BVA9503958 DOCKET NO. 92-16 761 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to service connection for residuals of a left knee injury. 2. Entitlement to service connection for residuals of a right hand injury. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Jeffrey J. Schueler, Associate Counsel INTRODUCTION The veteran served on active duty from June 1976 to June 1979 and from April 1985 to March 1989. The veteran appeals the April 1990 rating decision of the St. Petersburg, Florida, regional office (RO). After the veteran relocated to Bay City, Michigan, the claims folder was transferred to the Detroit, Michigan, RO, which confirmed the denial of the claim in a May 1994 rating action. CONTENTIONS OF APPELLANT ON APPEAL The veteran contends that residuals of injuries to his left knee and right hand were incurred in active duty. He maintains that he experiences severe pain in his left knee and that he walks with a limp. The veteran also asserts that he has pain in his right hand. DECISION OF THE BOARD The Board of veterans' Appeals (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 preponderance of the evidence is against the claim of entitlement to service connection for residuals of a left knee injury, and that the preponderance of the evidence is against the claim of entitlement to service connection for residuals of a right hand injury. FINDINGS OF FACT 1. All available relevant evidence necessary for an equitable disposition of the veteran's claims has been obtained by the RO insofar as possible. 2. Residuals of the veteran's left knee injury during service are not shown subsequent to service. 3. Residuals of the veteran's right hand injury during service are not shown subsequent to active service. CONCLUSIONS OF LAW 1. Residuals of a left knee injury were not incurred in or aggravated by active service. 38 U.S.C.A. §§ 1131, 5107 (West 1991); 38 C.F.R. §§ 3.103(a), 3.159(a), 3.303 (1994). 2. Residuals of a right hand injury were not incurred in or aggravated by active service. 38 U.S.C.A. §§ 1131, 5107 (West 1991); 38 C.F.R. §§ 3.103(a), 3.159(a), 3.303 (1994). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Board finds initially that the appellant's claims are well- grounded within the meaning of 38 U.S.C.A. § 5107(a) (West 1991); that is, the claims are not inherently implausible. We also find that the Department of Veterans Affairs (VA) has satisfied its statutory obligation to assist the veteran in the development of facts pertinent to the claims. 38 U.S.C.A. § 5107(a) (West 1991); 38 C.F.R. §§ 3.103(a), 3.159 (a) (1994). The case was remanded to the RO in December 1993 for a VA orthopedic examination, which was accomplished in February 1994. On appellate review, we see no areas in which further development may be fruitful. Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. § 1131 (West 1991). For a showing of chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "Chronic." Continuity of symptomatology is required where the condition noted during service is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303(b) (1994). I. Residuals of a Left Knee Injury A service entrance examination in February 1985 showed the veteran's lower extremity clinical evaluation to be normal and the veteran reported on his Report of Medical History that he did not have a trick or locked knee, or bone, joint, or other deformity. In a September 1985 service medical record, it was noted that the veteran complained of a twisted left knee for one week and the veteran continued to run on it and it gave out on him twice while running. He complained of pain to the lateral side. Examination showed pain to palpation to the lateral aspect without edema, no drawer sign, no crepitus but painful McMurrays' test. The collateral ligaments were intact. The assessment was rule out lateral meniscus tear. In another service medical record later that day, examination revealed minimal effusion, range of motion from zero degrees to 70 degrees, and tenderness. X-rays were negative. The examiner noted an assessment of no evidence of internal derangement and possible iliotibial band syndrome. In a February 1986 service medical record, the veteran had a complaint of stiffness. Examination revealed status post left knee arthroscopy, no complaints of pain, negative warmth and positive swelling and effusion, and negative tenderness. Range of motion for extension and flexion was full, and strength was good. The examiner noted slight anterior cruciate ligament laxity, positive patella excursion, positive crepitus, and negative atrophy. January 1986 service medical record showed a left knee arthroscope was normal with no problems, and examination revealed no effusion, full range of motion and healing well. At a March 1987 service examination, the veteran reported on his Report of Medical History that he did not have a trick or locked knee or a bone, joint or other deformity, although he did note that he had orthoscopic surgery at the age of 28 years. Examination revealed a normal lower extremity clinical evaluation, and did not refer to a left knee injury. A September 1988 service medical record indicated that the veteran complained of pain with stair climbing in the lateral and posterior areas of the left knee which had existed since September 1985 when he stepped in a hole, with complaints increasing recently. It was noted that there was no giving out or locking, and that the veteran had an arthroscopy in January 1986 and trimmed meniscus. Examination showed the veteran's left knee without ecchymosis, edema, or erythema, mild lateral joint line tenderness, and mild laxity on anterior drawer and lateral stress. A positive tender popliteal region and a small Baker's cyst were also noted. The assessment was of a knee strain, inflamed Baker's cyst, and old laxity of the anterior cruciate ligament and lateral cruciate ligament. Subsequent to service separation, the veteran underwent a VA examination in September 1989. It was noted that the veteran stated he suffered a torn cartilage in his left knee and that an arthroscopy was performed to remove some broken cartilage. Examination showed no swelling, heat, or redness of any joints, good strength and range of motion of all four extremities, and crepitance present in both knees with pain on motion. Orthopedic examination of the knees revealed range of motion from 180 degrees of extension to 50 degrees of flexion bilaterally. Manipulation of both knees failed to disclose any sign of internal derangement. There was normal ligamentous strength in and about both knees. There was no synovitis or effusions. Patella tests were negative. Circumferential volume three inches above the superior pole of the patella was 17-1/2 inches. The impression noted was of a negative examination in regard to both knees. An x-ray report showed multiple views of both knees with no abnormalities. The evidence of record also includes a VA examination in February 1994, wherein it was noted that the veteran complained of stiffness in the left knee and pain lateral to the left patella. The examination report indicates that the veteran provided a history of a twisting injury in 1985, a normal arthroscopy in 1986, and swelling, effusion and anterior cruciate ligament laxity and strain in February 1986, but nothing done to the left knee since then. The examiner stated that the veteran had a normal gait, that the patella seemed visually in place, that there was no effusion, that the collateral ligament was intact, and that the cruciate ligament seemed intact as Lachman sign and drawer's signs were normal. The examiner reported that there was no grating or popping of the knee, and pressure on the tibial tubercles and condyles produced no pain. Laxity of the anterior cruciate ligament was not found. Range of motion of the knee was zero to 130 degrees supine and zero to 135 degrees standing. The examiner recorded on an x-ray report that the left knee showed no apparent osseous or articular abnormality, that the bones and joints were unremarkable, that there was also no loose joint bodies, and that there was no joint effusion. An physical therapy consultation showed that the veteran had trouble going up and down stairs, and ambulation looked normal with no limp or antalgia, that the veteran could not heel walk, that he could tip-toe, and that approximate range of motion was zero to 110 degrees with some soreness. The examiner reviewed the physical therapist's findings and the final diagnosis reported was of status post right knee injury (believed to be a typographical error, intended to read " left" knee) with no pathology found. A review of the record indicates that the symptomatology associated with the September 1985 knee injury resolved. The January 1986 service medical record showed no complaints of pain, full range of motion, and a normal arthroscopy and the March 1987 service medical examination was normal. A September 1988 service medical record shows symptomatology associated with the left knee and an assessment of knee strain and old laxity of the anterior cruciate ligament. When the veteran was separated from service by reason of a bilateral foot disorder, no mention was made of a knee disorder. The September 1989 VA examination, although reporting crepitance in both knees with pain on motion and the veteran's history of a left knee injury during active service, showed a negative examination with respect to the knees and did not attempt to relate the crepitance and pain noted to active service. The February 1994 VA examination report revealed complaints of pain and stiffness and some limitation of range of motion, but noted that no pathology was found for the knee injury. The evidence, therefore, does not show a relationship between any current knee symptomatology and active service. While the veteran contends that such a relationship exists, lay statements, as opposed to evidence prepared by experts by knowledge, skill, and education, as to the etiology of a disorder are not capable of providing a probative diagnosis. See Espiritu v. Derwinski, 2 Vet.App. 492, 494-95 (1992). It is the determination of the Board that the preponderance of the evidence is against the claim of entitlement to service connection for residuals of a left knee injury. II. Residuals of a Right Hand Injury A service entrance medical examination in February 1985, and a service medical examination in March 1987, showed the veteran's upper extremity clinical evaluation to be normal and the veteran reported on his Report of Medical History that he did not have bone, joint, or other deformity. A July 1987 service medical record shows that the veteran was treated with liquid nitrogen for his right middle finger. In an October 1987 service medical record, it was noted that the veteran complained of right hand and wrist pain and swelling after a motor vehicle accident wherein he sustained an injury to the right hand. Examination revealed limited motion of the second, third, fourth, and fifth digits of the right hand with limited extension of the right wrist, pain on palpation at the base of the second and third digit at the dorsal aspect and palmar aspect. Capillary refill was normal in the right hand and there was negative paresthesia and negative gross deformities of the right hand. X-ray studies showed no fracture, and it was noted that there was positive swelling at the base of the third digit of the metaphalangeal joint and decreased range of motion, no pain on palpation, and no dislocation. In a November 1987 service medical record, the veteran complained of continued edema and pain in the right hand. The examiner reported edema and tenderness in the third, fourth, and fifth metacarpal joints. X-rays revealed no evidence of fracture. The assessment was of a soft tissue trauma. Subsequent November 1987 service medical records showed decreased pain, swelling, and slight stiffness. An examiner in June 1988 during service found a prominence of the base of the second metacarpal dorsally with good range of motion at the wrist, positive tenderness at the third metacarpophalangeal joint with mild swelling, good range of motion with crepitus, and neurovascular intact. X-ray studies showed no abnormalities, and the assessment was of probable post traumatic arthritis. Another June 1988 service medical record shows full range of motion except for lacking one centimeter of opposition. There was enlargement of "base" metacarpal and no tenderness. A June 1988 x-ray report revealed multiple views of the right hand and wrist which did not show recent or old fractures. At a September 1989 VA examination, it was reported that he had no swelling, heat, or redness of any joints and that he had good strength and range of motion of all four extremities. A bone callus was noted at the right wrist and the examiner noted that he had good peripheral pulses and good reflexes. Examination of the wrist and hands revealed full range of wrist motion on dorsal and plantar flexion, good grip strength and full range of digital motion. The examiner recorded that the only positive finding was that of tenderness at the base of the second metacarpal bone and a mild bony overgrowth in that region. The impression noted was of a negative examination regarding the hands and wrists. At a February 1994 VA examination, the veteran complained of pain in the right snuffbox area and gave a history of an October 1987 motor vehicle accident wherein he injured his right hand and wrist, and the examiner reported no deformity of the hand, no swelling, normal fist and normal range of motion of the fingers, grip equal but weak bilaterally and no finger deformity. X-ray studies of the right hand revealed some soft tissue swelling involving the thenar eminence but no osteomyelitis. The examiner wrote that the veteran did not locate the pain at that area but rather in the snuffbox area of the hand and he, the examiner, did not see any swelling when comparing the two hands. Occupational therapists did examinations of the hand strength and both were weak and about the same, concluding that the veteran displayed decreased grip strength for his age range. It was also noted that the veteran had decreased pinch and coordination scores in the right hand. All other areas tested were within normal limits except for decrease to right wrist, manual muscle test, and slight atrophy of the right thenar eminence. The examiner noted that there was conflict in as much as the occupational therapist said there was atrophy of the right thenar eminence and the x-rays indicated that there was a soft tissue swelling of the thenar eminence. The final diagnosis reported by the examiner was status post right hand sprain with bilateral weakness of both hands. A review of the record indicates that the veteran was treated for residuals of his October 1987 injury to the right hand, but that no fracture was noted and in November 1987 symptomatology had decreased. The June 1988 service medical record showed good range of motion of the wrist, mild swelling, and no abnormalities by X-ray. When separated from service by reason of a bilateral foot disorder, no abnormality of the right hand was noted. The September 1989 VA examination revealed full range of motion and good grip strength; although tenderness and a mild bony overgrowth was noted, the examiner reported that the examination was negative. The evidence does not show, therefore, residuals of the October 1987 injury prior to or approximately five months after service separation. The February 1994 VA examination reported essentially negative findings, but did note some soft tissue swelling and decreased grip strength. But the examiner did not relate the symptomatology associated with the right hand to the veteran's active service. The evidence does not show that the veteran has residuals of the right hand injury during service. As referred to above, while the veteran contends that he does, lay statements, as opposed to evidence prepared by experts by knowledge, skill, and education, as to the etiology of a disorder are not capable of providing a probative diagnosis. See Espiritu v. Derwinski, 2 Vet.App. 492, 494-95 (1992). It is the determination of the Board that the preponderance of the evidence is against the claim of entitlement to service connection for residuals of a right hand injury. ORDER Entitlement to service connection for residuals of a left knee injury is denied. Entitlement to service connection for residuals of a right hand injury is denied. WILLIAM J. REDDY 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. 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.