DEGENERATIVE ARTHRITIS OF THE SPINE (SPONDYLOSIS)

Summary

The veteran, who served in the Army and Air National Guard from June 1974 to June 1978, with subsequent inactive duty and federalized active duty through August 2003, appeals the denial of service connection for a low back disorder and a left knee disorder. The veteran claimed direct service connection for both conditions due to in-service injuries and the cumulative impact of strenuous physical duties, including "playing war games" with heavy gear. Alternatively, the veteran claimed secondary service connection for both the low back and left knee disorders due to a service-connected right ankle sprain. Service treatment records indicated isolated, resolved back strains in 1977 and 1978, with no chronic complaints noted at separation or in subsequent examinations until 2005. Similarly, service records showed an acute left knee complaint in 1977 with a normal examination, no chronic issues at separation, and only occasional post-service complaints. Multiple VA examinations were conducted, with examiners consistently opining that the veteran's current degenerative conditions were more likely due to aging and occupational stress, and that the in-service complaints were isolated and resolved. The Board afforded significant weight to these VA opinions, finding them well-reasoned and supported by the evidence, and found the veteran's lay opinions on etiology to be incompetent. The Board also found no evidence of compensable manifestation within one year of service for either condition, and no continuity of symptomatology. Therefore, service connection for both the low back and left knee disorders was denied.

Rationale

No evidence of chronic back disorder during service or within one year of separation.; VA examiner opinions consistently found condition less likely than not related to service.; Veteran's lay opinions on etiology deemed incompetent.

Full Decision Text

Citation Nr: 21045522
Decision Date: 07/26/21	Archive Date: 07/26/21

DOCKET NO. 13-21 897
DATE: July 26, 2021

ORDER

Service connection for a low back disorder is denied.

Service connection for a left knee disorder is denied.

FINDINGS OF FACT

1. A low back disorder is not shown to be causally or etiologically related to any disease, injury, or incident during service, did not manifest to a compensable degree within one year of discharge from active duty, and is not caused or aggravated by service-connected right ankle sprain.

2. A left knee disorder is not shown to be causally or etiologically related to any disease, injury, or incident during service, arthritis did not manifest to a compensable degree within one year of discharge from active duty, and such is not caused or aggravated by service-connected right ankle sprain.

CONCLUSIONS OF LAW

1. The criteria for service connection for a low back disorder have not been met. 38 U.S.C. §§ 101(24), 1101, 1110, 1112, 1131, 1137, 5107; 38 C.F.R. §§ 3.1, 3.6, 3.102, 3.303, 3.307, 3.309, 3.310.

2. The criteria for service connection for a left knee disorder have not been met. 38 U.S.C. §§ 101(24), 1101, 1110, 1112, 1131, 1137, 5107; 38 C.F.R. §§ 3.1, 3.6, 3.102, 3.303, 3.307, 3.309, 3.310.

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran served on active duty from June 1974 to June 1978, and during a period of federalized active duty in the Arkansas Air National Guard from October 2002 to August 2003. The Veteran performed additional inactive service in the Arkansas Army and National Guard during the period from January 1986 to December 2003.

This matter comes before the Board of Veterans' Appeals (Board) on appeal from a January 2011 rating decision issued by the Department of Veterans Affairs (VA) Regional Office. In October 2015, the Veteran and P.C. testified at a Board hearing before the undersigned Veterans Law Judge. A transcript of the hearing is associated with the record. 

In a May 2016 decision, the Board, as relevant, found no clear and unmistakable error (CUE) in the August 2006, September 2007, and October 2007 final rating decisions that denied service connection for a low back pain; denied an application to reopen a claim for service connection for a left ankle disorder; reopened and remanded the claim for service connection for a low back disorder; and remanded the claim for service connection for a left knee disorder. Thereafter, the Veteran appealed the decision to the United States Court of Appeals for Veterans Claims (Court). In February 2017, the Court granted a Joint Motion for Partial Remand (JMPR), in which the Secretary of VA and the Veteran (parties) moved the Court to vacate the May 2016 decision as to the above issues that were not remanded by the Board, determining that the decision was premature as all relevant federal records had not been obtained prior to its promulgation. At the parties' request, the Court did not disturb, as relevant, the Board's finding of no CUE in the August 2006, September 2007, and October 2007 rating decisions and the determination that new and material evidence had not been received in order to reopen the claims for service connection for low back pain.

The claims remanded by the Court in February 2017, as well as the claims remanded by the Board in May 2016, were subsequently returned to the Board for further consideration.  In July 2017, the Board remanded all claims to obtain the federal records identified as outstanding and potentially relevant in the parties' JMPR, namely VA treatment records, Social Security Administration (SSA) records, and service department records. Thereafter, all available records were obtained and the Veteran was informed of the unavailability of certain service records. Thus, there has been substantial compliance with the February 2017 JMPR and July 2017 remand directives. Stegall v. West, 11 Vet. App. 269 (1998); D'Aries v. Peake, 22 Vet. App. 97 (2008).

In May
2016, were subsequently returned to the Board for further consideration.  In July 2017, the Board remanded all claims to obtain the federal records identified as outstanding and potentially relevant in the parties' JMPR, namely VA treatment records, Social Security Administration (SSA) records, and service department records. Thereafter, all available records were obtained and the Veteran was informed of the unavailability of certain service records. Thus, there has been substantial compliance with the February 2017 JMPR and July 2017 remand directives. Stegall v. West, 11 Vet. App. 269 (1998); D'Aries v. Peake, 22 Vet. App. 97 (2008).

In May 2020, the Board reopened the Veteran's claim for service connection for a left ankle disorder and, at such time, in September 2020, and in February 2021, remanded the claims for service connection for left ankle, low back, and left knee disorders to obtain etiological opinions, which, as discussed below, were subsequently received. Id. Further, while on remand, a May 2021 rating decision awarded service connection for left ankle sprain, to include osteophytic spurring. As such constitutes a full grant of benefit sought on appeal with regard to such issue, it is no longer before the Board. Grantham v. Brown, 114 F.3d 1156, 1159 (Fed. Cir. 1997). The remaining claims now return to the Board for further appellate review.

Service Connection

A Veteran is a person who served in the active military, naval, or air service and who was discharged or released under conditions other "than dishonorable."  38 C.F.R. § 3.1(d).  The term "active military, naval, or air service" includes: (1) active duty; (2) any period of active duty for training (ACDUTRA) during which the individual concerned was disabled or died from a disease or injury incurred or aggravated in the line of duty; and (3) any period of in active duty for training (INACDUTRA) during which the individual concerned was disabled or died from an injury incurred or aggravated in the line of duty or from an acute myocardial infarction, a cardiac arrest, or a cerebrovascular accident which occurred during such training. 38 U.S.C. § 101(24); 38 C.F.R. § 3.6(a).  ACDUTRA includes full-time duty performed by members of the National Guard of any State or the Reserve.  38 C.F.R. § 3.6(c).  INACDUTRA includes duty other than full-time duty performed by a member of the Reserve or the National of any State.  38 C.F.R. § 3.6(d).

Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a).  Service connection may also be granted for any disease 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).  Direct service connection may not be granted without evidence of a current disability; in-service incurrence or aggravation of a disease or injury; and a nexus between the claimed in-service disease or injury and the present disease or injury. Id.; see also Caluza v. Brown, 7 Vet. App. 498, 506 (1995) aff'd, 78 F.3d 604 (Fed. Cir. 1996).

Additionally, for veterans who have served 90 days or more of active service during a war period or after December 31, 1946, certain chronic disabilities, such as arthritis and organic diseases of the nervous system, 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, 1137; 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 continuity of symptomatology after service. See 38 C.F.R. § 3.303(b). However, 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) and does not apply to other disabilities which might be considered chronic
 of discharge from service. 38 U.S.C. §§ 1101, 1112, 1137; 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 continuity of symptomatology after service. See 38 C.F.R. § 3.303(b). However, 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) and does not apply to other disabilities which might be considered chronic from a medical standpoint. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013).

Service connection may also be established on a secondary basis for a disability which is proximately due to or the result of service-connected disease or injury.  38 C.F.R. § 3.310(a).  Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability.  Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc).  Further, service connection may not be awarded on the basis of aggravation without establishing a pre-aggravation baseline level of disability and comparing it to the current level of disability.  38 C.F.R. § 3.310(b).  

When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990).

1. Entitlement to service connection for a low back disorder, to include as secondary to service-connected right ankle sprain.

At his October 2015 Board hearing and in documents of record, the Veteran contends that he has a current low back disorder as a result of his military service, to include injuries incurred therein while on barrack detail and the cumulative impact of his in-service physical duties, which he describes as "playing war games" while wearing heavy backpacks and other gear. In the alternative, he claims that his low back disorder is caused or aggravated by his right ankle sprain. Thus, the Veteran claims that service connection for such disorder is warranted. 

Service treatment records (STRs) reveal that the Veteran was diagnosed with a mild back strain in February 1977 after playing in a volleyball game.  In May 1978, he was treated for lower back pain after cleaning, and was diagnosed with muscle spasm. However, the Veteran's June 1978 separation examination and a May 2000 National Guard periodic examination were negative for any complaints or diagnosis referable to a low back disorder. Further, he denied any chronic conditions in December 2002. Post-service treatment records reflect occasional low back pain and stiffness beginning in November 2005, and the Veteran has current diagnoses of degenerative disc disease (DDD) by a 2010 MRI and degenerative joint disease (DJD) by a 2017 X-ray, with degenerative changes first seen in 2013. 

At a November 2010 VA examination, the Veteran reported that he strained his back in 1977 while working on his footlocker. At the time, he was diagnosed with a strain and was treated medically with improvement of symptoms. Additionally, he reported that since his exit from service, he has approximately two flare-ups a month. A recent MRI completed earlier in the year revealed degenerative disc changes. Following a review of the record and physical examination, the examiner opined that the Veteran's low back disorder is not attributable to the complaints in service. In this regard, he noted that the Veteran had isolated strains in 1977 and 1978, which were brief and treated. The examiner indicated that there was no evidence of ongoing problems or a chronic condition following separation from service in 1978, or upon review examination in 2000. Thus, he found that there was no chronic condition or ongoing complaints at the time of the Veteran's separation from service, and his in-service strains resolved without residuals. Rather, he found that, as evidenced by the Veteran's complaints in 2005 to the present, which lead to workup, his low back disorder was more consistent with aging and occupational stresses.

In June 2016, a different VA examiner reviewed the record and offered an
. In this regard, he noted that the Veteran had isolated strains in 1977 and 1978, which were brief and treated. The examiner indicated that there was no evidence of ongoing problems or a chronic condition following separation from service in 1978, or upon review examination in 2000. Thus, he found that there was no chronic condition or ongoing complaints at the time of the Veteran's separation from service, and his in-service strains resolved without residuals. Rather, he found that, as evidenced by the Veteran's complaints in 2005 to the present, which lead to workup, his low back disorder was more consistent with aging and occupational stresses.

In June 2016, a different VA examiner reviewed the record and offered an addendum opinion as to the etiology of the Veteran's low back disorder. At such time, he noted that the Veteran's STRs reflected that he was seen for a back muscle strain after playing volleyball in 1977, but such were silent for a chronic back problem. Specifically, the examiner observed that the record was silent for a chronic back problem at separation, and there was no documentation of a back disorder for over a year after separation. Thus, he found that there was insufficient evidence to support a chronic back disorder from an in-service muscle strain. The examiner further opined that it was less likely than not that the Veteran's low back disorder is caused or aggravated by his service-connected right ankle disability as he had a stable and normal appearing right ankle, there was no antalgic gait, and knee alignment when standing is within normal limits. 

As the November 2010 and June 2016 VA opinions did not address the Veteran's allegation that the cumulative impact of his in-service physical duties, described as "playing war games" while wearing heavy backpacks and other gear, resulted in his low back disorder, the claim was remanded in order to obtain an addendum opinion addressing such theory of entitlement. 

Thereafter, the Veteran was afforded a VA examination in August 2020, at which time the VA examiner opined that his low back disorder was less likely than not incurred in or caused by the claimed in-service injury, event, or illness.  In support thereof, he noted that the Veteran received treatment for a back condition in 1977 and 1978; however, he indicated that these were separate isolated incidents and there were no complaints of a back condition while separating from active duty.  Furthermore, the examiner noted that the Veteran's degenerative arthritis is more likely dur to aging and occupational stress. However, as the examiner did not offer an opinion as to whether the Veteran's low back disorder is related to the cumulative impact of his in-service physical duties, to include playing war games while wearing rucksacks and heavy gear, the Board again remanded the claim in order to obtain an addendum opinion addressing such matter. 

In November 2020, the August 2020 VA examiner again opined that the Veteran's low back disorder was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. In support of such opinion, he explained that DDD occurs over time as normal wear and tear on the lumbar spine, and the Veteran's low back disorder is not due to his playing war games while wearing rucksacks and other heavy gear while in service. The examiner also stated that playing war games while wearing rucksacks and other heavy gear and the Veteran's DDD are not related, and there was no evidence of DDD while in service. However, the Board previously found such opinion to be conclusory in nature as the examiner does not explain why the Veteran's low back disorder is unrelated to the cumulative impact of his in-service physical duties, which includes, but is not limited to, playing war games while wearing rucksacks and heavy gear. Furthermore, despite the current diagnosis of DJD of the lumbar spine, he did not address the etiology of such disorder. Thus, the matter was again remanded to obtain an addendum opinion.

In a February 2021 addendum opinion, a VA examiner reviewed the record and opined that it was less likely than not that the Veteran's low back disorder, diagnosed as DJD and DDD, had its onset in, or is otherwise related to, his military service, to include the cumulative impact of his in-service physical duties, which includes, but is not limited to, playing war games while wearing rucksacks and other heavy gear. In this regard, he noted the Veteran's diagnosis of DDD, but found no objective evidence of related complaints or treatment during service. The examiner observed that, while high impact physical duties can represent a risk factor for back pain, without direct medical evidence of related complaints or treatment during service, consideration that the current disorder would be related to service would represent mere speculation that would not be based on any factual medical evidence. Further,
 that the Veteran's low back disorder, diagnosed as DJD and DDD, had its onset in, or is otherwise related to, his military service, to include the cumulative impact of his in-service physical duties, which includes, but is not limited to, playing war games while wearing rucksacks and other heavy gear. In this regard, he noted the Veteran's diagnosis of DDD, but found no objective evidence of related complaints or treatment during service. The examiner observed that, while high impact physical duties can represent a risk factor for back pain, without direct medical evidence of related complaints or treatment during service, consideration that the current disorder would be related to service would represent mere speculation that would not be based on any factual medical evidence. Further, he noted that the initial diagnosis of DDD was not made until a 2010 MRI and the initial diagnosis of DJD was not made until a 2017 X-ray. 

However, as the examiner did not consider the Veteran's documented in-service back complaints in February 1977 and May 1978 when offering the foregoing opinion, an addendum opinion was obtained in March 2021. Specifically, at such time, the same examiner reviewed the record, to include such STRs, and again opined that the Veteran's low back disorder was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. In this regard, he noted that, despite the February 1977 and May 1978 STRs demonstrating back-related complaints during service, the symptoms were nonspecific, and there was no evidence of back-related complaints for many years after separation from service. The examiner again noted that DDD was not diagnosed until a 2010 MRI and DJD was not diagnosed until a 2017 X-ray. Thus, such current disorders were likely to represent a separate and discrete disease process. 

The VA examiner further opined that it is less likely than not that the Veteran's low back disorder, diagnosed as DJD and DDD, is related to the cumulative impact of his in-service physical duties, which includes, but is not limited to, playing war games while wearing rucksacks and other heavy gear. In this regard, he acknowledged that, while such duties, including war games and wearing heavy rucksacks and gear, can lead to chronic back pain, there is no evidence of subsequent related complaints for many years following separation from service. Furthermore, DDD and DJD are common age-related findings in the general population, which the examiner indicated is the more likely etiology of the Veteran's back disorders. 

The Board affords great probative weight to the November 2010, June 2016, August 2020, and March 2021 VA examiners' opinions as such considered all of the pertinent evidence of record, to include the statements of the Veteran and relevant medical history, and provided a complete rationale, relying on and citing to the records reviewed.  Moreover, the examiners offered clear conclusions with supporting data as well as reasoned medical explanations connecting the two.  Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008) (it is the factually accurate, fully articulated, sound reasoning for the conclusion that contributes to the probative value of a medical opinion); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A]medical opinion... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions"). Notably, there is no medical opinion to the contrary.

The Board has also considered the Veteran's assertions as to the etiology of his current low back disorder. In this regard, while he has worked as a mental health technician, he has not demonstrated that he has medical expertise in the area of orthopedic disorders. Thus, he is a lay person in such regard and does not have the requisite training and experience necessary to address such complex medical matters. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007) (noting general competence to testify as to symptoms but not to provide medical diagnosis).  In this regard, the etiology of DDD and DJD involve a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship.  Specifically, such requires knowledge of the musculoskeletal system and the impact rigorous physical training and prior injuries have on the spine. Therefore, such matters may not be competently addressed by lay evidence. See Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (explaining that while the claimant is competent in certain situations to provide a diagnosis of a simple condition such as a broken leg or varicose veins, the claimant is not competent to provide evidence as to
 as to symptoms but not to provide medical diagnosis).  In this regard, the etiology of DDD and DJD involve a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship.  Specifically, such requires knowledge of the musculoskeletal system and the impact rigorous physical training and prior injuries have on the spine. Therefore, such matters may not be competently addressed by lay evidence. See Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (explaining that while the claimant is competent in certain situations to provide a diagnosis of a simple condition such as a broken leg or varicose veins, the claimant is not competent to provide evidence as to more complex medical questions).  Accordingly, the Veteran's opinion as to the etiology of his low back disorder is not competent evidence and, consequently, is afforded no probative weight. 

Moreover, the Board finds that the evidence fails to show that the Veteran manifested DDD or DJD of the low back to a compensable degree within one year of his separation from active duty in June 1978 or August 2003. In this regard, the Veteran's June 1978 separation examination and May 2000 National Guard periodic physical examination were negative for any complaints or diagnosis referable to a low back disorder, and he denied any chronic conditions in December 2002. Rather, post-service treatment records reflect complaints of occasional low back pain and stiffness beginning in 2005, with subsequent imaging evidence of disc involvement in 2010 and degenerative changes in 2013. 

Furthermore, to the extent that the Veteran alleges that he has experienced continuous low back pain since his initial back injuries in 1977 and 1978 in connection with the instant claim, such reports are contradicted by his statements to medical professionals indicating the onset of back pain in 2009, 1970, and 1997, as reflected in April 2010, January 2014, and February 2014 treatment records, respectively, and his report of only occasional back pain and stiffness in 2005. Cucuras v. Sec'y of Health and Human Servs., 993 F.2d 1525, 1528 (Fed. Cir. 1993) (finding no error in fact-finder's decision to give more weight contemporaneous medical records generated for treatment purposes than to contrary lay testimony, reasoning that "[m]edical records, in general, warrant consideration as trustworthy evidence, and that "oral testimony in conflict with contemporaneous documentary evidence deserves little weight"); Williams v. Gov. of Virgin Islands, 271 F.Supp.2d 696, 702 (V.I. 2003) (noting that statements made for the purpose of diagnosis or treatment "are regarded as inherently reliable because of the recognition that one seeking medical treatment is keenly aware of the necessity for being truthful in order to secure proper care"). Thus, the Board finds that presumptive service connection, to include on the basis of continuity of symptomatology, for the Veteran's low back disorder is not warranted.  

Therefore, based on the foregoing, the Board finds that a low back disorder is not shown to be causally or etiologically related to any disease, injury, or incident during service, did not manifest to a compensable degree within one year of discharge from active duty, and is not caused or aggravated by service-connected right ankle sprain. Consequently, service connection for such disorder is not warranted.

In reaching this decision, the Board has considered the applicability of the benefit of the doubt doctrine. However, the preponderance of the evidence is against the Veteran's claim for service connection for a low back disorder. As such, that doctrine is not applicable in the instant appeal, and his claim must be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert, supra.

2. Entitlement to service connection for a left knee disorder, to include as secondary to service-connected right ankle sprain.

At his October 2015 Board hearing and in documents of record, the Veteran contends that he has a current left knee disorder as a result of his military service, to include an injury incurred therein and the cumulative impact of his in-service physical duties, which he describes as "playing war games" while wearing heavy backpacks and other gear. In the alternative, he claims that his left knee disorder is caused or aggravated by his right ankle sprain. Thus, the Veteran claims that service connection for such disorder is warranted.  

STRs reveal that, in December 1977, the Veteran reported aching and stiffness of the left knee after sitting or sleeping. He reported a left knee sprain in junior high school; however, he also denied incurring any injuries since then and had been physically active. The
 record, the Veteran contends that he has a current left knee disorder as a result of his military service, to include an injury incurred therein and the cumulative impact of his in-service physical duties, which he describes as "playing war games" while wearing heavy backpacks and other gear. In the alternative, he claims that his left knee disorder is caused or aggravated by his right ankle sprain. Thus, the Veteran claims that service connection for such disorder is warranted.  

STRs reveal that, in December 1977, the Veteran reported aching and stiffness of the left knee after sitting or sleeping. He reported a left knee sprain in junior high school; however, he also denied incurring any injuries since then and had been physically active. The Veteran's knee was normal on examination. Furthermore, his June 1978 separation examination was negative for any complaints or diagnosis referable to a left knee disorder. Additionally, while the Veteran reported left knee soreness at a National Guard periodic examination in November 1992, a May 2000 National Guard periodic examination were negative for any complaints or diagnosis referable to a low back disorder and he denied any chronic conditions in December 2002. Post-service treatment records reflect that, in April 2010, the Veteran reported left leg pain for the prior year.

At a July 2010 VA examination, the Veteran reported developing left knee pain in the mid-1970's without history of injury, and chondromalacia patellar syndrome/DJD of the left knee was diagnosed. In November 2010, the July 2010 VA examiner noted the Veteran had an isolated complaint of left knee pain in December 1977, but examination was normal at the time. He further observed that Veteran's June 1978 separation examination was negative and the record was silent for any subsequent knee complaints, to include in May 2000. Thus, the examiner opined that the Veteran's left knee disorder is more likely related to aging and occupational stresses over the years as the in-service left knee complaints resolved.  

However, as the July 2010/November 2010 VA examiner based his opinion on an inaccurate factual premise as the Veteran reported left knee soreness at a National Guard periodic examination in November 1992, the Board remanded the case in order to obtain an addendum opinion addressing the etiology of the Veteran's left knee disorder. 

In June 2016, a different VA examiner reviewed the record and offered an addendum opinion as to the etiology of the Veteran's left knee disorder. At such time, he noted that the Veteran had a left knee strain while in junior high school, and was seen for his left knee in service in 1977, at which time he had a normal examination. The examiner also observed that the STRs were silent for a chronic left knee problem, to include at separation and for over a year after discharge. Thus, he found that the record did not demonstrate a chronic left knee disorder. The examiner further opined that it was less likely than not that the Veteran's left knee disorder is caused or aggravated by his service-connected right ankle disability as he had a stable and normal appearing right ankle, there was no antalgic gait, and knee alignment when standing is within normal limits.

As the July 2010/November 2010 and June 2016 VA opinions did not address the Veteran's allegation that the cumulative impact of his in-service physical duties, described as "playing war games" while wearing heavy backpacks and other gear, resulted in his low back disorder, the claim was remanded in order to obtain an addendum opinion addressing such theory of entitlement. 

Thereafter, the Veteran was afforded a VA examination in August 2020, at which time left knee strain was diagnosed, and the VA examiner opined that his left knee disorder was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. In support thereof, he noted that the Veteran had reported having a severe knee sprain while in junior high school. However, while he sought treatment in service in 1977, such was acute only, and his 1978 separation examination showed no abnormalities of the left knee. Further, the examiner stated the Veteran's report of left knee pain in 1992 was not related to military service, and on a May 2000 National Guard examination, the Veteran denied any knee problems. He indicated that degenerative joint disease is a progressive disease that occurs over time and is considered normal wear and tear, and the degenerative arthritis documented in July 2010 did not occur during active duty service. Thus, he found that a nexus was not established.

However, as the August 2020 VA examiner did not offer an etiological opinion as to the Veteran's diagnosed chondromalacia patella syndrome and left knee sprain, address whether the Veteran's left disorder is related to the
 no abnormalities of the left knee. Further, the examiner stated the Veteran's report of left knee pain in 1992 was not related to military service, and on a May 2000 National Guard examination, the Veteran denied any knee problems. He indicated that degenerative joint disease is a progressive disease that occurs over time and is considered normal wear and tear, and the degenerative arthritis documented in July 2010 did not occur during active duty service. Thus, he found that a nexus was not established.

However, as the August 2020 VA examiner did not offer an etiological opinion as to the Veteran's diagnosed chondromalacia patella syndrome and left knee sprain, address whether the Veteran's left disorder is related to the cumulative impact of his in-service physical duties, to include playing war games while wearing rucksacks and heavy gear, or provide a rationale for his conclusion that the complaint of knee pain in 1992 was not related to the Veteran's military service, the Board again remanded the claim in order to obtain an addendum opinion addressing such matters. 

In November 2020, the August 2020 VA examiner essentially reiterated his prior opinion that it was less likely than not that the Veteran's left knee disorder was incurred in or caused by the claimed in-service injury, event, or illness. However, he did not address the etiology of each diagnosed left knee disorder, to include chondromalacia patella syndrome, DJD, or left knee sprain, and again failed to provide a rationale for his conclusion that the Veteran's complaint of knee pain in 1992 was not related to his military service. Further, when addressing whether the Veteran's left knee disorder was related to his in-service physical duties, to include playing war games while wearing rucksacks and heavy gear, the examiner stated the Veteran's degenerative disc disease was not related to such activities. However, a diagnosis of DDD is inapplicable to the knee. Thus, the Board again remanded the claim in order to obtain another addendum opinion addressing such matters.

In a February 2021 addendum opinion, a VA examiner reviewed the record and opined that it was less likely than not that the Veteran's left knee disorder, diagnosed as chondromalacia patella syndrome, DJD, and left knee strain, had its onset in, or is otherwise related to, his military service, to include the cumulative impact of his in-service physical duties, which includes, but is not limited to, playing war games while wearing rucksacks and other heavy gear. In this regard, he noted that the Veteran's left knee disorder had its onset in 2010, and there was no objective evidence of related complaints or treatment during service. In this regard, the examiner noted that left knee complaints in 1977, but observed that there were no subsequent treatment records until 2010. Thus, he found that the current disorder likely represents a separate and discrete disease process. The examiner further found the Veteran's report of left knee symptoms in November 1992 to be unrelated as such did not occur during a period of non-active duty, and there were no subsequent complaints or treatment until 2010. In a March 2021 addendum opinion, the examiner stated that that chondromalacia patella, DJD, and knee strain are common age-related findings in the general population, which the examiner indicated is the more likely etiology of the Veteran's left knee disorders.

The Board affords great probative weight to the June 2016, February 2021, and March 2021 VA examiners' opinions as such considered all of the pertinent evidence of record, to include the statements of the Veteran and relevant medical history, and provided a complete rationale, relying on and citing to the records reviewed.  Moreover, the examiners offered clear conclusions with supporting data as well as reasoned medical explanations connecting the two.  Nieves-Rodriguez, supra; Stefl, supra. Notably, there is no medical opinion to the contrary.

The Board has also considered the Veteran's assertions as to the etiology of his current left knee disorder. In this regard, while he has worked as a mental health technician, he has not demonstrated that he has medical expertise in the area of orthopedic disorders. Thus, he is a lay person in such regard and does not have the requisite training and experience necessary to address such complex medical matters. See Jandreau, supra. In this regard, the etiology of chondromalacia patella, DJD, and strain involve a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship.  Specifically, such requires knowledge of the musculoskeletal system and the impact rigorous physical training and prior injuries have on the spine. Therefore, such matters may not be competently addressed by lay evidence. See Woehlaert, supra
, while he has worked as a mental health technician, he has not demonstrated that he has medical expertise in the area of orthopedic disorders. Thus, he is a lay person in such regard and does not have the requisite training and experience necessary to address such complex medical matters. See Jandreau, supra. In this regard, the etiology of chondromalacia patella, DJD, and strain involve a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship.  Specifically, such requires knowledge of the musculoskeletal system and the impact rigorous physical training and prior injuries have on the spine. Therefore, such matters may not be competently addressed by lay evidence. See Woehlaert, supra. Accordingly, the Veteran's opinion as to the etiology of his left knee disorder is not competent evidence and, consequently, is afforded no probative weight. 

Moreover, the Board finds that the evidence fails to show that the Veteran manifested DJD of the left knee to a compensable degree within one year of his separation from active duty in June 1978 or August 2003. In this regard, the Veteran's June 1978 separation examination and May 2000 National Guard periodic physical examination were negative for any complaints or diagnosis referable to a left knee disorder, and he denied any chronic conditions in December 2002. Rather, post-service treatment records reflect complaints of left leg pain beginning in 2009, with subsequent imaging evidence of degenerative changes in 2010. Furthermore, to the extent that the Veteran alleges that he has experienced continuous left knee pain since his military service in connection with the instant claim, such reports are contradicted by his statements to medical professionals indicating the onset of back pain in 2009, as reflected in an April 2010 treatment records. Cucuras, supra; Williams, supra. Thus, the Board finds that presumptive service connection, to include on the basis of continuity of symptomatology, for the Veteran's left knee disorder is not warranted.  

Therefore, based on the foregoing, the Board finds that a left knee disorder is not shown to be causally or etiologically related to any disease, injury, or incident during service, arthritis did not manifest to a compensable degree within one year of discharge from active duty, and such is not caused or aggravated by service-connected right ankle sprain. Consequently, service connection for such disorder is not warranted.

In reaching this decision, the Board has considered the applicability of the benefit of the doubt doctrine. However, the preponderance of the evidence is against the Veteran's claim for service connection for a left knee disorder. As such, that doctrine is not applicable in the instant appeal, and his claim must be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert, supra.

 

 

A. JAEGER

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	J. Waite

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.