Citation Nr: 0004912 Decision Date: 02/25/00 Archive Date: 03/07/00 DOCKET NO. 95-39 200 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUE Entitlement to service connection for a bilateral knee disorder, to include Osgood-Schlatter disease. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Edward Walls, Associate Counsel INTRODUCTION The veteran served on active duty from July 1957 to July 1960. His appeal comes before the Board of Veterans' Appeals (Board) from a September 1991 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Louis, Missouri. The Board REMANDED this case in October 1997, and it is again before the Board for appellate consideration. FINDINGS OF FACT 1. The veteran's claim is well grounded and the VA has fulfilled its duty to assist by obtaining and fully developing all relevant evidence necessary for an equitable disposition of the claim. 2. The record contains clear and unmistakable evidence that the veteran had Osgood-Schlatter disease prior to his period of active service. 3. The preexisting Osgood-Schlatter disease was not permanently worsened by his active service. 4. There is no medical evidence which establishes a causal nexus between any other currently diagnosed bilateral knee disorder and the veteran's military service. CONCLUSION OF LAW The veteran's bilateral knee disorder, to include Osgood- Schlatter disease, was not incurred in or aggravated by active service. 38 U.S.C.A. §§ 1131, 5107 (West 1991); 38 C.F.R. § 3.306 (1999). REASONS AND BASES FOR FINDINGS AND CONCLUSION The veteran has offered two theories under which he believes that his bilateral knee disorder should be service connected. The veteran has reported that he entered service with Osgood- Schlatter disease and that he had knee pain during basic training. He has reported that he injured his knees on a missile trailer and that he was returned to duty at that time with a limited profile, which reflected that he should not stand for a prolonged period of time. Alternatively, the veteran has asserted that his current bilateral knee disorder is not related to any preexisting Osgood-Schlatter disease, but that it is instead due to an injury sustained in service. As a preliminary matter, the Board finds the veteran's claim plausible and capable of substantiation; it is therefore well grounded within the meaning of 38 U.S.C.A. § 5107(a) (West 1991). The Board also finds that the VA has fulfilled its duty to assist the veteran by obtaining and fully developing all relevant evidence necessary for an equitable disposition of the claim. A veteran is entitled to service connection for a disability resulting from a disease or injury incurred in or aggravated in the line of duty while in the active military, naval, or air service. See 38 U.S.C.A. § 1131 (West 1991). A preexisting injury or disease will be considered to have been aggravated by active military, naval, or air service, where there is an increase in disability during such service, unless there is a specific finding that the increase in disability is due to the natural progress of the disease. 38 U.S.C.A. § 1153 (West 1991); 38 C.F.R. § 3.306(a) (1999). The veteran is presumed to be in sound condition upon entry into service, except for any defects noted at the time of examination for entry into service. 38 U.S.C.A. § 1111. The presumption can be rebutted only by clear and unmistakable evidence that such a disability existed prior to service. See 38 U.S.C.A. § 1111; 38 C.F.R. § 3.304(b); Monroe v. Brown, 4 Vet. App. 513, 515 (1993); Green v. Derwinski, 1 Vet. App. 320, 322 (1991). In this case, the Board concludes the record contains clear and unmistakable evidence that the veteran had Osgood-Schlatter disease prior to entering active service. A radiology report dated in April 1965 reflects that the veteran's left knee had "an old avulsion fracture of the tibial tuberosity, probably associated with Osgood- Schlatter disease in childhood." Even more significantly, a letter dated in January 1992 by Ford Van Hagen, M.D., shows that the veteran's knee problems began in his mid-teens, and that the veteran was told he had Osgood-Schlatter disease in 1951. Moreover, the veteran in his January 1992 substantive appeal specifically stated that he had Osgood-Schlatter disease when he entered service. Although the veteran has since repudiated this statement, the Board must find clear and unmistakable evidence exists that the veteran had Osgood- Schlatter disease at the time of his entry into active service. The Board must determine whether the veteran's bilateral knee disorder, to include Osgood-Schlatter disease, was permanently worsened by his active service. On enlistment examination in July 1956, no abnormalities of the lower extremities was noted. The veteran was given a "2" profile for lower extremities at that time presumably in reference to a finding of pes planus on examination. The veteran also denied any significant medical history at that time. In November 1956, it was reported that the veteran had re- injured his left knee when he bumped it against a bed; a prior injury during basic training was noted. Examination at the time revealed slight tenderness and erythema below the patella. The veteran was provided with an ace bandage. The veteran was seen several years later in July 1959. At that time, the veteran reported a history of having a painful left knee with a childhood injury. The knee was noted to be painful when he bumped it or kneeled on it. X-rays taken at that time revealed no fracture or dislocation. The patella was noted to be displaced laterally. The tibial tubercle was noted to apparently have a separate small ossicle of bone situated in the region of the insertion of the patella tendon. Otherwise the knee joint was noted to appear normal. It was noted by the clinical examination that this x-ray showed Osgood-Schlatter disease. The veteran was given cortisone and in September 1959, a cylinder cast was place on the leg. He apparently wore a cast until October 1959 when the cast was removed. At that time, x-rays were again taken and it was noted that no changes were shown. The x-ray report noted again that there was no fracture or dislocation. However, previously described hypertrophic changes in the region of the tibial tubercle were noted to be persistent. There was apparently a separate center of ossification in the patellar tendon and changes associated with Osgood-Schlatter disease. In November 1959, the veteran was noted to continue to complain of tibial tubercle pain and he was given light duty and pain medication. Later in November 1959, he was given a temporary profile change for the Osgood-Schlatter disease affecting both knees. In January 1960, the veteran was seen following a fall on his left knee. A past medical history of Osgood-Schlatter disease was noted. The impression was that the veteran had a contusion on his knee. He was given a splint and ace bandage. The veteran was seen again in June 1960 with complaints of tenderness over the left tibial tubercle with no definite history of trauma. Examination confirmed that the veteran had such tenderness. Separation examination dated in July 1960 revealed no pertinent abnormalities of the lower extremities; it was noted that the veteran had "Slaughters" disease, both knees, for the past year. Upon discharge from service, the veteran was assigned a physical profile of "1" for his lower extremities. The number "1" indicates that the veteran "possess[ed] a high level of medical fitness" and, consequently, was medically fit for any military assignment. Post-service medical records indicate that that the veteran had at least two injuries to his knees since his separation from active service. Clifford J. Lynch, M.D., reported in an October 1964 letter that the veteran was working when "a faceplate struck his left knee directly." The blow caused swelling over the anterior aspect of the left knee. The damage was treated with three shots of Cortisone injections as of October 1964. The veteran complained that he was unable to kneel on the knee because of the severe pain which had occurred, but he had relief when he stood erect. X-rays revealed a large bony ossicle in the soft tissue adjacent to the anterior tibial tubercle superiorly as well as a small faintly calcified mass at the lower pole of the bony ossicle. X-ray findings were reported to be consistent with Osgood- Schlatter disease. The physician believed that the veteran had a preexisting Osgood-Schlatter disease accounting for the small bony ossicles what were present in the patellar tendon on x-ray. He opined that the injury which he sustained in 1964 aggravated that preexisting condition. The veteran again injured a knee while working at the Bunn-O- Matic Company in Springfield, Illinois in May 1972. According to medical notes dated in May 1972, the veteran was given injections of Celestone and Xylocaine to the tender inferior patellar bursa, and his leg was wrapped. Because his discomfort persisted, Dr. Van Hagen applied a long leg cast at that time to put the area completely at rest. X-rays taken of the knee in June 1972 revealed no fracture or fluid in the joint space, but the veteran did have "residual changes of the old Osgood-Schlatter disease at the tibial tubercle." A medical note dated in May 1972 shows that the veteran was working with a baling [sic] press and ran into a lock handle while the press was open. The lock handle struck his left knee, and the veteran had reported pain since that time. The examiner diagnosed tenderness and swelling in the left patellar tendon area. He did not believe that the injury was "an old disease, but rather, an acute new irritation of the knee." On VA examination in July 1991, the veteran reported that he indicated that he sustained two injuries to his knees in service. He also indicated that he was told in service that he had Osgood-Schlatter disease. Following examination, the examiner diagnosed history of Osgood-Schlatter disease, bilaterally, left greater than right with no functional impairment noted. X-rays were also reported to be negative. In a January 1992 letter, Ford Van Hagen, M.D., indicated that he had treated the veteran for a number of conditions since 1962. He noted that historically, the veteran did have a problem with his knees beginning in his mid-teens when he was apparently seen by a Dr. Motta in Springfield, Illinois (since deceased) and reportedly told somewhere around 1951 that he had Osgood-Schlatter disease which he would probably outgrow. Dr. Van Hagen reported that on induction, the veteran's Osgood-Schlatter disease was not symptomatic, but he did have trouble with his knees in service. Dr. Van Hagen also reported that it was the veteran's belief that the activities in service aggravated his preexisting Osgood- Schlatter disease. Dr. Van Hagen noted that Osgood-Schlatter disease is a disease of remission and exacerbation and reiterated that the veteran was asymptomatic on induction, but did have trouble in service due to aggravation by activities. He noted that the veteran has a recurrence of knee problems after service and sought treatment for such. Dr. Van Hagen concluded by stating that he had no knowledge of "what went on during the time of [the veteran's] military service." He did, however, note that the veteran had a serious enough problem to result in a revised physical condition profile in November 1959. VA outpatient treatment records indicate that the veteran was seen for treatment of severe degenerative joint disease of the left knee. It was noted that the veteran was status postoperative meniscectomy of the left knee. The veteran was afforded a VA fee basis examination in May 1999. At that time, the veteran reported that while in service, he slipped on a rain-soaked trailer and fell on both knees. The veteran denied any history of knee difficulty prior to service and also denied having a history of Osgood- Schlatter disease prior to service entry. He apparently emphasized that the only time he injured his knees was when he slipped and fell in service in 1959. Following review of the claims folder, including the veteran's service medical records, and examination of the veteran, the examiner concluded that the veteran had bilateral Osgood-Schlatter disease with persistent patella tendonitis as well as early patellofemoral arthritis, bilaterally. The examiner noted that with a reasonable degree of medical probability, the veteran's ambulation was limited due to his bilateral chronic patella tendonitis, but he also noted that the other limiting factors were the veteran's history of back disability, obesity and general medical condition associated with his diabetes. He noted that the veteran's x-rays documented that the veteran did have preexisting Osgood-Schlatter disease prior to entering service, and it was felt that the veteran's service could have aggravated the prior preexisting condition, but "to divide it would be pure speculation of the examiner's behalf." The Board notes that Dr. Van Hagen in his January 1992 letter appears to indicate that the veteran's Osgood-Schlatter disease was aggravated during service. However, when the letter is read in its entirety it appears to the Board that he is merely reiterating the veteran's contentions in this regard. As a lay person, the veteran, however, is not competent to provide such an etiological determination. LeShore v. Brown, 8 Vet. App. 406, 408 (1995). Dr. Van Hagen clearly reports that he had no idea of what happened to the veteran in service except to note that the veteran was placed on temporary profile during this time. The United States Court of Appeals for Veterans Claims (Court) has held that evidence which is simply information recorded by a medical examiner, unenhanced by any additional medical comment by that examiner, does not constitute competent medical evidence. LeShore v. Brown, 8 Vet. App. at 409. However, to the extent that Dr. Van Hagen's statement could be read as adopting the veteran's theory regarding aggravation, he provided no medical rationale or principle underlying the theory that the veteran's bilateral knee disorder was permanently aggravated in service, other than noting that the veteran was issued a profile in service, such that the Board could attach any significant probative weight to the letter. There is absolutely no discussion of service medical records or the post-service medical records including that documenting several injuries after service. Essentially, there is no indication that Dr. Van Hagen reviewed all of the relevant evidence in this case so as to form a well-reasoned opinion based upon the relevant evidence. For these reasons, the Board does not consider Dr. Van Hagen's letter to be of substantial probative value in this case. The Board notes further, that the one opinion of record which is based on a review of the entire evidentiary record does not support the veteran's contention in this case. In this regard, as stated above, the VA examiner in May 1999 thought that although the veteran's preexisting Osgood-Schlatter disease could have been aggravated in service, such a determination regarding aggravation would be pure speculation. To the extent that the Board it could be argued that the May 1999 VA examiner opinion provided the requisite medical nexus opinion by his statement that the veteran's Osgood-Schlatter disease that preexisted service could have been aggravated in service, the Board notes that the Court has found that purely speculative medical opinions do not provide the degree of certainty required for medical nexus evidence. See Stegman v. Derwinski, 3 Vet. App. 228, 230 (1992); Obert v. Brown, 5 Vet. App. 30, 33 (1993); Bostain v. West, 11 Vet. App. 124, 127 (1998). Granted, the Court has acknowledged that word parsing in other medical nexus cases may have created an unclear picture for ascertaining what constitutes sufficient evidence to satisfy the medical nexus requirement for well-grounded claims. Hicks v. West, 12 Vet. App. 86, 90 (1998). However, the Court has made it clear that what is sufficient for competent medical nexus evidence depends on the specific facts of the case. Bloom v. West, 12 Vet. App. 185 (1999) (the truth of the matter is that no template is possible that will apply to the almost infinite number of fact situations that can arise. What is speculative in one context might be less so in another.). While the Board acknowledges that the use of conditional language may be sufficient "nexus" evidence under certain circumstances, the Board finds in this case this opinion coupled with the examiner's opinion regarding the speculative nature of service aggravation causes the "negative" objective clinical evidence of record to outweigh that of any "positive" evidence in this case. The Board thus, finds the opinion to be too inconclusive to be of any significant probative value. The Board notes that other competent medical evidence of record reflects that the veteran's bilateral knee disorder was permanently worsened or aggravated by his period of active service. Service medical records show treatment for symptomatic Osgood-Schlatter disease in service. Moreover, the veteran has had several documented knee injuries subsequent to his active service requiring shots of various pain medications and the use of at least one long leg cast. In light of these factors, the Board does not find that the veteran's preexisting bilateral knee disorder was aggravated in any way by any incident of military service. Thus, the veteran's claim must be denied. With regard to the veteran's theory that his current bilateral knee disorder is directly related to his period of active service, the Board notes that the veteran has not offered any competent medical evidence that his current bilateral knee disorder is etiologically related to any knee injury he incurred while in service. ORDER Service connection for a bilateral knee disorder, to include Osgood-Schlatter disease, is denied. S. L. KENNEDY Member, Board of Veterans' Appeals