Citation Nr: 21040309 Decision Date: 07/03/21 Archive Date: 07/03/21 DOCKET NO. 15-32 791 DATE: July 3, 2021 ORDER Service connection for a bilateral knee disability, to include as secondary to a service-connected low back disability, is denied. VETERAN'S CONTENTIONS The Veteran contends that he has a bilateral knee disability as a result of heavy lifting and bending related to his military occupational specialty (MOS) as an Aerospace Maintenance Journeyman, or as a result of running in unsupportive shoes during basic training. Alternately, the Veteran contends that he has a bilateral knee disability secondary to his low back disability. FINDING OF FACT The Veteran's bilateral knee disability is not attributable to his active service or to any incident of service, including his service-connected low back disability. CONCLUSION OF LAW The criteria for service connection for a bilateral knee disability are not met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1131, 1137, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from December 1995 to February 2000. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a June 2014 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Boston, Massachusetts. The Veteran testified at a hearing before the undersigned Veterans Law Judge (VLJ) via videoconference in November 2018 and a transcript of the hearing has been associated with the claims file. This matter was previously before the Board at which times it was remanded for further development. Entitlement to service connection for a bilateral knee disability, to include as secondary to a service-connected low back disability Generally, service connection may be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred or aggravated in active military service. This means that the facts establish that a particular injury or disease resulting in disability was incurred coincident with service in the Armed Forces, or if preexisting such service, was aggravated therein. 38 U.S.C. § 1110; 38 C.F.R. § 3.303 (a). Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the current disability. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Hickson v. West, 12 Vet. App. 247, 253 (1999); Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996) (table). Service connection may also be granted through the application of statutory presumptions for chronic conditions, such as arthritis. See 38 U.S.C. §§ 1101 (3), 1110, 1112, 1113, 1131, 1137; 38 C.F.R. §§ 3.303 (b), 3.307(a)(3), 3.309(a). Arthritis is included under 38 C.F.R. § 3.309 (a); therefore, 38 C.F.R. § 3.303 (b) also applies. 38 C.F.R. § 3.307; Walker v. Shinseki, 708 F.3d 1331, 1337 (Fed. Cir. 2013). Presumptive service connection for "chronic diseases" must be considered on three bases: chronicity during service, continuity of symptomatology since service, and manifestations within one year of the claimant's separation from service. 38 C.F.R. § 3.303 (b); Walker, 708 F.3d at 1336-38. The application of these presumptions operates to satisfy the "in-service incurrence or aggravation" element and establish a nexus between service and a current disability, which must be found before entitlement to service connection can be granted. Further, service connection may be established on a secondary basis for a disability which was either caused or aggravated by a service-connected disability. 38 C.F.R. § 3.310 (a); Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). Determinations as to service connection will be based on review of the entire evidence of record, to include all pertinent medical evidence. VA must also consider all favorable lay evidence of record. See 38 U.S.C. § 5107 (b); see also Layno v. Brown, 6 Vet. App. 465, 469-70 (1994) (a Veteran is competent to report on that of which he or she has actually observed and is within the realm of his or her personal knowledge). The Veteran's service treatment records (STRs) document that he was diagnosed with a patellar contusion and given a temporary profile restricting ladder climbing, squatting, and prolonged walking. Post-service treatment records confirm a current diagnosis of patellofemoral syndrome. To the extent that the Veteran has stated that he has a bilateral knee disability attributable to service, the Board finds that he is competent to report on his symptoms and that of which he has personal knowledge, but he is not competent to provide an opinion as to the etiology of his bilateral knee disability because such a question is not answerable by the application of knowledge within the realm of a lay person. See Layno, 6 Vet. App. at 469-70; Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Therefore, the Board finds that the Veteran is not competent to relate his current bilateral knee disability to his service or to any incident therein, including his service-connected low back disability. The evidence of record otherwise includes a June 2014 VA Knee and Lower Leg Conditions examination report in which the examiner opined that it was less likely than not that the Veteran's claimed condition was incurred in or caused by the claimed in-service injury, event, or illness. The examiner reasoned that a February 18, 1997 note refers to a contusion of the right knee, no follow up needed; a January 2000 separation examination does not indicate a knee problem; and there were no further indications of a knee problem in the service medical records. In a September 2019 addendum, a VA examiner opined that it was less likely than not that the Veteran's claimed condition was incurred in or caused by the claimed in-service injury, event, or illness. The examiner reasoned that the service medical records showed a contusion of the right knee in February 1997 which was an acute injury and did not require follow up. The examiner explained that this kind of injury does not form a medical basis for chronic pain, or a nexus for the development of bilateral patellofemoral pain syndrome. The Veteran's chronic knee pain was first diagnosed in 2014 as bilateral patellofemoral pain syndrome. The Veteran reported during the June 2014 VA Knee and Lower Leg Conditions examination and November 2018 Board hearing that he experienced knee pain in service, which was minor, and he did not seek treatment. He further reported that the knee pain gradually worsened over time. While the Veteran's history of chronic knee pain has been established, the examiner determined that there is no medical evidence that the knee pain during service was proximately due to or related to the current knee condition of patellofemoral pain syndrome. The examiner considered it significant that the Veteran was employed loading trailers in a warehouse after service up until 2011, and determined that it was at least as likely as not that the 11 years of work loading trailers after service significantly contributed to the current chronic patellofemoral pain syndrome. Given this history, the examiner determined that a medical nexus for a bilateral knee condition related to service could not be established. With regard to secondary causation and aggravation, the September 2019 VA examiner opined that there was no medical nexus for patellofemoral pain syndrome proximately due to, related to, or aggravated by the diagnosed back condition. The examiner reasoned that patellofemoral pain syndrome, also known as "Runner's Knee," is often seen in athletes, but can be seen in anyone due to vigorous exercise or training with frequent running or jumping. The condition is due to stress on the muscles, tendons, and movement of the patella. While a change in footwear or a change in the running surface can contribute to patellofemoral pain syndrome, there is no medical evidence that back conditions cause or aggravate the condition. In a June 2020 addendum a VA examiner again opined that it was less likely than not that the Veteran's claimed condition was incurred in or caused by the claimed in-service injury, event, or illness. The examiner reasoned that the Veteran was seen and treated for a contusion of the right knee in February 1997. The examiner explained that a contusion is a bruise of the soft tissue usually caused by a fall or impact to the body. The treatment is rest, ice, and elevation to reduce pain and swelling. There were no documented complications or residuals from the contusion of the right knee, which was an acute injury and had no etiological or pathophysiological relationship to the diagnosis of bilateral patellofemoral syndrome (which was established upon the June 2014 VA Knee and Lower Leg Conditions examination). Regarding the Veteran's report of chronic knee pain since service, the Veteran is deemed competent to establish a chronicity of symptomatology. However, the Veteran is not capable of diagnosing those symptoms. The Veteran has a history of low back pain with sciatic pain radiating down the left leg. Radiculopathy, such as sciatic pain, can often be related to pain in the hip, knee, or leg. The examiner also considered the Veteran's contention that he developed his current knee condition due to running in unsupported shoes during service but determined that such was not supported by the objective evidence. The examiner explained that while patellofemoral pain syndrome is often associated with running (regardless of the type of running shoe), the condition would manifest as knee pain or swelling and inhibit running. Here, there was no in-service evidence demonstrating that the Veteran was unable to carry out his military occupational specialty (MOS) duties due to a knee condition. Indeed, the Veteran's service treatment records were absent any record of an inability to perform physical training during service due to a knee condition. The Veteran had no documented temporary or permanent profile during service due to a knee condition. Finally, in a March 2021 addendum, an examiner opined that the Veteran's current bilateral knee condition was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner reasoned that the Veteran is currently diagnosed with bilateral patellofemoral syndrome as of June 4, 2014 and there was no evidence of patellofemoral syndrome in service or at separation from service. The examiner observed that the separation examination dated January 20, 2000 was specifically negative for knee conditions. Additionally, th examiner noted with significance that there was no clinical evidence of a knee condition until at least 2012. The Veteran was seen for a back condition on July 16, 2012, at which time knee pain was noted in the past medical history, but there were no details. The Veteran was not diagnosed with patellofemoral syndrome until or around 2014. Rather, the examiner determined that the record best supported a finding that the Veteran had a single event in service due to local trauma on February 8, 1997, which was diagnosed as a patellar contusion. This contusion more likely than not (almost certainly), resolved as it was a bruise. The Veteran served an additional three years without evidence of a chronic knee condition. The examiner determined that it was highly unlikely such could have occurred without resolution of the injury in 1997. The examiner next concluded that a bruise that resolved without residual injury could not cause patellofemoral syndrome 14 years (or 12) later. The examiner explained that patellofemoral syndrome is a retropatellar condition and is not consistent with the mechanism of injury the Veteran sustained in 1997. Furthermore, the Veteran's current condition is bilateral, rendering the contusion moot with respect to the left knee. The examiner observed that the Veteran's occupation for 11 years post-service was warehouse duties involving heavy lifting and loading, and determined that it was more likely than not that this was the source of the Veteran's onset/nexus of his current knee problems. Here, there is no nexus established in service for patellofemoral syndrome or within one year of service. There were no in-service complaints even remotely similar to the typical patellofemoral complaints. The Veteran's singular, acute, self-limited episode of a contusion could not be responsible for the development of patellofemoral syndrome bilaterally 14 years later, or 12 years if one accepts the July 2021 past medical history report. Patellofemoral syndrome is generally considered to be an overuse injury, which as frequent bending of the knees and lifting as experienced during the Veteran's post-service duties. It may occur with running, regardless of shoes, but there is no evidence of this occurring in service. The examiner determined that the Veteran's claim of onset in service with continuity since service was not substantiated and was actually contradicted by the separation examination. The clinical onset of a chronic condition was not established in service, and there were no complaints or care that occurred within one year of service. For these reasons, the examiner determined that it was more likely than not that the Veteran's current knee conditions arose during and as a result of his post-service occupation, and it was less likely than not that the Veteran's bilateral patellofemoral syndrome was due to service or events in service including the right patellar contusion, running, physical training, or duties pertaining to the Veteran's MOS. After reviewing the evidence, the Board finds the June 2014, September 2019, June 2020, and March 2021 VA examiner opinions to be highly probative. The opinions were based on a review of the claims file and relevant facts, and the examiners provided detailed rationales. Id. There is no competent medical opinion of record to the contrary. Without any competent evidence that the Veteran's bilateral knee disability is related to service, direct service connection is not warranted. Additionally, there is no indication that the Veteran's service-connected low back disability caused or aggravated his bilateral knee disability, so secondary service connection is not warranted. There is no doubt to be resolved in this case. See 38 U.S.C. § 5107(b); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-56 (1990). S.C. Krembs Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Smith-Jennings, 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.