KNEE IMPAIRMENT OF

K. CONNER · 2026 · Case ID: A26011093

GRANTED

Summary

The veteran, an Army veteran who served from August 1996 to August 2000, appeals the denial of service connection for left and right knee disabilities. The veteran claims these conditions are secondary to his service-connected left ankle disability, which was established in a December 2003 rating decision. The Board reviewed the evidence, including service treatment records, VA examinations, private treatment notes, and a recent opinion from the veteran's treating physician. The Board found the January 2019 and October 2019 VA opinions to be of little probative value. The January 2019 opinion failed to provide a secondary service connection opinion for the left knee and did not address aggravation for the right knee. The October 2019 opinion's rationale for the left knee was unclear. Conversely, the Board found a March 2024 private opinion from the veteran's treating physician to be more persuasive. This opinion provided a thorough medical analysis linking the left ankle injury to the onset and symptoms of the veteran's left and right knee disabilities, including subluxation, chondromalacia, and degenerative arthritis. The Board also considered other private treatment notes that attributed the knee issues to the ankle injury. Based on this evidence, the Board found that service connection for both left and right knee disabilities is warranted as secondary to the service-connected left ankle disability.

Rationale

Current left knee disability diagnosed; Service-connected left ankle disability established; Causal relationship found via private medical opinions and treatment notes

Service Branch

ARMY

Special Benefit

NO SPECIAL BENEFIT

Docket No.

200602-90289

Full Decision Text

Citation Nr: A26011093
Decision Date: 02/05/26 Archive Date: 02/05/26

DOCKET NO. 200602-90289
DATE: February 5, 2026

ORDER

Entitlement to service connection for left knee degenerative arthritis with subluxation and chondromalacia is granted.

Entitlement to service connection for right knee degenerative arthritis is granted.

FINDINGS OF FACT

1. The Veteran's current left knee degenerative arthritis with subluxation and chondromalacia is due to his service-connected left ankle disability.

2. The Veteran's current right knee degenerative arthritis is due to his service-connected left ankle disability.

CONCLUSIONS OF LAW

1. The criteria for service connection for left knee degenerative arthritis with subluxation and chondromalacia have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310.

2. The criteria for service connection for right knee degenerative arthritis have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310.

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran served on active duty in the United States Army from August 1996 to August 2000.

This matter comes before the Board of Veterans' Appeals (Board) on appeal from a May 2020 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO), the Agency of Original Jurisdiction (AOJ), which denied service connection for left and right knee disabilities.

In June 2020, the Veteran submitted a VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement) on which he identified the May 2020 rating decision, the issues set forth above, and elected the Hearing docket. A Board hearing was held on April 30, 2024.

By way of background, in a January 2019 rating decision, the AOJ denied service connection for left and right knee disabilities. In July 2019, the Veteran submitted a VA Form 20-0995, Decision Review Request: Supplemental Claim, seeking readjudication of the January 2019 rating decision. In an October 2019 rating decision, the AOJ determined that new and relevant evidence had not been received sufficient to readjudicate the claims. Despite these findings, the AOJ readjudicated the claims on the merits and denied service connection for left and right knee disabilities. In May 2020, the Veteran submitted a supplemental claim, seeking readjudication of the previous denial of service connection for left and right knee disabilities. In the May 2020 rating decision on appeal, the AOJ determined that new and relevant evidence had not been received sufficient to readjudicate the claim of service connection for a left knee disability. Despite this finding, the AOJ readjudicated the claim on the merits and denied service connection for a left knee disability. Given the AOJ's readjudication of this claim on the merits, the Board finds that the AOJ made the favorable finding that new and relevant evidence had been received and will proceed accordingly. With respect to the claim of service connection for a right knee disability, for reasons unclear to the Board, the AOJ determined that new and material evidence had not been received sufficient to readjudicate the claim. The Board notes that the new and material standard is not applicable to cases in the AMA review system. Nevertheless, the AOJ adjudicated the claim on the merits and denied service connection for a right knee disability. As above, given the AOJ's readjudication of this claim on the merits, the Board finds that the AOJ made the favorable finding that new and relevant evidence had been received and will proceed accordingly. As indicated above, VA received the Veteran's Board appeal in June 2020, on which he identified the May 2020 rating decision.

1. Entitlement to service connection for left knee degenerative arthritis with subluxation and chondromalacia.

2. Entitlement to service connection for right knee degenerative arthritis.

The Veteran contends that his left knee degenerative arthritis with subluxation and chondromalacia (left knee disability) and his right knee degenerative arthritis (right knee disability) are secondary to his service-connected left ankle disability. See December 2018 VA Form 21-526EZ, July 2019 and May 2020 VA Form 20-0995.

Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service.
, on which he identified the May 2020 rating decision.

1. Entitlement to service connection for left knee degenerative arthritis with subluxation and chondromalacia.

2. Entitlement to service connection for right knee degenerative arthritis.

Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) 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 in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004).

Service connection may also be granted for a disability that is proximately due to, or aggravated by, a service-connected disability. 38 C.F.R. § 3.310. The three element test for secondary service connection requires evidence of: (1) a current disability; (2) a separate disability already service-connected; and (3) a causal relationship, i.e., a nexus, establishing that the current disability is due to, or aggravated beyond its natural progression by, the service-connected disability. See Allen v. Brown, 7 Vet. App. 439 (1995).

In rendering a decision on appeal, 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. Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the benefit of the doubt shall be given to the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102.

The Veteran's service treatment records (STRs) reflect that he injured his left ankle in service, in approximately 1996, and a proper diagnosis of avulsion fracture was not rendered until 1997, at which time he underwent arthroscopy and debridement.

The post-service treatment records reflect that in April 2002, the Veteran reported left knee pain that he said was caused by dislocation of his left knee while dancing. On physical examination, the Veteran was noted to walk with a slight limp. A review of systems reflected the Veteran's previous left ankle arthroscopy and debridement. The Veteran was diagnosed as having left knee patellar subluxation/dislocation by history.

In May 2002, the Veteran submitted a statement in which he claimed that he was told at the time of his left ankle injury, that "problems proximal to the ankle would eventually weaken and other problems may arise." During a November 2003 VARO hearing, the Veteran claimed that he had stiffness and swelling in his left ankle daily and that he had been in constant pain since the in-service injury. In a December 2003 rating decision, the RO awarded service connection for a left ankle disability, effective May 7, 2002.

The Veteran's VA treatment notes reflect that in September 2017, he reported chronic pain in his service-connected left ankle and chronic pain in his left knee. A December 2017 VA orthopedic surgery note reflects the Veteran's report that his left knee frequently dislocated. Following imaging, he was diagnosed as having chondromalacia and lateral subluxation of the left knee. A February 2018 initial physical therapy note reflects the Veteran's report that his left knee pain began around 2000, when he dislocated his patella. He indicated that his knee dislocates about once a year since that time. The clinician noted the Veteran's history of left ankle fracture and that his gait was mildly impaired. A November 2018 VA treatment note reflects the Veteran's report of right knee pain that he claimed was present since 2016. He also denied previous injury or surgery to the knee. Following imaging, the Veteran was diagnosed as having bilateral patellar femoral syndrome.

A December 2018
ondromalacia and lateral subluxation of the left knee. A February 2018 initial physical therapy note reflects the Veteran's report that his left knee pain began around 2000, when he dislocated his patella. He indicated that his knee dislocates about once a year since that time. The clinician noted the Veteran's history of left ankle fracture and that his gait was mildly impaired. A November 2018 VA treatment note reflects the Veteran's report of right knee pain that he claimed was present since 2016. He also denied previous injury or surgery to the knee. Following imaging, the Veteran was diagnosed as having bilateral patellar femoral syndrome.

A December 2018 private treatment note reflects the Veteran's history of left ankle fracture and chronic knee pain with recurrent patellar instability. After reviewing the Veteran's history, including a VA MRI from the previous year, the clinician diagnosed the Veteran as having left patellar instability and chondral defect lateral femoral condyle. In the Treatment Plan section of the note, the clinician stated that "I believe that the ankle injury has contributed to his left knee problems. I recommended a patellofemoral ligament reconstruction as well as an arthroscopy to treat the lateral condyle chondral defect. He's going to continue physical therapy and then we will recheck him in a couple months. Patient to return in 2 months for follow up."

In January 2019, the Veteran was afforded a VA examination, at which time he reported gradual onset of left knee pain within the first five years after service without injury and gradual onset of right knee pain in about 2016. The examiner noted diagnoses of left knee recurrent subluxation (diagnosed October 2017), bilateral degenerative arthritis (left knee diagnosed October 2017, right knee diagnosed November 2018), and left knee chondromalacia (diagnosed October 2017). In an accompanying opinion, the examiner determined that the Veteran's left knee disability was less likely than not related to his service. He reasoned that there was no evidence of a left knee injury in service, that certain individuals are genetically predisposed to develop degenerative arthritis, and that it is not uncommon for arthritis to gradually begin to affect weight bearing joints throughout the lower body due to the wear and tear of aging and an active lifestyle. With respect to the right knee, the examiner opined that it was less likely than not proximately due to or the result of the Veteran's service-connected left ankle disability. He reasoned that there is no indication that the left ankle disability caused mild arthritis in the contralateral knee. He also stated that while there is a common argument that a chronic antalgic limp can cause arthritis, the Veteran did not walk with a limp. The examiner stated that the Veteran's right knee disability is more likely than not related to a combination of genetic predisposition and the wear and tear of an active lifestyle.

In support of his July 2019 supplemental claim, the Veteran submitted a September 2019 knee and lower leg conditions disability benefits questionnaire (DBQ) completed by his treating VA physician. In the history section of the DBQ, the clinician noted "[s]ervice connected left tibia, fibular talar joint f[racture]. Chronic dislocation [greater than] 6 times/year and instability of the left knee are reported throughout patient's medical history. Proximal joints are showing signs of pathological degradation. Crepitus in left knee." He noted diagnoses of bilateral knee tendonitis/tendinosis (diagnosis made September 2012); left knee joint osteoarthritis (diagnosis made September 2012); left tibia and/or fibula fracture (diagnosis made May 1997); left recurrent patellar dislocation (diagnosis made September 2012); left recurrent subluxation (diagnosis made September 2012); left knee instability (diagnosis made September 2012); patellofemoral pain syndrome (no date noted); and left chondromalacia (diagnosis made September 2012). In the remarks section of the DBQ, the clinician stated, "[Veteran] presents with bilateral knee issues. Severe chronic dislocations of the left knee. [Veteran's] gait is altered due to pain and shifting weight to right leg when standing to compensation as a method to relieve pain and pressure. [Veteran] appeared guarded and nervous throughout the Valgus Stress test, consistent with recurring subluxation or dislocations. It is my opinion, that the joint pain, arthritis, and limited range of motion with the left and right knees are due to the ankle injury that occurred during his military service."

In
); and left chondromalacia (diagnosis made September 2012). In the remarks section of the DBQ, the clinician stated, "[Veteran] presents with bilateral knee issues. Severe chronic dislocations of the left knee. [Veteran's] gait is altered due to pain and shifting weight to right leg when standing to compensation as a method to relieve pain and pressure. [Veteran] appeared guarded and nervous throughout the Valgus Stress test, consistent with recurring subluxation or dislocations. It is my opinion, that the joint pain, arthritis, and limited range of motion with the left and right knees are due to the ankle injury that occurred during his military service."

In October 2019, the AOJ obtained an opinion regarding the etiology of the Veteran's left knee disability. The examiner opined that the Veteran's left knee disability is less likely than not proximately due to or the result of the Veteran's service-connected left ankle disability. She reasoned that "[g]iven that the opposite joint also has a history of injury it would be mere speculation to only say that the claimant's left ankle from 20+ years ago contributed to his left knee condition. . .."

In support of his May 2020 supplemental claim, the Veteran submitted an August 2019 private treatment note reflecting his report of continued left knee pain. In the history section of the note, the clinician indicated that, after his left ankle injury, the Veteran "was non weightbearing for quite some time and developed weakness in his lower extremities that needed to be rehabilitated. Subsequent to that, the [Veteran] started noticing at that time chronic dislocations of his left patella and occasionally the sensation of impending dislocation of the right patella." In the assessment section of the clinical note, the clinician stated, "[c]hronically dislocating left patella secondary to decreased size of lateral femoral condyle and developmental issues as well as weakening of the quadriceps mechanism years ago that never fully rehabilitated following prolonged non weightbearing from his ankle injury. The [Veteran] never had patellofemoral dislocations prior to his military related ankle injury and his immobilization. Therefore feel that the ankle injury contributed to and precipitated the problem with his left femoral patellar chondromalacia dislocation issues." In an April 2020 addendum to this clinical note, the clinician stated "[i]t is my professional opinion [the Veteran's] left knee condition is at least as likely as not (50 percent chance or greater) caused by his service-connected left ankle. The left ankle injury caused a long-standing gait disturbance which exerts stress and pain on the other joints in his lower extremities. The chronic gait problems due to left ankle surgery is likely to result in pain in the left ankle and bilateral knees as major weight bearing joints."

Following the April 2024 Board hearing, the Veteran submitted a March 2024 letter from Jennifer Pena, MD, who indicated that she had been the Veteran's treating physician since February 2023. She stated that she had been asked to write a statement in support of the Veteran's claim and noted that in preparation for such, she had reviewed his medical history, including service medical records and current medical records. She stated that she also reviewed the circumstances and events of his military service, including the left ankle injury. Dr. Pena opined that "[t]he altered gait pattern and biomechanical changes resulting from the left ankle surgery directly contributed to the development of bilateral knee subluxation. The abnormal distribution of weight and pressure on the lower extremities, due to compensatory mechanisms adopted by the body to accommodate the ankle injury, place excessive strain on the knee joints, leading to subluxation episodes." She further opined that "the persistent pain and limitations in motions experienced by [the Veteran] in both knees are directly linked to the biomechanical alterations induced by the left ankle surgery. The abnormal gait mechanics and altered joint loading patterns have exacerbated pre-existing vulnerabilities in the knee joints, resulting in pain, reduced range of motions, and functional limitations."

After reviewing the record, the Board finds that service connection for left and right knee disabilities is warranted.

As indicated above, in a December 2003 rating decision, the RO awarded service connection for a left ankle disability, effective May 7, 2002. Additionally, in the May 2020 rating decision on appeal, the AOJ made the favorable finding that the Veteran has current diagnoses of left knee degenerative arthritis with subluxation and chondromalacia and right knee degenerative arthritis, as evidenced by VA treatment records.

Thus, the first two elements for an award of secondary service connection have been met
have exacerbated pre-existing vulnerabilities in the knee joints, resulting in pain, reduced range of motions, and functional limitations."

After reviewing the record, the Board finds that service connection for left and right knee disabilities is warranted.

Thus, the first two elements for an award of secondary service connection have been met: (1) a current disability; and (2) a separate disability already service connected. The remaining element to be established is a causal relationship, i.e. a nexus, establishing that the current disability is due to, or aggravated beyond its natural progression by, the service-connected disability. See Allen v. Brown, 7 Vet. App. 439 (1995).

To that end, the Board finds the January 2019 VA opinion of little probative value in determining the question of nexus. Despite evidence in the record at the time of the examination that the Veteran's left knee disability was caused by his service-connected left ankle disability (see December 2018 private treatment note), the examiner failed to offer a secondary service connection opinion. Additionally, while he offered a negative secondary service connection opinion for the right knee, the examiner did not address the question of aggravation. To this extent, the opinion is inadequate. El-Amin v. Shinseki, 26 Vet. App. 136, 140-41 (2013) (holding that a secondary service connection opinion that addresses a causal relationship, but does not address the question of aggravation, is inadequate).

The Board also finds the October 2019 VA opinion of little probative value in determining the question of nexus with respect to the left knee disability. This is so because the examiner's rationale is unclear. Without any further discussion, she simply stated that any opinion on the etiology of the Veteran's left knee disability would be speculation because his right knee "also has a history of injury,"

On the other hand, the Board finds the March 2024 private opinion to be more probative. The clinician, who is one of the Veteran's treating physicians, applied a thorough medical analysis to the relevant facts of the case, including the history of the Veteran's service-connected ankle disability in relation to the onset and symptoms of his left and right knee disabilities, and provided a well-reasoned opinion accompanied by sufficient explanation. Also, as discussed above, there are several indications in the Veteran's private treatment records that his treating physicians attributed his left and/or right knee disabilities to his service-connected left ankle disability. See December 2018 private treatment note; September 2019 DBQ completed by the Veteran's treating physician; and August 2019 private treatment note.

Based on the foregoing, and considering the relative probative value of the conflicting opinions, the Board finds that the evidence is persuasively in favor of the Veteran's claims, and service connection for left and right knee disabilities is granted. 38 C.F.R. § 3.303, 3.310.

K. Conner

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board Madison, Siobhan K.

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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