Citation Nr: 21031835 Decision Date: 05/24/21 Archive Date: 05/24/21 DOCKET NO. 18-04 301 DATE: May 24, 2021 ORDER Entitlement to service connection for a right femoral neuropathy is granted. Entitlement to service connection for any other right lower extremity disability, to include right knee arthritis, is denied. FINDINGS OF FACT 1. The Veteran's right femoral neuropathy was caused by his service-connected hepatitis C. 2. The weight of competent and credible evidence is against finding that a right lower extremity disability other than right femoral neuropathy began during active service, was otherwise caused by service, or was caused or aggravated by a service-connected disability. CONCLUSIONS OF LAW 1. Entitlement to service connection for right femoral neuropathy is warranted. 38 U.S.C. §§ 1110,5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.310(2020). 2. The criteria for entitlement to service connection for a right leg disability other than right femoral neuropathy have not been met. 38 U.S.C. §§ 1110, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.310 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active duty in the United States Marine Corps from June 1971 to May 1973. The RO adjudicated the Veteran's claim solely as one for right knee arthritis, but a review of the Veteran's contentions clearly demonstrates that the claim encompasses his right thigh. As such, both aspects of the claim will be considered. See Clemons v. Shinseki, 23 Vet. App. 1 (2009) (holding that when a claimant makes a claim, he or she is seeking service connection for symptoms regardless of how those symptoms are diagnosed or labeled). 1. Entitlement to service connection for a right leg disability Service connection may be established for a disability resulting from personal injury suffered or disease contracted in the line of duty in the active military, naval, or air service. 38 U.S.C. §§ 1110. Certain diseases, to include arthritis, may be presumed to have been incurred in service when manifest to a compensable degree within one year of discharge from active duty. 38 U.S.C. § 1112; 38 C.F.R. §§ 3.307, 3.309. As there is no evidence or claim that the Veteran was diagnosed with arthritis of the right knee within one year of service the above provision is not applicable. To establish a right to compensation for a present disability on a direct basis, 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." Davidson v. Shinseki, 581 F.3d 1313, 1315-16 (Fed. Cir. 2009); Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). Further, service connection may not be awarded on the basis of aggravation without establishing a pre-aggravation baseline level of disability, comparing it to the current level of disability, and showing that the secondary condition was not due to the natural progression of a disease. 38 C.F.R. § 3.310(b). The Veteran's service treatment records include no complaints, treatment, or diagnosis of a right leg disability, to include arthritis. A May 1973 Report of Medical Examination prior to separation from service included a normal examination of the neurologic system and lower extremities. The Veteran has indicated that he did not go to sick call or otherwise report right leg problems because he was told to "tough it out." A November 2014 VA treatment record noted the Veteran's complaints of right knee pain, although when questioned he reported that the pain actually was more in the thigh area. The Veteran discussed how 2 to 3 years previously he gave himself injections into the thigh for hepatitis C treatment. During one or more of the injections into the thigh he felt a pain almost like a sharp nerve pain "and they actually told him later he probably did damage a nerve." After the injections, the Veteran had experienced ongoing sharp pain with tingling, but no radiation. In December 2014, the Veteran reported pain in the right thigh and right knee above the knee joint for the previous 2 years. The Veteran discussed 2011 and 2012 injections for hepatitis C. The impression was an injury to the nerve of the right thigh while giving injections for treatment of hepatitis C. He also was diagnosed with degenerative arthritis of the right knee joint. In a February 2015 statement, the Veteran stated that in 2012 he was prescribed injections for hepatitis C. After the injections, he started having pain in the right leg and ultimately sought treatment at the VA. X-rays of the leg showed "Arthritis in my [] right leg [k]nee and thigh." The Veteran claimed that the VA orthopedist "stated that this was a direct result of taking these injections in 2012." The Veteran was afforded a VA examination in May 2015. The examiner diagnosed femoral neuropathy. The Veteran reported symptoms of right lower extremity numbness, tingling, and weakness in the right thigh. Following examination, the examiner concluded that it was at least as likely as not that the Veteran's right femoral nerve injury was caused by or the result of taking interferon injections for hepatitis C in the right thigh. The rationale indicated that there was objective clinical evidence and diagnostic evidence of right femoral nerve injury. There was no evidence of a supervening injury since lumbar radiculopathy was negative in EMG studies and the injury was unilateral, which ruled out a systemic disease such as endocrinopathy. In a May 2015 medical opinion, the above VA examining physician concluded that it was less likely than not that the Veteran's right knee arthritis was due to or the result of the Veteran's service-connected hepatitis C. The rationale indicated that the Veteran was 63 years old and that degenerative arthritis was a result of wear and tear and was the result of normal aging. The arthritis often caused no symptoms. There was no evidence to suggest a causal relationship between taking interferon injections for hepatitis C in the right thigh and developing right knee arthritis. February 2018 x-rays of the right knee showed tricompartmental arthritis with no fracture, subluxation, or dislocation. During his April 2021 Board hearing, the Veteran reported right leg problems staring in service. The symptoms were pressure that increased over the years after separation from service. He stated that a physician had indicated the Veteran had torn a nerve giving himself injections for hepatitis C. Right Femoral Neuropathy Multiple medical professionals have found that the Veteran's right femoral neuropathy was caused by the injections for his service-connected hepatitis C. There is no medical evidence to the contrary. As such, the Board finds that entitlement to service connection for right femoral neuropathy is warranted. Other Right Lower Extremity Disability The Veteran otherwise claims that his right knee arthritis was caused by the injections for his service-connected hepatitis C disability that caused the femoral neuropathy granted above. In addition, during his Board hearing the Veteran testified that his right knee symptoms started during his active service and continued thereafter. The Veteran has a current diagnosis of right knee arthritis. Thus, the critical question is whether such disability was incurred in service, otherwise was caused by service, or was caused or aggravated by his service-connected hepatitis C. The sole evidence of in-service onset and a continuity of symptoms from service are the Veteran's representations during the April 2021 Board hearing. The Veteran had a normal examination prior to separation from service and there are no lay reports of problems at that time. In November 2014, the Veteran reported the onset of right lower extremity symptoms starting 2 to 3 years earlier after making multiple injections in his right thigh to treat his hepatitis C. Given the normal examination prior to separation and the Veteran's contradictory statements regarding the timing of onset of symptoms, the Board finds that granting entitlement to service connection for right knee arthritis based on a continuity of symptoms from service is not warranted. See Walker v. Shinseki, 708 F.3d 1331, 1340 (Fed. Cir. 2013) (holding that the provisions of 38 C.F.R. § 3.303(b) relating to chronicity and continuity of symptomatology in establishing service connection and that such provisions apply to those chronic conditions, such as arthritis, specifically listed in 3.309(a)). There is no medical evidence linking the Veteran's right knee arthritis to his active service. As such, entitlement to service connection on a direct basis is not warranted. As to granting entitlement to service connection for the right knee arthritis disability as having been caused or aggravated by the service-connected hepatitis C and, specifically, as the result of injections in the right thigh above the knee, the Board finds that the preponderance of the evidence is against such a finding. In that regard, the Board finds the May 2015 medical opinion of significant probative value. The physician considered the Veteran's contention that the arthritis was caused or aggravated by the injections for his hepatitis C, but the physician concluded instead that the arthritis was the result of the natural aging process. In addition, the physician stated that there was no medical evidence suggesting that injections in the thigh above the knee could cause or aggravate arthritis in the knee. The Board finds this evidence the most probative evidence of record, as the physician's opinion was based on the Veteran's reported history, an interview of the Veteran, physical examination, and included a complete rationale for the opinion provided. The Board has considered the Veteran's representations that VA treating medical professionals indicated that the right knee arthritis was caused or aggravated by the right thigh injections. The medical records, however, indicate only that the right femoral neuropathy was due to thigh injections and provide no opinion on the right knee arthritis. The Board acknowledges that the Veteran is competent to report what he was told by medical professionals regarding the cause of his right knee arthritis, but given the disparity of what he was verbally told and what is written in the records, as well as the lack of any listed rationale for the opinion that the injections caused or aggravated the right knee arthritis, the Board affords far greater probative weight to the conclusions of the May 2015 VA examiner. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). As to the Veteran's general lay contentions that the right knee arthritis was caused or aggravated by his service-connected hepatitis C or injections for that disability, the Veteran is competent to report physically observed symptoms. That said, given the complexity of linking injections into the right thigh with the development of right knee arthritis, the Board finds the May 2015 VA examiner's conclusions of far greater probative weight. The VA physician has a greater level of education, training, and experience in such a medically complex matter. See Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). Accordingly, the Board finds that the preponderance of the evidence is against service connection for a right lower extremity disability (other than right femoral neuropathy), to include right knee arthritis, so there is no reasonable doubt to resolve in the Veteran's favor. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. J.W. FRANCIS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board C. J. Houbeck, 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.