Citation Nr: 0004590 Decision Date: 02/23/00 Archive Date: 02/28/00 DOCKET NO. 98-20 674 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Jackson, Mississippi THE ISSUES 1. Entitlement to service connection for a bilateral knee disability. 2. Entitlement to service connection for a gastrointestinal disability. ATTORNEY FOR THE BOARD D. Orfanoudis, Associate Counsel INTRODUCTION The veteran served on active duty from February 1993 to February 1997. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a July 1998 rating decision of the Jackson, Mississippi, Regional Office (RO) of the Department of Veterans Affairs (VA), which denied entitlement to service connection for a bilateral knee disability and a gastrointestinal disability. The veteran filed a timely notice of disagreement and perfected a substantive appeal. This matter was previously before the Board in May 1999 wherein the cased was Remanded for additional development. FINDINGS OF FACT 1. All evidence necessary for an equitable resolution of this case has been secured. 2. There is no competent medical evidence showing the presence of a current disability involving the knees. 3. The gastrointestinal disability, variously diagnosed, is of service origin. CONCLUSIONS OF LAW 1. The claim for entitlement to service connection for a bilateral knee disability is not well grounded. 38 U.S.C.A. § 5107(a) (West 1991). 2. The gastrointestinal disability, variously diagnosed, was incurred during active duty. 38 U.S.C.A. §§ 1131, 5107(a) (West 1991); 38 C.F.R. § 3.303 (1999). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. § 1131. Continuity of symptomatology is required only where the condition noted during service is not, in fact, shown to be chronic, or where the diagnosis of chronicity may be legitimately questioned. Service connection may also be granted for a chronic disease, i.e. peptic ulcer disease, which becomes manifest to a compensable degree within one year after a veteran's separation from active service. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137 (West 1991); 38 C.F.R. §§ 3.307, 3.309 (1998). The threshold question that must be resolved with respect to the veteran's claims of entitlement to service connection for a bilateral knee disability and a gastrointestinal disability is whether he has submitted a well-grounded claim for benefits arising therefrom. 38 U.S.C.A. § 5107(a) (West 1991). A person who submits a claim for benefits administered by the Secretary shall have the burden of submitting evidence sufficient to justify a belief by a fair and impartial individual that the claim is well grounded. A well-grounded claim is a plausible claim, one that is meritorious on its own or capable of substantiation. Robinette v. Brown, 8 Vet.App. 69, 73-74 (1995); Murphy v. Derwinski, 1 Vet.App. 78, 81 (1990). The truthfulness of evidence is presumed for purposes of determining if a claim is well grounded. Robinette, 8 Vet.App. at 75-76; King v. Brown, 5 Vet.App. 19, 21 (1993). The United States Court of Appeals for Veterans Claims (Court) has held that where the determinative issue involves either medical etiology or a medical diagnosis, competent medical evidence is ordinarily required to fulfill the well- grounded claim requirement of section 5107(a). Edenfield v. Brown, 8 Vet.App. 384, 388 (1995). Thus, in order for a service connection claim to be well grounded, there must be (1) evidence of a current disability as provided by a medical diagnosis; (2) evidence of incurrence or aggravation of a disease or injury in service as provided by either lay or medical evidence, as the situation dictates; and, (3) a nexus, or link, between the inservice disease or injury and the current disability as provided by competent medical evidence. See Caluza v. Brown, 7 Vet.App. 498, 506 (1995). If the claimant has not presented a well grounded claim, then the appeal fails as to that claim, and the Board is under no duty under 38 U.S.C.A. § 5107(a) (West 1991) to assist the claimant any further in the development of that claim. Murphy, 1 Vet. App. at 81. I. Bilateral Knee Disability The veteran contends that he has a bilateral knee disability which was first manifested during his period of active service. Service medical records dated in January 1997 show that the veteran was treated for pain in the left knee with prolonged periods of standing and stair climbing. Physical examination revealed that there was positive patella grind, but was negative of erythema, effusion or laxity. There was full range of motion with flexion and extension with 5/5 found. McMurray's and Lachman's tests were negative. The diagnosis was patellofemoral syndrome. Subsequent treatment in February 1997 showed that the medial joint line was tender to palpation. The knee continued to have full range of motion with the joint stable. The examiner provided an assessment of patellofemoral syndrome which was resolving. The veteran underwent a VA examination in May 1997. At that time the veteran reported that every day running in physical training resulted in injuries to his knees in August 1996. Both knees would give out. He was treated with insoles, an exercise program, and nonsteroidal anti-inflammatories. He reported pain in both knees anteriorly with stair climbing or squatting. The right knee bothered him more than the left knee. The examination showed that the knees had full extension and 150 degrees of flexion. His gait was normal. There was no swelling, effusion, retropatellar crepitation or tenderness. Collateral ligaments were stable to varus and valgus stress in extension and 30 degrees of flexion. Anterior and posterior signs were negative. X-rays were within normal limits. The examiner concluded that he could find no evidence of organic pathology to explain the veteran's symptoms. The veteran received intermittent treatment at a VA during 1997 and 1998 for bilateral knee pain. X-rays in August 1997 showed a 2 mm size calcification adjacent to the inferior surface of the right lateral femoral condyle. The appearance was consistent with previous trauma to the area. The remainder of the examination was within normal limits. A September 1997 MRI of the right knee showed no abnormality. A VA examination was conducted in August 1999. The veteran reported that there was no history of specific injury to either knee during his military service, but that he developed pain in both knees when running. He indicated that the right knee would give out and he would almost fall when running. He reported current pain in his knees when going up and down stairs frequently. He indicated that he had three episodes during the past year. He stated that he avoided running and strenuous exercise for fear of making his knees hurt. The examination revealed that the veteran was well developed and walked with a normal gait. Examination of the right knee showed a very well developed quadriceps muscle. There was no swelling, effusion or retropatellar crepitation. The examiner was unable to sublux the patellar laterally with the knees flexed 30 degrees. His collateral ligaments were said to be stable to varus and valgus stress and extension and 30 degrees of flexion. His anterior drawer test, posterior drawer test and Lachman's test were negative. There was slight tenderness over the medial joint line. The veteran had full extension and 150 degrees of flexion in the right knee. An examination of the left knee showed full extension and 150 degrees of flexion. The veteran had a very well developed quadriceps muscle. He had no swelling, effusion, retropatellar crepitation or patellar instability. The collateral ligaments were stable to varus and valgus stress and extension and 30 degrees of flexion. The anterior drawer test, posterior drawer test and Lachman's test were negative. There was no point of tenderness. X-rays of both knees revealed no evidence of fracture, dislocation, destructive lesion, narrowing of the articular cartilage or osteophyte formation. There was a small rounded ossicle of bone posterior to the right knee, which was believed to be a fabella, which is a sesamoid bone in the lateral hamstring tendon. The examiner concluded that he could find no objective evidence of organic pathology to explain the veteran's symptoms. The veteran asserts that service connection is warranted for a bilateral knee disability as it was manifested during his period of active service. In this regard, the veteran is capable of reporting his symptoms. Falzone v. Brown, 8 Vet.App. 398, 403, 405 (1995). However, it has not been indicated that he possesses the requisite medical knowledge to be able to opine on a matter involving medical principles or medical causation. See Espiritu v. Derwinski, 2 Vet. App. 492 (1992). In this regard, the service medical records reveal that the veteran was treated for patellofemoral syndrome during his period of active service. Also he continued to complain of bilateral knee pain following service. August 1997 VA x-rays showed a 2 mm size calcification adjacent to the inferior surface of the right lateral femoral condyle, which was consistent with previous trauma to the area. However, August 1999 x-rays indicated that this was the fabella. Additionally, VA examinations conducted in May 1997 and most recently in August 1999 found no organic pathology involving the knees. Accordingly, without current medical confirmation showing the presence of disabilities involving, the claim is not well grounded and must be denied. II. Gastrointestinal Disability Initially, the Board finds that the veteran's claim is well grounded in that it is plausible. 38 U.S.C.A. § 5107(a) (West 1991); Murphy v. Derwinski, 1 Vet.App. 78, 81 (1990). This finding is based in part on the in service and postservice medical records showing treatment for gastrointestinal complaints. The Board is also satisfied that all pertinent evidence necessary to render a decision is of record and the statutory duty to assist the veteran has been met. The service medical records show that the veteran was seen in May 1993 for vomiting, diarrhea, dizziness, and headaches. The examiner provided an assessment of upper gastroenteritis. In August 1993, the veteran reported vomiting and stomach aches. There was a history of nausea, vomiting and diarrhea with subjective fever. He reported a decrease in appetite. He reported headaches. His abdomen had positive bowel sounds, and was non-tender and non-distended. There was no hepatosplenomegaly. The aortic pulse was visible and largely palpable. An assessment of acute gastroenteritis was provided. A chronological record of medical care dated in July 1994 shows that the veteran reported pain in the upper abdominal area for the last six weeks. He related that the pain, described as dull, usually lasted from several hours to all day. An impression of mild abdominal pain was provided. An undated service chronological record of medical care shows that the veteran was given an assessment of gastroenteritis. Subsequent to service, the veteran underwent a VA examination in March 1997. At that time the veteran gave a two month history of sharp and dull pains in the epigastric area. The pain was constant. He took over the counter medications which occasionally helped. Once a week he has gas and cramping pain with a soft bowel movement. The examination showed mild to moderate tenderness at the umbilicus. The diagnosis was epigastric pain, etiology unknown. VA outpatient treatment records dated in 1997 and 1998 show that was seen on several occasions for gastrointestinal complaints. A VA upper gastrointestinal series report dated in December 1997 provides an impression of thickening of the gastric folds and small erosions involving the gastric mucosa. The report also indicates that there could even be a couple of small ulcers present along the body of the stomach. There was no other abnormality seen. A VA medical record dated in May 1998 shows a diagnosis of gastritis and H. pylori. The veteran underwent a VA examination in May 1998. He reported dull aching abdominal pain accompanied by sharp burning epigastric pain. Physical examination revealed that the abdomen was flat without organomegaly, masses nor tenderness. He has mild diffuse epigastric tenderness and right upper quadrant tenderness with no rebound tenderness. Bowel sounds were normoactive. A diagnosis of history of peptic ulcer disease with positive H. pylori was provided. In a May 1999 Board Remand, a VA examination gastroenterologist was requested. Of record is a July 1999 statement from a VA gastroenterology section of a VA medical facility. The physician stated that the veteran "is" a patient at the G. I. section. It was reported that the veteran had undergone an upper gastrointestinal and small bowel follow though in December 1997, which revealed thickening of the gastric folds and small erosions involving gastric mucosa. It was noted that there could even be a couple of small ulcers present along the body of the stomach. There were no other abnormalities seen. An upper gastrointestinal endoscopy was performed in March 1999 revealing a normal esophagus, stomach and abdomen. The examiner concluded that it could not be determined that the cause of the veteran's upper gastric pain was related to his time in the service. The requested examination apparently was not done. Also it is unclear whether the VA physician had the opportunity to actually review the claims folder as requested by the Board. To summarize, the veteran's statements describing his symptoms are considered to be competent evidence. Falzone, 8 Vet.App. at 403, 405. However, it has not been indicated that he possesses the requisite medical knowledge to be able to opine on a matter involving medical principles or medical causation. See Espiritu, 2 Vet. App. at 492. In this regard, the service medical records reveal that the veteran was treated for abdominal pains and gastroenteritis during his period of active service. Additionally when examined by the VA in March 1997 he placed the onset of the abdominal pain in January 1997, while he was still on active duty. Also, he continued to be seen at a VA outpatient clinic during 1997 and 1998 for gastrointestinal complaints with a diagnosis of gastritis and H. pylori rendered in May 1998. The most recent VA examination for compensation purposes was conducted in May 1998. At that time the diagnosis was history of peptic ulcer disease with positive H. pylori. The Board points out that peptic ulcer disease is a chronic disability per 38 C.F.R. § 3.309 (1999). The July 1999 medical statement does not contain a current diagnosis. However, the VA physician clearly indicated that the veteran is currently receiving treatment at the G. I. clinic. In view of the inservice and post service gastrointestinal complaints and diagnoses, the Board is satisfied that the veteran has a chronic gastrointestinal disorder, which has been variously diagnosed. The Board further finds that the inservice gastrointestinal complaints and findings are indicative of a chronic gastrointestinal disorder. 38 C.F.R. § 3.303. Accordingly, service connection for a gastrointestinal disorder, variously diagnosed is warranted. ORDER Entitlement to service connection for a bilateral knee disability is denied. Entitlement to service connection for a gastrointestinal disability, variously diagnosed, is granted. ROBERT P. REGAN Member, Board of Veterans' Appeals