Citation Nr: 1301555 Decision Date: 01/15/13 Archive Date: 01/23/13 DOCKET NO. 10-23 133 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Muskogee, Oklahoma THE ISSUES 1. Entitlement to service connection for a bilateral knee condition, to include bilateral degenerative joint disease with effusion, status post arthroscopic surgery of the left knee in 1981. 2. Entitlement to service connection for hypertension, to include as due to herbicide exposure and as aggravated by service-connected type II diabetes mellitus. 3. Entitlement to service connection for a cervical and lumbar spine disability. REPRESENTATION Appellant represented by: Military Order of the Purple Heart of the U.S.A. WITNESSES AT HEARING ON APPEAL Appellant and JM ATTORNEY FOR THE BOARD D. Rogers, Associate Counsel INTRODUCTION The Veteran served on active duty from September 1964 to September 1967. These matters come before the Board of Veterans' Appeals (Board) on appeal from an August 2007 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Muskogee, Oklahoma, which denied service connection for the claimed disabilities on both a direct and presumptive basis. In a December 2008 rating decision, the RO denied entitlement to service connection for hypertension claimed as due to exposure to herbicides during service in Vietnam. In June 2009, the Veteran testified at a personal hearing before a Decision Review Officer (DRO) at the Muskogee RO. In May 2011, he testified at a Videoconference hearing before the undersigned Veterans Law Judge. Transcripts of these hearings are of record. The issues of entitlement to service connection for hypertension to include as due to herbicide exposure during service and as aggravated by service-connected type II diabetes mellitus and a cervical and lumbar spine disability are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDING OF FACT A bilateral knee condition, to include bilateral degenerative joint disease with effusion, status post arthroscopic surgery of the left knee in 1981 was not shown during the Veteran's active duty military service or for many years thereafter, and the weight of the probative evidence is against a finding that the Veteran's current bilateral knee disability is related to his active duty military service. CONCLUSION OF LAW Entitlement to service connection for a bilateral knee condition, to include bilateral degenerative joint disease with effusion, is not warranted. 38 U.S.C.A. §§ 1110, 1112, 1113, 1154(b) (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION The Board has reviewed all the evidence in the Veteran's claims file, his Virtual VA file, and his multiple contentions and hearing testimony. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, all the evidence submitted by or on behalf of the Veteran. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claim. The Veteran must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to the Veteran). The Veterans Claims Assistance Act of 2000 (VCAA) The requirements of the Veterans Claims Assistance Act of 2000 (VCAA) have been met. There is no issue as to providing an appropriate application form or completeness of the application. VA notified the Veteran in pre-rating correspondence dated in April 2007, of the information and evidence needed to substantiate and complete his claims for service connection for a bilateral knee disability, to include information regarding how disability evaluations and effective dates are assigned. VA fulfilled its duty to assist the claimant in obtaining identified and available evidence needed to substantiate the claim, and as warranted by law, providing VA examinations and obtaining a medical opinions. Review of the record shows that the claims file contains the Veteran's service treatment and personnel records and identified VA and private treatment records. The Board acknowledges that treatment records pertaining to a work-related twist injury and surgical treatment of the Veteran's left knee in 1981 are not of record and have not been requested by VA. In light of the Veteran's statements discussed below, however, which repeatedly indicated that he did not experience a symptoms or receive treatment of a disability of either knee prior the 1981 work-related left knee injury, or at any time since that injury until approximately 2005, the Board declines to remand the claim to request any associated private treatment records. Moreover, neither the Veteran nor his representative have requested VA's assistance in obtaining those records or indicated that they contain information or evidence relevant to the bilateral knee disability on appeal. Finally, the Veteran has repeatedly stated that he is unable to remember any details of injury and treatment of his left knee in 1981. As such, there is not sufficient information available with which to request those records. This it appears that efforts to obtain those records would be futile. See Hayre v. West, 188 F.3d 1327 (Fed. Cir. 1999). The Veteran was provided VA joints examinations pertaining to the claimed bilateral knee disability in July 2009 and February 2010. The examiners performed complete and thorough examinations. The July 2009 and February 2010 examinations and opinions are adequate for the purpose of adjudication of the claims. The examination reports reflect that the examiners reviewed the claims file and rendered appropriate diagnoses and opinions consistent with the remainder of the evidence of record. The Board, therefore, concludes that the examinations in combination with the other evidence of record are adequate for purposes of rendering a decision pertaining to the claim of service connection for a bilateral knee disability. See 38 C.F.R. § 4.2 (2012); see also Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). In sum, there is no evidence of VA error in notifying or assisting the claimant that reasonably affects the fairness of this adjudication. See 38 C.F.R. § 3.159(c). Analysis Generally, service connection may be granted for disability or injury incurred in or aggravated by active military service. See 38 U.S.C.A. § 1110 (West 2002); 38 C.F.R. § 3.303 (2011). Service connection may also be granted on a presumptive basis for certain chronic disabilities, including arthritis, when such are manifested to a compensable degree within the initial post-service year. See 38 U.S.C.A. §§ 1101, 1112, 1113 (West 2002); 38 C.F.R. §§ 3.307, 3.309(a) (2012). In order to establish service connection for the claimed disability, there must be (1) medical evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999). The determination as to whether these requirements are met is based on an analysis of all the evidence of record and the evaluation of its credibility and probative value. See Baldwin v. West, 13 Vet. App. 1, 8 (1999). In the case of any veteran who has engaged in combat with the enemy in active service during a period of war, satisfactory lay or other evidence that an injury or disease was incurred or aggravated in combat will be accepted as sufficient proof of service connection if the evidence is consistent with the circumstances, condition or hardships of such service, even though there is no official record of such incurrence or aggravation. See 38 U.S.C.A. § 1154(b) (West 2002); 38 C.F.R. § 3.304(d) (2012). The Court has held that 38 U.S.C.A. § 1154(b) can be used only to provide a factual basis upon which a determination could be made that a particular disease or injury was incurred or aggravated in service, not to link the claimed disorder etiologically to the current disorder. See Libertine v. Brown, 9 Vet. App. 521, 522-23 (1996). Section 1154(b) does not establish service connection for a combat veteran; it aids him by relaxing the adjudicative evidentiary requirements for determining what happened in service. A veteran must still generally establish his claim by competent medical evidence tending to show a current disability and a nexus between that disability and those service events. See Gregory v. Brown, 8 Vet. App. 563, 567 (1996). In Kessel v. West, 13 Vet. App. 9 (1999), the Court affirmed that the 38 U.S.C.A. § 1154(b) presumption only relates to the question of service incurrence, it does not relate to questions of whether the veteran has a current disability or whether there was a nexus between the in-service event and the current disability. In order to show a 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." When the fact or chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support a claim. There must be competent medical evidence unless the evidence relates to a condition as to which lay observation is competent to identify its existence. See 38 C.F.R. § 3.303(b) (2012). When all the evidence is assembled, 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. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). In this case, the Veteran contends that his bilateral knee disability is due to trauma sustained to his knees during combat in Vietnam. Specifically, he asserts that his knees were injured when he was thrown out of a helicopter that was shot down during take off from approximately 20 feet above ground causing it to land upside down on its rotor in 1966. He asserts that he has experienced bilateral knee pain continuously since 1966. It is undisputed that the Veteran has current diagnoses of degenerative joint disease with joint effusion of his bilateral knees as evidenced by the July 2009 and February 2010 VA joints examination reports. Thus, the evidence must show that such condition was incurred during or is related to an event or injury during military service. The Veteran's service personnel and medical records are negative for any evidence corroborating the alleged helicopter crash in 1966. His service personnel records confirm that he served in Vietnam from August 1965 to December 1966. His Military Occupational Specialties (MOS) included a wireman and a door gunner on an assault helicopter. He was involved in the Vietnam Defensive Campaign and the Republic of Vietnam Counteroffensive Campaign. His military decorations and awards include an Air Medal with one silver and two bronze Oak Leaf Clusters for meritorious achievement while participating in aerial flight for at least four periods in February, March and April 1966. Citations show that during each of those periods, he participated in more than 25 aerial missions over hostile territory in support of counterinsurgency operations. Thus, the Board does not dispute that the Veteran engaged in combat with the enemy in active service during a period of war or that he may have been involved in a helicopter crash in 1966 as alleged. The Veteran's service treatment records show that in January 1965, prior to the alleged helicopter crash, he complained of a sore right knee since two days prior without history of injury. He was treated with medication and returned to duty without limitations. October 1965 and July 1967 reports of medical history show a reported history of leg cramps, however, history of arthritis, bone or joint deformity, or trick or locked knee were denied on both occasions and physical examination of his lower extremities was normal in October 1965 and July 1967. Post-service treatment records and examination reports dating since 2001 show that following the Veteran's discharge from military service, he was employed as a truck driver for an oil company for 11 years, which required that he load and unload containers of motor oil. Thereafter, he was a truck driver for a bakery for 25 years, which entailed driving for periods of up to and in excess of nine hours at a time and loading and unloading items from his truck. The Veteran's statements of record consistently indicate that he retired from his usual occupation as a truck driver in March 2009 due to either age, duration of employment, or being laid off due lack of work. The earliest post-service treatment record that documents complaints or findings of a knee disability of either knee is dated in January 2006, nearly 40 years after the Veteran's separation from active service. As previously noted and discussed in more detail below, however, during VA examination in July 2009, the Veteran's reported surgical history included arthroscopic surgery of his left knee in 1981 following a work-related twist injury of his left knee. At the June 2009 DRO hearing, the Veteran testified that at the time of the alleged helicopter crash during service, he was thrown on his back. When asked whether he sustained any injury other than to his back at that time, he indicated that he was stunned and jumped up running as his concern was to help others who were still strapped in an to get away from the crash. He did not remember whether he sought treatment for right knee symptoms during service. He stated that other than "the fall," he did not know the cause of his current left knee symptoms. He stated that he was not receiving treatment for conditions of either knee, rather, he just deals with the aches and pains. In June 2009, the RO requested that the Veteran be scheduled for a VA examination to determine the nature and etiology of his claimed bilateral knee disability. The examination request included langue contained in 38 U.S.C.A. § 1154(b) and 38 C.F.R. § 3.304(d) pertaining to a veteran who has engaged in combat with the enemy and satisfactory lay or other evidence that will be accepted as sufficient proof of service connection if it is consistent with the circumstances, condition or hardships of such service. The examination request noted the Veteran's contention his current knee disability related to bilateral knee injuries sustained during a helicopter crash which is consistent with the circumstances of his military service. In July 2009, Veteran was afforded a VA joints examination for his claimed bilateral knee disability. He reported that his knees started to bother him three to four years prior without history of a specific injury of either knee. He stated that he was thrown from a helicopter crash during service, however, he did not remember sustaining any injuries and he did not seek medical treatment following the crash. He indicated that in 1981, he twisted his left knee in a work-related injury resulting in a chipped bone, torn cartilage, and fluid in his left knee for which he underwent arthroscopic surgery shortly thereafter. Following physical and x-ray examination of the Veteran's bilateral knees, which showed mild degenerative joint disease with mild joint effusion and questionable chondrocalcinosis, the examiner diagnosed mild degenerative joint disease of the bilateral knees. He opined that such diagnosis is not likely related to the Veteran's military service because his service medical records contain no evidence he sustained injury to either knee during service. He stated that although the Veteran sought treatment for a two day history of right knee pain in January 1965, he denied history of injury of his right knee at that time. Furthermore, despite the examiner's documentation of the Veteran's reported involvement in a helicopter crash during service, he found no evidence of injury of either knee during service. He reasoned that physical examination of the joints upon separation examination in July 1967 was normal. He concluded that the Veteran's bilateral conditions are most likely due to age-related wear and tear and his 35 year occupational history as a truck driver for a bakery and oil company that required him to load and unload his truck. In February 2010, the Veteran was afforded an additional VA joints examination. The examiner noted that the history provided by the Veteran during examination pertaining to history of the claimed disability is presumed to be accurate. On this occasion, the Veteran reported an onset of right knee pain in 2005 without history of injury of his right knee. He stated that gout began to affect his right knee in January 2010 and VA treatment for gout significantly improved his right knee symptoms. He reported an onset of left knee pain in 1981 following a twist injury of his left knee when he stepped out of his truck into a snowy ditch following a truck accident. At that time, the Veteran experienced immediate pain and swelling of his left knee. Orthopedic evaluation of his left knee the following day reportedly revealed chipped bone, torn cartilage and fluid in his left knee for which he underwent arthroscopic surgery on his left knee. He was unable to remember any details of his 1981 surgery but indicated that his left knee did very well following surgery. Left knee symptoms reportedly resolved until 2005 when the Veteran noticed pain and stiffness. The Veteran denied any right knee problems dating prior to 2005 and any left knee problems dating prior to the 1981 work-related twist injury. He also denied incurrence of a left knee injury during military service. Current treatment of bilateral knee symptoms included self-treatment with theragesic which significantly improved his bilateral knee symptoms. The Veteran stated that Dr. K, his private primary care physician since 2003 had recommended conservative care of his bilateral knee symptoms with weight loss and that a 32 pound weight loss during the two years prior also improved but did not resolve his bilateral knee pain and stiffness. Following physical and x-ray examination of the Veteran's bilateral knees in February 2010, the examiner diagnosed mild degenerative joint disease of the right and left knees, status post arthroscopic surgery of the left knee in 1981 due to a work-related injury. After a review of the medical records, documentation of the Veteran's reported history, performance of physical and x-ray examinations of the Veteran's knees, and review of the medical literature, the examiner opined that degenerative joint disease of the Veteran's bilateral knees is less likely as not a result of an in service injury or event and is at least as likely as not related to the Veteran's post-service activities of working manual labor for years driving and loading/unloading a truck, his obesity, the normal process of aging, and as to the left knee, the 1981 work-related twist injury and surgical treatment of the left knee. Regarding the right knee, the examiner reasoned that there is no evidence of knee complaints or injury during service with the exception of a note dated in January 1965 where the Veteran complained of soreness in the right knee for two days and was treated with Salicylates. The examiner further reasoned that the Veteran stated that right knee symptoms did not start until 2005, 38 years after he was discharged from service, and he did not relate his current symptoms to any event that occurred during service. Regarding the left knee, the examiner's rationale was that there is no evidence of left knee complaints or injury during service and the Veteran stated that he did not experience left knee problems at any time prior to the 1981 work-related twist injury of his left knee with symptoms much improved following arthroscopic surgery at that time through 2005, many years after his discharge from service and surgical treatment of his left knee in 1981. Moreover, during examination, the Veteran did not relate his current left knee symptoms to any event that occurred during service. During the May 2011 Videoconference hearing before the undersigned, the Veteran testified that during the 1966 helicopter crash, he was thrown to his back and knees and he experienced bilateral knee pain at that time. He did not seek treatment for knee symptoms at the time of the incident or at anytime prior to his discharge from military service because the mission and his fellow soldiers were more important than his own personal pain. He acknowledged that the record contained some reference to a work-related knee injury, however, he stated that he has experienced knee problems since 1966 and prior to 1981 during which time he denied experiencing any post-service injury or treatment of either knee. He stated that his knee pain simply worsened with time and he dealt with it. He admitted that no VA or private physician had related current conditions of either knee to any incident of his military service. His representative asserted that his combat service and the applicability of 38 U.S.C.A. § 1154(b) and 38 C.F.R. § 3.304(d) regarding the establishment of an in-service incurrence of an injury or event during service had not been appropriately considered by VA or the July 2009 or February 2010 VA examiners. Thus, he requested that the Veteran be afforded an additional VA examination where the examiner is provided with and has appropriately considered the provisions of 38 U.S.C.A. § 1154(b) and 38 C.F.R. § 3.304(d). Having carefully considered the Veteran's contentions in light of the evidence of record and the applicable law, the Board finds that service connection for the claimed bilateral knee disability, to include degenerative joint disease with joint effusion, is not warranted on any basis. Regarding evidence of an in-service incurrence of a disease or injury, the Board will address disease and injury separately. Concerning in-service disease, as previously noted, service treatment records show complaints of right knee pain for two days in January 1965 whereby the Veteran was treated with medication and returned to duty without limitations. Additionally, reports of leg cramps were noted on reports of medical history dated in October 1965 and during separation examination in July 1967, however, any history of arthritis, bone or joint deformity, or trick or locked knee was denied. Moreover, physical examinations of the lower extremities on both occasions, to include on separation examination, were normal. Following consideration of the Veteran's reported and documented history of the claimed bilateral knee disability, neither examiner found that degenerative joint disease of either knee had onset during military service. Accordingly, the Board finds that the contemporaneous and competent medical evidence of record weighs against a finding of the incurrence of a disease process in either knee, to include degenerative joint disease, during military service. Additionally, the record does not reflect medical evidence showing any manifestations of arthritis of either knee during the one-year presumptive period after the Veteran's separation from service. Indeed, the record does not reflect any complaints or findings of a knee disability of either knee until January 2006 (nearly 40 years after his separation from active service) and not until VA examination in July 2009 was a history of a 1981 arthroscopic surgery on the left knee following a work-related twist injury was noted. During the July 2009 examination, the Veteran dated the onset of his bilateral knee pain in approximately 2005 and during examination in February 2010 he denied experiencing problems with either knee at any time prior to 1981 regarding the left knee and 2005 regarding the right knee. Thus, the Board finds that there is no competent medical evidence on which to find that a disease process in either knee, to include degenerative joint disease, manifested to a compensable degree within the initial post-service year following the Veteran's discharge from military service. With respect to in-service event or injury, to include the bilateral knee injuries allegedly sustained during the 1966 helicopter accident, as previously stated, the occurrence of and the Veteran's involvement in that incident is not in dispute such is consistent with the circumstances of his military service. See 38 U.S.C.A. § 1154(b); 38 C.F.R. § 3.304(d). However, the weight of the evidence does not show that the Veteran developed a chronic disabling knee disability as a result of this injury or any other in-service injury. Specifically, while the Veteran's testimony in May 2011 suggests that he injured both knees when he was thrown onto his back and knees during that incident, his testimony in June 2009 indicates that he was thrown onto his back without any indication that he landed on his knees. While he did state during the June 2009 hearing that other than "the fall," he is unsure what happened to his left knee, it is unclear if "the fall" alluded to pertains to the in-service helicopter crash or the 1981 work-related twist injury of his left knee. Indeed, during the February 2010 examination, the Veteran explicitly denied sustaining any injury of his left knee during service. Similarly, during the February 2010 examination, he did not report experiencing problems with his right knee prior to 2005. In light of the Veteran's conflicting testimony and statements of record and documented during VA examinations as to whether he sustained injury to either knee during the 1966 helicopter crash the Board finds any current assertion that he has experienced knee pain or other knee related symptoms continuously since service to be not credible and entitled to no probative weight. The Board acknowledges that a layperson is competent to report on whether his knees were injured during the 1966 crash and as to the onset of his current bilateral knee symptomatology. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (noting that a Veteran is competent to report on that of which he or she has personal knowledge). The Board finds, however, that given the lack of contemporaneous medical evidence supporting such assertion and the Veteran's repeated denials of injury or problem with either knee at the time of the 1966 accident or at any time during service, his statements to this effect are not credible and carry no probative weight. In determining whether statements submitted by a veteran are credible, the Board may consider internal consistency, facial plausibility, and consistency with other evidence submitted on behalf of the claimant. Caluza v. Brown, 7 Vet. App. 498 (1995). Even if the Veteran's assertions regarding in-service incurrence of bilateral knee injuries were accepted as satisfactory lay evidence of establishment of an in-service incurrence of injury or disease, there is no competent or credible evidence of the required combination of manifestations sufficient to identify a disease entity of either knee and sufficient observation to establish chronicity of a disability of either knee during service as distinguished from merely isolated findings. Specifically, while the Veteran received treatment for right knee pain in January 1965, he was treated with medication and returned to service without limitation. Thus, it appears that right knee pain was merely acute and transitory as opposed to chronic or recurrent. Moreover, although he testified that he did not seek treatment for knee symptoms during service because the mission and his fellow soldiers were more important than his own personal pain, the Board notes that he returned to the United States from Vietnam 9 months prior to discharge and during that time he sought treatment for other medical complaints, to include shoulder pain after playing softball in March 1967 without any mention or complaint of knee pain. The Board notes that it would be incredible for the Veteran to seek in-service treatment for other medical complaints, to include orthopedic pain, without mention of bothersome and continuous bilateral knee symptoms as alleged. Thus, any assertion that absence of treatment for knee symptoms during service is due to the circumstances inherent in combat service to be not credible and entitled to no probative weight. The Board is aware of the provisions of 38 C.F.R. § 3.303 (b), discussed above, relating to chronicity and continuity of symptomatology. The Board notes that the Veteran appears to be contending that he has had bilateral knee disabilities continually since service. However, the first post-service evidence of complaint of, or treatment for, a left knee disability is dated in 1985 and a right knee disability is dated in 2005, many years following the Veteran's discharge from military service in 1967. While the Veteran is competent to report knee pain over the years since service, the Board notes that a knee disability of either knee was not reported at the time of his service discharge. The Board finds that his current statements and those of his daughter in a March 2010 statement regarding a continuity of a bilateral knee disability since service are not credible. His July 1967 separation examination as well as his reports of onset of knee symptoms during the July 2009 and February 2010 VA examinations contradict any current assertion that his current bilateral knee disabilities were manifested during service. There is no competent medical evidence that the Veteran complained of or was treated for a disability of either knee for many years after his separation from service. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) (noting that it was proper to consider the veteran's entire medical history, including the lengthy period of absence of complaint with respect to the condition he now raised); see also Mense v. Derwinski, 1 Vet. App. 354, 356 (1991) (affirming Board where it found that veteran failed to account for the lengthy time period after service for which there was no clinical documentation of the claimed condition). The Board accordingly places no probative value on the assertions of the Veteran and his daughter that there has been a continuity of symptomatology dating since service. Therefore, continuity of symptomatology after service is not demonstrated. Finally, regarding a nexus or link between the Veteran's current bilateral knee condition and military service, to include any injury to either knee that he may have sustained during service as alleged, the Board has carefully evaluated the evidence and, for reasons stated immediately below, finds that a preponderance of the competent and probative evidence of record supports a finding that the Veteran's current bilateral knee disability is not related to any incident of his military service. Despite the Veteran's reported involvement in a helicopter crash in 1966 whereby he allegedly sustained injury to both of his knees, the VA examiners concluded that degenerative joint disease of the Veteran's bilateral knees is less likely than not caused by or a result of any incident of the Veteran's military service. Rather, they opined that such disabilities are related to the Veteran's post-service occupational activities and left knee injury in 1981, his weight, and the natural wear and tear process that occurs with aging. The examination reports appear to have been based upon thorough review of the record, thorough examination of the Veteran, and thoughtful analysis of the Veteran's entire history. See Bloom v. West, 12 Vet. App. 185, 187 (1999) (the probative value of a physician's statement is dependent, in part, upon the extent to which it reflects "clinical data or other rationale to support his opinion"). Additionally, the February 2010 examiner cited her review of the medical literature in support of that opinion. Moreover, the opinions appear to be consistent with the Veteran's medical history, which is absent any symptomatology of a disability of either knee for several years after service and his service records which do not appear to show any injury or chronic disability of either knee during military service. The Veteran has not submitted a medical opinion to contradict the VA examiner's opinions. As was explained in the VCAA section above, the Veteran has been accorded ample opportunity to present competent medical evidence in support of his claim. He has failed to do so. See 38 U.S.C.A. § 5107(a) (West 2002) (it is the claimant's responsibility to support a claim for VA benefits). In relevant part, 38 U.S.C.A. 1154(a) (West 2002) requires that VA give "due consideration" to "all pertinent medical and lay evidence" in evaluating a claim for disability or death benefits. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). "Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional." Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); see also Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) ("[T]he Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence"). The Board notes that the Veteran, while entirely competent to report his symptoms both current and past (including knee pain), has presented no probative clinical evidence of a nexus between his current bilateral knee disability and his military service. The Veteran as a lay person is not competent to associate any of his claimed symptoms to knee pain or alleged injury during service. He is not competent to opine on matters such as the etiology of his current degenerative joint disease of his bilateral knees. Such opinion requires specific medical training and is beyond the competency of the Veteran or any other lay person. In the absence of evidence indicating that the Veteran has the medical training to render medical opinions, the Board must find that his contention with regard to a medical nexus between his bilateral knee disability and his military service to be of no probative value. See also 38 C.F.R. § 3.159(a)(1) (2012) (competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions). Accordingly, the statements offered by the Veteran in support of his own claim are not competent evidence of a medical nexus. Accordingly, the claim for service connection for a bilateral knee disability must fail as the evidence does not demonstrate that the Veteran has a current disability of either knee, to include bilateral degenerative joint disease with effusion, that was incurred in service or for many years thereafter or that is related to any incident of his military service. In reaching this determination, the Board acknowledges that VA is statutorily required to resolve the benefit of the doubt in favor of the Veteran when there is an approximate balance of positive and negative evidence regarding the merits of an outstanding issue. That doctrine, however, is not applicable in this case because the preponderance of the evidence is against the claim. See Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990); 38 U.S.C.A. § 5107(b) (West 2002). ORDER Entitlement to service connection for a bilateral knee condition, to include degenerative joint disease with effusion, is denied. REMAND Regarding the Veteran's claims for service connection for hypertension and cervical and lumbar spine disabilities, a review of the record reveals that additional development is warranted prior to adjudication of the claims. Hypertension Initially, the Veteran asserted that service connection is warranted for hypertension due to his exposure to herbicides during service in Vietnam. In a July 2008 statement, Dr. K, a private primary care physician, opined that the Veteran's hypertension is "as likely as not linked to [his] agent orange exposure," however, no supporting rationale was provided for that opinion. During the May 2011 Videoconference hearing, the Veteran and his representative further asserted that service connection for hypertension is warranted on the basis of aggravation of hypertension by type II diabetes mellitus for which service connection was granted in April 2010. The Veteran testified that he was diagnosed with hypertension in approximately 2001, which remained relatively stable until he was diagnosed with type II diabetes mellitus in or around 2008. He indicated that since he was diagnosed with type II diabetes mellitus associated with herbicide exposure during service, his blood pressure has fluctuated and has been adversely affected. He stated that approximately six months prior to the May 2011 hearing, a nurse at the Muskogee VA Medical Center stated that his hypertension is aggravated by his service-connected type II diabetes mellitus. The Veteran has not been afforded a VA examination to determine whether his hypertension may be related to military service, to include exposure to herbicides therein, or whether it is aggravated by his service-connected diabetes mellitus. It is necessary to obtain a VA examination or opinion in cases such as this where the evidence indicates that the claimed disability may be associated with service or service-connected disability, and the record does not contain sufficient medical evidence for VA to make a decision on the claim. See 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159; McClendon. Thus, the Veteran must be afforded a VA examination to determine the nature and etiology of his claimed hypertension disability. Cervical and Lumbar Spine The Veteran asserts that service connection is warranted as the claimed cervical and lumbar spine disabilities, which he asserts were caused by or are related to military service, to include his involvement in a helicopter crash in 1966. He asserts that he has experienced back pain since 1966 when the helicopter that he was riding in was shot down from approximately 20 feet in the air during take off which caused it flip upside down and land on its rotor. He has consistently reported that he was thrown from the helicopter onto his back. The Veteran's service treatment records show a complaint of back pain in December 1965 with report of some back trouble since a few months prior. Additionally, the Veteran indicated that he experienced recurrent back pain in October 1965 and July 1967 reports of medical history. Physical examination of the Veteran's back on all occasions, to include on separation examination in July 1967, was normal. Moreover, notation on his separation examination noted that there were no sequelae of recurrent back pain. The earliest post-service indication of a lumbar spine disability is dated in 1985. The July 2009 and February 2010 VA spine examination reports show that the Veteran reportedly sustained a pinched nerve in his lumbar spine upon lifting a light box of chips while working as a truck driver for a bakery. Consequently, a lumbar discectomy was performed shortly thereafter by Dr. I at St. Johns Hospital located in Tulsa, Oklahoma. There is no indication that clinical or hospital treatment records pertaining to the 1985 lumbar spine injury and discectomy have been requested or obtained from Dr. I or St. Johns Hospital. Additionally, although private treatment records were obtained from Dr. C dating from 2001 to 2003, it appears that there may be additional treatment records from Dr. C dating prior to December 2001. Also, private treatment records obtained from Dr. K show that the Veteran was referred to Dr. M, a private neurosurgeon, in January 2004 due to cervical disc degeneration; however, treatment records have not been requested or obtained from Dr. M. As the aforementioned private treatment records may provide additional evidence in support of the Veteran's claims for service connection for cervical and lumbar spine disabilities, an attempt should be made to obtain those records on remand. Finally, the Board observes that VA treatment records pertaining to hypertension and cervical and lumbar spine disabilities have not been obtained from the Muskogee VA Medical Center as alluded to by the Veteran during the May 2011 hearing. Additionally, VA treatment records from the Tulsa VA Medical Center were most recently updated in August 2010 and private treatment records from Dr. K were most recently updated in February 2008. A May 2010 VA treatment note shows that the Veteran was receiving ongoing primary care from Dr. K at that time. Additional relevant medical records, if any, should be obtained. 38 C.F.R. § 3.159(c)(2). Accordingly, the case is REMANDED for the following action: 1. Request that the Veteran identify the names, addresses, and dates of treatment for all medical care providers, VA and non-VA, inpatient and outpatient, who may possess additional records referable to diagnosis of and treatment of his hypertension, type II diabetes mellitus and spine that are not already of record dating since his discharge from service. In addition, the Veteran should be asked to submit treatment records for (or, in the alternative, submit the appropriate releases to allow VA to obtain treatment from) the following providers: a) private treatment records dated in 1985 from Dr. I and St. Johns Hospital in Tulsa, Oklahoma pertaining to diagnosis and clinical/surgical treatment of the lumbar spine as alluded to during the July 2009 and February 2010 VA examinations; b) treatment records from Dr. CC (primary care) dating prior to December 2001 c) treatment records from Dr. M (neurosurgeon) pertaining to diagnosis and treatment of any cervical spine disability dating since January 2004, and d) treatment records from Dr. DK (primary care) dating since February 2008. The Veteran should provide separate written releases for each provider. If any records identified cannot be obtained, the RO/AMC should notify the Veteran and his representative of such and describe the efforts taken to obtain them. 2. Request any relevant VA treatment records, to include any records from the Muskogee VA Medical Center as alluded to during the May 2011 hearing, and from the Tulsa VA Medical Center dating since August 2010. 3. Thereafter, the Veteran should be afforded a VA examination to ascertain the etiology of his claimed hypertension disability. The Veteran's claims file, to include any relevant records in Virtual VA, must be made available to the examiner for review in connection with the examination. Any indicated evaluations, studies, and tests deemed necessary by the examiner should be accomplished. The examiner is requested to review all pertinent records associated with the claims file and following this review and examination of the Veteran, offer an opinion as to whether it is at least as likely as not (a 50 percent probability or greater) that the Veteran's hypertension is (1) causally or etiologically related to the Veteran's military service, to include herbicide exposure therein, or (2) casually or etiologically related to his service-connected type II diabetes mellitus. The examiner is requested to acknowledge and discuss Dr. K's July 2008 statement and opinion. The examiner is also requested to provide an opinion as to whether it is at least as likely as not (a 50 percent probability or greater) that the Veteran's hypertension is aggravated (permanently worsened beyond normal progression and not a temporary flare-up or worsening) by the Veteran's service-connected type II diabetes mellitus. The examiner should comment as to whether the Veteran's service-connected type II diabetes mellitus chronically worsens or increases the severity of his hypertension disability. If aggravation is found, to the extent practicable, the examiner should indicate a baseline of symptomatology and the aggravation of such symptomatology by service-connected type II diabetes mellitus. A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. If any requested opinion cannot be provided without resort to speculation, the examiner should so state and explain why an opinion cannot be provided without resort to speculation. 4. After the development requested has been completed, review the examination report to ensure that it is in complete compliance with the directives of this REMAND. If the report is deficient in any manner, the RO/AMC must implement corrective procedures at once. 5. After completing these actions, the RO/AMC should conduct any other development necessary and as may be indicated by a response received as a consequence of the actions taken in the preceding paragraphs. This should include obtainment of an addendum opinion from the February 2010 VA spine examiner pertaining to the etiology of the claimed cervical and lumbar spine disabilities if indicated by any additional evidence received. 6. Thereafter, the RO/AMC should readjudicate the claims based on the entirety of the evidence. If the benefits sought on appeal are not granted, the Veteran and his representative should be provided with a supplemental statement of the case. An appropriate period of time should be allowed for response. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ DAVID L. WIGHT Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs