ANKLE IMPAIRMENT OF

KATHERINE KIEMLE BUCKLEY · 2021 · Case ID: 21057758

MIXED

Summary

The veteran, who served in the Army from April 1978 to April 1982, appeals the denial of service connection for bilateral ankle and knee disabilities. The veteran also had a period of active duty for training from June 1976 to October 1976. The primary contention is that current ankle and knee conditions are related to an in-service fall from a truck in June 1978. Alternatively, the veteran claims these conditions are secondary to a service-connected back disability. The Board reviewed multiple VA examinations and opinions obtained after previous remands. For the ankles, while service treatment records showed in-service complaints and treatment for pain and tendonitis, subsequent examinations and X-rays were largely negative for significant pathology or arthritis. The Board found the veteran's lay statements attributing ongoing pain to the in-service fall less credible due to a lack of contemporaneous medical evidence and normal separation examination findings. The Board also found the medical opinions regarding direct service connection and secondary connection to the back to be probative and against the claim. For the knees, service treatment records showed some knee pain and a diagnosis of chondromalacia, but later examinations and X-rays were negative for significant degenerative changes or arthritis. The Board found the veteran's lay statements attributing constant knee pain to the in-service fall less credible due to a lack of contemporaneous medical evidence and the absence of degenerative changes until many years after service. The Board also found the medical opinions regarding direct service connection and secondary connection to the back to be probative and against the claim. Service connection for bilateral ankle and knee disabilities was denied.

Rationale

Preponderance of evidence against nexus to service; Lack of contemporaneous medical evidence; Negative separation examination findings; Lay statements less credible than medical evidence; Medical opinions against direct and secondary service connection

Service Branch

ARMY

Special Benefit

NO SPECIAL BENEFIT

Docket No.

14-17 109

Full Decision Text

Citation Nr: 21057758
Decision Date: 09/16/21 Archive Date: 09/16/21

DOCKET NO. 14-17 109
DATE: September 16, 2021

ORDER

Entitlement to service connection for a right ankle disability is denied.

Entitlement to service connection for a left ankle disability is denied.

Entitlement to service connection for a right knee disability is denied.

Entitlement to service connection for a left knee disability is denied.

REMANDED

Entitlement to service connection for a right wrist disability is remanded.

Entitlement to service connection for a left wrist disability is remanded.

FINDINGS OF FACT

1. A current right ankle disability was not manifest in service and is not attributable to service.

2. A right ankle disability was not caused by or aggravated by a service-connected disease or injury.

3. A current left ankle disability was not manifest in service and is not attributable to service.

4. A left ankle disability was not caused by or aggravated by a service-connected disease or injury.

5. A current right knee disability was not manifest in service and is not attributable to service. Right knee arthritis was not manifest in service or within one year of separation and is not otherwise related to service.

6. A right knee disability was not caused by or aggravated by a service-connected disease or injury.

7. A current left knee disability was not manifest in service and is not attributable to service. Left knee arthritis was not manifest in service or within one year of separation and is not otherwise related to service.

8. A left knee disability was not caused by or aggravated by a service-connected disease or injury.

CONCLUSIONS OF LAW

1. A right ankle disability was not incurred in or aggravated by service. 38 U.S.C. §§ 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303.

2. A right ankle disability is not proximately due to or aggravated by a service-connected disease or injury. 38 C.F.R. § 3.310.

3. A left ankle disability was not incurred in or aggravated by service. 38 U.S.C. §§ 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303.

4. A left ankle disability is not proximately due to or aggravated by a service-connected disease or injury. 38 C.F.R. § 3.310.

5. A right knee disability including arthritis was not incurred in or aggravated by service and may not be presumed to have been incurred therein. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1131, 1137; 38 C.F.R. §§ 3.303, 3.307, 3.309.

6. A right knee disability is not proximately due to or aggravated by a service-connected disease or injury. 38 C.F.R. § 3.310.

7. A left knee disability including arthritis was not incurred in or aggravated by service and may not be presumed to have been incurred therein. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1131, 1137; 38 C.F.R. §§ 3.303, 3.307, 3.309.

8. A left knee disability is not proximately due to or aggravated by a service-connected disease or injury. 38 C.F.R. § 3.310.

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran served on active duty from April 1978 to April 1982. He also had a period of active duty for training from June 1976 to October 1976.

This matter comes before the Board of Veterans' Appeals (Board) on appeal from an August 2010 rating decision by the Department of Veterans Affairs (VA). The Board previously remanded the claims for service connection for bilateral wrist, knee, and ankle disabilities in September 2018 and July 2020 to obtain new VA examinations and medical nexus opinions. Review of the record reflects that the requested examinations and opinions were obtained in September 2019 and July 2020.

Regarding the opinions obtained for the Veteran's knees and ankles, we find that the Board's prior remand instructions have been substantially complied with. See Stegall v. West, 11 Vet. App. 268, 271 (1998). In combination, the September 2019 and July 2020 examiners provided opinions for direct service connection, arthritis, and secondary service connection in compliance with the Board's September 2018 and July 2020 remand instructions. We will address the opinions relating to the Veteran's wrists in
and July 2020 to obtain new VA examinations and medical nexus opinions. Review of the record reflects that the requested examinations and opinions were obtained in September 2019 and July 2020.

SERVICE CONNECTION

Service connection may be established for disability resulting from personal injury suffered or disease contracted in the line of duty in the active military, naval, or air service or for aggravation of a preexisting injury suffered or disease contracted in line of duty. 38 U.S.C. § 1131.

In general, 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).

Service connection is warranted on a secondary basis for disability which is proximately due to, aggravated by or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Such secondary service connection is warranted for any increase in severity of a nonservice-connected disability that is proximately due to or the result of a service-connected disability. 38 C.F.R. § 3.310(b). For secondary service connection to be granted, generally there must be (1) evidence of a current disability; (2) evidence of a service-connected disease or injury; and (3) nexus evidence establishing a connection between the service-connected disability and the current disability. Wallin v. West, 11 Vet. App. 509, 512 (1998).

Certain chronic diseases such as arthritis will be presumed related to service if they were noted as chronic in service; or, if they manifested to a compensable degree within a presumptive period following separation from service; or, if continuity of the same symptomatology has existed since service, with no intervening cause. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.303(b), 3.307, 3.309(a); Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2012); Fountain v. McDonald, 27 Vet. App. 258 (2015).

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; Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996).

1. Right ankle disability.

2. Left ankle disability.

The Veteran seeks service connection for a bilateral ankle disability. He primarily contends that his current ankle disabilities are related to an in-service injury when he fell off a truck. Alternatively, he contends that his current ankle disabilities are secondary to his service-connected back disability. After reviewing the evidence, we conclude that service connection is not warranted for left or right ankle disabilities.

Service treatment records show the Veteran reported pain in his both ankles after falling from a vehicle in June 1978. X-rays were negative. He was treated for bilateral foot pain in June 1978, five days after the fall, and was assessed with tendonitis. He reported ankle pain again in July 1978. The March 1982 separation examination shows clinically normal evaluations of the lower extremities, feet, and musculoskeletal system.

The Veteran first filed a claim of service connection for ankle disabilities in December 1991. He reported that he had injured his ankles in June 1978 falling from a vehicle and that the injuries had progressively worsened since. He was provided an examination in February 1992 and again reported injuring both ankles after falling backward off an Army truck. He reported both ankles become sore if he steps on the wrong ground
. X-rays were negative. He was treated for bilateral foot pain in June 1978, five days after the fall, and was assessed with tendonitis. He reported ankle pain again in July 1978. The March 1982 separation examination shows clinically normal evaluations of the lower extremities, feet, and musculoskeletal system.

The Veteran first filed a claim of service connection for ankle disabilities in December 1991. He reported that he had injured his ankles in June 1978 falling from a vehicle and that the injuries had progressively worsened since. He was provided an examination in February 1992 and again reported injuring both ankles after falling backward off an Army truck. He reported both ankles become sore if he steps on the wrong ground. Range of motion of the ankles was either full or noted as adequate, but the Veteran had soreness in both ankles. X-rays of both ankles showed no evidence of arthritis or other bone or joint pathology. The examiner diagnosed chronic strain of both ankles with anterior capsule tenderness. No nexus opinion was provided.

A January 1993 VA treatment records shows the Veteran was treated for aching ankle joints, which he attributed to the fall from a truck during service. The physician noted posttraumatic arthritis. Subsequent treatment records show the Veteran continued to report ankle pain. An August 1995 treatment records shows the Veteran injured his right ankle in a fall at work.

January 2004 VA records show the Veteran had full range of motion in both ankles with no effusion noted. His ankle ligaments were intact. Ankle arthralgias were noted in March 2004, although x-rays showed no significant abnormalities. In January 2010, the Veteran reported that his ankles had become more painful as he aged and he felt his ankle pain was from the in-service fall. X-rays of both ankles were normal and were noted to be negative for osteoarthritis. The impression was stiffness and arthralgia.

The Veteran was provided a VA ankle examination in August 2016. Range of motion was limited in both ankles and there was pain on motion and palpation. He reported increased pain with walking. The examiner diagnosed bilateral ankle arthralgia and determined the arthralgia was less likely as not due to injuries noted in the Veteran's service treatment records, explaining that there is no record of chronicity or continuity of care soon thereafter and that the arthralgia was more likely due to a history of smoking, obesity, and history of manual labor employment after service.

A new VA ankle examination with medical opinion was provided in September 2019. The examiner diagnosed bilateral ankle arthralgia. The Veteran reported that chronic pain began after falling off a truck during service, and that pain was always present. Range of motion was limited in both ankles and there was pain on motion and palpation. X-rays showed no fracture or joint space narrowing of the ankles; although, the examiner noted that degenerative or traumatic arthritis was documented.

In July 2020, the Board determined the opinion obtained was inadequate because the VA examiner did not provide any opinion on secondary service connection to the Veteran's back. The September 2019 examiner also did not provide a new opinion for direct service connection. The Board remanded the claims to obtain new opinions as to whether any bilateral ankle disabilities were etiologically related to service or any incident of service, whether arthritis manifested within a year of separation from service, and whether any bilateral ankle disability was caused by or aggravated by a service-connected back disability.

The new VA addendum opinions for the ankles were obtained in July 2020. Regarding direct service connection, the examiner concluded the Veteran's bilateral ankle arthralgia was related to normal age progression, a history of smoking, and a history of manual labor employment after service and not the Veteran's in-service subjective complaints, objective diagnoses, and treatments during service. The examiner explained that most strains, contusions, and musculoskeletal issues generally resolve without longterm residuals. He noted that the March 1982 separation examination showed normal lower extremities. The examiner also concluded there was no medical evidence to support an objective diagnosis of arthritis in either the right or left ankle. To this end, he explained that the September 2019 x-rays revealed no joint space narrowing.

Regarding secondary service connection, the July 2020 VA examiner concluded there was no physiologic mechanism by which the Veteran's current back disability could cause his current ankle disabilities or exacerbate his current ankle disabilities beyond normal natural progression.

After considering the
Veteran's in-service subjective complaints, objective diagnoses, and treatments during service. The examiner explained that most strains, contusions, and musculoskeletal issues generally resolve without longterm residuals. He noted that the March 1982 separation examination showed normal lower extremities. The examiner also concluded there was no medical evidence to support an objective diagnosis of arthritis in either the right or left ankle. To this end, he explained that the September 2019 x-rays revealed no joint space narrowing.

After considering the evidence, we conclude that service connection is not warranted for the claimed right and left ankle disabilities. The evidence shows the Veteran has had ankle pain during the period relevant to the appeal, and service treatment records show he injured his ankles falling off a truck. However, the preponderance of the evidence is against finding a nexus between any currently diagnosed right and left ankle disabilities and the Veteran's service, and is additionally against finding a nexus between service-connected disease or injury and an ankle disability.

Initially, although arthritis is a chronic disease, the Board finds that the Veteran does not have left or right ankle arthritis. We acknowledge that some post-service treatment records reflect a diagnosis of arthritis. Posttraumatic arthritis was noted in 1993, and the September 2019 VA examiner appears to have noted degenerative or traumatic arthritis present in one or both ankles. However, arthritis has not been established by x-ray findings in either ankle. All VA x-rays available are negative for arthritis of the ankles. Although posttraumatic arthritis was noted in 1993, this appears to have been self-reported history by the Veteran and there is no indication this was premised on x-ray findings. March 2004 x-rays showed no abnormalities. There was no significant ankle abnormality in August 2016. Despite the September 2019 examination report, the coinciding ankle x-rays showed no joint space narrowing. The July 2020 examiner clarified that the x-rays did not show arthritis of the ankles. Arthralgia (pain) has been diagnosed multiple times. However, the most probative evidence establishes that the Veteran does not have left or right ankle arthritis.

The Board has considered the lay evidence of record. VA must give due consideration to all pertinent medical and lay evidence in evaluating a claim for disability benefits. 38 U.S.C. § 1154(a); Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Although lay evidence cannot be determined to be not credible merely because it is unaccompanied by contemporaneous medical evidence, the lack of contemporaneous medical evidence can be considered and weighed against a Veteran's lay statements. See Buchanan v. Nicholson, 451 F.3d 1331, 1336-37 (Fed. Cir. 2006).

The Veteran has consistently asserted that right and left ankle pain began when he fell from a truck in June 1978 and has continued constantly since. He is competent to provide evidence of which he experiences, including his symptoms and medical history. See Layno v. Brown, 6 Vet. App. 465, 469 (1994). He is competent to report ankle pain, as pain is lay observable, and he is competent to report that the pain has been constant since he was injured in service.

However, the Board finds the Veteran's lay statements attributing ongoing ankle pain to his in-service injury are less credible than the remainder of the record. Service treatment records reflect the Veteran was treated for ankle pain twice in June 1978 after falling from a truck, and that he was treated for foot pain once. There were no further complaints or treatments for ankle pain during service, and at separation his lower extremities were clinically normal. Following separation from service he first reported ankle pain in December 1991, many years after he separation. A negative inference may be drawn from the absence of complaints or treatment for an extended period. See Maxson v. West, 12 Vet. App. 453, 459 (1999), aff'd sub nom. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000).

L
reflect the Veteran was treated for ankle pain twice in June 1978 after falling from a truck, and that he was treated for foot pain once. There were no further complaints or treatments for ankle pain during service, and at separation his lower extremities were clinically normal. Following separation from service he first reported ankle pain in December 1991, many years after he separation. A negative inference may be drawn from the absence of complaints or treatment for an extended period. See Maxson v. West, 12 Vet. App. 453, 459 (1999), aff'd sub nom. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000).

Lay evidence cannot be determined to be not credible merely because it is unaccompanied by contemporaneous medical evidence. See Buchanan, 451 F.3d at 1336-37. However, the lack of contemporaneous medical evidence can be considered and weighed against lay statements. Id. We also note that the medical record between the Veteran's in-service fall and the first documented treatments for bilateral ankle pain is not entirely silent. At separation from service, the March 1982 examination showed a clinically normal evaluation of the lower extremities and feet, and no ankle problems were otherwise noted by the examiner.

For a medical opinion (i.e., medical evidence) to be given weight, it must be: (1) based upon sufficient facts or data; (2) the product of reliable principles and methods; and (3) the result of principles and methods reliably applied to the facts. Nieves-Rodriquez v. Peake, 22 Vet. App. 295, 302 (2008). "It is the factually accurate, fully articulated, sound reasoning for the conclusion . . . that contributes probative value to a medical opinion." Id. at 304.

Here, we find the July 2020 VA nexus opinion is probative medical evidence as to whether a current left or right ankle disability is directly related to the Veteran's service. The Board notes that the examiner rendered the opinion after reviewing the claims file including the relevant medical records and pertinent medical history. The July 2020 examiner reviewed the Veteran's lay statements and subjective complaints of ankle pain, as required by the Board's previous remand instructions. The examiner noted the Veteran's pertinent history and diagnoses and provided a reasoned analysis of the case. See Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998); Gabrielson v. Brown, 7 Vet. App. 36, 40 (1994). We note that the examiner explained that most sprains, strains, contusions, and other musculoskeletal issues generally resolve without longterm residuals. Here, the Veteran was treated in June 1978 for ankle pain and the remainder of the service treatment records do not show any further ankle complaints or injuries, including the separation examination. Notably, there is no medical opinion to the contrary that attributes a current ankle disability to the Veteran's in-service fall.

Regarding secondary service connection, the only probative evidence of record addressing this issue is the July 2020 VA opinion concluding that there was no physiologic mechanism by which the Veteran's current back disability could cause or exacerbate his current ankle disabilities. The Veteran has not provided competent evidence beyond his suggestion that a right or left ankle disability may be related to his service-connected back disability. The Veteran alone is not competent to address this etiological issue, as making such a connection would require specialized education, training, or experience that the Veteran has not been shown to possess. See 38 C.F.R. § 3.159 (a)(2); Jandreau, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Although he has told medical professionals that he believes an ankle disability is related to his back, there is no indication that a medical professional has told him that his ankles are proximately due to or aggravated by his service-connected back arthritis. VA treatment records are absent any documentation of a relationship between a current ankle disability and service-connected diseases and injuries. There are no other medical records that suggest an ankle disability is associated with another service-connected disease or injury. The Veteran's lay statements are not competent evidence that a right or left ankle disability is proximately due to, the result of, or increased in severity because of a service-connected disease or injury.

For the foregoing reasons, the Board concludes that service connection for a left or right ankle disability is not warranted. The preponderance of the evidence is against the claims, and service connection for left and right ankle disabilities is denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet.
ankle disability and service-connected diseases and injuries. There are no other medical records that suggest an ankle disability is associated with another service-connected disease or injury. The Veteran's lay statements are not competent evidence that a right or left ankle disability is proximately due to, the result of, or increased in severity because of a service-connected disease or injury.

3. Right knee disability.

4. Left knee disability.

The Veteran seeks service connection for bilateral knee disabilities. He primarily contends that his current knee disabilities are related to an in-service injury when he fell off a truck. Alternatively, he contends that current knee disabilities are secondary to his service-connected back disability. After reviewing the evidence, we conclude that service connection is not warranted for left or right knee disabilities.

Service treatment records show the Veteran was treated for wrist and ankle pain following his fall from a truck in June 1978. He did not report nor was he treated for knee pain. In August 1979, he complained of left knee pain after "sticking" it on the floor one week prior and was assessed with a normal knee and a mild shin splint. In July 1980, he reported pain in his right knee radiating towards his hip and thigh, which was assessed as a sore muscle. In March 1982, he reported pain in his left knee for the past 24 hours when walking and running. On examination. the knee was within normal limits with very little tenderness, and he was assessed with left knee chondromalacia. The March 1982 separation examination shows clinically normal evaluations of the lower extremities.

The Veteran first filed a claim for service connection for knee disabilities in December 1991. He reported that he had injured his knees in June 1978 falling off a vehicle and that the injuries had progressively worsened since. He was provided an examination in February 1992 and again reported injuring both knees after falling backward off an Army truck. He reported both knees bother him if he does a lot of standing for a job and that he could not run far and limps. The knees were noted as stable and x-rays showed no evidence of arthritis or other bone or joint pathology. The examiner diagnosed symptomatic chondromalacia of both knees with essentially stable knees. No nexus opinion was provided.

A January 1993 VA treatment records shows the Veteran was treated for aching knee joints, which he attributed to the fall from a truck during service. The physician noted posttraumatic arthritis. Subsequent treatment records show the Veteran continued to report knee pain. January 2004 VA records show the Veteran had full range of motion of both knees with no effusion in either knee. Knee arthralgias were noted in March 2004, and an x-ray of the left knee showed early patellofemoral degenerative changes with no other significant abnormality.

In January 2010, the Veteran reported that his knees had become more painful as he aged and he felt the pain was from the in-service fall. January 2010 x-rays were normal for both knees and noted negative for osteoarthritis, and the impression stiffness and arthralgia.

The Veteran was provided a VA knee examination in August 2016. Range of motion was limited in both knees and there was pain on motion and palpation. He reported increased pain in both knees with any weight bearing activities, twisting, turning, and prolonged exertion or sitting. X-rays of both knees showed mild chondrocalcinosis likely related to early degenerative changes, and soft tissue calcification superior to the patella likely related to prior soft tissue injury. The examiner concluded the Veteran had bilateral knee degenerative joint disease, which was less likely as not due to injuries noted in the Veteran's service treatment records. The examiner explained that there is no record of chronicity or continuity of care soon thereafter and that the arthralgia was more likely due to a history of smoking, obesity, and history of manual labor employment after service. The examiner also stated that there had been approximately 35 years since the in-service musculoskeletal injury, and no degenerative joint disease was noted on x-rays in 2010.

In September 2018, the Board determined the August 2016 opinion was inadequate because the examiner relied on the absence of evidence after service and did not consider the Veteran's statements regarding knee pain since service. The September 2018 remand instructions also requested opinions as to whether a knee disability
in the Veteran's service treatment records. The examiner explained that there is no record of chronicity or continuity of care soon thereafter and that the arthralgia was more likely due to a history of smoking, obesity, and history of manual labor employment after service. The examiner also stated that there had been approximately 35 years since the in-service musculoskeletal injury, and no degenerative joint disease was noted on x-rays in 2010.

A new VA knee examination and medical opinion were provided in September 2019. The examiner diagnosed bilateral knee degenerative arthritis and chondrocalcinosis. The Veteran reported that chronic knee pain began after falling off a truck during service, and that pain was always present. Range of motion was limited in both knees and there was pain on motion and palpation. Weight-bearing x-rays of both knees showed preservation of the knee joints bilaterally with no fracture or joint effusion. There was calcification of the distal quadriceps tendons and bilateral cartilage calcification indicating chondrocalcinosis. The x-ray diagnostic impression was bilateral chondrocalcinosis and it was noted the knee joints were well preserved.

In July 2020, the Board determined the opinion obtained was inadequate because the VA examiner did not provide any opinion on secondary service connection to the Veteran's back. We note that the September 2019 examiner also did not provide a new opinion for direct service connection. The Board remanded to obtain new opinions as to whether any bilateral knee disabilities were etiologically related to service or any incident of service, whether arthritis manifested within a year of separation from service, and whether any bilateral knee disability was caused by or aggravated by a service-connected back disability.

The new VA addendum opinions for the knees were obtained in July 2020. Regarding direct service connection, the examiner concluded the Veteran's bilateral knee arthritis was related to normal age progression, a history of smoking, and a history of manual labor employment after service and not the Veteran's in-service subjective complaints, objective diagnoses, and treatments during service. The examiner also noted that most strains, contusions, and musculoskeletal issues generally resolve without longterm residuals and that the March 1982 separation examination showed normal lower extremities.

Regarding secondary service connection, the July 2020 VA examiner concluded there was no physiologic mechanism by which the Veteran's current back disability could cause his current knee disabilities or exacerbate his current knee disabilities beyond normal natural progression.

After considering the evidence, the Board concludes that service connection is not warranted for a right or left knee disability. The evidence shows the Veteran has had bilateral knee arthritis and chondrocalcinosis during the period relevant to the appeal, and service treatment records show he was treated for knee pain during service. However, the preponderance of the evidence is against finding a nexus between a current knee disability and the Veteran's military service, and against a finding of nexus between service-connected disease or injury and a knee disability.

The Board has considered the lay evidence of record. Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau, 492 F.3d at 1377. Although lay evidence cannot be determined to be not credible merely because it is unaccompanied by contemporaneous medical evidence, the lack of contemporaneous medical evidence can be considered and weighed against a Veteran's lay statements. Buchanan, 451 F.3d at 1336-37.

The Veteran has consistently asserted that right and left knee pain began when he fell from a truck in June 1978 and has continued constantly since. He is competent to provide evidence of which he experiences, including his symptoms and medical history. See Layno v. Brown, 6 Vet. App. 465, 469 (1994). He is competent to report knee pain, as pain is lay observable, and he is competent to report that the pain has been constant since he was injured in service. Knee pains are documented in the service treatment records, although he was not treated for knee pain in the context of his in-service fall.

However, the Board finds the Veteran's lay statements attributing knee symptoms to his service are less credible than the remainder of the record. Service treatment records reflect the Veteran was treated for left knee pain in August 197
8 and has continued constantly since. He is competent to provide evidence of which he experiences, including his symptoms and medical history. See Layno v. Brown, 6 Vet. App. 465, 469 (1994). He is competent to report knee pain, as pain is lay observable, and he is competent to report that the pain has been constant since he was injured in service. Knee pains are documented in the service treatment records, although he was not treated for knee pain in the context of his in-service fall.

However, the Board finds the Veteran's lay statements attributing knee symptoms to his service are less credible than the remainder of the record. Service treatment records reflect the Veteran was treated for left knee pain in August 1979, right knee and thigh pain in July 1980, and had left knee chondromalacia in March 1982. The subsequent March 1982 separation examination showed a clinically normal evaluation of the lower extremities. Pertinently, the only diagnosis rendered during service relevant to his knees was left knee chondromalacia, which he does not currently have. Following separation from service, the Veteran first reported knee pain in December 1991, many years after he separation. A negative inference may be drawn from the absence of complaints or treatment for an extended period. See Maxson v. West, 12 Vet. App. 453, 459 (1999), aff'd sub nom. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000).

Lay evidence cannot be determined to be not credible merely because it is unaccompanied by contemporaneous medical evidence. See Buchanan, 451 F.3d at 1336-37. However, the lack of contemporaneous medical evidence can be considered and weighed against lay statements. Id. We also note that the medical record between the Veteran's in-service fall and the first documented treatments for bilateral knee pain is not entirely silent. At separation from service, the March 1982 examination showed a clinically normal evaluation of the lower extremities.

For a medical opinion (i.e., medical evidence) to be given weight, it must be: (1) based upon sufficient facts or data; (2) the product of reliable principles and methods; and (3) the result of principles and methods reliably applied to the facts. Nieves-Rodriquez, 22 Vet. App.at 302. "It is the factually accurate, fully articulated, sound reasoning for the conclusion . . . that contributes probative value to a medical opinion." Id. at 304.

Here, we find the July 2020 VA nexus opinions are probative medical evidence as to whether a current left or right knee disability is directly related to the Veteran's service. The examiner rendered the opinion after reviewing the claims file, the relevant medical records, and after reviewing prior VA examinations where the examiners interviewed the Veteran regarding his symptoms. The July 2020 examiner also noted the Veteran's lay statements and subjective complaints of knee pain, as required by the Board's previous remand instructions. The examiner noted the Veteran's pertinent history and diagnoses and provided a reasoned analysis of the case. The examiner explained that most sprains, strains, contusions, and other musculoskeletal issues generally resolve without longterm residuals. Here, the Veteran was treated for knee pains three times during service, with an acute cause for the pain noted each time. The separation examination in March 1982 showed a clinically normal evaluation of the lower extremities.

Notably, there is no medical opinion to the contrary that attributes a current right or left knee disability to service. The Veteran has not provided competent evidence beyond his assertions that his in-service knee pain is related to his currently diagnosed arthritis or chondrocalcinosis. The Veteran alone is not competent to address this etiological issue, as making such a connection would require specialized education, training, or experience that the Veteran has not been shown to possess. See 38 C.F.R. § 3.159 (a)(2); Jandreau, 492 F.3d 1372, 1377 (Fed. Cir. 2007).

The Veteran has been diagnosed with degenerative arthritis of both knees, and arthritis is a chronic disease under 38 U.S.C. § 1101(3) and 38 C.F.R. § 3.309(a). Degenerative arthritis of the knees did not manifest in service and there is no evidence arthritis manifest within an applicable presumptive period. Although posttraumatic arthritis was noted in 1993, this appears to have been self-reported history by the Veteran and there is no indication this was premised on x-ray findings. Early patellofemoral degenerative changes of the left knee were first noted in March 2004, but January 2010 x-rays of both knees were normal and noted as negative for osteoarthritis. The August 2016 x-rays showed mild chondrocalcinosis likely related to early degenerative changes, and the September 2019 x-rays showed bilateral chondrocalcinosis and well-preserved bilateral knee joints. The July 2020 examiner concluded that there was no objective medical evidence to support finding the Veteran's bilateral knee degenerative arthritis manifested within one year of service, which is supported by the record.

Regardless, degenerative changes of the knees were first identified many years after separations from service. Furthermore, continuity of arthritis symptomatology may be questioned. The Veteran has regularly reported that his knees have constantly hurt since he fell from a truck during service. Although the service treatment records do not show complaints of knee pain when he was treated after the fall, the Veteran was treated for pain in his right and left knees during service and was diagnosed with chondromalacia in his left knee. The March 1983 separation examination report shows the Veteran's lower extremities were clinically normal. The Board find the Veteran's after-the-fact assertion of constant knee symptoms since service, and his contention that his currently diagnosed bilateral knee arthritis and chondrocalcinosis are related to service to be less credible than the contemporaneous evidence showing no degenerative changes of the knee until August 2016 and the July 2020 VA medical examinations.

The Board also notes that service connection for arthritis of the spine has been granted. Generally, subsequent manifestations of the same disease process are service connected. 38 C.F.R. § 3.303. However, service connection was granted for post-traumatic arthritis of the dorsal and lumbar spine grant of service connection for the spine, reflecting a traumatic process rather than a systemic or generalized process. Therefore, the arthritis of the knees is not a subsequent manifestation of the service-connected traumatic arthritis of the spine. The July 2020 examiner also determined that there was no relationship (causation or aggravation) between the Veteran's spine disabilities and his bilateral knee arthritis.

Regarding secondary service connection, the only probative evidence of record addressing this issue is the July 2020 VA opinion concluding that there was no physiologic mechanism by which the Veteran's current back disability could cause or exacerbate his current knee disabilities. The Veteran has not provided competent evidence beyond his suggestion that a right or left knee disability may be related to his service-connected back disability. The Veteran alone is not competent to address this etiological issue, as making such a connection would require specialized education, training, or experience that the Veteran has not been shown to possess. See 38 C.F.R. § 3.159 (a)(2); Jandreau, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Although the Veteran has told medical professionals that he believes his knee disabilities are related to his back, there is no indication that a medical professional has told him that a knee disability is proximately due to or aggravated by his service-connected back arthritis. VA treatment records are absent any relationship between a current knee disability and service-connected diseases and injuries. There are no other medical records that suggest a knee disability is associated with another service-connected disease or injury. The Veteran's lay statements are not competent evidence that a right or left knee disability is proximately due to, the result of, or increased in severity because of a service-connected disease or injury.

For the foregoing reasons, the Board concludes that service connection for left and right knee disabilities is not warranted. The preponderance of the evidence is against the claims, and service connection for left and right knee disabilities is denied. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990).

REASONS FOR REMAND

1. Entitlement to service connection for a right wrist disability is remanded.

2. Entitlement to service connection for a left wrist disability is remanded.

Another remand is required to obtain an adequate VA examination
in severity because of a service-connected disease or injury.

REASONS FOR REMAND

1. Entitlement to service connection for a right wrist disability is remanded.

2. Entitlement to service connection for a left wrist disability is remanded.

Another remand is required to obtain an adequate VA examination and nexus opinion for the Veteran's claimed right and left wrist disabilities.

The Board previously remanded these claims in September 2018, finding that opinions provided by an August 2016 VA examiner were inadequate because they relied on the absence of evidence after service, did not consider the Veteran's statement regarding pain since service, and did not discuss the Veteran's right ulnar deviation diagnosis when opining on the Veteran's wrists.

A new VA examination with opinion was provided in September 2019. In July 2020, the Board determined the opinion was inadequate because it failed to address the Veteran's previous right ulnar deviation diagnosis and merely reported that his bilateral wrist disability was not related to his active service.

New VA opinions for the wrists were obtained in July 2020. Unfortunately, the opinions are also inadequate. Although the examiner noted diagnoses of degenerative arthritis of the left and right wrist, the examiner provided an opinion only for the left wrist arthritis. The examiner determined there was no objective medical evidence the Veteran's degenerative arthritis of the left wrist is etiologically related to service and did not consider the Veteran's statements regarding pain in his wrists since service. The July 2020 opinion also cited the September 2019 opinion, noting a lack of objective continuity of care since service. These are broadly the same deficiencies the Board previously found with the August 2016 opinions.

In addition, regarding the diagnosis of a right ulnar nerve deviation, the July 2020 examiner merely stated that the Veteran had a right ulnar nerve deviation, and concluded the condition was a neurological issue and not an orthopedic issue. The examiner did not provide an opinion as to whether the right ulnar nerve deviation was at least as likely as not etiologically related to service or any event, injury, or disease during service, as required by the Board's July 2020 remand instructions.

It is also unclear whether the Veteran's right ulnar deviation is actually a neurological disorder. The Board noted "right ulnar nerve deviation" in the July 2020 remand instructions. Positive right ulnar deviation was first identified and diagnosed in the August 2016 x-ray report, suggesting the disability is musculoskeletal or orthopedic in nature. No nerve tests were indicated, and neither the August 2016 examiner nor the radiologist diagnosed a neurological disability. The September 2019 VA examiner did not diagnose a neurological disability. Review of the remainder of the record is absent any relevant neurological diagnosis. The July 2020 examiner appears to have relied solely on the Board's July 2020 remand instruction regarding whether the Veteran had an ulnar nerve disorder. The question of whether the Veteran's right ulnar deviation is musculoskeletal, neurological, or both must be clarified on remand.

Once VA undertakes to provide an examination or opinion, it must ensure that the examination is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Board's September 2018 and July 2020 remand instructions have not been complied with. See Stegall v. West, 11 Vet. App. 268, 271 (1998). Remand is required to provide the Veteran a new VA examination and to obtain adequate medical nexus opinions.

The matters are REMANDED for the following action:

1. Schedule a VA examination of the Veteran to determine the nature and etiology of any left and right wrist disabilities. The examiner should review the claim file and note such review was conducted. Any studies, tests, and evaluations deemed necessary by the examiner should be performed.

The examiner must clarify all current left and right wrist diagnoses. The examiner must clarify whether the Veteran's diagnosed right ulnar deviation is orthopedic or neurological in nature.

The examiner must provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that any diagnosed wrist disabilities are etiologically related to service or any event, injury, or disease during service. The examiner must consider all lay statements, including the Veteran's reports that he has had wrist pain since service. All previous medical evidence must be addressed.
iology of any left and right wrist disabilities. The examiner should review the claim file and note such review was conducted. Any studies, tests, and evaluations deemed necessary by the examiner should be performed.

The examiner must clarify all current left and right wrist diagnoses. The examiner must clarify whether the Veteran's diagnosed right ulnar deviation is orthopedic or neurological in nature.

The examiner must provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that any diagnosed wrist disabilities are etiologically related to service or any event, injury, or disease during service. The examiner must consider all lay statements, including the Veteran's reports that he has had wrist pain since service. All previous medical evidence must be addressed. The examiner must explicitly address any previously and currently diagnosed disabilities related to the wrists.

2. Review the claims file to ensure he foregoing requested development is completed. Arrange for any additional development indicated. Thereafter, readjudicate the claims. If a complete grant of the benefits sought is not granted, issue a Supplemental Statement of the Case to the Veteran and his representative.

Katherine Kiemle Buckley

Acting Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board S. Morse

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.

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