KNEE IMPAIRMENT OF

A. P. SIMPSON · 2025 · Case ID: A25061405

DENIED

Summary

The veteran, who served from July 1989 to May 1992, appeals the denial of service connection for a right knee disability, including strain and osteoarthritis, claimed as secondary to his service-connected bilateral pes planus and obesity. The Board reviewed the evidence of record at the time of the December 2021 rating decision. The veteran's claim was previously denied by the AOJ and the Board, and a subsequent appeal to the Court of Appeals for Veterans Claims resulted in a remand for further consideration of aggravation. The Board found that while the veteran has a current right knee disability (strain and osteoarthritis) and is service-connected for bilateral pes planus, the evidence persuasively weighs against a secondary connection. Three VA medical opinions from July and November 2021 concluded that the right knee disability was less likely than not proximately due to or the result of the service-connected pes planus. The examiners noted that medical literature does not support pes planus or plantar fasciitis as direct causes of knee joint symptoms without a severe limp, which was not documented or present. They also found the knee pathology to be separate from the foot condition. The Board found these opinions probative and that they addressed both causation and aggravation, ruling out the possibility of aggravation. The veteran's lay opinion was deemed nonprobative as causation requires medical expertise. The evidence did not favor the veteran, so the benefit of the doubt doctrine was not applied. The claim for secondary service connection for the right knee disability was denied.

Rationale

VA examiner opined right knee disability less likely than not due to service-connected pes planus.; Examiner noted no evidence that pes planus without severe limp causes knee symptoms.; Examiner found right knee pathology separate from feet.; Board found opinions addressed causation and aggravation, ruling out possibility.; Veteran's lay opinion deemed nonprobative for causation.

Special Benefit

NO SPECIAL BENEFIT

Docket No.

220106-211818

Full Decision Text

Citation Nr: A25061405
Decision Date: 07/17/25 Archive Date: 07/17/25

DOCKET NO. 220106-211818
DATE: July 17, 2025

ORDER

Entitlement to service connection for a right knee disability, to include right knee strain and osteoarthritis, as secondary to the service-connected bilateral pes planus with plantar fasciitis and calcaneal spur (bilateral pes planus), and to include as due to obesity as an intermediate step, is denied.

FINDING OF FACT

The Veteran's right knee disability is not caused or aggravated by a service-connected disability.

CONCLUSION OF LAW

The criteria for entitlement to service connection for right knee disability, to include right knee strain and osteoarthritis, as secondary to the service-connected bilateral pes planus, and to include as due to obesity as an intermediate step, have not been met. 38 U.S.C. § 5107; 38 C.F.R. §§ 3.102, 3.310.

REASONS AND BASES FOR FINDING AND CONCLUSION

The Veteran served on active duty from July 1989 to May 1992.

This matter comes to the Board on appeal from a January 2022 rating decision that was a higher-level review of a December 2021 rating decision. In the January 2022 rating decision, the Agency of Original Jurisdiction (AOJ), in pertinent part, continued the previous denial of service connection for right knee disability as secondary to the service-connected bilateral pes planus, and to include as due to obesity as an intermediate step.

In January 2022, the Veteran timely appealed the decision to the Board in a VA Form 10182, Decision Review Request: Board Appeal, and elected a "Direct Review" of the evidence by a Veterans Law Judge. In a September 2024 decision, the Board, in relevant part, also denied the secondary service-connection claim.

The Veteran appealed the September 2024 Board decision to the United States Court of Appeals for Veterans Claims (Court). In March 2025, the Veteran and the Secretary of VA (parties) entered a Joint Motion for Partial Remand (Joint Motion) related to the Veteran's secondary service-connection claim. The parties agreed that remand was warranted for the Board to address whether a new examination that addresses aggravation is warranted. The parties noted that El-Amin requires that a medical opinion addressing secondary service connection address both a direct causation theory and an aggravation theory. El-Amin v. Shinseki, 26 Vet. App. 136 (2013). The parties found that in the Veteran's case, neither medical opinion relied upon by the Board addressed an aggravation theory. The parties further indicated that while the Board found the examiner's statement that "the right knee is a separate condition from the feet" to satisfy El-Amin, this reasoning was not clear enough for the Court and the Veteran to understand precisely how these conditions being "separate" necessarily means that aggravation is not possible. See Mayfield v. Nicholson, 19 Vet. App. 103, 129 (2005). In a decision later that month, the Court granted the Joint Motion.

The appeal has now returned to the Board. In an Appeals Modernization Act (AMA) Direct Review appeal where the rating decision is a higher-level review, the Board may consider only the evidence of record at the time of the December 2021 rating decision. 38 C.F.R. § 20.302.

If evidence was associated with the claims file during a period of time when additional evidence was not allowed, the Board has not considered it in this decision. 38 C.F.R. § 20.300. If the Veteran would like VA to consider any evidence that was added to the claims file that the Board could not consider, the Veteran may file a Supplemental Claim (VA Form 20-0995) and submit or identify this evidence. 38 C.F.R. § 3.2501. If the evidence is new and relevant, VA will issue another decision on the claim, considering the new evidence in addition to the evidence previously considered. Id. Specific instructions for filing a Supplemental Claim are included with this decision.

Entitlement to service connection for right knee disability, to include right knee strain and osteoarthritis, as secondary to the service-connected bilateral pes planus, and to include as due to obesity as an intermediate step.

In her June 2021 VA Form 20-0995 Supplemental Claim application, the Veteran contends that service connection for a right knee disability is warranted as secondary to her service-connected bilateral pes planus with obesity as an intermediate step.

.F.R. § 3.2501. If the evidence is new and relevant, VA will issue another decision on the claim, considering the new evidence in addition to the evidence previously considered. Id. Specific instructions for filing a Supplemental Claim are included with this decision.

Service Connection

Service connection may be granted for a disability that is proximately due to, or the result of, a service-connected disability. See 38 C.F.R. § 3.310 (a). When service connection is established for a secondary disability, the secondary disability shall be considered a part of the original disability. Id. Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability.

In an opinion issued by VA's General Counsel, the General Counsel determined that obesity cannot be service connected on a direct basis and obesity cannot qualify as an in-service event for service-connection purposes. However, the General Counsel determined that obesity may serve as an intermediate step between a service-connected disability and a current disability that may be service connected on a secondary basis under 38 C.F.R. § 3.310 (a). VAOGCPREC 1-2017. In such case, that evidence would need to reflect: (1) a service-connected disability or disabilities that caused the veteran to become obese; (2) the obesity was a substantial factor in causing another disability; and (3) the disability would not have occurred but for the obesity caused by the veteran's service-connected disability or disabilities. Id.

In a decision by the United States Court of Appeals for Veterans Claims, it held that while obesity is not itself recognized as a disability by the Secretary of VA, it may be recognized as an intermediate step between a service-connected disability and a disability claimed as secondary to that service-connected disability, based on the service-connected disability causing or aggravating the obesity. See Walsh v. Wilkie, 32 Vet. App. 300, 306-07 (2020).

The Board has carefully reviewed the evidence of record and finds that the evidence persuasively weighs against the claim for service connection for a right knee disability. The reasons follow.

As to evidence of a current disability, in the July 2021 VA examination report, the examiner diagnosed the Veteran with a right knee strain and osteoarthritis. In the January 2022 rating decision, the AOJ found that the Veteran had been diagnosed with a disability. The Board is bound by this favorable finding. See 38 C.F.R. § 3.104(c).

To the extent that secondary service connection requires a primary, service-connected disability, the record reflects that the Veteran is service connected for bilateral pes planus with plantar fasciitis and calcaneal spur of the right foot (bilateral pes planus). Thus, the threshold element is also met. However, the evidence persuasively weighs against finding that the Veteran's service-connected bilateral pes planus caused or aggravated the Veteran's right knee disability.

In a July 2021 VA medical opinion, the examiner opined that the Veteran's right knee disability was less likely than not proximately due to or the result of the Veteran's service-connected condition. In reaching this opinion, the examiner stated that based upon current medical literature related to the Veteran's conditions, there was no evidence that pes planus or plantar fasciitis "without severe limp" may cause knee joint symptoms. The examiner explained that in the case of an antalgic gait secondary to foot pain, it would be necessary for the limp to be severe for it to have a significant impact on the initiation or aggravation of the knee conditions. The examiner then noted that this severe limp was neither indicated in the Veteran's records nor present upon evaluation during the Veteran's associated in-person examination.

A November 2021 VA examiner similarly concluded that the Veteran's right knee disability was less likely than not due to or the result of her service-connected bilateral pes planus. Specifically, the examiner stated that a review of the Veteran's file did not reveal any treatment record establishing that the Veteran's right knee disability was due to her bilateral pes planus. The examiner noted that according to a September
algic gait secondary to foot pain, it would be necessary for the limp to be severe for it to have a significant impact on the initiation or aggravation of the knee conditions. The examiner then noted that this severe limp was neither indicated in the Veteran's records nor present upon evaluation during the Veteran's associated in-person examination.

A November 2021 VA examiner similarly concluded that the Veteran's right knee disability was less likely than not due to or the result of her service-connected bilateral pes planus. Specifically, the examiner stated that a review of the Veteran's file did not reveal any treatment record establishing that the Veteran's right knee disability was due to her bilateral pes planus. The examiner noted that according to a September 2019 VA treatment record, the Veteran reported falling on cement in May 2018. She stated that since then, she has had right knee pain continuously. The September treatment record also indicated that a June 2018 x-ray of the Veteran's right knee revealed degenerative changes and ganglion cyst. The VA examiner further noted that the internal pathology of the right knee ganglion cyst and degenerative joint disease had nothing to do with the feet. As such, the examiner found that the right knee disability was a separate condition from the feet.

In a November 2021 addendum VA opinion, a different examiner stated that in the current medical literature, neither pes planus nor plantar fasciitis are direct causes or etiology for obesity. Additionally, the examiner stated that there was no documented evidence in the Veteran's medical records to suggest that her bilateral foot disability and symptoms contributed directly to her obesity. The examiner also documented that he agreed with the other November 2021 examiner who opined that the Veteran's right knee disability was a separate condition from the feet.

Turning to the Board's task of addressing whether a new examination that addresses aggravation is warranted, the Board finds that a new examination is not necessary. As noted in the Board's September 2024 decision, while the November 2021 examiners did not specifically address "aggravation," the Board finds the opinions distinguishable from the holding in El-Amin v. Shinseki, 26 Vet. App. 136 (2013). Here, the two November 2021 examiners opined that the right knee disability is a separate condition from the Veteran's bilateral pes planus. Specifically, the earlier November 2021 examiner stated that a June 2018 x-ray of the Veteran's right knee revealed degenerative changes and ganglion cyst. The examiner found that these diagnostic findings indicated that the internal pathology of the right knee ganglion cyst and degenerative joint disease had nothing to do with the feet. Given this, the examiner determined that the Veteran's right knee disability and her service-connected bilateral pes planus were separate conditions.

The Board notes that "Pathology (from the Greek word pathología, meaning the study of suffering) refers to the specialty of medical science concerned with the cause, development, structural/functional changes, and natural history associated with diseases." https://pmc.ncbi.nlm.nih.gov/articles/PMC7150046/. Given that pathology concerns not only the causation, but also the development and structural/functional changes of a disease, the Board finds the earlier November 2021 examiner's opinion that the Veteran's right knee disability has an internal pathology that has "nothing to do with the feet," and, therefore, is a separate condition, addresses both causation and aggravation. The latter November 2021 examiner agreed that the Veteran's right knee disability and the service-connected bilateral pes planus were separate conditions.

Because the examiners clearly opined that there was no connection between the right knee and bilateral foot disability, the examiners' statements, unlike that of the examiner in El-Amin, rule out the possibility that the service-connected disability may aggravate to some degree the non-service-connected disability. Thus, the Board finds that the examiners' opinions addressed both causation and aggravation and are, therefore, probative regarding whether the service-connected disability caused or aggravated the right knee disability.

The Board further notes that the author of the latter November 2021 opinion also authored the July 2021 opinion finding that the Veteran's right knee disability was not proximately due to or the result of the service-connected condition. In the July 2021 opinion, the examiner stated that medical literature did not support a nexus in cases such as that of the Veteran, where there was an absence of evidence of a severe limp to establish that an antalgic gait caused significant impact on the initiation or aggravation of a knee disability. The July 2021 opinion was based upon an in-person examination and a review of the Veteran's claims file. The Board notes that VA treatment records from the period on appeal document that the Veteran's gait is generally steady/normal with a mild antalgic gait. When the latter November 2021 VA opinion is read in conjunction with the July 2021 opinion, it lends further support to the conclusion that the examiner addressed both causation and aggravation when concluding that the Veteran's right knee disability and the service-connected bilateral foot disorder were separate conditions.

The Board finds the three VA medical opinions highly probative. Collectively, the examiners provided an in-person examination, reviewed the claims file, included detailed comments of the evidence in the examination report, and provided rationales for the opinions that relied on sound medical principles and the specific facts of the case. Consequently, the opinions serve as evidence against a nexus between the Veteran's current right knee disability and the service-connected bilateral pes planus, to include obesity as an intermediate step. There is no competent evidence to weigh against the VA medical opinions. Thus, the Board finds that the evidence persuasively weighs against finding a nexus between the Veteran's current right knee disability and the service-connected bilateral pes planus.

While the Veteran alleges that her right knee disability was caused or aggravated by the bilateral pes planus, to include obesity as an intermediate step, she is not competent to attribute the right knee disability to pes planus, as medical expertise is required. In this regard, the question of causation involves a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship. As such, the question of etiology in this case may not be competently addressed by lay evidence, and the Veteran's opinion is nonprobative evidence.

For the above reasons, the evidence is neither evenly balanced nor approximately so with regard to whether entitlement to service connection for a right knee disability, to include right knee strain and osteoarthritis, as secondary to the service-connected bilateral pes planus, and to include as due to obesity as an intermediate step, is warranted. Rather, the evidence persuasively weighs against the claim. The benefit of the doubt doctrine is therefore not for application. See 38 U.S.C. § 5107(b); Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021) (en banc) (only when the evidence persuasively favors one side or another is the benefit of the doubt doctrine not for application).

A. P. SIMPSON

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board P.C.

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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