Citation Nr: 21041343 Decision Date: 07/08/21 Archive Date: 07/08/21 DOCKET NO. 13-31 129A DATE: July 8, 2021 ORDER Service connection for a right knee disorder is denied. FINDING OF FACT The Veteran's right knee condition is not related to service. CONCLUSION OF LAW The criteria for service connection for a right knee disorder have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from December 2007 to December 2008. He had additional service in the Army National Guard, including a period of active duty for training (ACDUTRA) from April 2007 to August 2007. The case is on appeal from a May 2010 rating decision. In October 2016, the Veteran testified at a Board hearing. Most recently, in January 2020, the Board remanded the case for additional development. While the case was in remand status, in a June 2020 rating decision, the RO granted service connection for a lumbar spine condition. Thus, that issue is no longer on appeal. The Board has limited the discussion below to the relevant evidence required to support its finding of fact and conclusion of law, as well as to the specific contentions regarding the case as raised directly by the Veteran and those reasonably raised by the record. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015); Robinson v. Peake, 21 Vet. App. 545, 552 (2008). Service connection for a right knee disorder. Legal Criteria Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. See 38 U.S.C. § 1110; 38 C.F.R. § 3.303. A veteran seeking compensation under these provisions must establish three elements: "(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." Saunders v. Wilkie, 886 F.3d 1356, 1361 (Fed. Cir. 2018) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Analysis The Veteran contends that he injured his right knee during basic training after falling about 20 feet from a climbing rope, the same event from which he also hurt his service-connected back. See Veteran's October 2016 Board hearing testimony. Service treatment records (STRs) confirm that the Veteran was treated for right medial knee pain during service "consistent with medial tibial plateau stress fx" in June 2007. Additionally, STRs dated August 2007 show a diagnosis of patellar femoral syndrome (PFS). In December 2007, a medical history of stress fractures in both knees was reported on the medical certificate for deployment to the Persian Gulf, with a note of "able to perform MOS." In January 2010, he filed for service connection for his right knee, a little over one year following service. The Veteran was afforded a VA examination for his right knee in July 2010. During the examination he complained of giving way, instability, weakness, decreased joint speed motion, locking, swelling, and tenderness, and the physical examination found objective evidence of pain on active range of motion and after repetitive use, with less than full range of motion. However, x-rays found "no osseous or articular abnormalities," and the examiner opined that "there is insufficient clinical evidence at the present time to warrant a diagnosis of any acute or chronic disorder or residuals thereof." The Veteran was provided a new VA examination in August 2019. The examiner found a diagnosis of bursitis in both knees; however, it was opined that the right knee condition was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. As rationale, the examiner stated that there was no objective documentation of any symptoms for five years between 2010 and 2015, and that PFS is not currently present and is unlikely to be related to his current condition of bursitis of the right knee. Following the January 2020 Board remand, the Veteran was provided a new in-person examination in March 2020, and a medical review of the record and opinion provided by an orthopedic expert in February 2021. In March 2020, the Veteran denied right knee problems prior to service. He stated that when he fell, he reported it immediately, and was informed that he had "a patellofemoral issue." He reported his belief that he may have arthritis in his right knee, with usual pain level in his knee at a 6 out of 10. The examiner indicated that he did not have a current knee diagnosis with a normal physical exam and radiology report, and that his knee pain is subjective. She opined that any claimed condition was less likely than not incurred in or caused by an in-service injury. The examiner stated that the pain he experienced did not rise to the level of functional impairment as he was able to perform his duties. As to STR entries, she indicated that his diagnosis of PFS in service was "an acute & transitory knee condition during basic training," and that although a Fitness for Duty Form showed left foot pain and healing shin splints, it did not discuss his knees. In February 2021, an orthopedic specialist reviewed the Veteran's claim file, and also opined that the Veteran's right knee condition was less likely than not (less than 50 percent probability) incurred in or caused by an in-service injury, event or illness. The orthopedist first noted that, while a June 2007 bone scan found shin splints, this affected the tibia, not precisely the knees, and is a self-limiting condition that will heal with appropriate rest. He also opined that the medical records do not indicate knee complaints that rose to the level of functional impairment. He acknowledged the August 2019 diagnosis of knee bursitis, but indicated that there is no relation between that condition and the tibial stress fractures, MCL sprain, or PFS reported while on active duty. Finally, the specialist determined that there was no continuity of care for the right knee within the required one year following his active service discharge. With respect to the first element, the evidence of record establishes that the Veteran has a current diagnosis for the right knee, to include bursitis, as documented at his August 2019 VA examination. 38 C.F.R. § 3.303. The record also indicates an in-service injury of the knee with an August 2007 diagnosis of PFS and complaints of knee pain, and the Veteran's report of falling approximately 20 feet from a climbing rope during basic training. Id. However, the Board notes that there are no positive medical opinions of record providing a "nexus" or link between the Veteran's current right knee condition to his period of active service. The Board finds most probative the February 2021 opinion from the orthopedic expert, which is clear and unequivocal, and based on the relevant information, including the Veteran's STRs, post-service treatment records, personal medical history, and provided references to medical literature in support of his opinions. Moreover, the examiner's explanations are logical and follow from the facts and information given. The orthopedic specialist was unable to find a medical nexus between the Veteran's current right knee condition of bursitis, directly to any injury or medical condition experienced during service. While the Veteran reports pain in his right knee, and believes it could be arthritic as a result of an injury due to a fall during basic training, this is a complex medical question outside the competence of a non-medical expert to determine whether such a cause-and-effect relationship exists. Thus, this nexus question requires expert consideration and cannot be considered within the competence of a non-expert lay witness. The Veteran, as a lay person, has not established the competence needed to rebut expert medical opinions. As such, his opinion is not adequate to rebut the VA examiners' opinions, nor is it otherwise sufficiently probative to be considered competent evidence tending to increase the likelihood of a positive nexus between the Veteran's service and his right knee. The Board has also considered whether a claim for shin splints or a tibial condition should be remanded for initial adjudication as a related condition. See Grimes v. McDonough, No. 18-1017, 2021 U.S. App. Vet. Claims LEXIS 742 (holding a claim for service connection may encompass a related condition). However, as there is no evidence of current complaints or diagnosis of shin splints or a right leg issue, a remand is not warranted. In sum, the preponderance of the evidence is against the claim, particularly the direct nexus element, and the benefit of the doubt doctrine is not applicable. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Therefore, service connection for a right knee condition is not warranted. RYAN T. KESSEL Veterans Law Judge Board of Veterans' Appeals Attorney for the Board S. Morford, 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.