Citation Nr: 22013306 Decision Date: 03/09/22 Archive Date: 03/09/22 DOCKET NO. 16-48 979 DATE: March 9, 2022 ORDER Entitlement to service connection for a left knee disorder, diagnosed as chondromalacia patella, is granted. Entitlement to service connection for a right knee disorder, diagnosed as chondromalacia patella, is granted. Entitlement to service connection for a left hip disorder, diagnosed as tendonitis, is granted. FINDINGS OF FACT 1. The Veteran's left knee disorder, diagnosed as chondromalacia patella, is at least as likely as not related to active duty service. 2. The Veteran's right knee disorder, diagnosed as chondromalacia patella, is at least as likely as not related to active duty service. 3. The Veteran's left hip disorder, diagnosed as tendonitis, is at least as likely as not related to active duty service. CONCLUSIONS OF LAW 1. The criteria to establish entitlement to service connection for a left knee disorder, diagnosed as chondromalacia patella, have been met. 38 U.S.C. §§ 1101, 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. The criteria to establish entitlement to service connection for a right knee disorder, diagnosed as chondromalacia patella, have been met. 38 U.S.C. §§ 1101, 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. 3. The criteria to establish entitlement to service connection for a left hip disorder, diagnosed as tendonitis, have been met. 38 U.S.C. §§ 1101, 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had service in the United States Army and Army National Guard. He had a period of active duty for training (ACDUTRA) from August 2008 to March 2009, and active duty from January 2011 to February 2012. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a July 2014 rating decision. The Veteran testified at a Board hearing before the undersigned Veterans Law Judge in October 2021. A transcript from that proceeding is associated with the claims file. The Board notes that the Veteran was previously represented by the Colorado Division of Veterans Affairs. In an October 2021 statement, the Colorado Division of Veterans Affairs requested to withdraw as the Veteran's representative as the Veteran no longer resided in Colorado. The Board accepts this withdrawal and notes that the Veteran does not currently have a representative. However, the Veteran is not prejudiced by this fact as the Board is granting each of the service connection claims on appeal in this decision. Service Connection 1. Entitlement to service connection for a left knee disorder. 2. Entitlement to service connection for a right knee disorder. 3. Entitlement to service connection for a left hip disorder. 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; 38 C.F.R. § 3.303(a). To establish a right to compensation for a present disability, a Veteran 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-the so-called "nexus" requirement. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 38 F.3d 1163, 1167 (Fed. Cir. 2004)). The absence of any one element will result in denial of service connection. Service connection may also be granted for any disease initially diagnosed after service 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). In addition, for Veterans who have served 90 days or more of active service during a war period or after December 31, 1946, certain chronic disabilities, including arthritis, are presumed to have been incurred in service if they manifested to a compensable degree within one year of separation from service. 38 U.S.C. §§ 1101, 1112, 1113, 1131, 1137; 38 C.F.R. §§ 3.307, 3.309. For the showing of a chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity and sufficient observation to establish chronicity at the time. If chronicity in service is not established, a showing of continuity of symptoms after discharge is required to support the claim. 38 C.F.R. §§ 3.303(b), 3.309; Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). The advantage of certain evidentiary presumptions, provided by law, that assist veterans in establishing service connection for a disability do not extend to those who claim service connection based on a period of ACDUTRA or inactive duty for training (INACDUTRA). Paulson v. Brown, 7 Vet. App. 466, 470-71 (1995) (noting that the Board did not err in not applying presumptions of sound condition and aggravation to veteran's claim where he served only on ACDUTRA and had not established any service-connected disabilities from that period); McManaway v. West, 13 Vet. App. 60, 67 (1999), vacated on other grounds sub nom; McManaway v. Principi, 14 Vet. App. 275 (2001) (citing Paulson, 7 Vet. App. at 469-70, for the proposition that if a claim "relates to period of [ACDUTRA], disability must have manifested itself during that period; otherwise, period does not qualify as active military service and claimant does not achieve veteran status for purposes of that claim." (emphasis added in McManaway)); see also Biggins v. Derwinski, 1 Vet. App. 474, 479 (1991) (Steinberg, J., concurring). Thus, the evidentiary burden is on the claimant to show that he or she became disabled from an injury or disease incurred in line of duty during ACDUTRA or from an injury incurred in line of duty during INACDUTRA. The Veteran contends that he has left hip and bilateral knee disorders as a result of his period of active duty service from January 2011 to February 2012. The Veteran's service treatment records (STRs) do not show any complaint, treatment, or diagnosis related to the left hip or knees. The Veteran's January 2008 enlistment examination did not document any abnormalities related to the knees or left hip. A January 2008 Report of Medical History also showed that the Veteran did not report a history of any knee or other relevant joint problems. A subsequent January 2011 Pre-Deployment Health Assessment from the beginning of the Veteran's period of active duty service noted the Veteran's report that his health was very good and his denial of any current medical or dental problems. The provider indicated that the Veteran was cleared for deployment. In December 2011, a Post-Deployment Health Assessment for a deployment from February 2011 to December 2011 in Afghanistan for Operation Enduring Freedom noted that the Veteran's combat specialty was medic. The Veteran reported that overall, his health had been very good during the past month and physical health problems had not made it difficult at all for him to do his work or other regular daily activities in the past 4 weeks. The Veteran also reported that his health was much better now than it had been before he deployed. The Veteran denied having any history of swollen, stiff, or painful joints. After the Veteran's period of active duty service ended in February 2012, a May 2012 Post-Deployment Health Re-Assessment showed that the Veteran updated some of his earlier answers. He now reported that his health was about the same as before he deployed and that physical health problems had made it somewhat difficult to do his work or other regular activities. He also indicated that he was physically hurt during his deployment, and his related concerns included swollen, stiff, or painful joints. The assessment and referral indicated that the identified concerns included posttraumatic stress disorder (PTSD), a possible traumatic brain injury (TBI), depression, family/social relationship concerns, left shoulder pain, and decreased hearing. No left hip or knee problems were indicated. There continued to be no notable findings or reports in a November 2012 service examination or Report of Medical History. A December 2012 STR also noted that the Veteran denied taking over the counter medication or having joint pain. A subsequent December 2013 private treatment record noted the Veteran's report that his left hip was bothering him. The assessment was joint pain that was localized in the left hip. Later in December 2013, a private left hip x-ray was obtained in relation to the Veteran's history of pain in the joint, pelvic region, and thigh. The impression was negative. In January 2014, the private provider noted that the Veteran was seen for a follow up visit for left hip pain; and he had been doing physical therapy with some success. However, he continued to have left hip area pain. The assessment was tendonitis. The Veteran was provided with VA examinations in relation to his claims in July 2014. Regarding the claimed left hip disorder, the examiner noted a diagnosis of tendonitis of the left hip. The Veteran informed the examiner that he began to have pain in his left hip in July 2011. He had begun to run on trails at that time to improve his fitness. Although the Veteran denied sustaining a specific injury, he noted having pain in, and the anterior and posterior aspects of, his left hip in addition to a clicking sensation. The Veteran currently experiencing soreness in his hip with prolonged sitting, and his hip became painful when he stood up. The Veteran was able to run for 2 to 3 miles before the pain in his left hip caused him to stop. The Veteran saw his civilian doctor and underwent x-rays that showed normal results. He was referred to physical therapy, and he had been performing stretching and strengthening exercises that had helped a little. The July 2014 examiner provided a negative nexus opinion. The examiner noted that the Veteran was diagnosed with tendonitis of the left hip in addition to the Veteran's report that his left hip symptoms began in July 2011 when he began to run on trails to improve his physical fitness. The examiner also noted that the Veteran separated from service in February 2012. However, there was no documentation in the STRs that showed complaints of left hip pain. Although the STRs showed a complaint of joint pain, the details showed that this complaint was related to the left shoulder. It was less likely than not that the current left hip condition was incurred in or caused by the instances related to reports of joint pain in the STRs that occurred during military service. The examiner added that the opinion was based on the lack of supporting evidence in the STRs. Regarding the left and right knees, the July 2014 VA examination showed a diagnosis of chondromalacia patella in each knee. The Veteran reported that he began to notice pain in both knees in January 2012. Although the Veteran denied sustaining an injury to either knee, he believed that this problem began due to the amount of training he was doing. The Veteran did not have this condition evaluated during service. At the time of the examination, the Veteran reported that he had a painless cracking sound/sensation in both knees, adding that the left knee would pop when he was squatting. Both knees felt stable, and there was no locking in either knee. The left knee also swelled with increased activity. In relation to the Veteran's diagnosed chondromalacia patella in both knees, the July 2014 VA examiner gave a negative nexus opinion. In the rationale, the examiner noted the Veteran's report that his symptoms began in January 2012 as well as the fact that he separated from service in February 2012. The examiner noted that there was no documentation in the STRs that showed complaints of bilateral knee pain. Similar to the opinion for the left hip, the examiner noted that while the details in the STRs showed that the in-service complaint of joint pain was related to the left shoulder. It was less likely than not that the Veteran's current knee condition was incurred in or caused by the instances related to reports of joint pain in the STRs that occurred during military service. The examiner stated that the opinion was based on the lack of supporting evidence in the STRs. In an October 2013 statement, the Veteran reported that his left hip and bilateral knee issues were related to his military occupational specialty (MOS) of medic and the related duties that included lifting, stooping, bending, kneeling, and other repetitive motions. In a November 2014 statement, the Veteran reported that his left hip and bilateral knee pain began during service while he was overseas training for marches and a physical training test. These symptoms worsened when he returned home and was still in Reserve training. The Veteran reported that although he sought help for his knees and hip from his civilian doctor and received a referral for physical therapy, this treatment was not helpful. During the October 2021 Board hearing, the Veteran and his representative provided an explanation for the lack of documentation of relevant complaints in the STRs, stating that self-care was expected in the Veteran's MOS of healthcare specialist as part of his training. The Veteran's testimony reflects that his bilateral knee and left hip pan began during his latest deployment to Afghanistan. The deployment required the Veteran to assume several awkward positions to treat patents such as kneeling and bending, and he also needed to carry bags on his back a well as patients in order to help transport them. The Veteran noted that these activities placed a lot of stress on all of his joints, including his knees, hips, and back. However, the Veteran's knees and hips really began to hurt towards the end of his deployment after the Veteran had been working there for almost a year and performing a lot of care. The Veteran began to take ibuprofen and Tylenol at that time, and he iced his knees and hips after long days or periods of caring for patients. When the Veteran returned from Afghanistan, he began to self-treat with physical rehabilitation by engaging in strength-training exercises; and the Veteran indicated that he continued to self-treat with icing, ibuprofen, and Tylenol in addition to resting. Although the Veteran indicated that he tried to stay off his feet as much as possible, he continued to experience persistent pain; and this complaint prompted the Veteran to file his service connection claims. Although the Veteran also indicated that he experienced additional stress on his knee and joints after his active duty service while serving in a helicopter fight squadron, he indicated that the symptoms that he identified as beginning while on active duty continued and progressively worsened during his post-service activities. The Veteran indicated that he maintained his efforts to self-treat with over-the-counter medication, icing, and exercise routines in response to these continued symptoms. The Veteran specifically confirmed that his relevant symptoms in the knees and hip had been continuous and chronic since his active duty service. He also reported first seeking post-service treatment in 2012, within one year of his February 2012 discharge from active duty service. The Veteran recalled being told during this treatment that he had chondrodysplasia in both his knees and left hip tendonitis. Regarding the Veteran's reported history of left hip and bilateral knee pain that began during his active duty service and has progressively worsened since that time, the Board notes that the Veteran is competent to report his history of observable symptoms such as pain. Layno v. Brown, 6 Vet. App. 465 (1994); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). The Board also finds the Veteran's reported history to be credible as his reports have been consistent throughout the appeal period. The Veteran's reports are also consistent with the information in his service records as the Veteran's DD 214 for his period of active duty from January 2011 to February 2012 notes that he was ordered to active duty during this period in support of Operation Enduring Freedom, and the active duty included service in Afghanistan from February 2011 to January 2012. The DD 214 also confirms that his MOS during this period was healthcare specialist. In addition, the Veteran provided an explanation for the lack of in-service documentation of these complaints as the Veteran indicated that he was expected to self-treat during service with the knowledge and skills associated with his MOS of healthcare specialist. Moreover, the Veteran testified that he is currently a certified physician's associate. As such, he is competent to attest that his current left hip and bilateral knee pain is the same pain that he experienced while on active duty. Although the Board has considered the negative opinions provided by the July 2014 VA examiner, the Board finds that they provide little probative value. The examiner specifically stated in the rationales that the opinions were based on the lack of supporting evidence in the STRs. To the extent that the examiner used this lack of documentation as a basis to disregard the Veteran's competent and credible reports of continued symptoms since service, the Board notes that the lack of contemporaneous medical evidence does not warrant a conclusion of a lack of nexus. See Buchanan v. Nicholson, 451 F.3d 1331, 1336-37 (Fed. Cir. 2006). After comparing the probative value of the July 2014 opinions with the probative value of the Veteran's competent and credible reported history that he first began to experience symptoms of a left hip and bilateral knee disorder while on active duty, and these symptoms have continued to be present since that time; the Board finds that the most probative evidence establishes a nexus between active duty service and the Veteran's current left hip and bilateral knee disorders. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. As such, service connection is granted for a left hip disorder, diagnosed as tendonitis, and the Veteran's left and right knee disorders, diagnosed as chondromalacia patella. GAYLE STROMMEN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board K.C. Spragins, 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.