Citation Nr: 21042688 Decision Date: 07/13/21 Archive Date: 07/13/21 DOCKET NO. 17-05 870 DATE: July 13, 2021 ORDER Service connection for a left knee disability is denied. Service connection for a right knee disability is denied. REMANDED Service connection for gout is remanded. FINDINGS OF FACT 1. The preponderance of the evidence is against finding that the Veteran's left knee disability is related to service. 2. The preponderance of the evidence is against finding that the Veteran's right knee disability is related to service. CONCLUSIONS OF LAW 1. The criteria for service connection for a left knee disability are not met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 2. The criteria for service connection for a right knee disability are not met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from August 1966 to August 1968 in the U.S. Army, including service in Vietnam. This matter comes before the Board of Veterans' Appeals (Board) from a March 2015 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Winston-Salem, North Carolina. This case was most recently before the Board in October 2020, at which time the issues on appeal were remanded for further development. This case is now before the Board for appellate consideration. Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). Certain chronic diseases, including arthritis, will be presumed related to service if they were shown as chronic (reliably diagnosed) in service; or, if they manifested to a compensable degree within a presumptive period following separation from service; or, if they were noted in service, with continuity of symptomatology since service that is attributable to the chronic disease. 38 U.S.C. §§ 1101, 1112, 1113, 1137; Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2013); Fountain v. McDonald, 27 Vet. App. 258 (2015); 38 C.F.R. §§ 3.303, 3.307, 3.309. Service connection may be granted on a presumptive basis for certain diseases resulting from exposure to an herbicide agent (including Agent Orange) for veterans who, during active military, naval, or air service, served in the Republic of Vietnam between January 1962 and May 1975, so long as the requirements of 38 U.S.C. § 1116 and 38 C.F.R. § 3.307(a)(6)(iii) are met, and the rebuttable presumption provisions of 38 U.S.C. § 1113 and 38 C.F.R. § 3.307(d) are also satisfied. 38 C.F.R. § 3.309(e). The availability of presumptive service connection for a disability based on exposure to herbicides does not preclude a veteran from establishing service connection with proof of direct causation, or on any other recognized basis. Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). Left and Right Knee Disability The Veteran contends that his right and left knee disabilities are related to walking great distances with a 50-pound backpack and weapons during service. He stated that there were days and weeks when his feet, ankles, and knees felt like they were going to fall off, but he did not seek medical attention during service. See January 2017 Correspondence. Alternatively, the Veteran contends that his left and right knee disabilities are related to his presumed exposure to herbicide agents during service. A review of the Veteran's medical records shows that he has a current diagnosis of right knee degenerative arthritis, a left knee total knee replacement due to arthritis, and bilateral patellofemoral pain syndrome. The Veteran's service treatment records (STRs) do not show any notations of complaints, treatments, or diagnoses of any knee disability. Additionally, there is no diagnosis within one year of the Veteran's release from active duty. Furthermore, the Veteran reported that his knee symptoms began around 1985. See May 2021 VA Examination. Accordingly, there is no continuity of symptomatology. Additionally, while the Veteran's service in Vietnam creates a presumption of herbicide exposure, arthritis and patellofemoral pain syndrome are not on the list of diseases presumptively connected to herbicide exposure. 38 C.F.R. § 3.309(e). Accordingly, presumptive service connection based on herbicide exposure is not applicable. Regarding direct service connection, the Veteran was afforded a VA examination in May 2021. The examiner opined that the Veteran's left and right knee disabilities were less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The rationale stated that the Veteran reported that he began having knee pain in 1985, 17 years after separation from service. The examiner stated that it would be mere speculation to state that carrying 50-pound backpacks and weapons led to degenerative arthritis because degenerative arthritis is a progressive condition that occurs naturally over a period of time. Further, the examiner stated that there is no evidence of record to support the finding that the Veteran's knee disabilities began during active service. The examiner also stated that it would be mere speculation to contend that the Veteran's knee disabilities are due to in-service herbicide agent exposure because the medical literature does not show an established connection between herbicide agents and degenerative joint disease. The Board finds the May 2021 VA examination adequate as it is supported by sufficient rationale and review of the record, and therefore assigns it high probative weight. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302 (2008). The Board acknowledges the Veteran's contention that his left and right knee disabilities are related to service. While lay persons are competent to provide opinions pertaining to certain medical issues, the etiology of his left and right knee disabilities is outside the realm of common knowledge for someone, such as the Veteran, who does not possess medical training, specialized expertise, or experience. Jandreau v. Nicholson, 492. F.3d 1372, 1377 n.4 (Fed. Cir. 2007). As such, the Board finds no probative value in the Veteran's assertion. Based on the foregoing, the Board finds that the preponderance of the evidence is against the claim. Accordingly, the benefit-of-the-doubt rule is not for application, and the claim must be denied. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). REASONS FOR REMAND Gout Although further delay is regrettable, the Board cannot make a fully-informed decision on the issue of service connection for gout because no VA examiner has opined whether the Veteran's gout is related to his service connected disabilities. The Veteran was afforded a VA examination in May 2021. The examiner opined that the Veteran's gout is less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The rationale stated that there are modifiable risk factors for the development of gout, including cardiovascular disease, alcohol, and medications altering urate balance. The Veteran is service connected for coronary artery disease and posttraumatic stress disorder (PTSD) with alcohol dependency. As the evidence of record reasonably raises the theory entitlement to secondary service connection, the Board finds that remand is warranted to obtain an addendum opinion. The matter is REMANDED for the following action: Obtain an addendum opinion from an appropriate physician to determine the nature and etiology of the Veteran's claimed gout. The entire claims folder should be made available and reviewed by the physician. The physician should provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that the Veteran's gout is causally related to or aggravated by his service-connected PTSD with alcohol dependency or coronary artery disease, to include any medications prescribed to the Veteran for his service-connected disabilities. The examiner must include a rationale with all opinions, citing to supporting clinical data/medical literature as appropriate. JOHN Z. JONES Veterans Law Judge Board of Veterans' Appeals Attorney for the Board T. Kernen, 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.