OSTEOARTHRITIS

Summary

The Veteran, who served in the National Guard from June 1985 to July 1985, appeals the August 2021 rating decision denying service connection for left knee arthritis. The Veteran claimed aggravation of a pre-existing left knee condition during service, citing a fall during physical training in 1985. The enlistment examination noted a prior left leg injury in 1978 and a left knee surgery in 1979. Service treatment records from 1985 documented early post-traumatic arthritis, quadriceps atrophy, and loss of motion in the left knee, leading to a permanent profile. While a Medical Evaluation Board (MEB) initially concluded the condition was not permanently aggravated, contemporaneous clinical findings and the Veteran's consistent reports of increased symptoms post-injury suggest otherwise. The Board found the MEB's conclusion less persuasive due to conflicting evidence and the Veteran's credible accounts of worsening symptoms. Post-service VA opinions were inconsistent, with one initially finding a positive nexus and aggravation, then withdrawing it based on pre-existing conditions and brief service, while a treating provider later offered a positive opinion linking the condition to service demands and the in-service injury. The Board found the evidence regarding aggravation to be in approximate balance, resolving doubt in the Veteran's favor. Service connection for left knee arthritis is granted on an aggravation basis.

Rationale

Preexisting condition noted at entry, rebutting presumption of soundness.; In-service findings and Veteran's credible reports indicate worsening beyond natural progression.; Conflicting VA medical opinions and MEB conclusion are less persuasive than Veteran's account and treating provider's opinion.; Evidence in approximate balance, resolving doubt in Veteran's favor.

Full Decision Text

Citation Nr: A26039253
Decision Date: 04/28/26	Archive Date: 04/28/26

DOCKET NO. 210823-180986
DATE: April 28, 2026

ORDER

Entitlement to service connection for arthritis, left knee is granted.

FINDING OF FACT

The Veteran's left knee arthritis is presumed aggravated by service, and there is no clear and unmistakable evidence that the increase in the condition was due to the natural progression of the disability.

CONCLUSION OF LAW

The criteria for service connection for left knee arthritis are met.  38 U.S.C. §§ 1110, 1111, 1113, 1131, 1153, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.306.

REASONS AND BASES FOR FINDING AND CONCLUSION

The Veteran enlisted in the National Guard in April 1984.  He was credited with active duty from June 1985 to July 1985.  

The rating decision on appeal was issued in August 2021 and constitutes an initial decision; therefore, the modernized review system, also known as the Appeals Modernization Act (AMA), applies.

In the August 2021 VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement), the Veteran elected the Hearing docket.  A Board hearing was held on March 20, 2025, and a full transcript is of record.  Therefore, the Board may only consider the evidence of record at the time of the August 2021 agency of original jurisdiction (AOJ) decision on appeal, as well as any evidence submitted by the Veteran or representative at the hearing or within 90 days following the hearing.  38 C.F.R. § 20.302(a).  If evidence was submitted either (1) during the period after the AOJ issued the decision on appeal and prior to the Board hearing, or (2) more than 90 days following the hearing, the Board did not consider it in its decision.  38 C.F.R. §§ 20.300, 20.302(a), 20.801.

Entitlement to service connection for arthritis, left knee

The Veteran asserts that he aggravated his left knee arthritis during active duty.

The Veteran completed an enlistment examination and was found qualified during the spring of 1984.  He also reported on a medical history form from that same period that he had broken his left leg in 1978.  The Veteran's entrance examination noted the prior left knee injury.  See STR - Medical, January 11, 2019.

The Veteran later described having undergone left knee surgery in 1979 for a major injury treated with pins that were later removed.  During physical training as an AIT student in 1985, the Veteran suffered a left knee injury.  Service treatment records and imaging revealed early post traumatic arthritis of the left knee with quadriceps atrophy and loss of motion.  The diagnosis at that time was early post traumatic arthritis of the left knee with quadriceps atrophy and loss of motion.  See STR - Medical, January 11, 2019.

Medical Evaluation Board (MEB) proceedings issued during the summer of 1985 documented early post traumatic arthritis of the left knee with quadriceps atrophy and loss of extension, and a permanent profile was issued for left knee pain.  A narrative prepared several days later reiterated the prior left knee surgery in 1979 for a significant injury treated by pins later removed, noted that he could not fully extend the knee and experienced pain and swelling, and again described imaging findings of early post traumatic arthritis, quadriceps atrophy, and loss of motion in extension.  An EPTS (Existed Prior to Service) discharge was recommended.  A subsequent entry from July 1985 found that the Veteran was unable to perform duty because of a medical condition that existed prior to entry and that the MEB earlier that month had found him below retention standards and concluded that his pre-existing left knee arthritis had not been permanently aggravated during active duty.  See Military Personnel Record, January 11, 2019.

A VA examination conducted early in 2019 reflected the Veteran's report that the onset of knee problems occurred during service around mid 1984, consistent with the MEB information in the claims file, and he also reported an original onset of early arthritis in 1979.  He related falling into a hole during physical training and striking his knee on a wall locker shortly thereafter.  The Veteran stated that he was placed on profile during service and denied undergoing surgery or physical therapy since discharge.  His symptoms worsened with sitting and with climbing stairs, and he experienced stiffness and edema.  The examiner issued a negative aggravation opinion, citing
 been permanently aggravated during active duty.  See Military Personnel Record, January 11, 2019.

A VA examination conducted early in 2019 reflected the Veteran's report that the onset of knee problems occurred during service around mid 1984, consistent with the MEB information in the claims file, and he also reported an original onset of early arthritis in 1979.  He related falling into a hole during physical training and striking his knee on a wall locker shortly thereafter.  The Veteran stated that he was placed on profile during service and denied undergoing surgery or physical therapy since discharge.  His symptoms worsened with sitting and with climbing stairs, and he experienced stiffness and edema.  The examiner issued a negative aggravation opinion, citing the 1985 MEB findings, and imaging showed tricompartmental degenerative changes.  See C&P Exam, February 20, 2019.

A personal statement submitted at the beginning of 2021 described a fracture of the left knee while playing football in 1976, followed by several weeks in a cast and a full return to sports with no limitations.  He recounted slipping and falling into a hole during physical training in service, after which the knee popped and became swollen, and he was placed on light duty.  See Correspondence, January 7, 2021.

The Veteran was afforded another VA examination in connection with this claim.  Imaging revealed severe degenerative arthritic changes throughout the left knee, and an examiner diagnosed degenerative arthritis other than post traumatic.  The examiner initially issued a positive direct nexus opinion, concluding that the current degenerative arthritis was at least as likely as not related to the condition diagnosed during service in the mid 1980s.  The examiner also initially provided a positive aggravation opinion, reasoning that the pre existing left knee condition had been aggravated beyond natural progression by the demands of service and a reinjury in 1985.  These opinions were later withdrawn in a July 2021 addendum, which concluded that the left knee arthritis preexisted service and that the Veteran's brief period of service made it less likely than not that the condition was caused or aggravated during active duty.  See C&P Exam, July 29, 2021.

A statement submitted in March 2025 recounted a dislocation of the left knee at age nine while playing football, treated with a stabilizing pin, after which he returned to sports without further issues.  He explained that while running during physical training at Fort Lee, he stepped into a hidden hole and fell, and that he had experienced no difficulties before that incident.  Hearing testimony from that same month reflected that he did not seek treatment during service but again described stepping into a hidden hole during a morning physical training run and falling, after which his knee problems began.  He reported that he had experienced continuous symptoms since that in service injury and that he had no significant issues from the time of his childhood injury until the summer of 1985.  See Hearing Transcript, March 20, 2025; VA 21 4138 Statement in Support of Claim, March 26, 2025.

A treating provider offered a positive nexus opinion in early April 2025, concluding that the bilateral knee condition was a direct result of rigorous physical activity throughout military training and career combined with the knee injury sustained during physical training.  The provider documented that although the Veteran had sustained a remote left knee injury at age nine, he fully recovered, returned to normal activities and sports without issues, and entered the military with no limitations.  The provider noted that the Veteran's knee problems began in earnest after the training injury at Fort Lee.  See Medical Treatment Record - Non Government Facility, April 3, 2025.

Applicable Law and Regulation

A Veteran is presumed to have been sound upon entry into the military, except as to conditions noted at the time of the acceptance, examination, or enrollment, or where clear and unmistakable evidence demonstrates that the condition existed before acceptance and enrollment and was not aggravated by such service.  38 U.S.C. § 1111; Wagner v. Principi, 370 F.3d 1089, 1096 (Fed. Cir. 2004).  The presumption of soundness applies only when a disease or injury not noted upon entry to service manifests in service, and a question arises as to whether it preexisted service.  Gilbert v. Shinseki, 26 Vet. App. 48, 55 (2012), aff'd 749 F.3d 1370 (Fed. Cir. 2014).

The burden falls on VA to rebut the presumption of soundness by clear and unmistakable evidence that an injury or disease manifested in service was both preexisting and not aggravated by service.  See 38 U.S.C. § 1111.  Clear and unmistakable evidence means that
9, 1096 (Fed. Cir. 2004).  The presumption of soundness applies only when a disease or injury not noted upon entry to service manifests in service, and a question arises as to whether it preexisted service.  Gilbert v. Shinseki, 26 Vet. App. 48, 55 (2012), aff'd 749 F.3d 1370 (Fed. Cir. 2014).

The burden falls on VA to rebut the presumption of soundness by clear and unmistakable evidence that an injury or disease manifested in service was both preexisting and not aggravated by service.  See 38 U.S.C. § 1111.  Clear and unmistakable evidence means that the evidence cannot be misinterpreted and misunderstood, i.e., it is undebatable.  Quirin v. Shinseki, 22 Vet. App. 390, 396 (2009).  Clear and unmistakable evidence can consist of the Veteran's own admissions of a preservice disability.  Horn v. Shinseki, 25 Vet. App. 231, 237 (2012).  If there is clear and unmistakable evidence to show that the Veteran's disability was both preexisting and not aggravated by service, then the Veteran is not entitled to service-connected benefits for the preexisting condition.

When a question is raised as to whether a particular disability claimed by the Veteran pre-existed service, VA law provides that every Veteran shall be taken to have been in sound condition when examined, accepted, and enrolled for service, except as to defects, infirmities or disorders noted at the time of examination, acceptance, and enrollment into service.  See 38 U.S.C. § 1111; 38 C.F.R. § 3.304(b).  If a pre-existing disability is noted at entry, then the presumption of soundness is rebutted, and aggravation of that disability must be demonstrated for service connection to be granted.  A pre-existing injury or disease will be considered to have been aggravated during service where there is an increase in disability during service unless there is a specific finding that the increase in disability is due to the natural progress of the disease.  38 C.F.R. § 3.306.

When there is an approximate balance of evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant.  38 U.S.C. § 5107; 38 C.F.R. § 3.102 (reasonable doubt to be resolved in Veteran's favor); Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021) (the benefit-of-the-doubt rule applies if the competing evidence is in approximate balance).

Analysis

The record establishes that the Veteran's left knee condition was noted at entry, and therefore the presumption of soundness does not apply.  Because a preexisting disability was documented on the enlistment examination, the appropriate inquiry is whether the condition increased in severity during service, thereby triggering the presumption of aggravation.  The evidence developed during the course of the claim demonstrates that the Veteran's knee symptoms worsened during his period of active duty, and there is no clear and unmistakable evidence showing that such worsening was the result of the natural progression of the underlying condition.

Although the Medical Evaluation Board (MEB) concluded in 1985 that the preexisting knee disorder had not been permanently aggravated, the Board finds that conclusion less persuasive when viewed alongside the contemporaneous clinical findings showing early post traumatic arthritis, quadriceps atrophy, and a loss of motion that were not documented prior to service.  These in service findings reflect a level of objective pathology that reasonably suggests a worsening beyond the baseline condition noted on entry.  The MEB's conclusion also conflicts with the Veteran's credible descriptions of increased symptoms following the in service fall, and with later medical descriptions of significant functional decline during the period of active duty.  The Board also notes that the rationale offered for the MEB's determination is limited and does not reconcile the objective changes documented during service.

The post service medical opinions are also inconsistent with one another.  The 2019 VA examiner relied heavily on the MEB's conclusion without meaningfully addressing the in service imaging findings or the Veteran's reports of increased symptoms following the fall.  The 2021 VA examiner initially found both a direct nexus and aggravation, explicitly reasoning that the service injury and physical demands exceeded the natural progression of the preexisting condition.  That opinion was later withdrawn, but the basis for the withdrawal relied almost entirely on the brevity of service and the existence of the preexisting disorder, without explaining why the documented in service deterioration should be viewed as natural progression rather than aggravation.  The internal inconsistency between the examiner's initial and
 changes documented during service.

The post service medical opinions are also inconsistent with one another.  The 2019 VA examiner relied heavily on the MEB's conclusion without meaningfully addressing the in service imaging findings or the Veteran's reports of increased symptoms following the fall.  The 2021 VA examiner initially found both a direct nexus and aggravation, explicitly reasoning that the service injury and physical demands exceeded the natural progression of the preexisting condition.  That opinion was later withdrawn, but the basis for the withdrawal relied almost entirely on the brevity of service and the existence of the preexisting disorder, without explaining why the documented in service deterioration should be viewed as natural progression rather than aggravation.  The internal inconsistency between the examiner's initial and revised conclusions diminishes the probative weight of the addendum.

By contrast, the Veteran has consistently described returning to full function after his childhood injuries and experiencing a marked and immediate increase in symptoms following the in service fall.  A treating provider later offered a positive opinion that aligned with the Veteran's account, noting full recovery prior to service and a clear onset of persistent symptoms following the training incident.  While the history of the childhood injuries varies slightly in the retelling, the core assertion that the knee was asymptomatic before service remains consistent.  The slight differences in describing the exact nature of the childhood injury are not significant enough to undermine the overall credibility of the Veteran's reports or to establish that the condition progressed in a natural and inevitable course during service.

Taken as a whole, the evidence regarding aggravation is at least in approximate balance.  The in service findings reflect increased pathology, the Veteran's credible reports describe new and worsening symptoms following an in service injury, and the VA medical opinions are divided and internally inconsistent.  Because the presumption of aggravation applies and the record lacks clear and unmistakable evidence showing that the increase in disability was solely due to natural progression, the Board resolves reasonable doubt in the Veteran's favor.  The evidence therefore supports a finding that the Veteran's preexisting left knee arthritis was aggravated by active service.  Therefore, entitlement to service connection for left knee arthritis is warranted on an aggravation basis.

 

 

Frederic P. Gallun

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	Chris Bumgarner, Associate 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.