Citation Nr: A25041225 Decision Date: 05/06/25 Archive Date: 05/06/25 DOCKET NO. 220413-236827 DATE: May 6, 2025 ORDER Entitlement to service connection for knee osteoarthritis, left, is granted. FINDING OF FACT The evidence is at least in approximate balance as to whether the Veteran's knee osteoarthritis, left, was a result of her active-duty service. CONCLUSION OF LAW The criteria for Entitlement to service connection for knee osteoarthritis, left, have been met. See 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had active duty service with the United States Army from August 1984 to November 1989. This matter comes before the Board of Veterans' Appeals (Board) from a July 2021 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). On August 23, 2017, the President signed into law the Veterans Appeals Improvement and Modernization Act, Pub. L. No. 115-55 (codified as amended in scattered sections of 38 U.S.C.), 131 Stat. 1105 (2017), also known as the Appeals Modernization Act (AMA). The law creates a new framework for veterans dissatisfied with VA's decision on their claim to seek review, and this decision has been written consistent with the new AMA framework. In March 2019, the Veteran filed a VA Form 21-526EZ (Claim Application) seeking service connection for her left knee. In July 2019, the RO issued a rating decision denying entitlement to service connection. In June 2019, the Veteran filed a VA Form 20-0995, (Supplemental Claim Application). In July 2021, the Ro issued a rating decision confirming and continuing the previous denial. Subsequently, the Veteran filed her VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement), electing the Evidence Submission docket. See April 2022 Notice of Disagreement. Therefore, the Board may only consider the evidence of record at the time of the July 2021 agency of original jurisdiction (AOJ) decision on appeal, as well as any evidence submitted by the Veteran or her representative with, or within 90 days from receipt of, the VA Form 10182. 38 C.F.R. § 20.303. If evidence was submitted either (1) during the period after the AOJ issued the decision on appeal and prior to the date the Board received the VA Form 10182, or (2) more than 90 days following the date the Board received the VA Form 10182, the Board did not consider it in its decision. See 38 C.F.R. §§ 20.300, 20.303, 20.801. If the Veteran would like VA to consider any evidence that was submitted that the Board could not consider, the Veteran may file a Supplemental Claim (VA Form 20-0995) and submit or identify this evidence. See 38 C.F.R. § 3.2501. If the evidence is new and relevant, VA will issue another decision on the claim, considering the new evidence in addition to the evidence previously considered. Id. Specific instructions for filing a Supplemental Claim are included with this decision. 1. Entitlement to service connection for knee osteoarthritis, left, is granted. The Veteran contends that her osteoarthritis of the left knee is related to her active duty military service. Service connection may be established for a disability resulting from a disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. Service connection requires evidence showing: (1) a current disability; (2) incurrence or aggravation of a disease or injury in service; and (3) a nexus between the current disability and the disease or injury incurred or aggravated in service. See Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). When there is an approximate balance of positive and negative evidence regarding the merits of an issue, the benefit of the doubt shall be given to the Veteran. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. When the evidence persuasively favors one side or the other, the benefit-of-the-doubt rule does not apply. See Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001). As an initial matter, the RO has made the following favorable findings: The evidence shows that a qualifying event, injury, or disease had its onset during the Veteran's service. Her service treatment records show complaints of knee pain in November of 1984. She has been diagnosed with a disability. Upon VA contract examination, conducted June 17, 2019, the Veteran was diagnosed with osteoarthritis of the left knee. There being no clear and unmistakable error, the Board is bound by these favorable findings. See 38 C.F.R. § 3.104(c). The remaining issue, therefore, is whether there is a nexus between the Veteran's current disability and her military service. Analysis Regarding the third element of direct service connection, there are both probative favorable and unfavorable VA medical nexus opinions of record. The Veteran was afforded a VA examination in July 2019. The Veteran reported to the VA examiner that her symptoms worsened since the condition's onset in 1984. See July 2019 Knee and Lower Leg Conditions Disability Benefits Questionnaire (DBQ). She reported that in 1988, she injured her left knee and had physical therapy and x-rays done. Id. She reported pulling a muscle. Id. The DBQ notes that in 2009, she slid and twisted her left knee, requiring physical therapy. Id. The VA examiner opined that it was less likely than not that the Veteran's current left knee disability was incurred in or caused by the Veteran's left knee pain in service. See July 2019 VA medical nexus opinion. The VA examiner provided the rationale that the etiology of the Veteran's current left knee disability is most likely related to a left knee sprain suffered in spring 2015. Id. The VA examiner summarized the review of pertinent medical records, stating that the Veteran started with knee pain while in service and it got worse over time due to military duties and in 2015, it got worse after she twisted her left knee. Id. The VA examiner identified complaints of left knee pain in a September 2009 medical record. Id. The VA examiner noted that x-rays showing minimal degenerative changes were conducted in February 2016, and the associated medical evaluation reflected left knee pain since spring 2015 when she twisted it. The VA examiner further noted that the Veteran was sent for a brace due to left knee osteoarthritis or patellofemoral syndrome in January 2016. Id. The VA examiner stated that over time the Veteran had degenerative changes and continued to have left knee pain and some limitation due to it. Id. The Board observes that as a layperson, the Veteran is competent to describe her symptoms, such as pain, as these are within the realm of her personal knowledge and experience. See Layno v. Brown, 6 Vet. App. 465, 471 (1994). Here, the VA examiner has considered the Veteran's lay statements regarding the continuity of pain after her documented in-service injury, however, fails to adequately reconcile why the Veteran's current knee disability is likely due to her 2015 injury despite acknowledgement of the Veteran's reports that pain worsened after her in-service injury and the documented complaints of knee pain in September 2009. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (stating that "The Board must be able to conclude that a medical expert has applied valid medical analysis to the significant facts of the particular case in order to reach the conclusion submitted in the medical opinion."). To the extent that the July 2019 VA medical opinion is internally inconsistent, it is not adequate. Accordingly, the July 2019 VA medical nexus opinion is assigned low probative weight. After the June 2021 Supplemental Claim Application was received by VA, the Veteran was afforded an additional VA examination. During the July 2021 VA examination, the Veteran reported being put on a no-running profile in November 1984. See July 2021 VA Knee and Lower Leg Conditions DBQ. The VA examiner noted that the Veteran's subjective history regarding her left knee 'seems to pick back up 'about 5 years ago' when the Veteran was experiencing left knee pain with speed walking when her marginal left knee arthritis was recognized on imaging." Id. The VA examiner opined that it is less likely than not that the Veteran's currently claimed left knee arthritis was originally incurred during active service in the Army. See July 2021 VA medical nexus opinion. The VA examiner reasoned that the evidence of record shows that the Veteran's current left knee pain originated in the spring of 2015, which is the repeated subjective history provided by the Veteran at multiple primary care and orthopedic encounters. Id. The VA examiner also noted the Veteran's age and stated that primary arthritis of weight bearing joints would be expected as a natural progression of aging, citing to supporting medical literature. The VA examiner dismissed the September 2009 "subjective complaint" of left knee pain for five days as there was no diagnosis rendered and normal x-rays. Id. The VA examiner opined that there was no further documented continuity, and the Veteran denied having any other ongoing or prior problems with the left knee at that time. Id. The July 2021 medical nexus opinion reasoned that this was also consistent with the Veteran's November 1989 separation exam, which was silent for any complaints or findings consistent with acute or chronic left knee injuries. Id. The July 2021 VA medical nexus opinion concludes that there is a dearth of objective medical evidence to sufficiently support a nexus between her active duty period that ended two decades prior to the documented onset of her left knee pain, whether that happens to be in 2009 or 2015. Id. The July 2021 VA medical nexus opinion does not provide adequate consideration of the Veteran's lay statements regarding her symptoms of pain associated with her claimed left knee disability, stating that there was not sufficient evidence to support a nexus as there was "a dearth of objective medical evidence" from the time of the Veteran's active duty period ending in 1989 and the documented onset of pain "whether that happens to be in 2009 or 2015." Buchanan v. Nicholson, 451 F.3d 1331, 1336, n. 1 (Fed. Cir. 2006) (stating that an examiner's opinion failed to consider whether lay statements presented sufficient evidence of the etiology of the Veteran's disability such that his claim could be proven without contemporaneous medical evidence). While the September 2009 medical treatment record indicates that the Veteran had no prior history of related problem when she presented for treatment due to left knee pain, the Board observes that there are not post-separation treatment records associated with the claims file prior to October 2001. The lack of contemporaneous evidence is relevant, however, it may not generally serve as the sole basis for discrediting lay statements or testimony. Buchanan, 451 F.3d at 1337. Further, the absence of documentation cannot be considered substantive negative evidence. Buczynski v. Shinseki, 24 Vet. App. 221, 224 (2011). Accordingly, to the extent that the July 2021 VA medical nexus opinion fails to sufficiently consider the Veteran's credible lay statements, it is assigned low probative weight. (Continued on the next page) ? A third medical opinion was submitted by the Veteran in April 2022 with her April 2022 Notice of Disagreement. Here, the examiner, a VA advanced practice nurse, states that the Veteran had been under the clinician's patient care since October 2021 and had examined her on two occasions. See April 2022 Medical Nexus Opinion. The VA examiner opined that it was more likely than not that the Veteran's left knee disability was a direct result of the injury to her left knee as due to military service. Id. The opinion states that the VA examiner reviewed pertinent records, including the Veteran's written history regarding her injury, as well as x-ray and MRI reports in her VA record, and noted the circumstances and event of her military service. Id. The VA examiner opined that the Veteran did not have other risk factors that may have precipitated her condition. Id. The Board finds that April 2022 medical nexus opinion has provided a sufficient rationale and is adequate for adjudicative purposes. Accordingly, the Board assigns it probative weight. Based on the foregoing, the Board finds the evidence to be in nearly approximate balance as to whether the Veteran's osteoarthritis of the left knee was a result of military service. Resolving all doubt in her favor, the Board concludes that the Veteran's current disability of osteoarthritis of the left knee incurred as a result of his active military service. See 38 U.S.C.§§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a). Cynthia M. Bruce Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M.E. 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.