Citation Nr: 21041843 Decision Date: 07/10/21 Archive Date: 07/10/21 DOCKET NO. 16-00 241A DATE: July 10, 2021 ORDER Entitlement to service connection for a left knee disability is granted. Entitlement to service connection for a right knee disability is granted. FINDINGS OF FACT 1. Resolving all reasonable doubt in his favor, the Veteran's left knee disability is aggravated beyond its natural progression by his service-connected disabilities. 2. Resolving all reasonable doubt in his favor, the Veteran's right knee disability is aggravated beyond its natural progression by his service-connected disabilities. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for a left knee disability as secondary to service-connected disabilities have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. 2. The criteria for entitlement to service connection for a right knee disability as secondary to service-connected disabilities have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served in the United States Navy from January 1978 to November 1979. These matters come to the Board of Veterans' Appeals (Board) on appeal from a September 2015 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). These matters were previously before the Board in October 2019, at which time the Board remanded these issues in order to obtain a VA examination. The claims have since returned to the Board for further appellate review. Service Connection 1. Entitlement to service connection for a left knee disability 2. Entitlement to service connection for a right knee disability Service connection will be granted for a disability resulting from a disease or injury incurred in or aggravated by service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. Service connection may also be granted for a disease first diagnosed after discharge when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection requires competent evidence showing (1) a present disability; (2) an 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. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may also be established on a secondary basis for a disability that is shown to be proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). In order to prevail on the issue of secondary service connection, the record must show: (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) medical nexus evidence establishing a connection between the service-connected disability and the current disability. Wallin v. West, 11 Vet. App. 509, 512 (1998). Before deciding a claim, the Board is required to evaluate all relevant evidence on appeal, including lay and medical evidence. See 38 U.S.C. § 7104(a); Buchanan v. Nicholson, 451 F.3d 1331, 1335 (2006). The evaluation of evidence generally involves a determination as to the competency, credibility, and weight of the evidence. Lay evidence may be competent and sufficient to establish a claim for service connection. Specifically, lay evidence may be sufficient to establish a diagnosis of a condition when a layperson is competent to identify the medical condition, the layperson is reporting a contemporaneous medical diagnosis, or lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). The Board must then determine whether the evidence is credible or worthy of belief. Barr v. Nicholson, 21 Vet. App. 303, 308 (2007). After determining the competency and credibility of the relevant evidence, the Board must weigh its probative value. The standard of proof to be applied in decisions on claims for veterans' benefits is set forth in 38 U.S.C. § 5107. A claimant is entitled to the benefit of the doubt when there is an approximate balance of positive and negative evidence. See 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). The preponderance of the evidence must be against the claim for benefits to be denied. See Alemany v. Brown, 9 Vet. App. 518 (1996). The Veteran contends that his left and right knee disabilities are secondary to his service-connected disabilities. The first element for secondary service connection is satisfied in that the Veteran has been diagnosed with osteoarthritis of the left and right knees. The second element for secondary service connection is also satisfied as the Veteran is service-connected for multiple orthopedic disabilities. The remaining determination, therefore, is whether there is a link between the two. In its October 2019 remand, the Board instructed the RO to obtain a VA examination for the Veteran's left and right knee disabilities, and the Veteran received an examination in September 2020. The examiner was asked to opine on whether the Veteran's bilateral knee disabilities were directly due to his active service or if they were either proximately due to or aggravated by his service-connected bilateral metatarsalgia, bilateral hip disabilities, bilateral ankle disabilities, or his lumbosacral strain. The VA examiner addressed the question of direct service connection by noting that the Veteran first complained of knee pain in March 2015, stating his knee pain began between one and two years prior. X-rays taken in March 2018 revealed the Veteran had moderate osteoarthritis of his medial compartment and mild to moderate osteoarthritis of the patellofemoral compartment in his left knee, and mild osteoarthritis of the patellofemoral compartment in his right knee. The examiner also noted the Veteran's service treatment records showed no complaints of knee conditions during service, and thus found that his knee conditions were less likely than not due to service. As for whether the Veteran's service-connected disabilities were the proximate cause of his bilateral knee disabilities, the examiner opined that the March 2018 diagnosis of arthritis in both knees was caused by the normal degeneration of cartilage and not as a result of his other comorbidities. The examiner also stated the Veteran's left knee meniscus tear was the result of a fall and not due to his hip, ankle, foot, or spine conditions. Lastly, the examiner found that the Veteran's service-connected hip, ankle, foot, and spine disabilities aggravated his bilateral knee disabilities. The examiner explained that "[m]edically, any condition that causes misalignment of the joint leads to antalgic gait" and explained this can lead to other joints incurring stress while compensating for the injured joint that can lead to damage and pain. The examiner further states that "[w]ithout a doubt, the concurrent occurrence of other joints and spine conditions, such as lumbosacral strain, hips arthritis, metatarsalgia and bilateral lateral collateral ligament strain would exert more pressure and stress on the knee joint, thus aggravating it beyond it[s] natural progression." Based on the above, the Board finds that the evidence in this case is at least in equipoise with regard to whether the Veteran's left and right knee disabilities have been aggravated by his service-connected disabilities. In so finding, the Board assigns probative weight to the September 2020 VA examiner's reasoning. Here, the Board finds persuasive in particular the September 2020 VA examiner's reasoning that "without a doubt," musculoskeletal disabilities such as those for which the Veteran has been service-connected would aggravate his knee disabilities beyond their natural progression. As the Board resolves all doubt in the Veteran's favor, no further discussion of the evidence is necessary. In sum, the evidence is at least in equipoise that the Veteran has left and right knee disorders that have been aggravated by his service-connected disabilities. Entitlement to service connection for right and left knee disabilities is, therefore, warranted. The benefit of the doubt doctrine has been applied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The nature and extent of the disabilities are not before the Board at this time. Caroline B. Fleming Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Gabrielle Ongies, 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.