Citation Nr: 21042593 Decision Date: 07/13/21 Archive Date: 07/13/21 DOCKET NO. 16-09 501 DATE: July 13, 2021 ORDER Entitlement to service connection for a right knee disability is denied. FINDING OF FACT The Veteran's right knee disability was not shown as chronic in service and did not manifest to a compensable degree within the applicable presumptive period; continuity of symptomatology is not established; and the disability is not otherwise etiologically related to an in-service injury or disease. CONCLUSION OF LAW The criteria for entitlement to service connection for a right knee disability have not been met. 38 U.S.C. §§1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served honorably in the United States Army for 25 years, from July 1984 to February 2010. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a May 2021 supplemental statement of the case (SSOC), issued by the Department of Veterans Affairs (VA) Regional Office (RO). This issue has come before the Board twice before. In a January 2019 decision, the Board remanded the issue to provide the Veteran with a VA examination. Caffrey v. Brown, 6 Vet. App. 377 (1994); 38 C.F.R. § 3.327(a). The matter returned to the Board in March 2021 and was remanded again after the Board found that the rationale for the VA examiner opinion was founded on incomplete information. The VA obtained an addendum opinion for the Veteran's right knee condition and issued an SSOC. The Board is now satisfied that there was substantial compliance with its remand orders and is prepared to adjudicate the issue at hand. See Dyment v. West, 13 Vet. App. 141, 146-147 (1999); Stegall v. West, 11 Vet. App. 268, 271 (1998). 1. Entitlement to service connection for a right knee disability The Veteran contends that she is due entitlement to a right knee disability. Specifically, the Veteran seeks entitlement for the right knee disability due to the fact that evidence from the service treatment records (STRs) show that she had right knee issues during her time in service. Under the relevant laws and regulations, service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131. Generally, the evidence 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. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of matter, the benefit of the doubt will be given to the Veteran. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. The Veteran's STRs show her first complaint of bilateral knee pain in August 1989. The STRs are then absent of any complaints until August 1996, when the Veteran reports pain and swelling in the knee after running. The Veteran was subsequently diagnosed with a sprained knee. In November 2000, the Veteran was assigned a permanent profile due to her knee pain. The Veteran's assignment limitation stated that she was to run at her own pace and distance. The examination in November 2000 found slight tenderness to palpation in the region of the patellofemoral femoral joint with compression. It was also noted that the Veteran had a five-year history of bilateral knee pain. The Veteran reported pain before and after running, as well as pain going up and down stairs, and when getting out of a chair. The Veteran received x-rays that showed no evidence of significant degenerative change, loose body, fracture, or joint effusion. After the November 2000 permanent profile, there was another gap in the STRs, until April 2008, when it was noted that the Veteran had abnormal lower extremities, specifically showing crepitus in both knees. In September 2009, the Veteran filed an initial service connection claim for her bilateral knee pain. The Veteran also received a separation examination in September 2009. The separation exam specifically noted the Veteran's bilateral knee pain and the fact that she received a permanent profile due to her knee in November 2000. In connection with the Veteran's claim for service connection, she was afforded a VA examination in October 2009. The examiner noted that the Veteran reported symptoms of weakness, stiffness, swelling, giving way, locking, deformity, and pain in her knees. The Veteran also reported experiencing flare ups that were precipitated by physical activity. The examiner also found that the Veteran's range of motion in both knees was within normal limits and did not cause pain. The examiner also reviewed x-rays and found the right knee to be normal. The examiner also noted that the Veteran's right knee stability was within normal limits. The examiner offered no diagnosis for the right knee condition, concluding that there was no pathology to render a diagnosis. The Veteran was seen in June 2010 at the Ft. Benning VA Clinic to establish care. The Veteran reported that she suffered from chronic knee pain that was felt when she had to stoop down. The file also contains March 2011 treatment records from the Martin Army Community Hospital. The Veteran reported to the facility after scraping her right knee while working. X-rays taken were negative. The Veteran reported discomfort on palpation of the anterior aspect of the knee and reported having issues with the right knee for several years, particularly after exercising. The knee showed tenderness on palpation and on motion, as well as in the patellofemoral region. The motion of the knee was found to be normal and no pain was reported on motion of the knee. The providers at the hospital stated that there was no radiographic evidence of acute fracture or dislocation. They also reported that bone mineralization, bony alignment, joint spaces, and soft tissues were normal in appearance. Finally, it was reported that the Veteran had a right knee contusion with intact skin surface, with previous chronic problems particularly after activity. Later in March 2011, the Veteran was seen again where it was noted that she had suffered a contusion of the right anterior knee. The Veteran underwent an MRI which was found to be benign and showed no meniscus or ligament problems of the right knee. The MRI also showed slight chondromalacia but otherwise was reported as negative. In October 2014, the bilateral knees were examined, and it was reported that the Veteran had swelling and crepitus of the patellar regions on both knees. However, the examination also found normal motion of the knees and no pain elicited by motion. The Veteran was seen for another VA examination in February 2016. The Veteran reported that she began experiencing bilateral knee pain in 1999 and was issued a permanent profile while in service. She also stated that she attended physical therapy that provided no relief. She reported that she could not run for the remainder of her time in the military. She reported that she now experienced pain and swelling in both knees and claimed she had been diagnosed with early arthritis. The examiner did not find any arthritis upon conducting imaging tests on the knee. The examiner did note the diagnosis of a right knee strain on the exam. The examiner also conducted range of motion testing and found flexion and extension to be limited. The flexion and extension of the knee also exhibited pain, although there was no pain on weightbearing. There was also no tenderness or pain on palpation. The Veteran did employ occasional use of a knee brace. After the examination, the examiner opined that the claimed condition was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner remarked that there was no medical evidence of a right knee complaint or diagnosis during military service. In January 2019, the Board remanded the claim for a VA medical opinion, which was obtained in October 2019. The VA examiner reviewed the Veteran's file and opined that the claimed condition was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner stated that the Veteran was treated for right knee chondromalacia in October 2000 and overuse syndrome, leading to her being placed on permanent profile in November 2000. However, the examiner noted that there was no chronic, ongoing diagnosis, evaluations, complaints, or treatments for the right knee in the STRs or available medical records. The examiner also noted that the Veteran underwent an examination in 2009 where no abnormalities of the right knee were noted, and no diagnosis was established. However, the Board found this rationale to be based on an incomplete rationale, as the Veteran failed to mention or consider the April 2008 STRs, as well as the September 2009 separation exam. The Board remanded again for a new VA opinion that considered all instances of the Veteran's right knee pain. In May 2021, the VA offered another medical opinion. The examiner noted that he reviewed past disability benefit questionnaires, medical opinions, STRs, the separation exam, as well as pertinent post-service treatment records to include x-rays. The examiner opined that the claimed condition was less likely than not incurred in or caused by the claimed in service injury, event, or illness. The examiner offered an extensive and full rationale in the medical opinion. The examiner stated that the in-service events in 2000 appeared to be acute and self-limited. It was then noted that x-rays were negative and there was no further notation of pain until 2008 and 2009 reports. The examiner conceded continued symptoms of knee pain through 2011. However, the examiner reiterated that the x-rays in 2000 were negative bilaterally and that in 2011, the right knee x-ray was again found to be negative. It is noted that there are no further complaints of knee pain until 2016, a span of five years where there are no x-rays or diagnoses. The examiner stated that degenerative joint disease (DJD) is not present in the knee. However, even if DJD were present, it would be less likely than not related to events in-service, as it was clearly not present in-service or even as late as 2011. The examiner stated that DJD can be considered a naturally occurring condition and would be age appropriate if it were to be diagnosed. The examiner continued that any in-service diagnosis would not predispose the Veteran to any development of naturally occurring DJD. The examiner also acknowledged the events and complaints in service but noted that the Veteran lacked any continuity of care for her right knee condition. The examiner also found it noteworthy that while the absence of records is not disqualifying, due to the nature of the Veteran's complaints, it is unlikely that she could have endured a span of five years post-service without seeking care for the conditions reported in-service. The examiner also stated that the conditions noted in-service were related to overuse and strenuous activity and that the general decrease in such activities after service would allow for amelioration and resolution of the conditions. As stated above, for entitlement to service connection the evidence 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. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). Here, the Veteran has the diagnosis of a right knee strain in 2016. Therefore, the first Shedden element is met. The Veteran also has multiple reports in her STRs noting knee pain, and a permanent profile in service that precluded her from running due to her knee issues. She also had noted knee troubles on her separation exam. This evidence establishes the second Shedden element. However, the claim fails on the third Shedden element, that of a nexus between the in-service event and the current diagnosis. Here, there is no evidence of record that establishes a link between the Veteran's current knee disability and the in-service knee trouble. The Veteran also shows no continuity of symptomatology throughout the record, with large gaps in between complaints of and treatment for knee pain. The Board finds the May 2021 medical opinion to be highly probative as the examiner reviewed the record and offered a full and thorough rationale as to why the claimed right knee condition is less likely than not due to the Veteran's military service. The Board is grateful for the Veteran's honorable service. However, given the record before it, the Board finds that the evidence supporting this claim does not rise to a level of equipoise. See Skoczen v. Shinseki, 564 F.3d 1319, 1323-29 (Fed. Cir. 2009). Rather, the preponderance of the evidence is against finding that the Veteran deserves entitlement to service connection for her right knee disability. 38 C.F.R. §§ 3.303, 3.304. For these reasons, the benefit-of-the doubt standard of proof does not apply, and the claim for entitlement to service connection must be denied. See 38 U.S.C. § 5107 (b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Caroline B. Fleming Veterans Law Judge Board of Veterans' Appeals Attorney for the Board E.L. Aumiller, 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.