Citation Nr: 22015227 Decision Date: 03/16/22 Archive Date: 03/16/22 DOCKET NO. 17-37 403 DATE: March 16, 2022 ORDER Entitlement to service connection for a left knee disability is denied. FINDINGS OF FACT 1. The evidence persuasively weighs against a finding that the Veteran's current left knee disability had onset in, manifested within one year of separation from service, or is otherwise related to service. 2. The evidence persuasively weighs against a finding that the Veteran's current left knee disability is secondary to a service-connected disability or disabilities. CONCLUSION OF LAW The criteria for entitlement to service connection for a left knee disability, to include as secondary to a service-connected disability or disabilities, have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1131, 1137; 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSION The Veteran served on active duty in the United States Navy from March 1969 to December 1970, with additional active service in the United States Naval Reserve. A Board hearing was held before the undersigned Veterans Law Judge in October 2019, and a transcript of the hearing is of record. The Board remanded the current appeal in January 2020 and September 2021 for additional development. The Board finds the agency of original jurisdiction has substantially complied with the remand instructions, and the evidence of record is sufficient to proceed with a decision on the merits. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection may also be granted on a secondary basis for a disability if it is proximately due to or the result of a service-connected injury. 38 C.F.R. § 3.310(a). Additionally, for Veterans who have served 90 days or more of active service during a period of war or after December 31, 1946, certain chronic disabilities, including arthritis, are presumed to have been incurred in service if manifest to a compensable degree within one year of discharge from service. 38 U.S.C. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309. Alternatively, when a disease at 38 C.F.R. § 3.309(a) is not shown to be chronic during service or the one-year presumptive period, service connection may also be established by showing a continuity of symptomatology after service. 38 C.F.R. § 3.303(b). The use of continuity of symptoms to establish service connection is limited only to those diseases listed at 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). In this case, the Veteran seeks entitlement to service connection for a left knee disability, to include as secondary to his service-connected left foot disability and/or service-connected right knee disability. See January 2017 VA Form 21-526b; see also February 2022 Appellate Brief. As relevant to the current appeal, the decision herein includes a discussion of pertinent evidence related to the Veteran's service-connected left foot disability and right knee disability. Upon review of service treatment records, the Veteran reported pain in both knees (right greater than left) in April 1970. The service treatment provider reported there were no findings on examination. The Veteran's active duty service treatment records are otherwise silent for any reports related to a left knee condition. Shortly after his release from active duty, the Veteran filed a service connection claim for, among other conditions, a right knee disability and a left foot disability. See April 1971 VA Form 21-526. The Veteran did not report a left knee condition. In a June 1971 rating decision, the Veteran was awarded service connection for a right knee disability manifested by painful motion, and service connection for a healed fracture, second metatarsal, left foot. See also May 1971 radiographic report (documenting no intrinsic bone of joint pathology of the right knee). The Veteran was a participating member of the United States Naval Reserve from March 1982 through August 1992. See Abstract of Service and Medical History. During that timeframe, the Veteran underwent a number of medical examinations in which he denied swollen or painful joints, arthritis, bone, joint or other deformity, or trick or locked knee. See March 1982, May 1988, and June 1990 Report of Medical History. In August 2009, the Veteran filed an informal service connection claim for a right below the knee amputation as secondary to his service-connected right knee disability. See August 2009 VA Form 21-4138. On examination in September 2009, the examiner reported the Veteran's right below the knee amputation was due to nonservice-connected peripheral vascular disease. In a December 2009 rating decision, service connection for a right below the knee amputation was denied. The Veteran did not perfect an appeal concerning the denial of service connection for a right below the knee amputation. An October 2011 VA radiology report revealed minor degenerative joint disease of the bilateral knees. In a November 2013 VA knee examination, the Veteran denied left knee pain. In a December 2015 VA primary care note, the Veteran reported left knee pain, and requested physical therapy. In a January 2016 VA physical medicine consult, the Veteran reported his left knee had been aggravating him for the previous two years. The Veteran reported an increase in the frequency of his left knee pain. The Veteran reported that he had started a new job in August, and that he noticed an increase in left knee pain due to standing for prolonged periods of time. The provider reported the Veteran's left knee pain was likely due to iliotibial band tightness, as well as generalized tightness of lower extremity musculature. In a July 2017 VA primary care note, the Veteran reported a history of left knee pain for three weeks. The Veteran reported a history of knee injury in service. The provider's assessment was left medial collateral ligament strain. The Veteran sought evaluation of his left knee with a private treatment provider in January 2018. Dr. J.S. reported the Veteran endorsed no pain in the left knee until the summer of 2017, when he endorsed several buckling episodes. The Veteran reported a history of several minor traumas. The Veteran was diagnosed with arthritis and posterior cruciate ligament (PCL) tear of the left knee. During the October 2019 Board hearing, the Veteran testified that he was treated for left knee pain in service. The Veteran indicated that he lived with the discomfort and pain in his left knee because he did not want it to interfere with his duties in service. The Veteran indicated that he self-treated his left knee after service, such as by using a knee brace to control the pain. The Veteran reported he experienced issues with his left knee ever since the injury in service. The Veteran reported that the doctor that diagnosed the PCL tear informed him that the tear had been there for a very long time. Additionally, the Veteran indicated that his nonservice-connected right below the knee amputation had altered the way that he performed physical activities and walked. In a private October 2019 evaluation with Dr. R.P., the Veteran reported the onset of left knee pain in the summer of 2017, at which time he endorsed several buckling episodes. Dr. R.P. noted a January 2018 diagnosis of chronic PCL sprain of the left knee. The Veteran reported a history of multiple traumas to both knees in service. Dr. R.P. reported the Veteran believed his current PCL tear had onset in service, and that service treatment records corroborated this belief. Radiologic interpretation noted subluxation of the tibia posterior to the femur in association with a chronic PCL tear. Pursuant to a January 2020 Board remand, the Veteran was afforded a VA knee examination in February 2020. Based on a review of the evidence of record and examination of the Veteran, the examiner opined that the Veteran's left knee injury in service was a minor, soft tissue injury that resolved. The examiner opined that the left knee pain reported in service was not degenerative joint disease. The examiner further opined that the acute and transitory injury in service would not cause the Veteran's current diagnosis of degenerative joint disease of the left knee. Pursuant to a September 2021 Board remand, another VA medical opinion was obtained in November 2021. The examiner opined that the Veteran's currently diagnosed left knee conditions, including degenerative joint disease, osteoarthritis, and chronic PCL tear, less likely than not had onset in or are otherwise related to service. In reaching this conclusion, the examiner noted the Veteran's report of left knee pain in April 1970, and the service treatment provider's report of "no findings" upon examination of the knee. The examiner considered the Veteran's credible report of left knee pain and several injuries to his left knee while playing basketball in service, but stated that such reports of knee pain were not diagnostic of his current left knee pathology. The examiner noted that the Veteran reported right knee (only) pain following separation from service. The examiner also noted that the Veteran was not diagnosed with bilateral degenerative joint disease until nearly 40 years after his discharge from active duty. See May 1971 radiographic report (documenting no intrinsic bone of joint pathology of the right knee); see also April 2004 VA radiology report (documenting a normal right knee), and October 2011 VA radiology report (documenting minor bilateral degenerative joint disease). Additionally, the examiner noted that the Veteran reported the onset of his current left knee pain was in the summer of 2017, and that Dr. J.S. diagnosed the Veteran with chronic PCL sprain of the left knee approximately six months later in January 2018. See also July 2017 VA primary care note (Veteran reported a history of left knee pain for three weeks, and was diagnosed with left medial collateral ligament strain). The examiner also addressed the Veteran's theory of entitlement to secondary service connection for his current left knee disability. The examiner opined that the Veteran's current left knee condition was not caused or aggravated by his service-connected left foot disability and/or his service-connected right knee disability. The examiner reported that, according to orthopedic medical literature, an injury to one joint would not have any significant impact on another or opposite uninjured joint or limb, unless the injury resulted in major muscle or nerve damage causing partial or incomplete paralysis, or gait pattern that has been altered to the extent that there is an obvious Trendelenburg gait. The examiner noted that the medical evidence of record confirmed that neither the Veteran's service-connected left foot disability nor his service-connected right knee disability resulted in gait alteration. The examiner acknowledged that VA treatment records document the Veteran had gait alteration. See November 2013 and January 2021 VA physical medicine note. However, treatment providers have consistently attributed the Veteran's gait alteration and/or altered biomechanics to his nonservice-connected right below the knee amputation. Based on the medical evidence of record demonstrating that the Veteran's service-connected left foot disability and/or service-connected right knee disability did not result in gait alteration or major muscle or nerve damage, the examiner opined that such disabilities did not cause or aggravate the Veteran's current left knee condition, diagnosed as degenerative joint disease, osteoarthritis, and chronic PCL tear. With respect to direct service connection, the Board has considered the entire record and finds that the most probative evidence is against a finding that the Veteran's current left knee disability (diagnosed as degenerative joint disease, osteoarthritis, and chronic PCL tear) had onset in or manifested within one year of separation from service, or is otherwise related to service. Although the Veteran is competent to report that he experienced left knee pain in service, and such is supported by the April 1970 service treatment record, he has not been shown to have the requisite medical expertise or training to diagnose and opine as to the origin of his current left knee disability. 38 C.F.R. § 3.159. The Veteran testified that he lived with the discomfort and pain following his in-service left knee injury because he did not want it to interfere with his duties in service, and that he continued to experience pain in his left knee following his separation from service. However, the Veteran's reported continuity of symptoms of his current left knee disability since the April 1970 in-service injury is not consistent with other evidence of record. See Caluza v. Brown, 7 Vet. App. 498 (1995) (in determining whether lay evidence is satisfactory, the Board may also properly consider internal inconsistency of the statements, facial plausibility, and consistency with other evidence submitted on behalf of a veteran). In April 1971, the Veteran sought service connection for a right knee disability due to the April 1970 in-service injury, which he reported sometimes bothered him when he played basketball. The Veteran did not report or seek service connection for a left knee condition in April 1971. The Board finds that it would be reasonable to expect that the Veteran would have reported a left knee condition at that time if he was also experiencing pain or discomfort in his left knee. Despite reporting and seeking treatment for right knee symptoms (and other conditions) on numerous occasions following separation from service, the Veteran explicitly denied left knee pain prior to his first report of left knee pain nearly 40 years after his discharge from active duty. See Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006) (While the lack of contemporaneous medical records does not, in and of itself, render lay evidence not credible, such may be considered and weighed against a veteran's lay evidence.). In January 2016, the Veteran reported a two-year history of left knee pain that was attributed to ITB tightness and generalized tightness of the lower extremity musculature. With respect to the Veteran's current diagnosis of chronic PCL tear, such was initially diagnosed as a left medial collateral ligament strain in July 2017 following the Veteran's report of left knee pain and several buckling episodes. In an initial private evaluation in January 2018, Dr. J.S. diagnosed the Veteran with arthritis and PCL tear of the left knee. In an October 2019 private evaluation, Dr. R.P indicated the Veteran had a diagnosis of chronic PCL strain of the left knee. Prior to July 2017, the Veteran did not report any buckling or instability of the left knee. Moreover, the Veteran did not report such symptoms on previous VA examinations that tested for joint stability of the Veteran's left knee. The Veteran reported in October 2019 that he believed his current PCL tear had onset in service, and that service treatment records corroborated this belief. However, contrary to the Veteran's assertion, service treatment records document "no findings" on examination related to the Veteran's report of bilateral knee pain in April 1970. The Board places weight on the contemporaneous evidence in service treatment records, which do not indicate a diagnosis related to the Veteran's report of left knee pain in April 1970. See Curry v. Brown, 7 Vet. App. 59, 68 (1994) (contemporaneous evidence has greater probative value than history as reported by the Veteran). Although the Veteran was separately diagnosed with pulled muscles in both legs in January 1970, the competent medical evidence of record does not establish a link between this and the Veteran's current diagnosis of chronic PCL strain of the left knee. To the contrary, the February 2020 and November 2021 VA examiners found that the medical evidence of record did not support a nexus between the 1970 report of pulled muscles and/or knee pain, and the Veteran's current left knee disability. In the October 2019 left knee evaluation, Dr. R.P. noted the Veteran's report of injuries to his left knee in service and reported medical history, but did not offer a medical opinion concerning whether the Veteran's current diagnosis of chronic PCL strain had onset in or was otherwise related to the Veteran's service. With respect to the assertion that the Veteran's left knee disability is secondary to his service-connected left foot disability and/or service-connected right knee disability, the competent medical evidence of record does not support this theory of entitlement. The Board assigns probative weight to the November 2021 medical opinion, which determined that the Veteran's current left knee condition was not caused or aggravated by his service-connected left foot disability, or his service-connected right knee disability. The examiner's opinion was supported with a clinical rationale, and based on consideration of orthopedic medical literature, as well as the medical and lay evidence of record in this particular case. The examiner acknowledged that the medical evidence of record documented the Veteran's alteration in gait, which may result in impact on another or opposite uninjured joint. However, as discussed by the examiner in forming her opinion, the medical evidence of record in this case has consistently attributed the Veteran's gait alteration to his nonservice-connected right below the knee amputation. See also October 2019 Board hearing transcript (the Veteran indicated that his nonservice-connected right below the knee amputation had altered his biomechanics). There are no positive medical opinions of record pertaining to the Veteran's service connection claim for a left knee disability, diagnosed as degenerative joint disease, osteoarthritis, and chronic PCL tear. The Board finds that the evidence persuasively weighs against a finding that the Veteran's current left knee disability had onset in service, manifested within one year of service, or is otherwise related to service. Additionally, the Board finds that the evidence persuasively weighs against a finding that the Veteran's current left knee disability is secondary to his service-connected left foot disability and/or service-connected right knee disability. Accordingly, entitlement to service connection for a current left knee disability, diagnosed as degenerative joint disease, osteoarthritis, and chronic PCL tear, is denied. V. Chiappetta Veterans Law Judge Board of Veterans' Appeals Attorney for the Board B. Mask, 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.