OSTEOARTHRITIS

Summary

The Veteran, who served in the U.S. Navy from December 1959 to November 1963, appeals the denial of service connection for left knee osteoarthritis, claimed as secondary to his service-connected right knee osteoarthritis following a meniscal tear. The Veteran contended that degenerative changes in his left knee resulted from an altered gait and increased stress due to his service-connected right knee condition. The Board found the preponderance of the evidence weighed against this claim. Service treatment records were silent regarding left knee complaints or diagnoses, and examinations at enlistment and separation showed normal findings for the left knee. Post-service records indicated bilateral knee osteoarthritis, with the left knee showing milder changes than the right. A private physician opined that the left knee's degenerative changes were likely related to the right knee's osteoarthritis and altered gait. However, the VA examiner concluded that the left knee osteoarthritis was secondary to joint aging and chronic overuse, independent of the service-connected right knee condition. The examiner noted normal range of motion and no pain on examination of the left knee, concluding it was less likely than not related to service. The Board found the private opinion conclusory due to a lack of supporting diagnostic findings and rationale, according more weight to the VA examiner's opinion, which was based on a review of the full medical history and diagnostic testing. The Board denied service connection for the left knee osteoarthritis, finding no nexus to service or to the service-connected right knee condition.

Rationale

Service treatment records silent for left knee complaints/diagnosis; VA examiner found left knee osteoarthritis secondary to aging/overuse, not service-connected right knee condition; Private opinion conclusory; VA opinion accorded more weight

Full Decision Text

Citation Nr: A20013403
Decision Date: 08/21/20	Archive Date: 08/21/20

DOCKET NO. 200425-80102
DATE: August 21, 2020

ORDER

Entitlement to service connection for left knee osteoarthritis, to include as secondary to service-connected osteoarthritis status-post (s/p) meniscal tear of the right knee, is denied.

FINDING OF FACT

The preponderance of the evidence weighs against finding that the Veteran’s left knee osteoarthritis is causally related to active service, to include as secondary to service-connected osteoarthritis status-post (s/p) meniscal tear of the right knee.

CONCLUSION OF LAW

The criteria for establishing entitlement to service connection for left knee osteoarthritis, to include as secondary to service-connected osteoarthritis status-post (s/p) meniscal tear of the right knee have not been met.  38 U.S.C. §§ 1110, 1131, 5107 (2014); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2018).

REASONS AND BASES FOR FINDING AND CONCLUSION

On August 23, 2017, the President signed into law the Veterans Appeals Improvement and Modernization Act, Pub. L. No. 115-55 (to be codified as amended in scattered sections of 38 U.S.C.), 131 Stat. 1105 (2017), also known as the Appeals Modernization Act (AMA). This law creates a new framework for Veterans dissatisfied with VA’s decision on their claim to seek review.  This decision has been written consistent with the new AMA framework.

The Veteran reports honorable active duty service with the United States Navy from December 1959 to November 1963.

In February 2020, the Veteran submitted a VA Form 20-0996 Request for Higher-Level Review.  In the same month, a rating decision considered the evidence and denied the claim. The Veteran timely appealed the February 2020 rating decision via a VA Form 10182 Notice of Disagreement.  Direct review of the evidence by a Veterans Law Judge was requested.

Duty to Assist and to Notify

VA is required to notify a claimant of what information or evidence is necessary to substantiate the claim; what subset of the necessary information or evidence, if any, the claimant is to provide; and what subset of the necessary information or evidence, if any, the VA will attempt to obtain.  38 C.F.R. § 3.159(b) (2018).  Copies of compliant VCAA notices were located in the claim’s file.

VA’s duty to assist includes providing a thorough and contemporaneous medical examination, especially where it is necessary to determine the current level of a disability.  Peters v. Brown, 6 Vet. App. 540, 542 (1994).

In this case, neither the Veteran nor his representative has raised any issues with the duty to notify or duty to assist. See Scott v McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that “the Board’s obligation to read filings in a liberal manner does not require the Board... to search the record and address procedural arguments when the veteran fails to raise them before the Board.”); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to duty to assist argument).

Thus, upon careful review of the file, the Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the Veteran.  See Bernard v. Brown, 4 Vet. App. 384 (1993).

Service connection, generally

Service connection may be granted for any current disability that is the result of a disease contracted or an injury sustained while on active duty service.  38 U.S.C. § 1110, 1131 (2014); 38 C.F.R. §§ 3.303 (a), 3.304 (2018).

Entitlement to service connection benefits is established when the following elements are satisfied: (1) the existence of a current disability; (2) in-service incurrence or aggravation of a disease or injury; and, (3) a causal relationship between the current disability and the disease or injury incurred or aggravated during service (the medical ‘nexus’ requirement).  See Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004); 38 C.F.R. § 3.303 (a) (2018).

Service connection also
4); 38 C.F.R. §§ 3.303 (a), 3.304 (2018).

Entitlement to service connection benefits is established when the following elements are satisfied: (1) the existence of a current disability; (2) in-service incurrence or aggravation of a disease or injury; and, (3) a causal relationship between the current disability and the disease or injury incurred or aggravated during service (the medical ‘nexus’ requirement).  See Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004); 38 C.F.R. § 3.303 (a) (2018).

Service connection also is permissible on a secondary basis for disability that is proximately due to, the result of, or aggravated by a service-connected disability.  38 C.F.R. § 3.310 (a) and (b) (2018).  See also Allen v. Brown, 7 Vet. App. 439, 448 (1995).  In order to prevail on the issue of entitlement to secondary service connection, there must be (1) evidence of a current disability; (2) evidence of a service-connected disability; and, (3) nexus evidence establishing a connection between the service-connected disability and the current disability.  See Wallin v. West, 11 Vet. App. 509, 512 (1998).

Furthermore, in determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied.  38 U.S.C. § 5107 (2014); 38 C.F.R. § 3.102 (2018); Gilbert v. Derwinski, 1 Vet. App. 49 (1990).  When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of the matter, the benefit of the doubt will be given to the Veteran. Id.

The Board notes that it has thoroughly reviewed the record in conjunction with this case.  Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence submitted by the Veteran or on his behalf.  See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record but does not have to discuss each piece of evidence).  Rather, the Board’s analysis below will focus specifically on what the evidence shows, or fails to show, on the claim.  See Timberlake v. Gober, 14 Vet. App. 122, 129 (2000) (noting that the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive and provide the reasons for its rejection of any material evidence favorable to the claimant).  

Lay evidence, if competent and credible, may serve to establish a nexus in certain circumstances.  See Davidson v. Shinseki, 581 F.3d 1313 (2009) (noting that lay evidence is not incompetent merely for lack of contemporaneous medical evidence).  When considering whether lay evidence may be competent, the Board must determine, on a case by case basis, whether the Veteran’s particular disability is the type of disability for which lay evidence may be competent.  Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007) (holding that “[w]hether lay evidence is competent and sufficient in a particular case is a factual issue.

1. Entitlement to service connection for left knee osteoarthritis

The Veteran contends that his left knee osteoarthritis is causally related to active service, to include as secondary to service-connected osteoarthritis s/p meniscal tear of the right knee. More specifically, he contends that the degenerative changes in his left knee resulted from an altered gait and increased stress due to his service-connected right knee condition.  The preponderance of the evidence is against his claim.

In analyzing the asserted claim, the threshold inquiry before the Board is whether the Veteran has a current disability that began during active service or is at least as likely as not related to an in-service injury, event, or disease.

The Board concludes that, while the Veteran has a current diagnosis of left knee osteoarthritis, and the record shows
 his left knee osteoarthritis is causally related to active service, to include as secondary to service-connected osteoarthritis s/p meniscal tear of the right knee. More specifically, he contends that the degenerative changes in his left knee resulted from an altered gait and increased stress due to his service-connected right knee condition.  The preponderance of the evidence is against his claim.

In analyzing the asserted claim, the threshold inquiry before the Board is whether the Veteran has a current disability that began during active service or is at least as likely as not related to an in-service injury, event, or disease.

The Board concludes that, while the Veteran has a current diagnosis of left knee osteoarthritis, and the record shows in-service treatment for a right knee meniscus tear, the preponderance of the evidence weighs against finding that the Veteran’s osteoarthritis of the left knee is causally related to active service, to include as associated with his service-connected right knee condition.

Service treatment records are silent for complaints of left knee pain, a related injury, or a diagnosis of osteoarthritis.  At enlistment, no bilateral knee abnormalities were observed during a physical examination in October 1959. The Veteran was deemed qualified for active service. In a report of medical history bearing the same date, he denied any complaints of a trick or locked knee.  A physical examination of the left knee yielded normal findings at separation in October 1963. 

Post service treatment records show frequent complaints of bilateral knee pain.  In July 2014, X-ray findings revealed moderate to severe osteoarthritic changes involving medial compartment right knee joint and right patellofemoral space with marginal osteophytes.  As to the left knee, mild osteoarthritic changes were shown involving the medial compartment of left knee joint with minimal narrowing of the joint space.  Mild osteoarthritic changes also impacted the left patellofemoral space with tiny marginal osteophytes. Bilateral vascular calcifications were also indicated.

Again, in August 2018, X-ray films revealed mild to moderate left knee osteoarthritis and moderate right knee osteoarthritis.  

In May 2019, the Veteran underwent an orthopedic evaluation due to complaints of bilateral knee and back pain. During the clinical evaluation, the Veteran reported a long history of low back and knee pain.  At times, pain was rated at a 7 on a 10-point scale.  Other symptoms included locking, popping, and clicking of the bilateral knees.  Swelling and effusion was also noted.  Due to the reported symptoms, the Veteran experiences difficulty with prolonged walking and standing. He also endorsed walking with a limp.  

A rehabilitation consultation record, dated the same month, referenced chronic bilateral knee pain due to osteoarthritis.  The Veteran’s symptoms were managed conservatively with bracing.  A prior history of treatment included surgical repair of a right meniscus tear.  Complaints of low back pain were reportedly related to or exacerbated by the shorter length of the right leg.  Other symptoms include constant pain that worsened with flexion while walking.  The Veteran also reported difficulty with prolonged sitting, standing, lifting, and walking with leaning forward. To treat pain the Veteran endorsed use of oral medications and corticosteroid injections.

In November 2019, a private medical opinion was associated with the claim’s file.  Therein, the physician acknowledged the Veteran’s current diagnosis of right knee osteoarthritis with complete loss of his medial joint space.  The condition was described as severe.  Due to symptom progression, the Veteran currently suffers from moderate to severe degenerative osteoarthritis of the left knee.  An altered gait resulting from right knee osteoarthritis causes increasing stress on the left knee. Therefore, the physician concluded that degenerative changes in the Veteran’s left knee are most likely related to his right knee osteoarthritis. 

On examination in December 2019, current diagnoses included left knee joint osteoarthritis.  Degenerative arthritic changes were also observed.  Other diagnoses included right knee osteoarthritis s/p meniscal tear.  

During the clinical evaluation, the Veteran reported constant pain that impairs his ability to walk.  Frequent falls were reported due to knee instability.  The Veteran suggested an altered gait due to the shorter length of his right leg, s/p meniscal repair of the right knee. Use of assistive devices included regular use of bilateral knee braces and a cane to aid with ambulation.  The Veteran also endorsed use of a lift in the right shoe.  To treat pain, prescribed treatments included Tylenol, cortisone injections, and Hydrocodone 7.5 mg/Diclofenac Sodium topical gel.  Ice and heat were used to reduce swelling.  


 knee osteoarthritis s/p meniscal tear.  

During the clinical evaluation, the Veteran reported constant pain that impairs his ability to walk.  Frequent falls were reported due to knee instability.  The Veteran suggested an altered gait due to the shorter length of his right leg, s/p meniscal repair of the right knee. Use of assistive devices included regular use of bilateral knee braces and a cane to aid with ambulation.  The Veteran also endorsed use of a lift in the right shoe.  To treat pain, prescribed treatments included Tylenol, cortisone injections, and Hydrocodone 7.5 mg/Diclofenac Sodium topical gel.  Ice and heat were used to reduce swelling.  

On physical examination, no flare ups of pain were reported.  Functional loss was described as an inability to walk more than a few yards or stand for prolonged periods which limits work-related and social activities.

Range of motion of both knees was described as normal.  There was no evidence of pain, localized tenderness or pain to palpation on physical examination.  No loss of range of motion or additional functional loss was observed with repetitive use testing.  Neither pain, weakness, fatiguability, or incoordination impaired the Veteran’s functional ability over time.  No additional factors were listed as contributing to the Veteran’s left knee disability.  Muscle strength and joint stability testing yielded normal findings.  There was no evidence of muscle atrophy or ankylosis.   Prior surgical intervention included a meniscal tear repair involving the right knee only.  A painful scar measuring at 6 centimeters (cm) in length and 0.1 cm in width was noted.

Diagnostic imaging demonstrated bilateral knee osteoarthritis.  Degenerative joint disease was also noted.  Minimal medial joint space compromise was noted in the left knee.

Following the clinical evaluation, the examiner opined that the Veteran’s left knee joint osteoarthritis is secondary to joint aging and chronic overuse.  The condition was deemed independent and not proximately due to or caused by the right knee joint osteoarthritis condition.  In support of the stated conclusion, the examiner noted that a physical examination revealed full range of motion of the bilateral knees without pain.  There is no evidence of pain on passive range of motion or with non-weight bearing. Thus, the examiner opined that it is less likely than not (less than 50 percent probability) that the Veteran’s left knee condition was proximately due to or the result of the right knee osteoarthritis s/p meniscal tear.

In a lay statement attached to his VA Form 10182 Notice of Disagreement, the Veteran suggested that the VA examiner’s opinion was inadequate.  Specifically, he asserts that the VA examiner’s opinion suggested improvement of his bilateral knee condition but failed to conclude that the improvement was sustained. Further, the examiner failed to adequately explain the basis for evaluating the Veteran’s bilateral knee condition or the observed improvement.  The examiner’s opinion was deemed inconsistent with the favorable conclusions asserted by Veteran’s private physician.

Considering the forgoing, the Board finds that the Veteran’s left knee osteoarthritis is not etiologically related to active service, to include as secondary to his service-connected osteoarthritis s/p meniscal tear of the right knee.

In making all determinations, the Board has fully considered all lay assertions and medical evidence of record. Generally, the Veteran is deemed competent to report on his current symptoms and their onset. However, the record is silent for evidence showing that he possesses the specialized skills and expertise necessary to render complex medical opinions or opine as nature and etiology of his current symptoms. Layno v. Brown, 6 Vet. App. 465, 470 (1994); see also Jandreau v. Nicholson, 492 F.3d 1372, 1377. Further, mere conclusory or generalized lay assertions that an in- service event or illness caused a current disability are insufficient to establish nexus in the absence of competent medical evidence. Waters v. Shinseki, 601 F.3d 1274, 1278.

In this case, the medical evidence reveals that the Veteran has a current diagnosis of osteoarthritis of the bilateral knees. Service treatment records are silent for any complaints of left knee pain or any related diagnosis. Post-service treatment records show a current diagnosis of left knee osteoarthritis with degenerative changes.  A private medical opinion suggested a causal linkage between the degenerative changes in his left knee and an altered gait due to increased stress from his service-connected right knee condition. On examination in December 2019, the examiner noted that the Veteran’s range of motion was normal, bilaterally.  There was no evidence of pain on examination.  While diagnostic findings confirmed bilateral knee osteoarthritis with degenerative changes, the examiner
In this case, the medical evidence reveals that the Veteran has a current diagnosis of osteoarthritis of the bilateral knees. Service treatment records are silent for any complaints of left knee pain or any related diagnosis. Post-service treatment records show a current diagnosis of left knee osteoarthritis with degenerative changes.  A private medical opinion suggested a causal linkage between the degenerative changes in his left knee and an altered gait due to increased stress from his service-connected right knee condition. On examination in December 2019, the examiner noted that the Veteran’s range of motion was normal, bilaterally.  There was no evidence of pain on examination.  While diagnostic findings confirmed bilateral knee osteoarthritis with degenerative changes, the examiner concluded that the Veteran’s left knee osteoarthritis was secondary to joint aging and chronic overuse.  No causal linkage was established to the Veteran’s service-connected right knee condition.  In support of the stated conclusion, the examiner noted that range of motion testing yielded normal findings.  Moreover, there was no evidence of pain on passive range of motion or with non-weight bearing of the bilateral knees.

While the Board recognizes the Veteran’s subjective belief that his left knee osteoarthritis is causally related is causally related to his service-connected right knee condition, to include as due to an altered gait; the evidence of record does not support a finding of “nexus.”  In fact, the VA examiner suggested that the Veteran’s left knee condition is due to the natural aging process and overuse, and not his service-connected right knee condition.  The Board has fully considered the favorable opinion of the Veteran’s private physician.  However, the conclusions asserted were merely conclusory and as the physician failed to identify any supportive diagnostic findings or related rationale.  Under the circumstances, the Board accords more probative weight to the VA examiner’s opinion as it reflects a review of the Veteran’s full medical history, appropriate diagnostic testing, and reached conclusions that were reasonably drawn from the record.

Accordingly, as the preponderance of the evidence is against the claim, the provisions of 38 U.S.C. § 5107 (b) regarding reasonable doubt are not applicable. The Veteran’s claim of entitlement to service connection for osteoarthritis of the left knee, to include as associated with the Veteran’s service-connected right knee condition must be denied.

 

 

B. MULLINS

Veterans Law Judge

Board of Veterans’ Appeals

Attorney for the Board	N. Whitaker, 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.