BVA9502559 DOCKET NO. 92-05 137 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUE Entitlement to service connection for left knee disability. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD G. Wm. Thompson, Counsel INTRODUCTION The veteran had active service from January 1976 to October 1984. This appeal arises from an October 1991 Department of Veterans Affairs (VA) Montgomery, Alabama, Regional Office (RO) rating action that granted service connection for chondromalacia patella, right knee, and assigned a 10 percent rating. In that same decision service connection was denied for residuals of left knee injury. The case was remanded for additional development in December 1992, and May 1994. The RO has returned the case to the Board of Veterans' Appeals (Board) for further appellate consideration. CONTENTIONS OF APPELLANT ON APPEAL The veteran contends, in essence, that the RO erred in not finding that his left knee disability was incurred in service. He points out that he did sustain knee injuries in service, and claims that the current knee problems are directly related to such injuries. DECISION OF THE BOARD The Board, in accordance with the provisions of 38 U.S.C.A. § 7104 (West 1991), has reviewed and considered all of the evidence and material of record in the veteran's claims file. Based on its review of the relevant evidence in this matter, and for the following reasons and bases, it is the decision of the Board that the weight of the evidence is in equipoise; therefore, entitlement to service connection for left chondromalacia patella and calcified medial collateral ligament is granted. FINDINGS OF FACT 1. All relevant evidence necessary for an equitable disposition of this appeal has been obtained by the RO. 2. The veteran sustained left knee injuries in service that were treated conservatively and resolved. 3. Neither chondromalacia patella nor calcification of the medical collateral ligament, left knee, was found in service. 4. The post-service chondromalacia patella and calcification of the medial collateral ligament of the left knee are related to service. CONCLUSION OF LAW Left chondromalacia patella and calcified medial collateral ligament were incurred in active military service. 38 U.S.C.A. §§ 1131, 5107(a)(b) (West 1991); 38 C.F.R. § 3.303 (1994). REASONS AND BASES FOR FINDINGS AND CONCLUSION The veteran's claim is well-grounded and the VA has met its duty to assist by obtaining or attempting to obtain all relevant evidence. The requirements mandated by 38 U.S.C.A. § 5107(a) have been fulfilled. Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by military service. 38 U.S.C.A. § 1131 (West 1991); 38 C.F.R. § 3.303 (1994). "A determination of service connection requires a finding of the existence of a current disability and a determination of a relationship between that disability and an injury or disease incurred in service." Watson v. Brown, 4 Vet.App. 309, 314 (1993). A showing of continuity of symptomatology (not continuity of treatment) after service discharge is required to support a claim when the fact of chronicity in service is inadequately supported. 38 C.F.R. § 3.303(b) (1994) The appellant is not obligated to show that the claimed condition was present during service; a nexus between the current condition and service may be established with the showing of a direct relationship. Godfrey v. Derwinski, 2 Vet.App. 354 (1992) History Enlistment examination for the veteran in January 1976 revealed a scar on the left tibia, below the knee; however no left knee disability was demonstrated. In February 1979 he was seen for complaints of left leg pain, between the knee and ankle. He reported that he felt the knee and ankle pop about 30 minutes earlier. There was no visible injury; ranges of motion of the leg were accompanied by pain. X-ray studies of the left knee and leg were normal. Orthopedic clinic records for October 1979 show that the veteran experienced a lateral twisting injury to the left knee while playing football. The assessment was sprain, medial left knee ligaments. He was in a cylinder cast for 10 days and profiled for 1 month. When seen later in October the assessment was resolving medial collateral ligament sprain. In June 1980 the veteran was seen for left knee pain after pulling a muscle in the left thigh, while stretching for martial arts. The assessment was recurrent left knee injury due to muscle strain. The annual examination in August 1982 did not show any complaints or findings of chronic left knee disability. In June 1983 the veteran was seen for complaints of right knee pain and swelling since aerobic exercises. It was noted that he had a similar problem after a football injury the month before. The assessment was medial capsular leg strain. In August 1983 the veteran struck his left knee on an aircraft and complained of tenderness and decreased range of motion. Examination showed 1 plus joint effusion and tenderness in the lateral aspect of the patella. Mild patella crepitus was noted. The assessment was direct trauma to the knee, "mild patella softening" probably present prior to injury. When the veteran filed his claim for disability benefits in June 1991 he did not report any post-service medical treatment for knee disability. The veteran was examined by the VA in August 1991. He reported knee injuries in service, and complained about sharp pain in the right knee around the knee cap, and weakness of the right knee. On walking, the veteran favored the right knee and complained of pain with deep knee bends. Examination showed right knee tenderness around the patella, patellar pain on compression, and slight crepitus. The left knee was unremarkable. X-ray studies of the knees showed a calcification of the medial collateral ligament of the left knee, with no other abnormality noted. The diagnosis was residuals of injury to the knees, with chondromalacia patella, right knee. The veteran was seen by a private physician for knee complaints in November 1992 and March 1993. In November 1992 the veteran reported left knee swelling, popping and pain, with the onset 2 to 3 week before. He reported minor trauma in the past but no recent major trauma. Examination showed popping with flexion and extension of the left leg, and mild tenderness with patellar compression. The assessment was knee pain, arthralgia, most likely secondary to intraarticular problems with the meniscus. When seen in March 1993, there was bilateral patellar tenderness, crepitus and positive McMurray's sign (indicative of meniscus damage). The assessment was knee pain. Examination by the VA was performed in July 1993. The veteran reported knee injuries in service, and complained of pain and swelling. Examination showed some tenderness to palpation at the inferior margins of the patellae, left greater than right. Patellar compression produced some pain at both knees, left greater than right. Gait, heel and toe walking, deep knee bends and duck walk were normal. Hopping on the legs produced complaints of pain. McMurray's and Apley's tests were normal, drawer signs were normal, and there was no limitation of motion, swelling, or joint effusion of the left knee. X-ray studies of the left knee showed only calcified medial collateral ligament. The diagnosis was bilateral chondromalacia patellae. Per the May 1994 remand request, the veteran's medical records were reviewed in June 1994. The physician opined that from the record he felt that the most likely etiology for the veteran's complaints of knee pain, stiffness, and swelling was chondromalacia patellae. Chondromalacia patellae was defined as irregularity and roughness of the cartilage at the underside of the patella. It was reported that chondromalacia was a very common finding, and that it could develop from various causes, including previous trauma. The examiner also noted that the presence of the chondromalacia did not necessarily mean that it was the sole etiology of all of the veteran's particular complaints. The diagnosis was chondromalacia patellae, bilateral. Summary While service medical records do show injuries to the veteran's left knee, they do not show chronic left knee disability. Each injury was different, and separate. The February 1979 complaints involved the left leg, and the October 1979 incident was a twisting injury spraining the medial ligaments. In June 1980 he pulled a thigh muscle, causing knee pain, with no injury to the knee itself. Following aerobic exercises in June 1983 the veteran sustained medial capsular leg strain. Finally, the only direct trauma to the left knee was in August 1983, resulting in effusion, tenderness and crepitus. The service records do not indicate that the veteran had less than full recovery from each injury. The veteran has not submitted any medical evidence showing that he had chondromalacia patella, or calcified medial collateral ligament, left knee, in service. Further, he has not submitted any objective evidence of chronic left knee disability since service. Chronicity is not adequately supported. The veteran himself is not shown to possess the medical expertise to determine the etiology of his various symptoms or their relationship to service, and his claims of medical causation are of limited probative value. Espiritu v. Derwinski, 2 Vet.App. 492 (1992). However, the medical records do show that left patellar softening was demonstrated in August 1983, of unknown origin, and there was injury to the left medial collateral ligament. Further, the VA examiner in June 1994 reported that while chondromalacia was very common, and could develop from a variety of sources, that previous trauma was a source of chondromalacia. Since the examiner reviewed the veteran's entire claims folder and did not indicate any other specific source of chondromalacia, in this case, serious consideration must be given to trauma as a source. Based on the service medical records and the VA opinion in June 1994, the only nexus between the post-service chondromalacia and military service is left knee injury in service, and the patellar softening. The only nexus for the calcified ligament is the injury to the ligament in service. When examined by a private physician in 1992, the veteran denied any post-service left knee injury which would constitute an intervening event. After comprehensive review of the entire record, the Board finds the evidence for and against entitlement to service connection for left chondromalacia patella and calcified medial collateral ligament to be in equipoise; therefore, entitlement to service connection for left chondromalacia patella and calcified medial collateral ligament is in order. 38 U.S.C.A. §§ 1131, 5107(b); 38 C.F.R. § 3.303(d). In passing, the Board also notes that the VA examiner in June 1994 indicated that the chondromalacia was not necessarily the sole source of all of the veteran's complaints. ORDER Service connection for chondromalacia patella, left knee, and calcified medial collateral ligament is granted. THOMAS J. DANNAHER Member, Board of Veterans' Appeals The Board of Veterans' Appeals Administrative Procedures Improvement Act, Pub. L. No. 103-271, § 6, 108 Stat. 740, ___ (1994), permits a proceeding instituted before the Board to be assigned to an individual member of the Board for a determination. This proceeding has been assigned to an individual member of the Board. (Continued on next page) NOTICE OF APPELLATE RIGHTS: Under 38 U.S.C.A. § 7266 (West 1991), a decision of the Board of Veterans' Appeals granting less than the complete benefit, or benefits, sought on appeal is appealable to the United States Court of Veterans Appeals within 120 days from the date of mailing of notice of the decision, provided that a Notice of Disagreement concerning an issue which was before the Board was filed with the agency of original jurisdiction on or after November 18, 1988. Veterans' Judicial Review Act, Pub. L. No. 100-687, § 402 (1988). The date which appears on the face of this decision constitutes the date of mailing and the copy of this decision which you have received is your notice of the action taken on your appeal by the Board of Veterans' Appeals.