joint disease of the left or right knee in active duty nor for many years after separation from active duty service. The Board finds the March 2021 opinion inadequate. Specifically, as the January 2021 Board remand noted, in a March 2015 Notice of Disagreement (NOD), the Veteran stated that he experienced pain in his legs during service but did not see a doctor because he was told that they were growing pains. The March 2021 VA opinion did not address the Veteran's lay statements that he experienced pain in his legs during service. While the Board regrets the additional delay, a remand is necessary to obtain another opinion that addresses the Veteran's lay statements. The matters are REMANDED for the following action: 1. Obtain an addendum opinion from an appropriate clinician. The reviewing clinician is to provide opinions (based on a review of the record) to answer the following: Is it at least as likely as not (a 50 percent or greater probability) that the Veteran's osteoarthritis of the left and right knees had their: (a) onset during service, (b) onset within the first year after separation from service, or (c) is related to an in-service injury, disease, or event. The examiner is asked to address Dr. T.B.'s July 2013 opinion that the compressive force of walking on the steel decks, stairways, and ladders of ships in the Navy over 27 years of service "positively contributed" to the onset of osteoarthritis. See 09/28/2018 Medical Treatment Record Non-Gov't Facility. In doing so, the examiner should address the significance, if any, of the Veteran's March 2015 reports of leg pain in service. The examiner is also requested to address the Veteran's competent and credible lay statements that he experienced pain in his legs during service but did not see a doctor because he was told that they were growing pains. See March 2015 Notice of Disagreement (NOD). A complete rationale for all opinions must be provided. If the clinician cannot provide a requested opinion without resorting to speculation, it must be so stated, and the clinician must provide the reasons why an opinion would require speculation. The clinician must indicate whether there was any further need for information or testing necessary to make a determination. Additionally, the clinician must indicate whether any opinion could not be rendered due to limitations of knowledge in the medical community at large and not those of the particular examiner. 2. After completing the above action, and any other development as may be indicated by any response received as a consequence of the actions taken in the paragraphs above, the claim must be readjudicated. GAYLE STROMMEN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board C. E. Grossman, 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.