KNEE IMPAIRMENT OF

Summary

The Veteran served in the Navy from May 1968 to October 1991. He appeals the denial of service connection for a bilateral knee disorder, claiming it is secondary to his service-connected lumbar spine disability. The Veteran testified to experiencing knee discomfort during service due to heavy lifting, though he did not seek formal treatment at that time. Service treatment records from his military service were negative for knee complaints or diagnoses. Post-service treatment records from 1993 showed degenerative joint disease in his knees. A March 2009 VA examination diagnosed knee osteophytic spur condition but opined it was not related to service-connected cervical spine changes and was likely due to aging. A May 2014 VA spine examination found lumbar spondylosis proximately due to cervical spine condition, noting biomechanical principles suggest effects on neighboring joints. A private medical opinion in October 2013 suggested the back and knee problems started in service due to heavy lifting. A November 2013 VA opinion found degenerative knee arthritis less likely than not related to service directly, but did not consider secondary connection. Following a remand, a private opinion in October 2018 opined the bilateral knee disorder was related to the service-connected lumbar spine disability, citing biomechanical principles. A subsequent October 2020 VA addendum opinion found the knee disorders less likely than not due to service-connected disability, citing lack of adjacent connection and absence of hip complaints. The Board found the evidence in relative equipoise, affording the Veteran the benefit of the doubt. Service connection for the bilateral knee disorder, as secondary to his service-connected lumbar spine disability, is granted.

Rationale

Current diagnosis of bilateral knee arthritis.; Secondary to service-connected lumbar spine disability.; Evidence in relative equipoise, benefit of the doubt applied.

Full Decision Text

Citation Nr: 21023762
Decision Date: 04/21/21	Archive Date: 04/21/21

DOCKET NO. 15-06 354
DATE: April 21, 2021

ORDER

Service connection for a bilateral knee disorder is granted.

FINDING OF FACT

Resolving all doubt in his favor, the Veteran has a current diagnosis of bilateral knee arthritis which has been related to his service-connected lumbar spine disability. 

CONCLUSION OF LAW

The criteria for service connection for a bilateral knee disorder, as secondary to service-connected lumbar spine disability, have been met.  38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.310.

REASONS AND BASES FOR FINDING AND CONCLUSION

The Veteran had active military service from May 1968 to October 1991.

This matter comes before the Board of Veterans’ Appeals (Board or BVA) on appeal from an April 2014 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Manila, the Philippines which, in part, continued a previous denial of entitlement to service connection for a bilateral knee disorder. 

In February 2016, the Veteran testified before the undersigned at a Board hearing. A transcript of that hearing is of record.

In July 2018, the Board reopened the previously denied claim of entitlement to service connection for a bilateral knee disorder based on the submission of new and material evidence and remanded the claim to obtain outstanding treatment records and an addendum medical opinion.

Legal Criteria

Service connection requires evidence of three elements: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship or nexus between the current disability and the disease or injury incurred or aggravated during active service. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). 

Service connection may be established on a secondary basis for a disability which is proximately due to or the result of service-connected disease or injury.  38 C.F.R. § 3.310(a).  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.  Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). 

When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant.  38 U.S.C. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). 

Analysis

The Veteran contends that service connection is warranted for a bilateral knee disorder, either on a direct basis or as secondary to his service-connected cervical and/or lumbar spine disabilities.  Specifically, during the February 2016 Board hearing, the Veteran testified that during his military service he was continuously tasked with lifting heavy materials, using the knee lifting method versus the back lifting method.  He began feeling discomfort in his knees during his military service but self-treated the symptoms with pain medication and did not seek formal treatment.  The Veteran continued to experience discomfort in his knees after his separation from service in 1991 but did not seek formal treatment until 1993.  At that time, he was told that his knees were normal, but he continued to experience discomfort in his knees, which increased in severity as he grew older.  

Service treatment records are absent for complaints, findings, or diagnoses of knee problems during service.  Examination reports dated in February 1968 and March 1972 for enlistment and reenlistment into the Navy, respectively, show abnormalities which appear to be scars on both patellae (LS and CS left patella and CS right patella); however, the Veteran’s lower extremities were evaluated as normal.  Examination reports dated in April 1988 and July 1991 show normal lower extremities; and no knee disorders were noted under the summary of defects and diagnoses.  In reports of medical history dated in March 1987, April 1988, and July 1991, the Veteran denied ever having swollen or painful joints and “trick” or locked knee; and no knee disorders were noted under the physician’s summary and elaboration of all pertinent data. 

Post-service treatment records show that the Veteran first sought treatment for right knee pain without
 show abnormalities which appear to be scars on both patellae (LS and CS left patella and CS right patella); however, the Veteran’s lower extremities were evaluated as normal.  Examination reports dated in April 1988 and July 1991 show normal lower extremities; and no knee disorders were noted under the summary of defects and diagnoses.  In reports of medical history dated in March 1987, April 1988, and July 1991, the Veteran denied ever having swollen or painful joints and “trick” or locked knee; and no knee disorders were noted under the physician’s summary and elaboration of all pertinent data. 

Post-service treatment records show that the Veteran first sought treatment for right knee pain without trauma in March 1993, however, this was approximately 15 months after his discharge from service at which time he reported knee pain and “locking” for several months.  At that time, however, physical and radiologic examinations were normal.  VA and private treatment records show a diagnosis of degenerative joint disease of the knees as early as July 2008.

The Veteran submitted an initial claim for service connection for a bilateral knee disorder in February 2009.  In connection with this claim, he was afforded a VA examination in March 2009 at which time he was diagnosed with knee osteophytic spur condition of both patellae.  Significantly, the March 2009 VA examiner opined that the Veteran’s knee osteophytic spur condition of both patellae was not caused by or a result of service-connected cervical spine osteophytic changes and that the degenerative osteophytic spur condition of patellae was most likely due to aging.  The examiner noted that for the cervical spine to affect the knee, the lumbar spine and hips had to show abnormal, osteo degenerative changes first before the knees and noted that this was not the case. 

However, a VA examiner who conducted a spine examination in May 2014 found that the Veteran’s lumbar spondylosis, diagnosed between 2006 and 2008, was proximately due to the Veteran’s cervical spine condition.  The examiner noted “Principles of Biomechanics dictate that any chronic derangement in a weight-bearing joint (including the spine) will eventually affect the neighboring weight bearing joints above and below this index joint.”  In fact, the record indicates that the Veteran had been having chronic back pain in May 2004 and a diagnosis of spondylosis in February 2007.  As above, the earliest evidence of arthritis of the knees is dated in July 2008.  Thus, the evidence appears to indicate that the Veteran’s lumbar spine exhibited degenerative changes prior to his knees.  The Board also notes that the Veteran has been awarded service connection for lumbar spondylosis.

In connection with the Veteran’s October 2013 claim to reopen, the Veteran submitted an October 2013 medical opinion from Dr. J.T.D. wherein the physician diagnosed the Veteran as having degenerative arthritis in both knees as well as lumbar spondylosis, L2 to L5 with degenerative disc disease L5-S1.  Significantly, Dr. J.T.D. opined that the Veteran’s back and bilateral knee problem started while the Veteran was still in the service of the United States Navy.  For two years the patient worked as storeroom supervisor which required a lot of lifting, bending and twisting resulting to low back and knee pain.

As the October 2013 opinion from Dr. J.T.D. appeared to be based solely on the Veteran’s reports of in-service knee pain, a VA medical opinion was obtained in November 2013.  Significantly, the November 2013 VA physician opined that the Veteran’s degenerative osteoarthritis of both knees was less likely than not related to the Veteran’s military service on a direct basis but did not consider whether the Veteran’s bilateral knee disorders are related to a service-connected disability.  As such, the case was remanded in July 2018 to obtain such an opinion.

Following the July 2018 Board remand, Dr. J.T.D. submitted a second medical opinion in October 2018 regarding secondary service connection.  Significantly, Dr. J.T.D. opined that the Veteran’s bilateral knee disorder is related to the Veteran’s service-connected lumbar spine disability.  As rationale for this opinion, Dr. J.T.D. noted that, from a medical perspective, the Principles of Biomechanics dictate that any chronic derangement in a weightbearing joint including the spine, therefore also the knees, will eventually affect neighboring weightbearing joints above and below the index joint.  Therefore, the Veteran’s bilateral knee disorder is secondary to service-connected lumbar spondylosis based on the principles of biomechan
 2018 Board remand, Dr. J.T.D. submitted a second medical opinion in October 2018 regarding secondary service connection.  Significantly, Dr. J.T.D. opined that the Veteran’s bilateral knee disorder is related to the Veteran’s service-connected lumbar spine disability.  As rationale for this opinion, Dr. J.T.D. noted that, from a medical perspective, the Principles of Biomechanics dictate that any chronic derangement in a weightbearing joint including the spine, therefore also the knees, will eventually affect neighboring weightbearing joints above and below the index joint.  Therefore, the Veteran’s bilateral knee disorder is secondary to service-connected lumbar spondylosis based on the principles of biomechanics.  Likewise, the Veteran’s lumbar spine shows abnormal osteodegenerative changes, resulting in numbness, loss of coordination and balance, muscle weakness and uneven gait which affected the Veteran’s knees resulting in degenerative arthritis in both knees. 

Most recently, in October 2020 a VA addendum opinion was obtained regarding the theory of secondary service connection.  Significantly, the examiner opined that the Veteran’s bilateral knee disorders were less likely than not (less than 50 percent probability) due to or the result of a service-connected disability.  As rationale for this opinion, the examiner noted that the Veteran’s service-connected cervical spine disability was in no way related to the Veteran’s bilateral knee disability since there was no adjacent connection or common innervation between the cervical vertebrae and the knees.  As for the lumbar spine, lumbar vertebra is connected to the pelvis which adjusts depending on the form and strain of the lumbar vertebra.  Any back pain could have possible hip pains due to compensation of the body to alleviate the back pain.  Complaints of hip pain or discomfort should have occurred prior to knee complaints if it was due to lumbar spondylosis and the Veteran has had no hip joint complaints.  Degenerative arthritis on any joint in the body increases in incidence with age and is not necessarily connected or caused by degenerative arthritis of other joints in the body.

Upon review of the evidence, the Board finds that the evidence of record is in relative equipoise and, affording the Veteran the benefit of the doubt, service connection for a bilateral knee disability is warranted.   

As an initial matter, the Board finds that the Veteran has a current diagnosis of bilateral knee arthritis.  Furthermore, there is medical evidence that such disability may be related to the Veteran’s service-connected disabilities.  As to this matter, the record contains both positive and negative nexus opinions.  

It is the responsibility of the Board to assess the credibility and weight to be given the evidence.  See Hayes v. Brown, 5 Vet. App. 60, 69-70 (1993) (citing Wood v. Derwinski, 1 Vet. App. 190, 192-93 (1992)).  The probative value of medical evidence is based on the physician’s knowledge and skill in analyzing the data, and the medical conclusion the physician reaches; as is true of any evidence, the credibility and weight to be attached to medical opinions are within the province of the Board.  See Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993). 

When reviewing such medical opinions, the Board may appropriately favor the opinion of one competent medical authority over another.  See Owens v. Brown, 7 Vet. App. 429, 433 (1995).  However, the Board may not reject medical opinions based on its own medical judgment.  See also Obert v. Brown, 5 Vet. App. 30 (1993); Colvin v. Derwinski, 1 Vet. App. 171 (1991).  In assessing medical opinions, the failure of the physician to provide a basis for his opinion goes to the weight or credibility of the evidence in the adjudication of the merits.  See Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998).  Other factors for assessing the probative value of a medical opinion are the physician’s access to the claims file and the thoroughness and detail of the opinion.  See Prejean v. West, 13 Vet. App. 444, 448-49 (2000).  A medical opinion may not be discounted solely because the examiner did not review the claims file.  Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). 

As above, the “principles of Biomechanics dictate that any chronic derangement in a weight-bearing joint (including the spine) will eventually affect the neighboring weight bearing joints above and below this index
1998).  Other factors for assessing the probative value of a medical opinion are the physician’s access to the claims file and the thoroughness and detail of the opinion.  See Prejean v. West, 13 Vet. App. 444, 448-49 (2000).  A medical opinion may not be discounted solely because the examiner did not review the claims file.  Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). 

As above, the “principles of Biomechanics dictate that any chronic derangement in a weight-bearing joint (including the spine) will eventually affect the neighboring weight bearing joints above and below this index joint” and, in an October 2018 statement, Dr. J.T.D. found that the Veteran’s lumbar spine shows abnormal osteodegenerative changes, resulting in numbness, loss of coordination and balance, muscle weakness and uneven gait which has affected the Veteran’s knees resulting in degenerative arthritis in both knees.  While the October 2020 VA examiner provided a negative nexus opinion, finding that, in order for the Veteran’s knees to have been affected by his lumbar spine, his hips would have been affected as well, the opinion does not consider whether the Veteran’s bilateral knee disabilities are aggravated by his service-connected cervical/lumbar spine disabilities based on an uneven gait. 

At this time, the Board declines to remand for an additional opinion as such would resemble a fishing expedition for negative evidence, which, in view of the available medical evidence, is not necessary.  Indeed, obtaining such additional evidentiary development in this instance would only result in additional delay with no benefit to the Veteran.  Sabonis v. Brown, 6 Vet. App. 426 (1994); VAOPGCPREC 5-04, 69 Fed. Reg. 59,989 (2004).  As such, the Board will resolve reasonable doubt in favor of the Veteran and find that the Veteran’s bilateral knee disabilities are related to his service-connected cervical/lumbar spine disabilities.  Therefore, service connection for a bilateral knee disability is warranted. 

 

 

K. OSBORNE

Veterans Law Judge

Board of Veterans’ Appeals

Attorney for the Board	April Maddox, 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.