BVA9504447 DOCKET NO. 91-47 575 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in Roanoke, Virginia THE ISSUE Entitlement to service connection for bilateral knee disabilities. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD James L. March, Associate Counsel INTRODUCTION The veteran had active service from August 1945 to January 1947. This appeal comes to the Board of Veterans' Appeals (Board) from a May 1990 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Roanoke, Virginia. In February 1992, the Board found that new and material evidence had been submitted to reopen the previously denied claim of entitlement to service connection for bilateral knee disabilities. The claim was reopened and remanded to the RO for a de novo adjudication. In February 1993, the Board remanded the case for additional development. CONTENTIONS OF APPELLANT ON APPEAL The veteran contends that he injured both knees during service. He alleges that his knees have bothered him ever since the injury. 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 preponderance of the evidence is against the claims for service connection for bilateral knee disabilities. FINDINGS OF FACT 1. All relevant evidence necessary for an equitable disposition of the appeal has been obtained. 2. Any knee injuries sustained during service resolved without residuals. 3. There is no credible medical evidence of bilateral knee disability for many years after service. 4. The veteran's current bilateral knee disability is not due to knee injuries in service. CONCLUSION OF LAW Bilateral knee disabilities were not incurred in or aggravated by service, nor may arthritis of the knees be so presumed. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131, 1137, 5107 (West 1991); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (1993). REASONS AND BASES FOR FINDINGS AND CONCLUSION As a preliminary matter, the Board finds that the veteran's claim is plausible and capable of substantiation, and thus well grounded within the meaning of 38 U.S.C.A. § 5107(a). When a veteran submits a well-grounded claim, VA must assist him in developing facts pertinent to that claim. 38 U.S.C.A. § 5107(a). The Board is satisfied that all available relevant evidence has been obtained regarding the veteran's claim, and that no further assistance to the veteran is required to comply with 38 U.S.C.A. § 5107(a). Service connection may be established for disability resulting from personal injury suffered or disease contracted in line of duty, or for aggravation of a pre-existing injury suffered or disease contracted in line of duty. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. Arthritis may be presumed to have been incurred during service if it becomes manifest to a degree of 10 percent within one year following separation from service, even though there is no evidence of arthritis during the period of service. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137 (West 1991); 38 C.F.R. §§ 3.307, 3.309 (1993). Regulations also provide that service connection may be granted for any disease diagnosed after discharge when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). However, continuity of symptomatology is required where the condition noted during service is not shown to be chronic. 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). 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 a preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet.App. 49 (1990). The veteran's service medical records were involved in a 1973 fire at the National Personnel Record Center and are incomplete. The available service medical records are a portion of the entrance examination report dated in August 1945, morning sick reports from September and November 1946, and the separation examination report dated in December 1946. Although the morning sick reports do involve the veteran, they do not reveal the veteran's ailments. The entrance and separation examination reports indicate that there were no musculoskeletal defects. A private medical report dated on August 24, 1972, indicates that the veteran reported that he fell in service in 1946 and had had painful knees since then. The examination was within normal limits. The diagnosis was painful knees and legs, no cause found. In August 1972, the veteran filed a claim for service connection for residuals of bilateral leg injuries. He reported that he had had no medical treatment of the claimed residuals subsequent to service. Several lay statements were submitted. In a March 1976 statement, [redacted] indicated that he had known the veteran for the previous 17 years. He stated that "for some time," it had been difficult for the veteran to perform his duties because of constant pain and discomfort in his knees. He indicated that the veteran had to wear support bandages on his knees. Mr. [redacted] attributed the discomfort to an injury the veteran allegedly suffered in service. He stated that the injury resulted in arthritis. D.G. Sturgill indicated in a May 1976 statement that he had known the veteran for five years. He stated that during those five years, the veteran had had a recurring knee problem which caused much suffering. He reported that the veteran wore support knee bandages and had to keep the knees elevated. In October 1976, [redacted] stated that she had known the veteran for 17 years, and that she had seen the veteran in much pain and discomfort as a result of his knees. She also indicated that the veteran wore support knee bandages. She opined that as a result of his knee injury, arthritis developed in different parts of his body. A statement dated in January 1977 was received from Lieutenant Colonel [redacted]. He stated that he was with the veteran while serving in the European Theater of Operations. He recalled that sometime between February and December 1946, the veteran had an accident and injured his knees to the extent that he wore some type of knee support. He noted that he was not a witness to the injury. He remembered the veteran received treatment from a German prisoner of war named Shultz as the nearest medical facility was some distance away. He had not had contact with the veteran since service. In May 1977, the veteran's mother submitted a statement. She stated that when the veteran returned home from the service in January 1947, he was wearing bandages on his knees. She indicated that he had had pain and difficulty with his legs ever since. VA medical records dated from March 1976 to March 1983 were received. In March 1976, the veteran reported having a lot of trouble with his left knee. The examination revealed popping on extension of the left knee. There was tenderness of the anterior end of the medial meniscus and the upper femoral synovial reflection. The tentative diagnosis was traumatic arthritis of the left knee, but X-rays later revealed no evidence of fracture, dislocation or bony abnormalities. There were no soft tissue calcifications present. As a result, the examining physician noted that the problem was probably soft tissue in nature. In February 1977, the veteran was seen again complaining of knee disability. He reported injuring the knees in a fall in 1946. The diagnosis was traumatic arthritis, rule out rheumatoid arthritis. In March and June 1977, the diagnosis was changed to osteoarthritis of multiple joints. He was seen on several occasion through March 1983 with this diagnosis; however, February 1978 X-rays were negative for recent or old injuries and there was no evidence of arthritic disease. A statement dated in November 1983 was received from Charles A. Fulton, M.D. Dr. Fulton stated that he had been treating the veteran for various medical problems including moderate-to-severe arthritis. He indicated that this involved significant pain, stiffness and limitation of motion of the joints. An October 1984 statement was received from [redacted]. Mr. [redacted] stated that he was in charge of the medical dispensary when he served with the veteran in the European Theater of Operations. He recalled that between February and December 1946, the veteran had an accident, injuring his knees to the extent that he required medical treatment and a type of knee support. He indicated that the veteran continued with this medical treatment, and upon being shipped out was supplied with additional knee supports. A February 1985 statement was received from [redacted]. Mr. [redacted] stated that he had known the veteran for 14 years, and that the veteran had often discussed the discomfort of arthritis in his joints, especially in the hands. He indicated that the veteran's knee often bothered him, particularly while walking up stairs. He opined that some of the veteran's health problems were service related. A February 1985 statement was also received from [redacted]. Mr. [redacted] stated that for the previous several years he had been aware of the progressive deterioration of the veteran's health. He noted that it had become almost impossible for the veteran to climb steps. Dr. Fulton submitted another statement dated in October 1985. He stated that the veteran suffered from osteoarthritis. He noted that the veteran had stiffness, swelling and limitation of motion of most joints of his body--most notably in the hands. In June 1986, a hearing was held before a hearing officer at the RO. The veteran testified that during service he injured both knees when he fell with his full weight on them. He stated that he was treated by a German prisoner of war who had had medical training. The treatment consisted of Ace bandages. He alleged that since that time he had had trouble with both knees, with the left being worse than the right. He stated that shortly after service, he had trouble walking, and that he had worn knee supports or braces ever since. He testified that prior to service, he was very athletic. He stated that after service he was offered opportunities to play football at two universities, but that he could not play because of his knees. He indicated that he had had no X-rays of the knees in service or in the first year following service. Dr. Fulton submitted a statement dated in June 1986. He indicated that the veteran suffered from osteoarthritis. He stated that the veteran reportedly was injured in an accident in the military during World War II. He reported that since then the veteran had had some progressive problems with swelling, tenderness and heat in both knees. He stated that the veteran had a full range of motion in both knees with crepitance, soft tissue swelling and tenderness. A statement dated in October 1987 was also received from Dr. Fulton. He stated that for the previous four years, he had treated the veteran for severe symptoms of osteoarthritis. He indicated that the veteran had significant symptoms involving the knees as well. He stated that the veteran had an injury to the knees in World War II, and he opined that the injury significantly exacerbated his osteoarthritic development in the knees and contributed to his current level of dysfunction. A VA medical report dated in December 1987 is of record. The report indicates that the veteran was treated for osteoarthritis of multiple joints, including the knees. A statement dated in June 1989 was received from a friend of the veteran. He stated that he had known the veteran since 1948 when he roomed with the veteran at the University of Virginia. He indicated that at that time, the veteran had problems with his knees, which required him to wear Ace bandages. He stated that the knee problems limited the veteran's physical activities. Thomas E. Renfro, M.D., submitted a letter dated in March 1990. He indicated that he had treated the veteran since July 1988, for, among other things, degenerative arthritis/osteoarthritis with a component of fibromyalgia and fibrositis. Dr. Renfro discussed evidence submitted by the veteran and concluded that bilateral knee injuries occurred during service. He opined that the veteran suffered with this discomfort and arthritis involving his knees since then. In August 1991, another hearing was held at the RO. The veteran testified that he injured his knees twice during service. First, he reported an incident in which he was involved in a truck accident. He stated that he banged his knees on the dashboard, but that he did not receive treatment at that time. He alleged that a second incident occurred when he fell in the barracks. He stated that he was treated by a sergeant and a German prisoner of war, and given medication and bandages. He indicated that rheumatoid arthritis and osteoarthritis were first diagnosed in the 1970's. He alleged that in 1952, he was treated by a private physician for complaints of pain; however, no records were available. A VA orthopedic examination was conducted in April 1993. The reported history included a discussion of an alleged motor vehicle accident and a subsequent fall in which the veteran injured both knees. The veteran stated that in 1947, he began experiencing severe pain in the knees. He complained of constant pain in the knees, partially relieved by Ace bandages and hot packs. He stated that both knees were weak and unstable. The pain was reportedly aggravated by driving, standing or walking on hard surfaces. He indicated that he was not able to climb or participate is sports such as tennis or golf, and that nocturnal pain interfered with sleep. Other painful joints were also discussed. The general examination revealed slight shuffling in gait. X-rays of the knees revealed that the joint spaces were intact and equal. The bony structure appeared to be intact, and there was no evidence of any old fracture. The impression was no significant abnormality. Laboratory data was positive for rheumatoid arthritis factor. Pertinent diagnoses included rheumatoid arthritis effecting the knees, and synovitis of both knees secondary to trauma and rheumatoid arthritis. An orthopedic examination for VA purposes was conducted in April 1993. The examiner noted that the veteran complained of pain and swelling, with the left knee worse than the right. Examination of the knees in a supine position revealed no effusion of either knee. The veteran had significant tightness in both legs as he held his muscles contracted, and there was difficulty in having the veteran relax to allow flexion and extension of the knees. Full extension and flexion were noted, however. There was no significant patellofemoral crepitation on either knee and no joint line crepitation or popping through the range of motion. There was excellent stability to varus and valgus stress of both medial and lateral collateral ligaments of each knee, and there was an excellent end point to Lachman exam, with no evidence of pivot shift to either knee. There was excellent motor tone, mass and strength throughout all muscle groups of the lower extremities. The veteran reported that he used a cane, but he did not have it with him at the examination. X-rays taken revealed no evidence of bony abnormality or fracture. There was no evidence of degenerative changes or changes consistent with osteoarthritis or rheumatoid arthritis. The impression was that the veteran did not suffer a significant injury to either knee as there were no significant degenerative changes consistent with a post-traumatic syndrome. The examiner stated that he found no basis for impairment related specifically to the left or right knee. The Board has reviewed all of the evidence of record, and finds that the preponderance of the evidence is against the veteran's claim. Although several lay statements, including those from service comrades, support the veteran's claim that he injured his knees in service, the separation examination report was completely negative for any complaints or findings of any residuals of such an injury. The first medical evidence of any complaints involving the knees is from August 1972, and that report indicated that there were no clinical findings of disability. The veteran testified in August 1991 that he received treatment for knee pain in 1952; however, at the time of his August 1972 claim, he had indicated that following service, he did not receive any treatment for his knees until August 1972. Although the veteran, his mother and college roommate allege that the veteran had knee difficulties immediately following service, the Board finds the absence of any medical evidence of knee problems for 25 years following service much more probative. The Board notes that the several lay witnesses who attributed the veteran's current knee complaints to an injury in service, based that opinion on the veteran's own reported history. In any event, as lay individuals, they are not qualified to proffer medical opinions or diagnoses. Espiritu v. Derwinski, 2 Vet.App. 492, 494-95 (1992). Concerning the opinions of Drs. Fulton and Renfro that the injuries during service contributed to current arthritis, their opinions were also based on the veteran's reported history. Neither mentioned the negative separation examination report, or the absence of any medical evidence of knee complaints for the 25 years following service. Similarly, the VA examiner's diagnosis in April 1993 of synovitis of the both knees secondary to trauma was based on the veteran's description of trauma. The Board notes that although the veteran has had diagnoses of arthritis of the knees, of one sort or another, since March 1976, there has never been X-ray evidence of such arthritis of the knees. Indeed, April 1993, VA X-rays revealed no evidence of any arthritis in the knees. The Board finds that if knee injuries were sustained during service, they resolved without residuals. With the absence of any credible medical evidence of knee disability for the 25 years following service, and specifically the absence of arthritis during the one year following service, and the current VA examination findings of no significant knee impairment, service connection for bilateral knee disabilities is not in order. ORDER Service connection for bilateral knee disabilities is denied. F. JUDGE FLOWERS 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.