KNEE IMPAIRMENT OF

Summary

The Veteran, who served from January 1983 to December 1985, appeals the denial of service connection for a right knee condition, claiming it is secondary to his service-connected right ankle condition. The Board reviewed evidence from both VA and private medical providers. The VA examiners in April 2016 and March 2021 opined that the Veteran's right knee condition, diagnosed with osteoarthritis and meniscal tears, was less likely than not related to his service-connected right ankle, attributing the knee issues to age, obesity, and the Veteran's occupation as a bricklayer. However, multiple private medical opinions from November 2015, January 2016, May 2017, August 2017, January 2021, and March 2022 provided a favorable nexus. These private opinions, particularly the March 2022 opinion from the Veteran's treating physician, argued that the knee condition was more likely than not a result of increased joint stress and altered biomechanics caused by the service-connected ankle injury. The Board found the private opinions more persuasive, noting they more thoroughly considered the relationship between the ankle and knee conditions and disagreed with the VA examiners' conclusions regarding occupational factors. Finding the evidence in equipoise, the Board applied the benefit of the doubt and granted service connection for the right knee condition as secondary to the service-connected right ankle condition.

Rationale

Service-connected right ankle condition satisfies first two elements of secondary SC.; Conflicting medical opinions regarding nexus between ankle and knee conditions.; Private opinions found more persuasive than VA opinions.; Evidence found to be in equipoise, conferring benefit of doubt.

Full Decision Text

Citation Nr: A26040930
Decision Date: 04/30/26	Archive Date: 04/30/26

DOCKET NO. 210608-164708
DATE: April 30, 2026

ORDER

Entitlement to service connection for a right knee condition is granted.

FINDING OF FACT

Resolving reasonable doubt in the Veteran's favor, his right knee condition is secondary to his service-connected right ankle condition.

CONCLUSION OF LAW

The criteria for service connection for a right knee condition have been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. § 3.303.

REASONS AND BASES FOR FINDING AND CONCLUSION

The Veteran had active service from January 1983 to December 1985. 

On August 23, 2017, the President signed into law the Veterans Appeals Improvement and Modernization Act, Pub. L. No. 115-55 (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.

In a May 2021 rating decision, the Agency of Original Jurisdiction (AOJ) confirmed and continued the previous denial of service connection for a right knee condition. The Veteran submitted a timely VA Form 10182 (Notice of Disagreement) in June 2021 and, in so doing, requested the Hearing docket. 

Based on the Veteran's selection of the Hearing Lane, the Board may only consider the evidence of record at the time of the rating decision on appeal, as well as any evidence submitted by the Veteran or his representative, if any, at the hearing or within 90 days following the hearing. 38 C.F.R. §?20.302(a). 

In September 2024, the Veteran requested to withdraw his hearing request. Accordingly, the Board may only consider the evidence of record at the time of the decision on appeal, as well as any evidence submitted by the Veteran within 90 days following receipt of the withdrawal. 38 C.F.R. § 20.302(b).

Evidence was added to the claims file during a period of time when new evidence was not allowed. As such, the Board may not consider this evidence in its decision. 38 C.F.R. § 20.300. The Veteran may file a Supplemental Claim 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.

The Board observes that, in the May 2021 rating decision, the AOJ found that new and relevant evidence had been received to reopen the Veteran's previously denied claim for service connection for a right knee condition. The Board is bound by this favorable finding. 38 C.F.R. § 3.104(c). Accordingly, a discussion as to whether new and relevant evidence has been received sufficient to readjudicate the claim is not required herein.

1. Entitlement to service connection for a right knee condition

Service connection is granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active service. 38 U.S.C. § 1131; 38?C.F.R. §?3.303. Service connection requires competent evidence of: (1) the existence of a present disability; (2) inservice incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Under?38?C.F.R. §?3.303(b), service connection will be presumed where there are either chronic symptoms shown in service or continuity of symptomatology since service for diseases identified as "chronic" in?38?C.F.R. § 3.309(a).?Walker v. Shinseki,?718 F.3d 1331 (Fed. Cir. 2013).

Service connection may be established on a secondary basis for a disability which is proximately due to or the result of a service-connected disease or injury; or any increase in severity of a nonservice-connected disease or injury which is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the nonservice-connected disease or injury. 38
303(b), service connection will be presumed where there are either chronic symptoms shown in service or continuity of symptomatology since service for diseases identified as "chronic" in?38?C.F.R. § 3.309(a).?Walker v. Shinseki,?718 F.3d 1331 (Fed. Cir. 2013).

Service connection may be established on a secondary basis for a disability which is proximately due to or the result of a service-connected disease or injury; or any increase in severity of a nonservice-connected disease or injury which is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the nonservice-connected disease or injury. 38 U.S.C. § 1131; 38 C.F.R. §§ 3.303, 3.310(a)-(b). Secondary service connection requires evidence of (1) a current disability, (2) a service-connected disability, and (3) a nexus, or link, between the service-connected disability and the current disability. Wallin v. West, 11 Vet. App. 509, 512 (1998).

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 the weight of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination, the benefit of the doubt is afforded the claimant.

To deny a claim on its merits, the weight of the evidence must persuasively stand against a finding that the evidence is in "approximate balance" or "nearly equal" to the evidence that supports the claim. Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021) (en banc).

The Veteran contends that he has a right knee condition is secondary to his service-connected right ankle condition. December 2015 and June 2016 Fully Developed Claim and December 2024 Correspondence. 

Available medical evidence includes diagnoses of right knee meniscal tear, right knee joint osteoarthritis, right knee instability, right medial cruciate ligament (MCL) sprain, right popliteal cyst, and right knee degenerative arthritis other than post-traumatic. January 2016 Disability Benefits Questionnaire (DBQ) and March 2021 VA Examination. 

The Veteran's residuals of right ankle fracture with degenerative arthritis and tendonitis has been service connected since March 2014. Thus, the first and second elements of secondary service connection are satisfied, and the remaining question is whether the evidence establishes that his right knee condition was caused or aggravated by his service-connected right ankle condition. On this question, there is evidence both in favor of and against the Veteran's claim. 

An April 2016 VA examiner opined that the Veteran's right knee condition is less likely than not proximately due to, or the result of, his service-connected right ankle condition. The examiner remarked that the Veteran has bilateral mild medial and patellofemoral degenerative changes and that this symmetrical presentation is more likely than not secondary to the normal aging process and the physical labor the Veteran performed for 27 years as a brick layer and farmer. The examiner noted that degenerative joint disease is commonly seen on X-rays of individuals over the age of 50 and age-related, non-traumatic degenerative joint disease is usually bilaterally symmetrical. An aggravation opinion was not provided, and the examiner did not provide further rationale specifically considering the potential relationship between the Veteran's right knee condition and his service-connected right ankle condition.

Another VA examination is of record dated March 2021. The examiner provided a diagnosis of bilateral degenerative arthritis other than post-traumatic. The examiner opined that the Veteran's right knee condition is less likely than not proximately due to, or the result of, his service-connected right ankle condition. The examiner remarked that the Veteran has degenerative arthritis from being a brick layer and being on his knees. The examiner further noted that age and obesity are contributing factors for his knee pain and there is no basis for an ankle fracture to cause bilateral arthritis of the knees. An aggravation opinion was not provided, and the examiner did not provide further rationale.

A private medical opinion is of record dated November 2015. The examiner conducted a physical examination of the Veteran and opined that the Veteran's right knee condition is more likely than not the result of the increased joint stress subsequent to his service-connected right ankle condition. The examiner noted that the provided opinion is supported by medical literature establishing the structural relationship and interdependence of the lower limb joints. While additional rationale was not provided, the provider's
enerative arthritis from being a brick layer and being on his knees. The examiner further noted that age and obesity are contributing factors for his knee pain and there is no basis for an ankle fracture to cause bilateral arthritis of the knees. An aggravation opinion was not provided, and the examiner did not provide further rationale.

A private medical opinion is of record dated November 2015. The examiner conducted a physical examination of the Veteran and opined that the Veteran's right knee condition is more likely than not the result of the increased joint stress subsequent to his service-connected right ankle condition. The examiner noted that the provided opinion is supported by medical literature establishing the structural relationship and interdependence of the lower limb joints. While additional rationale was not provided, the provider's statement is favorable to the Veteran's claim.

A January 2016 private DBQ is of record. The examiner provided diagnoses of right knee meniscal tear, right knee joint osteoarthritis, right knee instability, right MCL sprain, and right popliteal cyst. The examiner noted that the Veteran began experiencing right knee pain in 2007 which has steadily worsened to the present date. The examiner opined that, given the history and examination findings, it is as likely as not that the Veteran's in-service right ankle injury never fully resolved and the subsequent joint damage is more likely than not to have led to increased biomechanical stresses to the right knee, resulting in his current right knee condition. 

Another private medical opinion is of record dated May 2017. The examiner noted that the Veteran's medical records had been reviewed along with current medical literature. The examiner responded to the April 2016 VA examiner's opinion and remarked that the opinion does not account for the significant pain differences between the Veteran's right and left knee, nor does it allow for the limitations of X-rays to accurately and completely assess soft tissue health and function. In support of their opinion that the Veteran's post-traumatic ankle dysfunction resulted in increased biomechanical stresses on the knee, the examiner referred to multiple medical articles, including an article discussing the effect of limitation in ankle dorsiflexion on knee joint function which noted that post-traumatic restriction of ankle dorsiflexion can cause knee joint overload. While a definitive medical opinion was not provided, the examiner's statement was favorable to the Veteran.

A private medical opinion is of record dated August 2017. The examiner opined that it is more likely than not that the Veteran's service-connected ankle injury is contributing to his chronic knee pain and dysfunction. The examiner remarked that the Veteran's right ankle condition has caused the need for knee surgery and that his service-connected right ankle condition affects his entire leg. The examiner noted that this opinion was based on their experience as a sports medicine physician and former U.S. Navy physician. While additional rationale was not provided, the provider's statement is favorable to the Veteran's claim.

Another private medical opinion is of record dated January 2021. The examiner, a family practice physician, reviewed the Veteran's medical history, military service, and noted that the Veteran has been a patient under their care since January 2019. The examiner noted that the Veteran's right ankle conditions are a contributing factor in the Veteran's right knee condition and that he has no other known risk factors that may have precipitated his current condition. The examiner opined that it is more likely than not that the Veteran's right knee condition is a direct result of his service-connected right ankle fracture. The examiner remarked that it is well known, based on their personal experience and the medical literature, that internal derangement of the ankle secondary to fracture can lead to the Veteran's chronic pain, arthritis, and the degenerative/inflammatory conditions. While additional rationale was not provided, the provider's statement is favorable to the Veteran's claim.

The same private physician provided an additional medical opinion in March 2022. The examiner, the Veteran's primary care provider, noted that they had examined the Veteran many times and has been directly involved in the treatment of his chronic pain affecting the bilateral lower extremities. The examiner opined that the Veteran's right knee condition is directly related to his service-connected right ankle condition. The examiner explained that the Veteran's ankle and knee joints do not function independently of each other in weightbearing and ambulation activities and that internal derangement and altered function of the ankle will lead to compensatory changes in gait, altering the normal biomechanics of the knees. The examiner noted that, over time, these alterations in biomechanics will likely lead to pain, inflammation, and degenerative changes. The examiner opined that it is more likely than not that these mechanisms described regarding the Veteran's right knee condition are related to his service-connected right ankle condition. The examiner reviewed the prior negative opinion and disagreed with the prior opinion that the Veteran's right knee degenerative arthritis is due to his being a brick layer. The examiner noted that they discussed the
 that the Veteran's ankle and knee joints do not function independently of each other in weightbearing and ambulation activities and that internal derangement and altered function of the ankle will lead to compensatory changes in gait, altering the normal biomechanics of the knees. The examiner noted that, over time, these alterations in biomechanics will likely lead to pain, inflammation, and degenerative changes. The examiner opined that it is more likely than not that these mechanisms described regarding the Veteran's right knee condition are related to his service-connected right ankle condition. The examiner reviewed the prior negative opinion and disagreed with the prior opinion that the Veteran's right knee degenerative arthritis is due to his being a brick layer. The examiner noted that they discussed the duties of a brick layer with the Veteran and found the prior examiner's reasons to be unfounded. 

The Board ascribes more weight to the private opinions of record and finds the April 2016 and March 2021 VA opinions to be of little probative value. The private examiners more fully considered the possible relationship between the Veteran's right knee and right ankle conditions and fully considered the etiology of the Veteran's condition. 

As such, the Board finds that the evidence is, at minimum, in equipoise regarding the question of secondary service connection. The benefit of the doubt will be conferred in the Veteran's favor, and his claim for service connection for right knee condition, as secondary to the service-connected right ankle condition, is granted.

 

 

Marcus N. Fulton

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	Goreham, A.

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.