GASTROESOPHAGEAL REFLUX DISEASE (GERD)

TANYA SMITH · 2024 · Case ID: 24025475

MIXED

Summary

The veteran, who served in the Army from July 1972 to October 1978, appeals the denial of service connection for several conditions, including stomach issues (ulcers, GERD), right elbow, right shoulder, bilateral feet, right knee, and back disabilities. The Board denied service connection for all these conditions. For the stomach claim, the veteran alleged GERD was related to in-service indigestion and jet fuel exposure, while ulcers were linked to jet fuel. Despite the veteran's claims and some in-service treatment for indigestion and right foot issues, the Board found the medical evidence, particularly from a November 2023 VA examination, did not establish a nexus to service. The examiner concluded that the veteran's GERD was less likely than not caused by service or aggravated by his service-connected left knee condition, citing lack of chronicity, continuity, and appropriate risk factors. Similarly, for the right elbow, right shoulder, bilateral feet, right knee, and back claims, the Board relied on the November 2023 VA examinations. These examinations found the conditions were less likely than not related to service, citing normal in-service x-rays, lack of documented in-service injuries or continuity of symptoms, and the presence of other risk factors like age, obesity, and systemic conditions (chondrocalcinosis) as more probable causes. The Board found the veteran's lay testimony regarding medical causation to be not competent due to the complexity of the medical issues. The claim for a right hip disability was remanded for a new VA examination to determine its relationship to the service-connected left knee condition, considering the veteran's theory of altered gait and leg length discrepancy.

Rationale

No evidence of chronicity of care or continuity of symptoms to suggest GERD was present in service.; In-service indigestion did not represent GERD or a condition that would predispose to GERD.; No evidence of in-service injury, event, illness, exposure, complaint, symptom, or condition likely to result in or predispose to GERD.

Service Branch

ARMY

Special Benefit

NO SPECIAL BENEFIT

Docket No.

17-59 079

Full Decision Text

Citation Nr: 24025475
Decision Date: 07/08/24 Archive Date: 07/08/24

DOCKET NO. 17-59 079
DATE: July 8, 2024

ORDER

Entitlement to service connection for a stomach disability, claimed as ulcers and gastroesophageal reflux disease (GERD), is denied.

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

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

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

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

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

Entitlement to service connection for a back disability is denied.

REMANDED

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

FINDINGS OF FACT

1. The Veteran's stomach disability, claimed as ulcers and GERD, did not manifest during service, and the evidence weighs persuasively against finding that the Veteran has a current stomach disability that was caused or aggravated by service (to include jet fuel exposure) or a service-connected disability, to include as caused or aggravated by obesity that was caused or aggravated by a service-connected disability.

2. The Veteran did not have a chronic right elbow disability in service, osteoarthritis of the right elbow did not manifest during service or to a compensable degree within one year of separation from service, and the evidence weighs persuasively against finding that the Veteran's right elbow disability is related to service.

3. The Veteran's right shoulder disability did not manifest during service, osteoarthritis of the right shoulder did not manifest during service or to a compensable degree within one year of separation from service, and the evidence weighs persuasively against finding that the Veteran's right shoulder disability is related to service.

4. The Veteran's right foot disability did not manifest during service, osteoarthritis of the right foot did not manifest during service or to a compensable degree within one year of separation from service, and the evidence weighs persuasively against finding that the Veteran has a current right foot disability that was caused or aggravated by service.

5. The Veteran's left foot disability did not manifest during service, osteoarthritis of the left foot did not manifest during service or to a compensable degree within one year of separation from service, and the evidence weighs persuasively against finding that the Veteran has a current left foot disability that was caused or aggravated by service or a service-connected disability, to include as caused or aggravated by obesity that was caused or aggravated by a service-connected disability.

6. The Veteran's right knee disability did not manifest during service, osteoarthritis of the right knee did not manifest during service or to a compensable degree within one year of separation from service, and the evidence weighs persuasively against finding that the Veteran has a current right knee disability that was caused or aggravated by service or a service-connected disability to include as caused or aggravated by obesity that was caused or aggravated by a service-connected disability.

7. The Veteran's back disability did not manifest during service, osteoarthritis of the back did not manifest during service or to a compensable degree within one year of separation from service, and the evidence weighs persuasively against finding that the Veteran has a current back disability that was caused or aggravated by service or a service-connected disability, to include as caused or aggravated by obesity that was caused or aggravated by a service-connected disability.

CONCLUSIONS OF LAW

1. The criteria for entitlement to service connection for a stomach disability, claimed as ulcers and GERD, have not been met. 38 U.S.C. §§ 1110, 1112, 1131, 5107; 38 C.F.R. §§ 3.303, 3.310.

2. The criteria for entitlement to service connection for a right elbow disability have not been met. 38 U.S.C. §§ 1110, 1131, 5103, 5103A, 5107; 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309.

3. The criteria for entitlement to service connection for a right shoulder disability have not been met. 38 U.S.C. §§ 1110, 1112, 1131, 5103, 5103A, 5107; 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309, 3.310.

4. The criteria for entitlement to service connection for a right foot disability have not been met. 38 U.S.C. §§ 1110, 1112, 1131, 5103, 5103
3.303, 3.304, 3.307, 3.309.

4. The criteria for entitlement to service connection for a right foot disability have not been met. 38 U.S.C. §§ 1110, 1112, 1131, 5103, 5103A, 5107; 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309, 3.310.

5. The criteria for entitlement to service connection for a left foot disability have not been met. 38 U.S.C. §§ 1110, 1112, 1131, 5103, 5103A, 5107; 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309, 3.310.

6. The criteria for entitlement to service connection for a right knee disability have not been met. 38 U.S.C. §§ 1110, 1112, 1131, 5103, 5103A, 5107; 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309, 3.310.

7. The criteria for entitlement to service connection for a back disability have not been met. 38 U.S.C. §§ 1110, 1112, 1131, 5103, 5103A, 5107; 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309, 3.310.

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran served on active duty from July 1972 to October 1978. This matter comes before the Board on appeal from a March 2015 Regional Office (RO) rating decision. In March 2023, the Veteran testified at a hearing before the undersigned Veterans Law Judge.

In May 2023, the Board remanded these claims and a claim of entitlement to service connection for an acquired psychiatric disability for additional development. On remand, a March 2024 rating decision granted entitlement to service connection for adjustment disorder with anxiety and assigned a 10 percent rating effective June 25, 2014. That decision constitutes a full grant of the benefit that was sought, and the issue of entitlement to service connection for an acquired psychiatric disability is no longer on appeal.

The Board further notes that one of the reasons for the May 2023 Board remand was to obtain private medical records from Hanger Clinic, where the Veteran testified that he is treated for musculoskeletal disabilities. Those records were obtained in June 2023, and they have been considered, below.

Service Connection

Service connection is warranted where the evidence of record establishes that an injury or disease resulting in disability was incurred in the line of duty in the active military service or, if pre-existing such service, was aggravated thereby. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a).

Service connection may also be granted for any injury or disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303(d).

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, or nexus, between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004).

Service connection may also be granted for listed chronic diseases, such as osteoarthritis, if such were shown as chronic in service; manifested to a compensable degree within a presumptive period (usually one year) after separation from service; or were noted in service with continuity of symptomatology since service. 38 U.S.C. §§ 1112, 1113; Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013);
or nexus, between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004).

A disability that is proximately due to, or results from, a service-connected disease or injury shall be considered a part of the original condition. 38 C.F.R. § 3.310(a). Secondary service connection on the basis of aggravation is permitted. 38 C.F.R. § 3.310(b). Compensation is payable for that degree of aggravation of a non-service-connected disability caused by a service-connected disability and not due to the natural progress of the nonservice-connected disease. Allen v. Brown, 7 Vet. App. 439 (1995).

Although obesity is not recognized by VA as a disease or disability for compensation purposes, it may serve as an intermediate step when considering secondary service connection under 38 C.F.R. § 3.310. See VAOPGCPREC 1-2017. In Walsh v. Wilkie, 32 Vet. App. 300, 307 (2020), the United States Court of Appeals for Veterans Claims (Court) held that proper interpretation of G.C. Prec. Op. 1-2017 requires consideration of both proximate causation and aggravation in its analytical framework: (1) whether the service-connected disability caused the veteran to become obese/aggravated the veteran's obesity; (2) if so, whether the obesity/aggravation of obesity as a result of the service-connected disability was a substantial factor in causing/aggravating the current disability; and (3) whether the current disability would not have occurred but for obesity caused/aggravated by the service-connected disability.

A veteran who was exposed to herbicides during service and develops certain diseases, listed in 38 C.F.R. § 3.309(e), will be service connected for such disorder on a presumptive basis. In the case at hand, the Veteran contends that he was exposed to herbicides at MacDill Air Force Base (AFB) from 1973 to 1976. There is no presumption for herbicide exposure for individuals who served at MacDill AFB. Therefore, a development letter was sent to the Veteran in May 2017 requesting that he provide "an explanation of when, where, and how you were exposed." The Veteran did not provide the requested information. Therefore, VA was unable to refer this claim to the US Army and Joint Services Records Research Center (JSRRC), and the Veteran's claimed herbicide exposure has not been established and may not be presumed.

The Sergeant First Class Heath Robinson Honoring our Promise to Address Comprehensive Toxics Act of 2022 ("PACT Act"), which is implemented, in part, in 38 U.S.C. § 1168, requires VA to schedule certain veterans for an examination and request a medical opinion for certain non-presumptive diseases if they engaged in a toxic exposure risk activity (TERA). Section 1168 requires VA to "obtain a medical opinion.... as to whether it is at least as likely as not that there is a nexus between the disability and the toxic exposure risk activity." 38 U.S.C. § 1168 (a)(1)(B). Unlike general opinions for service connection, TERA opinions must consider "the total potential exposure through all applicable military deployments of the veteran and the synergistic, combined effect of all toxic exposure risk activities of the veteran." 38 U.S.C. § 1168 (a)(2)(A) and (B). In the case at hand, however, there is no service department confirmation that the Veteran engaged in a TERA, and a February 2024 VA memorandum determined that the Veteran has not engaged in a TERA. It did find, however, that the Veteran had "Exposure to Jet Fuel."

1. Entitlement to service connection for a stomach disability, claimed as ulcers and GERD, is denied.

The Veteran contends that he has a current GERD diagnosis that first manifested during service. His VA
military deployments of the veteran and the synergistic, combined effect of all toxic exposure risk activities of the veteran." 38 U.S.C. § 1168 (a)(2)(A) and (B). In the case at hand, however, there is no service department confirmation that the Veteran engaged in a TERA, and a February 2024 VA memorandum determined that the Veteran has not engaged in a TERA. It did find, however, that the Veteran had "Exposure to Jet Fuel."

1. Entitlement to service connection for a stomach disability, claimed as ulcers and GERD, is denied.

The Veteran contends that he has a current GERD diagnosis that first manifested during service. His VA medical records reflect that he has been diagnosed with GERD.

The Veteran also contends that his ulcers are related to the jet fuel that he used during service. (See Board hearing transcript, page 4.) His military occupational specialty (MOS) of "Aerospace Ground Equip Repairman" is consistent with jet fuel exposure.

While he has claimed service connection for an ulcer, he testified at his Board hearing that "I don't believe I have an active ulcer now, but I have had, and I take Protonix every day because of the acid reflux from having those problems." (See Board hearing transcript, page 5.) VA has expanded this issue to contemplate stomach conditions more broadly, including GERD (with which he is diagnosed).

The Veteran's service treatment records reflect that he reported a history of, or current, frequent indigestion in September 1978 and September 1980 medical history reports.

He reported at his February 2015 VA stomach and duodenal conditions examination that he "started having recurrent abdominal pain and diarrhea in 1973. He states that he was treated for an ulcer. He says that he used to take about 12 Aspirin daily for his knee pain which upset his stomach." Based on review of the record and interview and examination of the Veteran, the examiner diagnosed a gastric ulcer. The examiner opined, however, that this condition was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. Her rationale was that "Although the veteran states that his ulcer treatment was in 1973, during his time in service, I did not see medical records to support this."

The Board remanded this claim to obtain an etiology opinion with respect to his diagnosed GERD. In particular, the remand directed that VA obtain an opinion that addresses the Veteran's in-service reports of frequent indigestion, his statement connecting his GERD to medication he has taken for his service-connected knee disability, and his current GERD diagnosis.

An October 2023 VA esophageal conditions examination report diagnosed GERD, and three etiology opinions were obtained. These opinions were provided in November 2023 by the physician who had personally interviewed and examined the Veteran in October 2023.

The first of the November 2023 VA medical opinions addressed the direct service connection theory of entitlement and concluded that the Veteran's GERD was less likely than not caused by the claimed in-service injury, event, or illness. The examiner provided a highly detailed rationale. She noted that "service records do not document GERD or symptoms suggestive of GERD. Veteran reported the nonspecific 'indigestion' on the 1978 separation exam, but not in the routine 1979 and 1980 exams." She found that there was no evidence of chronicity of care or continuity of symptomatology to suggest that GERD was present in service or that the Veteran's reported indigestion "represented GERD or a condition that would result in or predispose to development of GERD." She also determined that the "service records do not document an in-service injury, activity, event, illness, exposure, complaint, symptom, or condition likely to result in or predispose to development of GERD." She hypothesized that "Given the necessity of rapid meals in the military it is likely that the 'indigestion' reported on the 1978 separation exam represented dyspepsia or over-fullness after eating which does not result in or predispose to development of GERD. Symptoms now are due to GERD."

The second of the November 2023 VA medical opinions addressed the secondary service connection based on causation theory of entitlement and concluded that the Veteran's GERD was less likely than not caused by or the result of the Veteran's service-connected condition of left knee strain with meniscus tear and meniscectomy with residual nonpainful scar. The examiner provided a highly detailed rationale. She noted that "gastroesophageal reflux disease (GERD) results from several pathophysiologic mechanisms causing esophagogastric junction (EGJ) incompetence which include transient lower esophageal sphincter relaxations, a hypotensive lower esophageal sphincter (LES), and anatomic disruption of the gastroesophageal junction, often associated with a hiatal hernia.... Impairment in esophageal acid clearance also contributes." She noted that "Risk factors for GERD include hiatal hernia, obesity, pregnancy, estrogen use, and specific foods/substances (fat, chocolate, peppermint, caffeine, alcohol, nicotine), and medications (anticholinergics, nitrates, calcium channel blockers, tricyclene antidepressants, opioids, theophylline, diazepam, barbiturates) that cause refluxes by inducting LES hypotension." She provided a detailed rationale that included citation to multiple pieces of medical literature and to facts in the Veteran's case to support her opinion.

With respect to the Veteran's specific secondary service connection claim, the examiner (in the second opinion) notes that the Veteran's diagnosed left knee disability "is not a medically recognized cause of GERD. Medications used, including NSAIDS, to treat left knee strain with meniscus tear and meniscectomy with residual nonpainful scar are not a medically recognized cause of GERD." She also addressed the issue of whether the Veteran's left knee disability resulted in obesity that would lead to GERD, stating that "Additionally, [the diagnosed left knee disability] has also not been shown to result in metabolic disturbances that would result in weight gain and/or obesity as an intermediate step in the development of GERD that could not be managed by calorie restriction. The referral to the VA MOVE program is evidence that the Veteran's care providers had confidence that calorie restriction would induce weight loss." She provided a detailed rationale that included citation to multiple pieces of medical literature and to facts in the Veteran's case to support her opinion.

The third of the November 2023 VA medical opinions addressed secondary service connection in the context of aggravation and concluded that the Veteran's GERD was less likely than not aggravated beyond its natural progression by the Veteran's service-connected condition of left knee disability. In her rationale, the examiner noted that "left knee strain with meniscus tear and meniscectomy with residual nonpainful scar is not a condition that is medically recognized as an exacerbator of GERD." She provided a highly detailed rationale that was consistent with that which she provided for the direct service connection causation opinion. She provided a detailed rationale that included citation to multiple pieces of medical literature and to facts in the Veteran's case to support her opinion.

The third etiology opinion also addressed the medication and obesity theories of entitlement based on aggravation. She provided a detailed rationale, noting in part that "Specifically, NSAIDs are not medically recognized aggravators of GERD." Finally, she opined that the Veteran's service-connected left knee disability "has also not been shown to result in metabolic disturbances that would result in weight gain and/or obesity as an intermediate step in the aggravation of GERD that could not be managed by calorie restriction." She cited multiple pieces of medical literature and to facts in the Veteran's case to support her opinion.

The February 2015 VA stomach and duodenal conditions examination report findings have been confirmed. The Board finds that the November 2023 examination report and medical opinions are highly probative to the direct, secondary, direct and secondary based on aggravation, and direct and secondary based on obesity theories of entitlement to service connection for GERD in this case. They were authored by a physician who possesses the necessary education, training, or experience to provide competent medical evidence under 38 C.F.R. § 3.159 (a)(1). See Cox v. Nicholson, 20 Vet. App. 563 (2007). They are based on review of the claims file and interview and examination of the Veteran, and they contain detailed rationales that include a discussion of the facts of the Veteran's case and pertinent medical principles.

With respect to the
2023 examination report and medical opinions are highly probative to the direct, secondary, direct and secondary based on aggravation, and direct and secondary based on obesity theories of entitlement to service connection for GERD in this case. They were authored by a physician who possesses the necessary education, training, or experience to provide competent medical evidence under 38 C.F.R. § 3.159 (a)(1). See Cox v. Nicholson, 20 Vet. App. 563 (2007). They are based on review of the claims file and interview and examination of the Veteran, and they contain detailed rationales that include a discussion of the facts of the Veteran's case and pertinent medical principles.

With respect to the jet fuel theory of service connection, the November 2023 direct service connection opinion found that "service records do not document an in-service ... exposure ... likely to result in or predispose to development of GERD." This opinion contemplates the Veteran's jet fuel exposure. The examiner who offered this opinion provided multiple opinions for the Veteran's other claims, some of which expressly contemplate the jet fuel exposure. The Board therefore concludes that the examiner was aware of the Veteran's jet fuel exposure and that such exposure was contemplated by her etiology opinions.

With respect to the jet fuel theory of entitlement, the Veteran's representative stated that:

When you go to the VA website public health page on fuels, it describes some of that. There are some articles out there which I'll send one that describes what fuel - JP-4 can cause in a Veteran if he's around it a lot. And this Veteran worked on it his whole time in service.

(See Board hearing transcript, page 4.) After the hearing, the Veteran submitted multiple records discussing the health effects of jet fuel exposure. However, each of these articles only discusses a potential link between jet fuel exposure and hearing loss. They do not address a stomach condition. Therefore, this literature is not relevant to the issue at hand.

There is also no persuasive medical evidence or persuasive credible lay evidence that the Veteran's claimed disorder manifested to a compensable degree within a year of his separation from service or had its onset in service and continued ever since service. Therefore, service connection based on presumptive service connection for a chronic disease or based on a theory of continuity of symptomatology is not warranted.

In short, the Board finds that entitlement to service connection for a stomach condition, claimed as ulcers and GERD, is not warranted, on a direct basis, on a secondary basis, on a direct and secondary basis based on aggravation, due to obesity directly or based on aggravation, or due to jet fuel exposure is not warranted.

Accordingly, the evidence is persuasively against the claim. As there is not an approximate balance of positive and negative evidence, the benefit-of-the-doubt doctrine is not applicable, and the claim must be denied. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102.

2. Entitlement to service connection for a right elbow disability is denied.

The Veteran contends that his right elbow was injured when he hit a wall and fell while playing racquetball. (See Board hearing transcript, page 9.)

With respect to his service treatment records, the Veteran reported a history of, or current, painful or trick shoulder or elbow on his September 1978, March 1979, and September 1980 medical history reports.

A May 1978 service treatment record reflects that the Veteran suffered a right elbow contusion. A radiographic report notes that the Veteran has pain in his right elbow laterally secondary to injury. It lists an impression of "Normal right elbow."

An August 1978 service treatment record notes that the Veteran sought treatment for right elbow pain, noting that he "has hit
was injured when he hit a wall and fell while playing racquetball. (See Board hearing transcript, page 9.)

An August 1978 service treatment record notes that the Veteran sought treatment for right elbow pain, noting that he "has hit it several times."

Another August 1978 service treatment record notes that the Veteran "states he Reinjured his elbow while moving furniture a couple nights ago." A radiographic report notes a pertinent clinical history of "several episodes of injury" and lists an impression of "Normal right elbow."

A September 1978 SGT USAF examination notes that the Veteran has a "h/o [history of] painful Right elbow since racketball [sic] injury in Feb 78, treated at MacDill, still has pain."

The Veteran's post-service medical records reflect that he has been treated for right elbow pain. For example, a May 2019 VA x-ray report notes "a probable joint effusion no obvious fracture seen mild degenerative changes are noted."

This claim was remanded in May 2023 so that the Veteran could undergo a VA examination and an etiology opinion could be obtained.

The Veteran underwent a VA elbow and forearm conditions examination in October 2023. Based on review of the record and interview and examination of the Veteran, the examiner diagnosed the right elbow disabilities of osteoarthritis and chondrocalcinosis. In a November 2023 opinion, the examiner opined that these disabilities were less likely than not incurred in or caused by the claimed in-service injury, event, or illness. In her rationale, she noted that the September 1978 separation examination shows complaints involving the Veteran's right elbow or shoulder and that 1978 service treatment records show "[right] elbow contusion & triceps tendonitis." She also noted that "Post military private/VA treatment records dated 2019 shows fall 2019 and CT showed chondrocalcinosis and [osteoarthritis]." She noted that "Chondrocalcinosis is also known as calcium pyrophosphate crystal deposition (CPPD) disease." In her rationale, she noted that the "Veteran was seen in service for contusion of the R elbow & triceps tendonitis R elbow.... There is no evidence of chronicity of care or continuity of symptoms to suggest that the R elbow contusion and triceps tendonitis represented an injury that would result in or predispose to development of osteoarthritis R elbow & chondrocalcinosis R elbow." She noted that the in-service x-rays that were taken in May 1978 and August 1978 "were normal in service indicating the currently diagnosed osteoarthritis right elbow and chondrocalcinosis R elbow were not present in service." She further noted that "service records do not document an in-service injury, activity, event, illness, exposure, complaint, symptom, or condition likely to result in or predispose to development of R elbow pathology or the diagnosed osteoarthritis R elbow & chondrocalcinosis R elbow." Rather, she noted that "The most common risk factors for osteoarthritis are advanced age, family history of osteoarthritis, being overweight, radiographic evidence of injury to the joint, history of inflammatory joint disease, metabolic or hormonal disorders, such as hemochromatosis and acromegaly, congenital joint abnormalities, repetitive stressful joint use, and crystal deposits in joints.... The Veteran has these risk factors." She cited pertinent medical literature to support her opinion.

The November 2023 opinion then discussed chondrocalcinosis, describing it as "a metabolic condition associated with excessive cartilage pyrophosphate production leading to local calcium pyrophosphate (CPP) supersaturation and CPP crystal formation or deposition." She noted that "The Veteran has evidence of chondrocalcinosis on x-rays of multiple other joints as well indicating a systemic disorder of calcium pyrophosphate metabolism." She also noted that "Chondrocalcinosis is medically accepted as a risk factor in the development of osteoarthritis."

She then noted that the Veteran's "R elbow pain in service was diagnosed as and was consistent with contusion of the R elbow & triceps tendonitis R elbow.... Neither condition results in or predisposes to development of the diagnosed
osis, describing it as "a metabolic condition associated with excessive cartilage pyrophosphate production leading to local calcium pyrophosphate (CPP) supersaturation and CPP crystal formation or deposition." She noted that "The Veteran has evidence of chondrocalcinosis on x-rays of multiple other joints as well indicating a systemic disorder of calcium pyrophosphate metabolism." She also noted that "Chondrocalcinosis is medically accepted as a risk factor in the development of osteoarthritis."

She then noted that the Veteran's "R elbow pain in service was diagnosed as and was consistent with contusion of the R elbow & triceps tendonitis R elbow.... Neither condition results in or predisposes to development of the diagnosed osteoarthritis R elbow and chondrocalcinosis R elbow." She stated that "In the absence of documented radiographic injury to the elbow joint, repeated contusions of the right elbow do not result in or predispose to development of right elbow osteoarthritis. Right elbow pain now is due to osteoarthritis R elbow & chondrocalcinosis R elbow."

The Board finds that the October 2023 examination report and November 2023 medical opinion are highly probative, as they were authored by a physician who possesses the necessary education, training, or experience to provide competent medical evidence under 38 C.F.R. § 3.159(a)(1). See Cox v. Nicholson, 20 Vet. App. 563 (2007). They are based on review of the claims file and interview and examination of the Veteran. The etiology opinion contains detailed rationales that cite to the facts of the Veteran's case and pertinent medical principles.

In light of the above, the Board finds that entitlement to service connection for a right elbow disability is not warranted on a direct basis.

3. Entitlement to service connection for a right shoulder disability is denied.

The Veteran contends that he injured his right shoulder in the same accident in which he injured his right elbow. (See Board hearing transcript, page 9.) He noted that "we were at a gym playing racquetball, and clumsy me wound up falling and hitting - hitting the wall in the - in the racquetball court, and caused issues with the right shoulder." (See Board hearing transcript, page 9.) He contends that "that could've been when the rotator cuff got torn." (See Board hearing transcript, page 9.)

His service treatment records do not reflect right shoulder treatment. The Veteran did, however, report a history of, or current, painful or trick shoulder or elbow on his September 1978, March 1979, and September 1980 medical history reports. It is unclear whether any of these reports reference the right shoulder.

Post-service medical evidence reflects that the Veteran has had a rotator cuff tear.

This claim was remanded in May 2023 so that the Veteran could undergo a VA examination and an etiology opinion could be obtained.

The Veteran underwent a VA shoulder and arm conditions examination in October 2023. Based on review of the record and interview and examination of the Veteran, the examiner diagnosed right rotator cuff tendonitis.

Post-service medical evidence reflects that the Veteran has had a rotator cuff tear.

This claim was remanded in May 2023 so that the Veteran could undergo a VA examination and an etiology opinion could be obtained.

In her November 2023 etiology opinion, the examiner opined that the Veteran's right shoulder disability was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. Among the pertinent records, she noted the above service treatment records and the fact that "Post military private/VA treatment records dated 2014 shows R rotator cuff repair." In her rationale, she noted that the Veteran's service treatment records document treatment for the right elbow but not the right shoulder, making it "more likely than not that the reference to "Painful or 'trick' shoulder or elbow" in the 1978 separation exam and subsequently referred to the right elbow and not the shoulder." She noted that there is no evidence of chronicity of care of continuity of symptoms since service, and "There is no evidence ... that the R elbow symptoms represented an injury that would result in or predispose to development of R shoulder rotator cuff tendonitis." She noted that "Because rotator cuff tendonitis is a chronic use condition associated with overhead activity, it is unlikely that "hitting" the right elbow once or several times or moving furniture once without documented acute R shoulder injury would result in or predispose to development of R shoulder tendonitis."

She further noted that "service records do not document an in-service injury, activity, event, illness, exposure, complaint, symptom, or condition likely to result in or predispose to development of R shoulder pathology or the diagnosed R shoulder rotator cuff tendonitis." She further noted that "Given his in-service age and level of fitness and lack of service records documenting right shoulder pathology, any R shoulder pain experienced during service was likely due to delayed onset muscle soreness (DOMS) associated with physical activity. DOMS does not result in or predispose to development of R shoulder rotator cuff tendonitis."

The Board finds that the October 2023 examination report and November 2023 medical opinion are highly probative, as they were authored by a physician who possesses the necessary education, training, or experience to provide competent medical evidence under 38 C.F.R. § 3.159 (a)(1). See Cox v. Nicholson, 20 Vet. App. 563 (2007). They are based on review of the claims file and interview and examination of the Veteran. The etiology opinion contains detailed rationales that cite to the facts of the Veteran's case and pertinent medical principles.

In light of the above, the Board finds that entitlement to service connection for a right shoulder disability is not warranted on a direct basis.

4. Entitlement to service connection for a right foot disability is denied.

The Veteran contends that he has current right foot disabilities due to an in-service right foot fracture. (See Board hearing transcript, page 4.)

The Veteran's service treatment
service connection based on presumptive service connection for a chronic disease or based on a theory of continuity of symptomatology is not warranted.

4. Entitlement to service connection for a right foot disability is denied.

The Veteran contends that he has current right foot disabilities due to an in-service right foot fracture. (See Board hearing transcript, page 4.)

The Veteran's service treatment records reflect that he received treatment for his right foot in service. The Veteran reported a history of, or current, foot trouble on his September 1978, May 1979, and September 1980 medical history reports. He denied any such symptoms on his April 1972 enlistment medical history report.

The Veteran reported in a statement that accompanied either the September 1978 or the March 1979 medical history report that he injured his "Rt. Foot from fuel hose throwing up & back down hard while fueling [illegible]."

A February 1973 service treatment record notes that the Veteran sought treatment for right foot pain that he had been experiencing for three weeks. Following examination, the impression was tendonitis.

A March 1973 service treatment record notes that the Veteran sought treatment for right foot burning pain that had had its onset approximately three weeks earlier after having fallen from a height of six to eight feet. He reported pain at the "base of metatarsal 4th - dorsum." He had multiple follow-up appointments, and x-rays were negative.

Another March 1973 service treatment record notes that the Veteran sought treatment for complaints involving the bone of the fourth metatarsal of the right foot, and it was noted that an injection brought no relief.

Another March 1973 service treatment record notes that the Veteran's "Symptoms persist as above. Tenderness [illegible] metatarsal. ? paresthesias to toe. 4+ pain on lateral [illegible]." It was noted that he was given medication and an injection.

A September 1973 service treatment record notes that the Veteran sought treatment for a right foot injury. It was noted that the Veteran reported that he felt a "pop" in his right foot while playing football. The record appears to indicate that x-rays showed a fracture, the location of which is difficult to read, but the record itself states that the fracture "looks old to me." The Veteran was given crutches.

An October 1973 service treatment record reflects that the Veteran sought treatment for right foot pain and was referred to orthopedics. He was treated in the orthopedic clinic.

A June 1980 service treatment record notes that the Veteran has been having right foot pain for a week. It was noted that the Veteran had right foot swelling and that he had tenderness at the first and second distal metatarsals, with more on the first metatarsal. An assessment of metatarsalgia was given.

The Veteran underwent a VA foot conditions examination in October 2017. The resulting examination report diagnosed bilateral pes planus; right foot Morton's neuroma; right foot metatarsalgia; bilateral hammer toes; and degenerative arthritis of both feet. At that time, the Veteran claimed that he had bilateral pes planus and arthritis of both feet that were "related to a fall from a refueling tanker 03/08/1973 related to refueling a plane and injuring his feet. Was treated for tendonitis and possible [M]orton's neuroma Rt foot."

The Veteran underwent VA examinations in connection with this claim in February 2015 and October 2017.

The February 2015 VA examiner diagnosed right foot pes planus and osteoarthritis. He opined that the claimed condition was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The rationale was that "Medical records reviewed did not show evaluation of this condition." The Board notes that this opinion is not probative, as the Veteran's service treatment records contain evidence of in-service right foot treatment.

The Veteran then underwent a VA examination in October 2017, at which time the examiner diagnosed bilateral pes planus, right foot Morton's neuroma, right foot metatarsalgia, bilateral hammer toes, and degenerative arthritis of both feet. Based on review of the record and interview and examination of the Veteran, the examiner opined that the Veteran's claimed right foot disability was less likely than not incurred
was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The rationale was that "Medical records reviewed did not show evaluation of this condition." The Board notes that this opinion is not probative, as the Veteran's service treatment records contain evidence of in-service right foot treatment.

This veteran is claiming his B/L pes plan[]us, hammer toes, mid foot osteoarthritis conditions are ... resulting from falling from a refueling truck 1973. His Rt foot pain 03/08/1973 was diagnosed as tendonitis/metatarsalgia and possible Morton's neuroma while he was active duty making his current claim of pes plan[]us and hammer toes less likely than not as a result of his fall.

In its May 2023 remand, the Board found that a new examination was required, as the VA examination reports of record only provide an etiology opinion for the Veteran's pes planus and hammer toes. They do not provide an opinion for the Veteran's right foot Morton's neuroma, right foot metatarsalgia, and degenerative arthritis of both feet.

Nor did they address the service treatment records dated in September 1973 (reflecting a right foot fracture), October 1973, and June 1980, or the medical history reports of foot trouble dated in September 1978, May 1979, and September 1980.

The Veteran underwent a VA foot conditions examination in October 2023. Based on review of the record and interview and examination of the Veteran, the examiner diagnosed bilateral flat foot (pes planus), hammer toes, hallux valgus, and arthritis.

The October 2023 VA examiner provided an etiology opinion in November 2023. Based on review of the record and interview and examination of the Veteran, she determined that the Veteran's bilateral foot disabilities were less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner provided a detailed description of the relevant evidence in this case. In her rationale, the examiner noted that the "Veteran was seen for acute treatment of right foot metatarsalgia following fall/jump from a tank in Feb. 1973 and for a right 4th metatarsal fracture in September 1973." She noted that "Metatarsalgia does not result in or predispose to development of right foot pes planus, R hammer toes, hallux valgus, or arthritis." She noted that "Right foot x-rays in 1980 showed that the right foot 4th metatarsal fracture healed complete without sequelae.... Thus, the transient R 4th metatarsal fracture also could not result in or predispose to development of right foot pes planus, R hammer toes, hallux valgus, or arthritis."

She also determined that the "service records do not document an in-service injury, activity, event, illness, exposure, complaint, symptom, or condition likely to result in or predispose to development of right foot pes planus, R hammer toes, hallux valgus, or arthritis," and that "a transient R foot injury due to a fuel hose would not result in or predispose to development of" the claimed right foot disabilities.

With respect to the pes planus diagnosis, she noted that "Risk factors for development of pes planus include obesity, certain injuries to the foot or ankle such as fracture of the navicular, first metatarsal, or calcaneal, or injury to the Lis-Franc ligament complex, rheumatoid arthritis, aging, and diabetes." She found that "There is no evidence that the Veteran had a right foot fracture to the navicular, first metatarsal, or calcaneal, or injury to the Lis-Franc ligament complex." She noted that "The aging Veteran does, however, have a long history of obesity and diabetes which are more likely to have contributed to the development of R foot pes planus."

With respect to hallux valgus, she noted that "Hallux valgus is multifactorial in origin and causes include abnormal foot mechanics affecting the first ray, abnormal first metatarsophalangeal anatomy, joint hypermobility, and genetic influences." She stated that "There
umatoid arthritis, aging, and diabetes." She found that "There is no evidence that the Veteran had a right foot fracture to the navicular, first metatarsal, or calcaneal, or injury to the Lis-Franc ligament complex." She noted that "The aging Veteran does, however, have a long history of obesity and diabetes which are more likely to have contributed to the development of R foot pes planus."

With respect to hammer toes, she noted that "Hammer toes are caused by wearing ill-fitting shoes and often by diabetes.... The hammer toe develops while the ill-fitting shoes are being worn, not many years later." She noted that "Hammer toes do not result from fall/jump resulting in foot pain, a fuel hose injury, or from metatarsalgia." She concluded that, "Since there is no evidence that the Veteran had hammer toes during service and since he has a long history of diabetes..., it is more likely the diabetes that resulted in the hammer toes."

With respect to osteoarthritis, she noted that "Risk factors for development of osteoarthritis include age, gender, genetic influences, being overweight, injury to the joint, history of inflammatory joint disease, metabolic or hormonal disorders, such as hemochromatosis and acromegaly, congenital joint anomalies, repetitive stressful joint use, and crystal deposits in joints." She noted that "The Veteran's foot arthritis involves the mid foot. Metatarsalgia involves the forefoot and does not result in or predispose to development of osteoarthritis." She stated that "A fall/jump from 6-8 feet or fuel hose injury without documented midfoot fracture/injury, which is lacking in this case, cannot result in foot osteoarthritis many years later." With respect to risk factors, she stated that "The aging Veteran has a long history of obesity and also has chondrocalcinosis, a metabolic condition that predisposes to development of osteoarthritis."

She further noted that "Right foot pain in service was diagnosed as and responded to treatment for metatarsalgia. Right foot pain now is due to right foot pes planus, R hammer toes, hallux valgus, and arthritis."

The Board finds that the October 2023 examination report and November 2023 medical opinion are highly probative, as they were authored by a physician who possesses the necessary education, training, or experience to provide competent medical evidence under 38 C.F.R. § 3.159 (a)(1). See Cox v. Nicholson, 20 Vet. App. 563 (2007). They are based on review of the claims file and interview and examination of the Veteran. The etiology opinion contains detailed rationales that cite to the facts of the Veteran's case and pertinent medical principles.

In light of the above, the Board finds that entitlement to service connection for a right foot disability is not warranted on a direct basis.

5. Entitlement to service connection for a left foot disability is denied.

The Veteran contends that he has a left foot disability that is secondary to his service-connected left knee disability. He also contends that his left foot was injured at the same time as his right foot was injured. (See Board hearing transcript, page 13.)

As noted above, the Veteran reported a history of, or current, foot trouble on his September 1978, May 1979, and September 1980 medical history reports. He denied any such symptoms on his April 1972 enlistment medical history report. It is unclear whether any of these reports is referencing the Veteran's left foot.

As discussed above, the Veteran was treated for right foot injuries that were suffered in a six to eight foot fall. The service treatment records do not mention the Veteran's left foot having been injured in this accident. The Veteran's service treatment records do, however, contain a June 1980 service treatment record reflecting that the Veteran sought treatment for pain in the ball of his left foot that had its onset the prior morning. There was tenderness on examination and x-rays showed no fracture. The assessment was that the Veteran had metatarsalgia.

As noted above, the Veteran underwent a VA examination in October 2017, at which time the examiner diagnosed bilateral pes planus, bilateral hammer toes, and degenerative arthritis of both feet. Based on review of the record and interview and examination of the Veteran, the examiner opined that the Veteran's claimed foot disabilities were less likely than not incurred in or caused by the claimed in-service injury, event, or illness. His rationale reads as follows:

In its May 2023 remand, the Board found that a new examination was required, as the VA examination report of record does not address the Veteran's left foot degenerative arthritis, and it does not address his June 1980 treatment for left foot metatarsalgia.

Furthermore, the examiner did not provide an adequate secondary service connection opinion that addresses the Veteran's theory of entitlement. Specifically, he contends that an altered gait from his service-connected left knee disability either caused or aggravated a current left foot disability.

The October 2023 VA examiner provided three separate etiology opinions in November 2023. The first of these found that the claimed condition was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. She noted that "service records provided do not document a left foot condition likely to result in or predispose to development of left foot pes planus, hammer toes, hallux valgus or degenerative arthritis." She noted that "Service records document RIGHT foot pain after a fall/jump from a tank in 1973.... Lack of documentation of LEFT foot pain on several visits following the incident makes it unlikely that the LEFT foot was injured in the fall/jump." She further stated that "However, had the left foot been injured in the 1973 fall/jump, it is unlikely that such injury would result in or predispose to development of the diagnosed left foot pes planus, hammer toes, hallux valgus or degenerative arthritis." She noted that that the Veteran was seen for right foot metatarsalgia in service, but
foot pes planus, hammer toes, hallux valgus or degenerative arthritis." She noted that "Service records document RIGHT foot pain after a fall/jump from a tank in 1973.... Lack of documentation of LEFT foot pain on several visits following the incident makes it unlikely that the LEFT foot was injured in the fall/jump." She further stated that "However, had the left foot been injured in the 1973 fall/jump, it is unlikely that such injury would result in or predispose to development of the diagnosed left foot pes planus, hammer toes, hallux valgus or degenerative arthritis." She noted that that the Veteran was seen for right foot metatarsalgia in service, but "Had the LEFT foot been involved, however, it is still less likely than not that left foot metatarsalgia resulted in or predisposed to development of left foot pes planus, hallux valgus, hammer toes, or degenerative arthritis." She stated that, "Further, service records do not document an in-service injury, activity, event, illness, exposure, complaint, symptoms, or condition likely to result in or predispose to development of the diagnosed condition of left foot pes planus, hallux valgus, hammer toes, or degenerative arthritis."

She then discussed the individual diagnoses, with the rationale consistent with the rationale she provided for the same diagnoses in the right foot.

With respect to the pes planus diagnosis, she noted that "Risk factors for development of pes planus include obesity, certain injuries to the foot or ankle such as fracture of the navicular, first metatarsal, or calcaneal, or injury to the Lis-Franc ligament complex, rheumatoid arthritis, aging, and diabetes." She found that "There is no evidence that the Veteran had left foot fractures or injury to the Lis-Franc ligament complex in the 1973 fall/jump or subsequently." She noted that "The aging Veteran does, however, have a long history of obesity and diabetes which are more likely to have contributed to the development of L foot pes planus."

With respect to osteoarthritis, she noted that "Risk factors for development of osteoarthritis include age, gender, genetic influences, being overweight, injury to the joint, history of inflammatory joint disease, metabolic or hormonal disorders, such as hemochromatosis and acromegaly, congenital joint anomalies, repetitive stressful joint use, and crystal deposits in joints." She noted that "The Veteran's foot arthritis involves the mid foot. Metatarsalgia involves the forefoot and does not result in or predispose to development of osteoarthritis." She stated that "A fall/jump from 6-8 feet without documented midfoot fracture/injury, which is lacking in this case, cannot result in foot osteoarthritis many years later." With respect to risk factors, she stated that "The aging Veteran has a long history of obesity and also has chondrocalcinosis, a metabolic condition that predisposes to development of osteoarthritis."

She further noted that "Given his in-service age and level of fitness and lack of service records documenting left foot pathology other than confusion regarding which foot was involved with metatarsalgia in 1980..., any left foot pain experienced during service was likely due to delayed onset muscle soreness (DOMS) associated with physical activity. DOMS does not result in or predispose to development of pes planus, hallux valgus, hammer toes, or degenerative arthritis. L foot pain now is due to pes planus, hallux valgus, hammer toes, or degenerative arthritis." She cited multiple pieces of medical literature and facts of the
a metabolic condition that predisposes to development of osteoarthritis."

The October 2023 VA examiner provided a second etiology opinion in November 2023, addressing the question of whether the Veteran's service-connected left knee disabilities caused his left foot disability. The examiner opined that the claimed condition is less likely than not proximately due to or the result of the veteran's service connected condition of left knee strain with meniscus tear and meniscectomy with residual nonpainful scar." In her rationale, she noted that "left knee strain with meniscus tear and meniscectomy with residual nonpainful scar is not a medically recognized cause of left foot pes planus, hallux valgus, hammer toes or arthritis." She re-described the risk factors for developing those four foot disabilities, as appeared in her first etiology opinion, above. She also found that the Veteran's treating providers have not suggested a causal relationship between the two disabilities.

She next addressed obesity, noting that "left knee strain with meniscus tear and meniscectomy with residual nonpainful scar has not resulted in metabolic disturbances that would result in weight gain and/or obesity as an intermediate step in the development of left foot pes planus & arthritis that could not be managed by calorie restriction." She again noted that "The referral to the VA MOVE program is evidence that the Veteran's care providers had confidence that calorie restriction would induce weight loss." She cited multiple pieces of medical literature and facts of the Veteran's case to support her opinion.

The October 2023 VA examiner provided a third etiology opinion in November 2023, addressing the question of whether the Veteran's left foot disability was aggravated beyond its natural progression by his left knee disabilities. In her rationale, she noted that "there was no evidence of worsening of the bilateral foot condition on subsequent podiatric follow up in 2019." She noted that "The Veteran's current symptoms are arch pain primarily that is partially relieved by use of shoe inserts, similar to the symptoms described in the 2016 baseline exam." She also noted that, "Additionally, there is no plausible mechanism whereby left knee strain with meniscus tear and meniscectomy with residual nonpainful scar would aggravate left foot pes planus, hallux valgus, hammer toes and arthritis beyond their natural progression." She cited multiple pieces of medical literature and facts of the Veteran's case to support her opinion.

The Board finds that the November 2023 examination report and medical opinions are highly probative to the direct, secondary, direct and secondary based on aggravation, and direct and secondary based on obesity theories of entitlement to service connection for a left foot disability in this case. They were authored by a physician who possesses the necessary education, training, or experience to provide competent medical evidence under 38 C.F.R. § 3.159 (a)(1). See Cox v. Nicholson, 20 Vet. App. 563 (2007). They are based on review of the claims file and interview and examination of the Veteran, and they contain detailed rationales that cite to the facts of the Veteran's case and pertinent medical principles.

In short, the Board finds
See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). The Board finds, however, that the questions posed by this claim are of such complexity as to require that individuals who provide competent medical evidence on this matter possess a level of expertise that a layperson simply does not possess. Specifically, the Board finds that the Veteran, as a layperson, is not competent to link his left foot arthritis to service. Nor is he competent to opine as to the medical relationship between a left foot disability and his service-connected left knee disabilities. Nor is he competent to provide an opinion discussing the relationship between a left knee disability and obesity.

In short, the Board finds that entitlement to service connection for a left foot disability is not warranted, on a direct basis, on a secondary basis, on a direct and secondary basis based on aggravation, or due to obesity directly or based on aggravation is not warranted.

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

The Veteran contends that he has a right knee disability that occurred in service. The Veteran also contends that his right knee disability is caused or aggravated by his service-connected left knee disability. (See Board hearing transcript, page 10.)

The Veteran's service treatment records contain a September 1973 record reflecting that he was treated for bilateral knee chondromalacia. He was also found to have chondromalacia patella in July 1977 after seeking treatment for knee pain that had worsened over the past months. He had a July 1977 in-service orthopedic consultation in which it was noted that he had a 6-year history of bilateral knee pain. He was examined and determined to have chondromalacia patella.

He reported that he has "Good health but having trouble with knees and feet" in his May 1979 medical history report. He also reported having a history of, or current, trick or locked knees on medical history reports dated in September 1978, May 1979, and September 1980. Some of these records, however, make clear that these complaints are related specifically to his left knee.

The Veteran underwent a VA knee and lower leg conditions examination in October 2017. Under the diagnosis section, the examiner listed "Arthritis, other types" and specified "Chondromalacia" with a date of diagnosis of September 11, 1973. The examination report also notes an impression of chondrocalcinosis from August 2017 x-rays. While the Board finds the diagnoses to be highly probative, the examiner provided an etiology opinion that is non-probative, as it is based on a fundamental misunderstanding of the question of secondary service connection. It also contains an unclear direct service connection opinion. This claim was remanded so that the Veteran could undergo a VA examination and an etiology opinion could be obtained.

The Veteran underwent a VA knee and lower leg examination in October 2023, and three etiology opinions were provided in November 2023. Based on review of the record and interview and examination of the Veteran, the examiner diagnosed right knee osteoarthritis.

In the first of her November 2023 etiology opinions, the VA examiner noted the right knee osteoarthritis and chondrocalcinosis diagnoses. She noted the Veteran's service treatment records and that "Post military private/VA treatment records dated 3/79, 4/80, 4/81, 8/17, 2021, 5/2019 shows post svc routine exams without mention of RIGHT knee pain, always mention of pre-svc L knee meniscectomy." She noted that "X-rays R knee tricompartmental OA [osteoarthritis] & chondrocalcinosis. X-rays L [shoulder] & R elbow chondrocalcinosis indicating systemic condition & not localized." In her rationale, she noted that "service records provided document acute treatment only for self-limited right knee pain with diagnosis of
the Veteran's service treatment records and that "Post military private/VA treatment records dated 3/79, 4/80, 4/81, 8/17, 2021, 5/2019 shows post svc routine exams without mention of RIGHT knee pain, always mention of pre-svc L knee meniscectomy." She noted that "X-rays R knee tricompartmental OA [osteoarthritis] & chondrocalcinosis. X-rays L [shoulder] & R elbow chondrocalcinosis indicating systemic condition & not localized." In her rationale, she noted that "service records provided document acute treatment only for self-limited right knee pain with diagnosis of chondromalacia patella, which, with normal x-rays, would more accurately be called patellofemoral syndrome." She noted that "There is no evidence of chronicity of care of continuity of symptoms to suggest that the right knee condition/symptoms in service represented a condition that would result in or predispose to development of the diagnosed right knee osteoarthritis and chondrocalcinosis." She noted that "Right knee x-rays in service were normal and so there is no evidence that the right knee osteoarthritis and chondrocalcinosis were present in service." She noted that "Records provided do not document a gait or other abnormality due to the in-service LEFT knee conditions severe enough to result in or predispose to development of the R knee osteoarthritis."

She also determined that the "service records do not document an in-service injury, activity, event, illness, exposure, complaint, symptom, or condition likely to result in or predispose to development of right knee pathology or the diagnosed right knee osteoarthritis and chondrocalcinosis." She further noted that "Right knee pain in service was self-limited and diagnosed as due to chondromalacia patella/patellofemoral syndrome. Chondromalacia patella/patellofemoral syndrome do not result in or predispose to development of osteoarthritis of chondrocalcinosis." She stated that "R knee pain now is due to right knee osteoarthritis and chondrocalcinosis."

She also addressed the role of age and obesity in his right knee disability, noting that "the aging veteran has been and is obese.... Age and obesity are both well established right factors for development of knee osteoarthritis." She stated that "Neither right nor left knee conditions or symptoms in service resulted in metabolic disturbances that would result in weight gain and/or obesity as an intermediate step in the development of right knee osteoarthritis that could not be managed by calorie restriction." She stated that "The referral to the VA MOVE program is evidence that the Veteran's care providers had confidence that calorie restriction would induce weight loss."

She then noted that "the Veteran has evidence of systemic chondrocalcinosis also known as calcium pyrophosphate crystal deposition (CPPD) disease, describing it as "a metabolic condition associated with excessive cartilage pyrophosphate production leading to local calcium pyrophosphate (CPP) supersaturation and CPP crystal formation or deposition." She noted that "The Veteran has evidence of chondrocalcinosis on x-rays of multiple other joints as well ... indicating a systemic process that could not have been the result of R (or left) knee pain in service." She also noted that "Chondrocalcinosis is medically accepted as a risk factor in the development of osteoarthritis." Throughout this first opinion, the examiner cited to multiple pieces of medical literature as well as to the facts of the Veteran's case.

In a second November 2023 opinion, the examiner addressed the question of causation on a secondary basis, opining that the claimed condition is less likely than not due to or the result of the Veteran's service-connected condition of left knee strain with meniscus tear and meniscectomy with residual nonpainful scar. In her rationale, she noted that:

[I]t is medically accepted that there is no evidence to suggest that an injury to one lower extremity would have any significant impact on the opposite uninjured limb unless the injury resulted in major muscle or nerve damage causing partial or complete paralysis of the damaged leg, and/shortening of the injured lower extremity resulting in a limb length discrepancy of more than four or five centimeter[]s so that the individual's gait pattern has been altered to the extent that clinically there is an obvious lurching type gait (a significant limp). In order for this type of gait to have impact on the opposite or uninjured leg, it is likely that the abnormal gait or limp would need to be present over an extended period of time - years. A temporary abnormality in gait, e.g. a limp over a relatively short period of time of weeks or months is unlikely to have any effect on the opposite leg. The use of a cast, cane, and crutches is also unlikely to have any major impact on the stress borne by the uninjured limb.... Records provided to not document such conditions caused by the service-connected left knee strain with meniscus tear and meniscectomy with residual nonpainful scar.

She then reiterated her chondrocalcinosis discussion from the prior opinion, explaining how "Chondrocalcinosis is medically accepted as a risk factor in the development of osteoarthritis." She also reiterated her earlier discussion of the common rick factors for osteoarthritis, noting that "The Veteran's age, presence of joint chondrocalcinosis, and long history of obesity are medically accepted risk factors for the development of the diagnosed right knee osteoarthritis."

With respect to obesity, she found that "Left knee strain with meniscus tear and meniscectomy with residual nonpainful scar has also not been shown to result in metabolic disturbances that would result in weight gain and/or obesity as an intermediate step in the development of" his right knee disabilities, again noting the Veteran's "referral to the VA MOVE program is evidence that the Veteran's care providers had confidence that calorie restriction would induce weight loss." Throughout this second opinion, the examiner cited to multiple pieces of medical literature as well as to the facts of the Veteran's case.

The third November 2023 opinion provided an opinion on secondary service connection based on aggravation, finding that the Veteran's right knee disability was not at least as likely as not aggravated beyond its natural progression by his service-connected left knee disabilities. In her rationale, the examiner noted that "ROM [range of motion] has not decreased from exam in 2017, there are no new x-rays that indicate worsening of the R knee tricompartmental degenerative arthritis or evidence of operative intervention for the R knee degenerative arthritis, and no new documented R knee symptoms to indicate worsening." She reiterated her discussion, above, about how "it is medically accepted that there is no evidence to suggest that an injury to one lower extremity would have any significant impact on the opposite uninjured limb unless" there were conditions present that the Veteran did not satisfy. Throughout this third opinion, the examiner cited to multiple pieces of medical literature as well as to the facts of the Veteran's case.

The Board finds that the November 2023 examination report and medical opinions are highly probative to the direct, secondary, direct and secondary based on aggravation, and direct and secondary based on obesity theories of entitlement to service connection for GERD in this case. They were authored by a physician who possesses the necessary education, training, or experience to provide competent medical evidence under 38 C.F.R. § 3.159 (a)(1). See Cox v. Nicholson, 20 Vet. App. 563 (2007). They are based on review of the claims file and interview and examination of the Veteran, and they contain detailed rationales that cite to the facts of the Veteran's case and pertinent medical principles.

The only contrary opinion comes from the Veteran himself. The Board recognizes that there are instances in which a layperson may be competent to offer testimony on medical matters, such as describing symptoms observable to the naked eye or even diagnosing simple conditions. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). The Board finds, however, that the questions posed by this claim are of such complexity as to require that individuals who provide competent medical evidence on this matter possess a level of expertise that a layperson simply does not possess. Specifically, the Board finds that the Veteran, as a layperson, is not competent to link his current right knee disabilities to injuries that occurred decades earlier in service. Nor is he competent to opine as to the medical relationship between his
a layperson may be competent to offer testimony on medical matters, such as describing symptoms observable to the naked eye or even diagnosing simple conditions. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). The Board finds, however, that the questions posed by this claim are of such complexity as to require that individuals who provide competent medical evidence on this matter possess a level of expertise that a layperson simply does not possess. Specifically, the Board finds that the Veteran, as a layperson, is not competent to link his current right knee disabilities to injuries that occurred decades earlier in service. Nor is he competent to opine as to the medical relationship between his right knee disabilities and his service-connected left knee disabilities. Nor is he competent to provide an opinion discussing the relationship between his left knee disabilities, obesity, and right knee disabilities.

In light of the above, the Board finds that entitlement to service connection for a right knee disability is not warranted on a direct basis based on causation or aggravation, on a secondary basis based on causation or aggravation, or based on causation or aggravation of obesity on a direct or secondary basis.

7. Entitlement to service connection for a back disability is denied.

The Veteran contends that he has a back disability that is due to the in-service fall that was described above. (See Board hearing transcript, pages 13-14.) A March 1973 service treatment record notes that the Veteran sought treatment for right foot burning pain that had its onset approximately three weeks earlier after having fallen from a height of six to eight feet.

The Veteran also contends that his back disability is caused or aggravated by his service-connected left knee disability.

The Veteran was diagnosed with intervertebral disc syndrome, degenerative disc disease, and spinal fusion in an October 2017 VA back conditions examination report. The examiner provided an etiology opinion that is non-probative, as it is based on a fundamental misunderstanding of the question of secondary service connection. It also contains an unclear direct service connection opinion. Therefore, the Board remanded this claim in order to obtain a new opinion.

The Veteran underwent a VA back conditions examination in October 2023, and three etiology opinions were provided in November 2023. Based on review of the record and interview and examination of the Veteran, the examiner diagnosed intervertebral disc syndrome (IVDS) and degenerative disc disease other than IVDS.

In the first November 2023 etiology opinion, the October 2023 VA examiner addressed the direct theory of service connection. She opined that the claimed condition is less likely than not incurred in or caused by the claimed in-service injury, event, or illness. In her rationale, she noted that "there is no mention of back pain in the service records provided, including after the fall/jump 6-8 feet from a tanker." She further noted that "In the absence of spinal injury even repeated parachute jumps do not result in or predispose to development of degenerative spinal changes, so it's unlikely that a single fall/jump in 1973 would cause the current degenerative spinal change...." She stated that "There is no evidence of chronicity of care or continuity of symptoms to suggest that the degenerative disc disease lumbar spine, IVDS or L lower extremity radiculopathy were present in service or that the fall/jump from a tank represented an injury that would result in or predispose to development of degenerative disc disease lumbar spine, IVDS or L lower extremity radiculopathy." She noted that "The Veteran denied recurrent back pain on four different exams," and that "Further, service records do not document an in-service injury, activity, event, illness, exposure, complaint, symptom, or condition likely to result in or predispose to development of back pathology or the diagnosed degenerative disc disease lumbar spine, IVDS, or L lower extremity radiculopathy."

She further noted that "Given his in-service age and level of fitness and lack of service records documenting back or spine pathology, any back
or that the fall/jump from a tank represented an injury that would result in or predispose to development of degenerative disc disease lumbar spine, IVDS or L lower extremity radiculopathy." She noted that "The Veteran denied recurrent back pain on four different exams," and that "Further, service records do not document an in-service injury, activity, event, illness, exposure, complaint, symptom, or condition likely to result in or predispose to development of back pathology or the diagnosed degenerative disc disease lumbar spine, IVDS, or L lower extremity radiculopathy."

She further noted that "Given his in-service age and level of fitness and lack of service records documenting back or spine pathology, any back pain experienced during service was likely due to delayed onset muscle soreness (DOMS) associated with physical activity. DOMS does not result in or predispose to development of degenerative disc disease lumbar spine, IVDS, or L lower extremity radiculopathy." Throughout this first opinion, the examiner cited to multiple pieces of medical literature as well as to the facts of the Veteran's case.

In her second November 2023 opinion, the October 2023 VA examiner opined that the claimed condition is less likely than not proximately due to or the result of the Veteran's service connected condition of left knee strain with meniscus tear and meniscectomy with residual nonpainful scar. In her rationale, she noted that "there is no support in the medical literature for left knee strain with meniscus tear and meniscectomy with residual nonpainful scar causing degenerative spinal changes or resultant IVDS and lower extremity radiculopathy." She noted that "The most common risk factors for degenerative spinal conditions are advanced age, being overweight, injury to the spine, congenital spinal disorders such as pars defects and family history." She noted that "In this case the aging veteran has been and is obese," and that "Age and obesity are both well established aggravators of spinal degenerative changes and resultant IVDS and lower extremity radiculopathy." She also noted that "records provided do not document a gait or other abnormality due to the service connected condition severe enough to cause the lumbar degenerative disc disease or resultant IVDS and lower extremity radiculopathy." She stated that "Left knee strain with meniscus tear and meniscectomy with residual nonpainful scar has also not been shown to result in metabolic disturbances that would result in weight gain and/or obesity as an intermediate step in the development of degenerative disc disease lumbar spine, resultant IVDS and lower extremity radiculopathy that could not be managed by calorie restriction." As noted above, the examiner observed that "The referral to the VA MOVE program is evidence that the Veteran's care providers had confidence that calorie restriction would induce weight loss." Throughout this second opinion, the examiner cited to multiple pieces of medical literature as well as to the facts of the Veteran's case.

In the third November 2023 opinion, the October 2023 VA examiner opined that the Veteran's back disability was not at least as likely as not aggravated beyond its natural progression by the left knee strain with meniscus tear and meniscectomy with residual nonpainful scar. Her rationale was that "there is no support in the medical literature for left knee strain with meniscus tear and meniscectomy with residual nonpainful scar causing or aggravating beyond their natural progression degenerative spinal changes, or causing IVDS or L lower extremity radiculopathy." She noted that "The current level of severity of the claimed condition is greater than the baseline."

She reiterated her earlier discussion of the most common risk factors for degenerative spinal conditions. She also stated that "Left knee strain with meniscus tear and meniscectomy with residual nonpainful scar has also not been shown to result in metabolic disturbances that would result in weight gain and/or obesity as an intermediate step in the aggravation of degenerative disc disease lumbar spine, resultant IVDS and lower extremity radiculopathy that could not be managed by calorie restriction," again citing the Veteran's referral to the VA MOVE program as "evidence that the Veteran's care providers had confidence that calorie restriction would induce weight loss." She cited multiple pieces of medical literature and facts of the Veteran's case to support her opinion.

The Board finds that the November 2023 examination report and medical opinions are highly probative to the direct, secondary, direct and secondary based on aggravation, and direct and secondary based on obesity theories of entitlement to service connection for a back disability in this case. They were authored by a physician who possesses the necessary education, training, or experience to provide competent medical evidence under 38 C.F.R. §
lower extremity radiculopathy that could not be managed by calorie restriction," again citing the Veteran's referral to the VA MOVE program as "evidence that the Veteran's care providers had confidence that calorie restriction would induce weight loss." She cited multiple pieces of medical literature and facts of the Veteran's case to support her opinion.

The Board finds that the November 2023 examination report and medical opinions are highly probative to the direct, secondary, direct and secondary based on aggravation, and direct and secondary based on obesity theories of entitlement to service connection for a back disability in this case. They were authored by a physician who possesses the necessary education, training, or experience to provide competent medical evidence under 38 C.F.R. § 3.159 (a)(1). See Cox v. Nicholson, 20 Vet. App. 563 (2007). They are based on review of the claims file and interview and examination of the Veteran, and they contain detailed rationales that cite to the facts of the Veteran's case and pertinent medical principles.

In short, the Board finds that entitlement to service connection for a back disability is not warranted on a direct basis, on a secondary basis, on a direct and secondary basis based on aggravation, or due to obesity directly or based on aggravation is not warranted.

REASONS FOR REMAND

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

The Veteran contends that his right hip disability is related to his other disabilities for which he has claimed service connection. Of the claimed disabilities, service connection is in effect for his left knee disability. His theory of entitlement is as follows:

Well, the right hip I - myself and what some of the doctors have told me it's just when you hurt your feet, you walk a certain way trying to keep the pain off of it, and, you know, you put pressure on other parts of your body. Well, the problem with the feet and the knees had worked its way to the hip. So, the hip - when - before I had this hip surgery, my left leg was my long leg, right leg was the shorter leg. Now by the time I got to the fourth - the third hip, fourth surgery, they - they had to put in such a big prosthetic piece, I wound up being an inch longer on my left leg instead of being the right - I mean, I'm sorry, my right leg is an inch longer than the left. That causes a lot of pressure on that hip. They tried putting a build up on my shoe. That didn't work. I've tripped over it more than it helped me. So, it's just what you have - you know, the way I walk is the way I walk, and it - in and itself walking incorrectly causes more problems with pain and everything.

(See Board hearing transcript, page 9.)

The undersigned rephrased the Veteran's contentions, noting that "the altered gait affected your knees, and then, of course, so the back and the knees also affected the right hip." (See Board hearing transcript, pages 14-15
longer than the left. That causes a lot of pressure on that hip. They tried putting a build up on my shoe. That didn't work. I've tripped over it more than it helped me. So, it's just what you have - you know, the way I walk is the way I walk, and it - in and itself walking incorrectly causes more problems with pain and everything.

(See Board hearing transcript, page 9.)

In October 2017, an etiology opinion was obtained with respect to the question of whether his right hip disability was secondary to his right foot and right knee disabilities. The examiner at the time noted that service connection was not in effect for a right foot or right knee disability. The Board notes, however, that service connection is in effect for a left knee disability, and no opinion was provided with respect to that theory of entitlement. Therefore, a remand is required so that the Veteran may undergo a VA examination and an etiology opinion may be obtained.

The matters are REMANDED for the following action:

1. Obtain all relevant VA and private treatment records not currently associated with the claims file, to include any VA medical records that were created since the Veteran's records were last obtained.

2. Schedule the Veteran for an examination with an appropriate examiner to determine the nature and etiology of his current right hip disability. The Veteran should be interviewed, and all indicated tests and studies should be accomplished. All findings should be reported in detail.

The Veteran's claims folder must be reviewed by the examiner in conjunction with the examination.

For each diagnosed disability, the examiner should provide an opinion as to whether it is at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that such disability was caused or aggravated (regardless of permanence) by his service-connected left knee strain with meniscus tear and meniscectomy with residual nonpainful scar. Please discuss the Veteran's contentions that leg length discrepancy due to his left knee disability led to his right hip disability.

A complete rationale for all opinions should be provided, including discussion of the facts of the Veteran's case and pertinent medical principles.

TANYA SMITH

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board Elizabeth Jalley, Counsel

The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.

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