Citation Nr: 1241024 Decision Date: 11/30/12 Archive Date: 12/05/12 DOCKET NO. 10-00 753 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Portland, Oregon THE ISSUES 1. Entitlement to service connection for left knee disability. 2. Entitlement to service connection for right knee disability, to include as secondary to a service-connected disease or injury. 3. Entitlement to service connection for lumbar spine disability, to include as secondary to a service-connected disease or injury. REPRESENTATION Appellant represented by: Oregon Department of Veterans' Affairs ATTORNEY FOR THE BOARD Thomas D. Jones, Counsel INTRODUCTION The Veteran had active service from May 1966 until March 1968. This matter comes before the Board of Veterans' Appeals (BVA or Board) from a December 2008 rating decision of the Department of Veterans Affairs (VA), Regional Office (RO) in Seattle, Washington. During the pendency of this appeal, jurisdiction was transferred to the RO in Portland, Oregon. The issues on appeal were previously presented to the Board in June 2011, at which time they were remanded for additional development. They have now been returned to the Board. The required development has been completed and this case is appropriately before the Board. See Stegall v. West, 11 Vet. App. 268 (1998). FINDINGS OF FACT 1. A chronic left knee disability, to include arthritis, did not manifest in service or for many years thereafter. 2. A chronic right knee disability, to include arthritis, did not manifest in service or for many years thereafter, and is unrelated to service or a service connected disease or injury. 3. A chronic low back disability, to include arthritis, did not manifest in service or for many years thereafter, and is unrelated to service or a service connected disease or injury. CONCLUSIONS OF LAW 1. A chronic disability of the left knee, to include arthritis, was not incurred in or aggravated by service, or manifested to a compensable degree within a year thereafter. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309 (2012). 2. A chronic disability of the right knee, to include arthritis, was not incurred in or aggravated by service, or manifested to a compensable degree within a year thereafter, and is not due to or aggravated by a service connected disease or injury. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309, 3.310 (2012). 3. A chronic disability of the low back, to include arthritis, was not incurred in or aggravated by service, or manifested to a compensable degree within a year thereafter, and is not due to or aggravated by a service connected disease or injury. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309, 3.310 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Assist and Notify The Veterans Claims Assistance Act of 2000 (VCAA) enhanced VA's duty to notify and assist claimants in substantiating a claim for VA benefits, as codified in pertinent part at 38 U.S.C.A. §§ 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.102, 3.159, 3.326(a) (2011). For the reasons to be discussed below, the Board finds that VA has satisfied its duties to the appellant under the VCAA. A VCAA notice consistent with 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) must: (1) inform the claimant about the information and evidence not of record that is necessary to substantiate the claim; (2) inform the claimant about the information and evidence that VA will seek to provide; and (3) inform the claimant about the information and evidence the claimant is expected to provide. See Quartuccio v. Principi, 16 Vet. App. 183 (2002). VCAA notice requirements apply to all five elements of a service connection claim: (1) veteran status; (2) existence of disability; (3) connection between service and the disability; (4) degree of disability; and (5) effective date of benefits where a claim is granted. Dingess v. Nicholson, 19 Vet. App. 473, 484 (2006). VA has made all reasonable efforts to assist the Veteran in the development of his claims, has notified him of the information and evidence necessary to substantiate the claims, and has fully disclosed VA's duties to assist him. In May 2008, October 2008, August 2010, September 2011, and August 2012 letters, the Veteran was notified of the information and evidence needed to substantiate and complete the claims on appeal. Additionally, the May 2008 letter provided him with the general criteria for the assignment of an effective date and initial rating. Id. The Board notes that, in the present case, initial notice was issued prior to the various adverse determinations on appeal; thus, no timing issue exists with regard to the notice provided the claimant. See Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). Finally, the Board notes that the Veteran is represented by a veterans service organization (VSO) and that organization is presumed to have knowledge of what is necessary to substantiate a claim for VA benefits. Neither the Veteran nor his representative have pled prejudicial error with respect to the content or timing of any VCAA notice. See Shinseki v. Sanders, 129 U.S. 1696 (2009). The Board further finds that VA has complied with the duty to assist by aiding the appellant in obtaining evidence. It appears that all known and available records relevant to the pending appeal have been obtained and are associated with the Veteran's claims files. The RO has obtained the Veteran's service treatment records, as well as VA and non-VA medical records. He has also been afforded a VA medical examination in July 2009. The Board notes that the VA medical evidence contains sufficiently specific clinical findings and informed discussion of the pertinent history and clinical features of the disability on appeal and is adequate for purposes of this appeal. The Board is not aware, and the Veteran has not suggested the existence of, any additional pertinent evidence not yet received. The Board notes that no medical examination has been conducted and/or medical opinion obtained with respect to the Veteran's service connection claims for right knee or low back disabilities. The Board finds, however, that the record, which does not reflect competent evidence showing a nexus between service and the disorders at issue, warrants the conclusion that a remand for an examination and/or opinion is not necessary to decide these claims. See 38 C.F.R. § 3.159(c)(4). As outlined in McLendon v. Nicholson [20 Vet. App. 79 (2006)], in disability compensation (service connection) claims, the VA must provide a VA medical examination when there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability, and (2) evidence establishing that an event, injury, or disease occurred in service or establishing certain diseases manifesting during an applicable presumptive period for which the claimant qualifies, and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the Veteran's service or with another service-connected disability, but (4) insufficient competent medical evidence on file for the VA to make a decision on the claim. Simply stated, the standards of McLendon are not met in this case, as evidence has not been presented linking such disabilities to service or a service-connected disability, as will be discussed in greater detail below. Based on the foregoing, the Board finds that the Veteran has not been prejudiced by any failure of VA in its duties to notify and assist him, and that any such violations could be no more than harmless error. See Conway v. Principi, 353 F.3d 1369 (Fed. Cir. 2004). In any event, the Veteran has neither alleged nor demonstrated any prejudice with regard to the content or timing of VA's notices or other development. See Shinseki v. Sanders, 129 U.S. 1696 (2009) (reversing prior case law imposing a presumption of prejudice on any notice deficiency, and clarifying that the burden of showing that an error is harmful, or prejudicial, normally falls upon the party attacking the agency's determination). Thus, adjudication of his claims at this time is warranted. II. Service connection The Veteran seeks service connection for several disabilities. Service connection may be awarded for a disability arising from a disease or injury incurred in or aggravated by active military service. 38 U.S.C.A. § 1110 (West 2002); 38 C.F.R. §§ 3.303, 3.304 (2012). Service connection may also be awarded for certain disabilities, such as arthritis, which manifest to a compensable degree within a year of service separation. 38 U.S.C.A. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. Service connection may also be awarded for any disability which is proximately due to or the result of, or is otherwise aggravated by, a service-connected disease or injury. 38 C.F.R. § 3.310. As with any claim, when there is an approximate balance of positive and negative evidence regarding any matter material to the claim, the claimant shall be given the benefit of the doubt. 38 U.S.C.A. § 5107. VA is bound to consider all pertinent theories of service connection, whether or not a theory is raised by the Veteran. See Schroeder v. West, 212 F.3d 1265 (Fed. Cir.2000) (holding that a claim for disability compensation should be broadly construed to encompass all possible theories of entitlement). In the present case, the Veteran has alleged both that he injured his knees and low back during service, and that his disabilities of the right knee and low back are secondary to his left knee disability. Each of these theories of entitlement to service connection will be considered in turn. a. Left knee disability The Veteran seeks service connection for a left knee disability, allegedly as a result of an in-service injury. On examination for service entrance in April 1966, he denied any history of a left knee disability, and his left knee was normal on objective examination. He was accepted for active duty service. In May 1967, the Veteran sought treatment for a left knee complaint. He reported an initial injury to his left knee in February of that year, but denied seeking any treatment at that time. Then, two days ago, he struck his left knee against his foot locker, resulting in swelling and pain of the left knee. On examination, the left knee was without swelling or redness but did exhibit effusion. The impression was of traumatic effusion, and bed rest was recommended. Several days later, his effusion had decreased somewhat, and he denied any pain. Nine days later, his effusion was almost gone, and the Veteran again denied any pain. He did not seek further treatment for his left knee during service. On his February 1968 report of medical history, the Veteran affirmatively denied any history of a trick or locked knee, and a concurrent service separation examination noted a normal left knee, without abnormality. In June 1975, the Veteran sought treatment from a private physician for left knee pain. He reported onset of stiffness and swelling in the left knee approximately one month ago. No specific traumatic injury was noted, and he denied any history of effusion in the knee. He reported a prior in-service injury to his knee, but could not remember if the knee injured in service was the left or the right. He denied any difficulty with the affected knee following service. Currently, he denied any locking or giving way of the left knee. On physical evaluation his left knee exhibited +1 effusion. Chondromalacia patella was also evident, based on crepitation with flexion. X-rays of the left knee indicated mild patella-femoral osteophyte formation, but were otherwise within normal limits. The impression was of internal derangement of the left knee, with a possible posterior horn tear of the left medial meniscus. He was told to return in three weeks to determine if his symptoms persisted. The Veteran sought treatment in 1999 from a private physician for left knee pain, with onset approximately three months ago. He reported a twisting injury to his left knee while playing tennis. He initially treated his injury with rest. After several weeks, he felt he had recovered, and resumed playing tennis. He then experienced another episode of knee pain. Current symptoms included pain, swelling, and limitation of motion of the left knee. The final impression was of a tear of the lateral meniscus of the left knee. In December 1999, the Veteran again sought treatment for left knee pain. He was afforded an arthroscopy of the left knee that same month at a private facility. The Veteran's initial service connection claim was received in April 2008, at which time he claimed service connection for a right knee disability, as well as left knee and low back disabilities resulting therefrom. He stated that he injured his right knee during service in approximately 1967. A VA orthopedic examination was afforded the Veteran in July 2009. He gave a history of a left knee injury sustained while playing basketball in service. He was given a period of light duty, and then returned to full duty. The Veteran could not remember any sick call visits or problems of the low back during service. Regarding his right knee, the Veteran stated problems with his right knee began approximately one year after he injured his left knee, as a result of limping. A total right knee replacement in 2007 was noted. Physical examination of the left knee confirmed degenerative joint disease of the left knee. The examiner was unable to determine the cause or date of onset of such a disorder without resorting to speculation. In October 2011 and August 2012 addendums to this examination report, the examiner stated that it was less likely than not that any current disabilities of the knees and back were related to any incident of service. The examiner noted the lack of evidence of in-service onset of a chronic disorder of the left knee. While the Veteran did report a left knee injury, this injury appeared to self-resolve, as the Veteran did not require further follow-up, and no further entries involving the left knee were noted. Additionally, no disability of the left knee was noted at service separation. A written statement from the Veteran's wife was received in February 2010. She stated that she has known the Veteran since 1969, and he allegedly had his knee drained in 1969 and again in 1972. Additionally, he has worn bilateral knee braces for physical activity since she first met him. A similar statement was received from a friend of the Veteran. After considering the totality of the record, the Board finds the preponderance of the evidence to be against the Veteran's service connection claim for a left knee disability, and it must be denied. While the Veteran did report and seek treatment for pain and swelling at the left knee during service, clinical findings were essentially negative, and this disorder was acute and transitory, without residuals, as subsequent in-service clinical notations indicated his effusion subsided, and the Veteran denied any pain. Additionally, no orthopedic abnormalities of the left knee were noted at service separation; rather, the lower extremities were normal at separation. A VA examiner concluded within a 2009 examination report, with 2011 and 2012 addendums, that the Veteran's current degenerative arthritis of the left knee was not due to either an in-service disease or injury. The Board also notes that the Veteran did not seek treatment for a left knee disorder for many years following service separation. This lengthy period without complaint or treatment is evidence that there has not been a continuity of symptomatology, and weighs heavily against the claim. See Maxson v. Gober, 230 F.3d 1330 (Fed. Cir. 2000). His first post-service treatment of the left knee dates to June 1975, when the Veteran sought treatment from a private physician for left knee pain. At that time, he reported onset of stiffness and swelling in the left knee only one month ago, and he denied any history of effusion in the knee. He reported an in-service injury to his knee, but could not remember if the knee injured in service was the left or the right. He denied any difficulty with the affected knee following service. The Board notes that the fact the Veteran could not remember which knee he injured in service strongly suggests this disability had resolved in service, without complications thereafter. While the Veteran does have a current diagnosis of degenerative arthritis of the left knee, competent evidence has not been presented establishing onset of this disorder during service or within a year thereafter. In the absence of competent evidence that a left knee disability to that effect, service connection for such a disorder must be denied. The Veteran has himself alleged that his left knee disorder was incurred in service. Additionally, lay statements have been received from his spouse and a friend, both of whom reportedly have known him since 1969. The Board does not find these lay parties competent to testify regarding the etiological basis of his degenerative arthritis, as this question is of the type that the courts have found to be beyond the competence of lay witnesses. Lay statements may be competent to support a claim for service connection by supporting the occurrence of lay-observable events or the presence of disability or symptoms of disability subject to lay observation. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); see also Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006) (addressing lay evidence as potentially competent to support presence of disability even where not corroborated by contemporaneous medical evidence). Some medical issues, however, require specialized training for a determination as to diagnosis and causation, and such issues are therefore not susceptible of lay opinions on etiology, and the Veteran's statements therein cannot be accepted as competent medical evidence. See Clemons v. Shinseki, 23 Vet. App. 1, 6 (2009) ("It is generally the province of medical professionals to diagnose or label a mental condition, not the claimant"); Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (unlike varicose veins or a dislocated shoulder, rheumatic fever is not a condition capable of lay diagnosis); Jandreau, 492 F.3d at 1377, n. 4 ("sometimes the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer"). Lay testimony is not competent in the present case, because the Veteran is not competent to state that arthritis was incurred in service. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Kahana v. Shinseki, 24 Vet. App. 428, 433, n. 4 (2011) (lay witnesses are competent to opine as to some matters of diagnosis and etiology, and the Board must determine on a case by case basis whether a veteran's particular disability is the type of disability for which lay evidence is competent). The Board does find the Veteran competent to report the chronicity of such observable symptomatology as left knee joint pain, but in light of the dearth of evidence within the record of treatment of such symptoms following service, his testimony is considered less probative than the VA medical examination report. While the Veteran was seen for left knee pain during service, he specifically denied any history of a trick or locked knee on his service separation report of medical history, suggesting against a continuity of joint pain symptomatology following his in-service left knee injury. Regarding the other lay statements, the Board grants them little probative weight, as they appear to be contradicted by more contemporaneous evidence. For example, both the Veteran's wife and friend stated they have known him to experience bilateral knee pain since they first met him in approximately 1969. According to the July 1975 treatment summary from a private physician, however, the Veteran denied any difficulties involving his knees following service until 1975, when he sought private treatment. The 1975 record also does not indicate the Veteran had his knee twice drained, as reported by these lay parties. As these statements appear to conflict with the impartial medical evidence of record, the Board grants them little probative weight. For the foregoing reasons, the preponderance of the evidence is against the claim for entitlement to service connection for a left knee disorder and the claim must be denied. The benefit-of-the-doubt doctrine is therefore not for application, and the claims must be denied. b. Right knee The Veteran seeks service connection for a right knee disability, both as having been incurred during service, and as a result of a left knee disability. The Veteran's service treatment records are negative for any diagnosis of or treatment for a right knee disability. On his February 1968 report of medical history, the Veteran affirmatively denied any history of a trick or locked knee, and a concurrent service separation examination noted a normal right knee, without abnormality. The Veteran sought treatment for a right knee disability in November 1988. He reported injuring his right knee while in service approximately 20 years ago. He reported experiencing swelling of the right knee, which eventually subsided. Eight years ago, he had a similar experience, wherein he fell and twisted his right knee, resulting in swelling. He stated that X-rays taken at that time were normal. His current symptoms included stiffness with some pain with activity. He denied instability. X-rays confirmed degenerative changes, and post-traumatic degenerative joint disease with a possible meniscal cyst/tear of the right knee was diagnosed. In August 1990, the Veteran again sought private treatment for pain of the right knee. Onset was reportedly approximately three weeks ago, when he noticed gradual onset of right knee pain while playing tennis. On physical evaluation, the Veteran had some limitation of motion, and the examiner suspected an inflammatory response to degenerative joint disease of the right knee. The doctor requested the Veteran return if his symptoms persisted. While seeking treatment for his left knee in 1999, both the Veteran's knees were afforded X-ray examination, and degenerative arthritis was confirmed in the right knee. The Veteran again reported right knee pain to his private examiner in October 2006. Onset was reportedly two days ago, with stiffness of the joint reported. The Veteran denied locking or giving way of the right knee. An October 2006 MRI examination of the Veteran's right knee indicated severe osteoarthritis, effusion of the knee, and multiple loose bodies. Right knee pain and swelling were again reported in November and December 2006, and April and May 2007. A VA orthopedic examination was afforded the Veteran in July 2009. He gave a history of a left knee injury sustained while playing basketball in service. He was given a period of light duty, and then returned to full duty. The Veteran could not remember any sick call visits or problems of the low back during service. Regarding his right knee, the Veteran stated problems with his right knee began approximately one year after he injured his left knee, as a result of limping. A total right knee replacement in 2007 at a private facility was noted. The examiner was unable to determine the cause or date of onset of the Veteran's right knee disability without resorting to speculation. In October 2011 and August 2012 addendums to this examination report, the examiner stated that it was less likely than not that any current disabilities of the knees and back were related to any incident of service. The examiner noted the lack of evidence of in-service onset of a chronic disorder of the right knee. A written statement from the Veteran's wife was received in February 2010. She stated that she has known the Veteran since 1969, and he allegedly had his knee drained in 1969 and again in 1972. Additionally, he has worn bilateral knee braces for physical activity since she first met him. A similar statement was received from a friend of the Veteran. After considering the totality of the record, the Board finds the preponderance of the evidence to be against the Veteran's service connection claim for a right knee disability, and it must be denied. His service treatment records are negative for any diagnosis of or treatment for a right knee disability during service, and no orthopedic abnormalities of the right knee were noted at service separation. Rather, the lower extremities were normal. A VA examiner concluded within a 2009 examination report, with 2011 and 2012 addendums, that the Veteran's right knee disability, status post total knee replacement, was not due to either an in-service disease or injury. The Board also notes that the Veteran did not seek treatment for a right knee disorder for many years following service separation. This lengthy period without complaint or treatment is evidence that there has not been a continuity of symptomatology, and weighs heavily against the claim. See Maxson v. Gober, 230 F.3d 1330 (Fed. Cir. 2000). His first post-service treatment of the right knee dates to November 1988, when the Veteran sought treatment from a private physician for right knee pain. At that time, he reported an in-service injury to the right knee, without complications until approximately 1980, when he experienced a similar injury to his right knee. The Board again notes that while the Veteran's service treatment records confirm an injury to the Veteran's left knee in service, a right knee injury was not noted at that time or reported by the Veteran. While the Veteran did undergo a 2007 total knee replacement of the right knee, and has previously been diagnosed with degenerative joint disease of the right knee, competent evidence has not been presented establishing onset of a right knee disorder during service or within a year thereafter. In the absence of competent evidence that a right knee disability to that effect, service connection for such a disorder must be denied. Regarding the Veteran's assertion that his right knee disability is secondary to his left knee disability, such a claim must be denied as service connection has been denied for the underlying left knee disability. Thus, a claim for service connection as secondary to a left knee disability must be denied as a matter of law. See Sabonis v. Brown, 6 Vet. App. 426 (1994). The Veteran has himself alleged that his right knee disorder was incurred in service. Additionally, lay statements have been received from his spouse and a friend, both of whom reportedly have known him since 1969. The Board does not find these lay parties competent to testify regarding the etiological basis of his degenerative arthritis, as this question is of the type that the courts have found to be beyond the competence of lay witnesses. Lay statements may be competent to support a claim for service connection by supporting the occurrence of lay-observable events or the presence of disability or symptoms of disability subject to lay observation. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); see also Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006) (addressing lay evidence as potentially competent to support presence of disability even where not corroborated by contemporaneous medical evidence). Some medical issues, however, require specialized training for a determination as to diagnosis and causation, and such issues are therefore not susceptible of lay opinions on etiology, and the Veteran's statements therein cannot be accepted as competent medical evidence. See Clemons v. Shinseki, 23 Vet. App. 1, 6 (2009) ("It is generally the province of medical professionals to diagnose or label a mental condition, not the claimant"); Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (unlike varicose veins or a dislocated shoulder, rheumatic fever is not a condition capable of lay diagnosis); Jandreau, 492 F.3d at 1377, n. 4 ("sometimes the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer"). Lay testimony is not competent in the present case, because the Veteran is not competent to state that arthritis was incurred in service. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Kahana v. Shinseki, 24 Vet. App. 428, 433, n. 4 (2011) (lay witnesses are competent to opine as to some matters of diagnosis and etiology, and the Board must determine on a case by case basis whether a veteran's particular disability is the type of disability for which lay evidence is competent). The Board does find the Veteran competent to report the chronicity of such observable symptomatology as right knee joint pain, but in light of the normal findings at separation, the denial of pertinent pathology at separation, the dearth of evidence within the record of treatment of such symptoms following service, his testimony is considered less probative and less credible than the VA medical examination report. Regarding the other lay statements, the Board grants them little probative weight, as they appear to be contradicted by more contemporaneous evidence. For example, both the Veteran's wife and friend stated they have known him to experience bilateral knee pain since they first met him in approximately 1969. According to the July 1975 treatment summary from a private physician, however, the Veteran denied any difficulties involving his knees following service. The 1975 record also does not indicate the Veteran had his knee twice drained, as reported by these lay parties. As these statements appear to conflict with the impartial medical evidence of record, the Board grants them little probative weight. For the foregoing reasons, the preponderance of the evidence is against the claim for entitlement to service connection for a right knee disorder and the claim must be denied. The benefit-of-the-doubt doctrine is therefore not for application, and the claims must be denied. c. Low back The Veteran seeks service connection for a low back disability, both as having been incurred during service, and as a result of a left knee disability. The Veteran 's service treatment records are negative for any diagnosis of or treatment for a low back disability. On his February 1968 service separation examination, his spine and torso were normal on objective examination, and on a concurrent report of medical history, he checked "no" regarding any history of recurrent back pain. The Veteran first sought treatment for a low back disability in 1992, when he was seen for low back pain. He reported onset of low back pain in 1973, when he experienced a sharp pain rising from a sitting position. He reported participating in tennis and downhill skiing on a frequent basis. He was afforded a course of physical therapy. A VA orthopedic examination was afforded the Veteran in July 2009. He could not remember any sick call visits or problems of the low back during service. Physical examination of the lumbosacral spine confirmed degenerative disc disease. The examiner was unable to determine the cause or date of onset of such a disorder without resorting to speculation. In October 2011 and August 2012 addendums to this examination report, the examiner stated that it was less likely than not that any current disability of the low back were related to any incident of service. The examiner noted the lack of evidence of in-service onset of a chronic disorder of the low back. After considering the totality of the record, the Board finds the preponderance of the evidence to be against the Veteran's service connection claim for a low back disability, and it must be denied. His service treatment records are negative for any diagnosis of or treatment for a low back disability during service, and no abnormalities of the low back were noted at service separation. A VA examiner concluded within a 2009 examination report, with 2011 and 2012 addendums, that the Veteran's low back disability, degenerative disc disease, was not due to either an in-service disease or injury. The Board also notes that the Veteran did not seek treatment for a low back disorder for many years following service separation. This lengthy period without complaint or treatment is evidence that there has not been a continuity of symptomatology, and weighs heavily against the claim. See Maxson v. Gober, 230 F.3d 1330 (Fed. Cir. 2000). His first post-service treatment of the low back dates to 1992, when the Veteran sought treatment from a private physician for low back pain. At that time, he did not report an in-service injury to the low back; rather, he reported a post-service injury to his low back in 1973. While the Veteran has been diagnosed with degenerative disc disease of the low back, competent evidence has not been presented establishing onset of a low back disorder during service or within a year thereafter. In the absence of competent evidence that a low back disability to that effect, service connection for such a disorder must be denied. Regarding the Veteran's assertion that his low back disability is secondary to his left knee disability, such a claim must be denied as service connection has been denied for the underlying left knee disability. Thus, a claim for service connection as secondary to a left knee disability must be denied as a matter of law. See Sabonis v. Brown, 6 Vet. App. 426 (1994). The Veteran has himself alleged that his low back disorder was incurred in service. The Board does not find the Veteran competent to testify regarding the etiological basis of his degenerative disc disease of the lumbosacral spine, as this question is of the type that the courts have found to be beyond the competence of lay witnesses. Lay statements may be competent to support a claim for service connection by supporting the occurrence of lay-observable events or the presence of disability or symptoms of disability subject to lay observation. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); see also Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006) (addressing lay evidence as potentially competent to support presence of disability even where not corroborated by contemporaneous medical evidence). Some medical issues, however, require specialized training for a determination as to diagnosis and causation, and such issues are therefore not susceptible of lay opinions on etiology, and the Veteran's statements therein cannot be accepted as competent medical evidence. See Clemons v. Shinseki, 23 Vet. App. 1, 6 (2009) ("It is generally the province of medical professionals to diagnose or label a mental condition, not the claimant"); Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (unlike varicose veins or a dislocated shoulder, rheumatic fever is not a condition capable of lay diagnosis); Jandreau, 492 F.3d at 1377, n. 4 ("sometimes the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer"). Lay testimony is not competent in the present case, because the Veteran is not competent to state that arthritis was incurred in service. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Kahana v. Shinseki, 24 Vet. App. 428, 433, n. 4 (2011) (lay witnesses are competent to opine as to some matters of diagnosis and etiology, and the Board must determine on a case by case basis whether a veteran's particular disability is the type of disability for which lay evidence is competent). The Board does find the Veteran competent to report the chronicity of such observable symptomatology as low back pain, but in light of the normal findings of at separation, the denial of pertinent pathology at separation and dearth of evidence within the record of treatment of such symptoms following service, his testimony is considered less probative and less credible than the VA medical examination report and the other evidence of record. For the foregoing reasons, the preponderance of the evidence is against the claim for entitlement to service connection for a low back disorder and the claim must be denied. The benefit-of-the-doubt doctrine is therefore not for application, and the claims must be denied. ORDER Entitlement to service connection for internal derangement of the left knee is denied. Entitlement to service connection for degenerative joint disease of the right knee is denied. Entitlement to service connection for degenerative changes of the lumbar spine is denied. ____________________________________________ H. N. SCHWARTZ Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs