Citation Nr: 22018792 Decision Date: 03/30/22 Archive Date: 03/30/22 DOCKET NO. 18-53 213A DATE: March 30, 2022 ORDER Entitlement to service connection for a right knee disability is granted. Entitlement to service connection for a left knee disability is granted. Entitlement to service connection for a back disability is granted. Entitlement to service connection for an acquired psychiatric disability, to include depressive disorder and other specified stressor disorder, is granted. REMANDED Entitlement to a heart disability is remanded. FINDINGS OF FACT 1. The Veteran's right knee disability is related to an in-service injury or disease. 2. The Veteran's left knee disability is related to an in-service injury or disease. 3. The Veteran's back disability is related to an in-service injury or disease. 4. The Veteran's acquired psychiatric disability is related to an in-service injury or disease. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for a right knee disability have been met. 38 U.S.C. §§ 1101, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for entitlement to service connection for a left knee disability have been met. 38 U.S.C. §§ 1101, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 3. The criteria for entitlement to service connection for a back disability have been met. 38 U.S.C. §§ 1101, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 4. The criteria for entitlement to service connection for an acquired psychiatric disability, to include depressive disorder and other specified stressor disorder, have been met. 38 U.S.C. §§ 1101, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from May 1984 to May 1987. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a September 2014 rating decision issued by a Department of Veterans Affairs (VA) agency of original jurisdiction (AOJ). The Veteran attended a hearing with the undersigned in February 2021. A transcript of the hearing is of record. A claim for service connection for a psychiatric disability is deemed to encompass all psychiatric diagnoses reasonably presented in the record. See Clemons v. Shinseki, 23 Vet. App. 1 (2009). Accordingly, the Veteran's claim for depression has been characterized as an acquired psychiatric disability. 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, 1131, 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). 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). 1. Entitlement to service connection for right and left knee disabilities. The Veteran contends she injured both her right and left knees during service and that her knee disabilities began in service and continued since service. The Veteran has a diagnosis of bilateral osteoarthritis. See September 2014 VA examination. Therefore, the first element of service connection has been met. The Veteran testified at the February 2021 Board hearing that she injured her knees in service. She stated that she was playing a basketball game and fell onto both her knees. She reported she was treated with ibuprofen, but the pain continued, and she would experience swelling and pain during service. She stated that she had fluid removed and an arthroscopy during service. She stated that she experienced these problems throughout service and after service. She testified that she sought treatment after service from both private providers and at the VA. The Veteran's service treatment records (STRs) show she was treated in March 1985 for right knee pain. She reported pain and swelling, and an examination was positive for crepitus. The record noted she may need arthroscopy. The Veteran also reported bilateral shin splints in June 1985. STRs also show October 1986 treatment for shin splints that started after she was playing basketball. On the February 1987 report of medical history at separation, the Veteran marked that she had a bone, joint or other deformity. However, the doctor's notation indicated that there was a deformity to the right little finger. Based on the testimony and STRs, the Board finds the record supports an in service incurrence of right and left knee disabilities. The Veteran attended a VA examination in September 2014. The examiner found that it was less likely than not that the Veteran's knee disabilities were incurred in or caused by the claimed in-service injury, event, or illness. The examiner noted in service reports of knee pain in 1985 but found that the medical records were silent for ongoing knee pain, and the separation examination was silent. The examiner stated that the current degenerative joint disease does not represent late complications of the in-service complaints of knee pain and that there is not continuity of symptoms. The Board notes that the Veteran reported bilateral shin splints in June 1985 and in October 1986. As such, she had additional complaints of symptoms related to her knees. In addition, she testified at the hearing that she had continued pain and knee problems during service, and that these continued after service. The examiner was unable to consider these lay statements. Therefore, the Board finds the examiner's opinion of little probative value. The record contains a March 2021 independent medical opinion from Dr. G. Regarding the knee disability, the doctor noted the Veteran's reports that she injured her knees in service after a basketball game and that the knee pain continued in service and since service. The examiner noted the in-service reports of knee pain and shin splints in the STRs. The examiner provided the opinion that the Veteran's impairments had a causal nexus to military service. The evidence of record supports that the Veteran had bilateral knee pain in service, and that this pain has continued since service. While the VA examiner's opinion did not use the standard of "at least as likely as not," the opinion as a whole makes it clear that he believes the Veteran's disability is at least as likely as not related to her service, as the doctor clearly articulated that standard in the first paragraph of the opinion. The Board also finds the Veteran's statements regarding her continuous knee pain, which began during service and has continued since, credible and probative. Therefore, the persuasion of the evidence supports finding that the Veteran's right and left knee disabilities are related to her service. As such, entitlement to service connection is granted. There is no reasonable doubt to be resolved as to this issue. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. 2. Entitlement to service connection for a back disability The Veteran contends she injured her back during service and that her back disability began in service and has continued since. The Veteran has a diagnosis of chronic lumbosacral pain with intravertebral disc syndrome. See March 2021 opinion from Dr. G. Therefore, the first element of service connection has been met. The Veteran testified at the February 2021 Board hearing that she was in a car accident at the beginning of service. She stated that she injured her back and had muscle spasms. She was treated in service and given ibuprofen and told to take it easy. She stated she was often in the infirmary seeking treatment for back pain throughout service, and after she left service, she continued having problems with back pain. She stated it has continued since and gotten worse with time. She testified that she got private care shortly after service for back pain. The Veteran's STRs show treatment in November 1984 for lower back pain radiating to the buttocks. She was treated with bedrest and Motrin. The Veteran also reported 3 months of lower back pain in June 1985. Therefore, the record supports an in service incurrence of her back disability. The evidence of record contains January 1990 medical records for treatment for lower back pain. The record also contains a March 2021 independent medical opinion from Dr. G. Regarding the back disability, the doctor noted that the Veteran reported a car accident during service right after basic training that injured her back. The doctor acknowledged the Veteran's reports of back pain throughout service and continuing after service. The doctor noted the STRs indicating back pain in service. The examiner provided the opinion that the Veteran's impairments had a causal nexus to military service. The evidence of record supports that the Veteran had back pain in service, and that this pain has continued since service. While the VA examiner's opinion did not use the standard of "at least as likely as not," the opinion as a whole makes it clear that he believes the Veteran's disability is at least as likely as not related to her service, as the doctor clearly articulated that standard in the first paragraph of the opinion. The Board also finds the Veteran's statements regarding her continuous back pain, which began during service, and has continued since, credible and probative. Therefore, the persuasion of the evidence supports finding that the Veteran's back disability is related to her service. As such, entitlement to service connection is granted. There is no reasonable doubt to be resolved as to this issue. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. 3. Entitlement to service connection for an acquired psychiatric disability The Veteran contends she is entitled to service connection for an acquired psychiatric disability. The Veteran has a diagnosis of depressive disorder and other specified stressor disorder. See April 2021 independent medical evaluation. While the April 2021 examiner Dr. A-S noted that Veteran likely experiences the full constellation of symptoms sufficient for a posttraumatic stress disorder (PTSD) diagnosis, she determined a diagnosis of other specified stressor disorder was more appropriate given the Veteran's guarded presentation in discussing her full symptoms. Therefore, the first element of service connection has been met. At the February 2021 Board hearing, the Veteran testified that her depression is in part due to her physical disabilities. She also testified that she was sexually assaulted in service. The Veteran's STRs show that at separation in February 1987, she reported she had symptoms of depression or excessive worry. In addition, the STRs show that the Veteran sought care for gynecological symptoms numerous times during service, to include in October 1984, July 1985, March 1986, and September 1986. The Board finds that the evidence of record support in-service event and symptoms of depression, as reported at separation. The Veteran's record contains a January 1990 medical record that notes the Veteran started Prozac and an antidepressant. The record also contains an April 2021 independent medical evaluation from Dr. A-S. The doctor opined that the Veteran's depressive disorder and other specified stressor disorder were as likely as not related to military service events. The doctor noted that during service, the Veteran was seen for gynecological care multiple times with vague complaints, often seeking a Pap smear. The Veteran reported she was sexually assaulted while in service, which caused her to become despondent. She was seen in March 1986 with concerns of pregnancy. The independent medical examiner noted that while a Pap smear does not detect STDs, many women believe it is an STD test, and the Veteran's behavior is consistent with reports that she feared having gonorrhea after her sexual assault. The doctor stated that the Veteran's records, specifically numerous gynecological visits with vague complaints, show markers of sexual assault during service. The Board finds the April 2021 independent medical examination the most probative evidence of record, and supports a finding that the Veteran's psychiatric disability is related to her service. Therefore, the persuasion of the evidence is in favor of finding the Veteran is entitled to service connection for an acquired psychiatric disorder, to include depressive disorder and other specified stressor disorder. There is no reasonable doubt to be resolved as to this issue. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. REASONS FOR REMAND 1. Entitlement to service connection for a heart disability is remanded. At the hearing, the Veteran testified that her chest pain started when her physical disabilities got worse, which was around 2012. At that time, she was taking a large number of medications for her physical disabilities, and developed heart problems after being on these numerous medications. Therefore, the question of secondary service connection due to medication used to treat a service-connected disability has been raised by the record. The Veteran has not been afforded a VA examination, and as such remand is required for a VA examination. McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006). The matters are REMANDED for the following actions: 1. Obtain updated VA treatment records. 2. Schedule the Veteran for a VA examination for her heart disability. The examiner must review the claims file. The examiner is asked to provide a response to the following. Each opinion must be supported by rationale: (Continued on the next page) (a.) Is the Veteran's heart disability at least as likely as not (a 50 percent or greater probability) caused by a service-connected disability, to include medication used to treat a service-connected disability? (b.) Is the Veteran's heart disability at least as likely as not aggravated (i.e. worsened beyond its normal progression) by a service-connected disability, to include medication used to treat a service connected disability? Tiffany Dawson Veterans Law Judge Board of Veterans' Appeals Attorney for the Board N. Patrick, 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.