Citation Nr: 1303586 Decision Date: 02/01/13 Archive Date: 02/08/13 DOCKET NO. 09-07 759 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Seattle, Washington THE ISSUES 1. Entitlement to service connection for a right knee disability, to include on a secondary basis. 2. Entitlement to service connection for a left knee disability, to include on a secondary basis. REPRESENTATION Appellant represented by: National Association for Black Veterans, Inc. WITNESS AT HEARING ON APPEAL Appellant and his Wife ATTORNEY FOR THE BOARD Dan Brook, Counsel INTRODUCTION The Veteran served on active duty from August 1952 to August 1973. This matter comes before the Board of Veterans' Appeals (Board) from a May 2008 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO) that denied service connection for right and left knee disabilities. In October 2010, the Veteran testified before the undersigned at a hearing held at the RO. A transcript of the hearing is associated with the claims file. In April 2011, the case was remanded for further development. In July 2012, the Board requested a medical expert opinion from the Veteran's Health Administration (VHA). That opinion was provided in August 2012 and an addendum to it was provided in October 2012. In October 2012, the Veteran and his representative were provided with a copy of the opinion and the addendum and were allowed the appropriate amount of time for response. 38 C.F.R. § 20.903 (2012). No additional argument has been received. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). 38 U.S.C.A. § 7107(a)(2) (West 2002). FINDINGS OF FACT 1. A right knee disability did not become manifest in service and is not shown to be related to service, or to service-connected degenerative joint disease of the shoulders, hands or wrists. 2. A left knee disability did not become manifest in service and is not shown to be related to service, or to service-connected degenerative joint disease of the shoulders, hands or wrists. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for a right knee disability are not met. 38 U.S.C.A. §§ 1110, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309, 3.310 (2012). 2. The criteria for entitlement to service connection for a left knee disability are not met. 38 U.S.C.A. §§ 1110, 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 Duty to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) describes VA's duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the Veteran and his representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a) (West 2002); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper VCAA notice must inform the Veteran of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. See 38 C.F.R. § 3.159(b)(1). An October 2007 letter explained the evidence necessary to substantiate the claims and VA's and the Veteran's responsibilities and duties for obtaining evidence. See 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). In addition, the letter explained how a disability rating is determined and the basis for determining an effective date upon the grant of any benefit sought, in compliance with Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). This letter was provided to the Veteran prior to the initial adjudication of his claims, pursuant to Pelegrini v. Principi, 18 Vet. App. 112 (2004). With regard to the duty to assist, the claims file contains the service treatment records, VA treatment records, outpatient records from Madigan Army Medical Center (MAMC), the reports of VA examinations, the expert medical opinion with addendum, and the assertions of the Veteran, his wife, his son and his representative, including testimony from the October 2010 Board hearing. The Board notes that during the October 2010 hearing, the Veteran testified that he had received treatment for knee disability from MAMC during the time frame from separation from service in 1973 until 1989. Pursuant to the April 2011 remand, the Appeals Management Center specifically requested copies of all treatment records from MAMC from 1973 to 1990. In a September 2011 response, MAMC sent the AMC records from the year 1990 and indicated that it had provided the requested records. Given that MAMC had previously provided copies of all available records found in their database in July 2009, without being limited to a specific time frame, the Board finds that their more recent response, considered in conjunction with the July 2009 response, indicates that there were no other MAMC records available. Thus, there is no basis for a further remand to search for such records. The Veteran also indicated during the hearing that he had received some treatment for knee problems while overseas after separation from service. He has not identified any specific providers, however. Consequently, VA did not have any ability to attempt to obtain any records of such treatment. 38 C.F.R. § 3.159(c)(1). The Board has found nothing to suggest that there is any additional outstanding available evidence with respect to the Veteran's claims. No further action is required to comply with the duty to notify and assist the Veteran in developing the facts pertinent to his claims. II. Analysis Service connection may be granted for disability or injury incurred in or aggravated by active military service. 38 U.S.C.A. § 1110. Generally, the evidence must show (1) the existence of a current disability; (2) the existence of the disease or injury in service, and; (3) a relationship or nexus between the current disability and any injury or disease during service. See Cuevas v. Principi, 3 Vet. App. 542 (1992). For the showing of 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 disease identity is established, there is no requirement of an evidentiary showing of continuity. 38 C.F.R. § 3.303(b). Certain listed, chronic disabilities, including degenerative joint disease (i.e. arthritis), are presumed to have been incurred in service if they become manifest to a compensable degree within one year of discharge from service. 38 U.S.C.A. §§ 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. Continuity of symptomatology is required only where the condition noted during service (or in the presumptive period) is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. Id. The foregoing law and regulations notwithstanding, 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). A disability which is proximately due to or the result of a service- connected disease or injury shall be service connected. 38 C.F.R. § 3.310(a). A claimant is also entitled to service connection on a secondary basis when it is shown that a service-connected disability aggravates a nonservice- connected disability. Allen v. Brown, 7 Vet. App. 439 (1995). The Board acknowledges that the Veteran is competent to give testimony about what he experienced. For example, he is competent to report that he was exposed to loud noise in service and that he experienced ringing in his ears in and since service. See, e.g., Layno v. Brown, 6 Vet. App. 465 (1994). As a layman, however, he is not qualified to render opinions which require medical expertise, such as the diagnosis of his symptoms or the cause of a particular disability. 38 C.F.R. § 3.159(a); Espiritu v. Derwinski, 2 Vet. App. 492, 494-95 (1992). Therefore, his opinion, without more, is not dispositive. 38 C.F.R. § 3.159(a). Competency must be distinguished from weight and credibility, which are factual determinations going to the probative value of the evidence. See Rucker v. Brown, 10 Vet. App. 67, 74 (1997). In weighing credibility, VA may consider interest, bias, inconsistent statements, bad character, internal inconsistency, facial plausibility, self interest, consistency with other evidence of record, malingering, desire for monetary gain, and demeanor of the witness. Caluza v. Brown, 7 Vet. App. 498 (1995). The Board may weigh the absence of contemporaneous medical evidence against the lay evidence in determining credibility, but the Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence. Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). In deciding this appeal, the Board must weigh the evidence and decide where to give credit and where to withhold the same and, in so doing, accept certain medical opinions over others. Schoolman v. West, 12 Vet. App. 307, 310-11. The Board is mindful that it cannot make its own independent medical determination, and that there must be plausible reasons for favoring one medical opinion over another. Evans v. West, 12 Vet. App. 22, 31 (1998). The probative value of a medical opinion is generally based on the scope of the examination or review, as well as the relative merits of the expert's qualifications and analytical findings, and the probative weight of a medical opinion may be reduced if the examiner fails to explain the basis for an opinion. Sklar v. Brown, 5 Vet. App. 140 (1993). In this regard, contemporaneous evidence has greater probative weight than a history reported by the Veteran. Curry v. Brown, 7 Vet. App. 59, 68 (1994). When all of 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 fair preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). The Veteran contends that his current right knee disability is directly related to the physical rigors of service, including marching for long periods of time and running on hard surfaces, and that his left knee disability was caused and/or aggravated by the right knee disability. He also contends that the arthritis of the shoulders, hands and wrists for which he was treated in service, and for which he is in receipt of service-connected compensation, has spread to his knees, leading to his current knee disabilities. The service treatment records reflect that in March 1971, the Veteran complained of having pain in the knees and shoulders for approximately eight months. X-ray examination of the knees showed no significant abnormality. In December 1971, the Veteran complained of a long history of pain in the shoulders, knees, and back. He had episodic, momentary pains in his knees and back. The knees showed no symptoms of inflammatory joint disease. He began treatment for arthritis of the back. In June 1972, the Veteran sustained a laceration to the right knee. On his March 1973 retirement report of medical history, the Veteran reported continuing pain in the shoulders, wrists, and arms but did not report any problems with "trick or locked knees" or otherwise indicate that he had current problems with the knees. On March 1973 retirement examination, the Veteran's lower extremities were found to be normal. On December 1973 VA examination, the Veteran reported that several years previously, he had been treated at Madigan General Hospital for myalgia and bone aches, with cough productive of a blood tinged sputum. After the febrile reaction was cleared, he noticed residual chest pain. A few months later, he began to notice the onset of articular discomfort in the wrists and fingers, which spread to his shoulders, elbows, knees, and ankles. He reported that he treated these symptoms with over the counter pain medication. He denied ever experiencing any gross swelling or erythema of the joints. There was some crepitus. He had received local injections for his symptoms, and at one point had received Butazolidin (an NSAID), which seemed to help for a period. Physical examination did not reveal any traumatic or inflammatory process. There was crepitus of the knees at flexion to a full 140 degrees. There was no loss of motion and there was no disturbance of gait. X-ray examination showed no significant osseous or soft tissue abnormality of either knee. A diagnosis of degenerative arthritis of the shoulder, hands and wrists was rendered. No diagnosis was rendered in relation to either knee. Records from MAMC reflect that in December 2006, the Veteran reported experiencing joint pain in the right knee. There was effusion of the joint. The Veteran denied any previous trauma. It was suspected that he had degenerative joint disease verses tendonitis. On January 2, 2007, it was noted that he was continuing to experience right knee pain. He had been wearing a knee brace that had improved his swelling but not his pain. He complained of pain on weight-bearing, which increased with activity and decreased with rest. The diagnostic assessment was right knee sprain of the medial collateral ligament. The brace was discontinued and the Veteran was to start using a cane for support. Later in January 2007, the Veteran was seen in the emergency room for left knee pain secondary to degenerative joint disease. He was provided with a knee immobilizer to use while active and while sleeping and was instructed to do range of motion exercises three times a day. A January 2007 X-ray of the right knee produced a diagnostic impression of osteochondral defect of the medial femoral condyle with mild osteoarthritic changes of the knee. Subsequent MRI of the right knee revealed a medial meniscus tear, bone contusion at the anterior medial tibial plateau, mild chondromalacia, and a small Baker's cyst. In February 2007, the Veteran specifically reported a history of onset of significant right knee pain three months prior, accompanied by effusions. He indicated that he had intermittent pain in both knees prior to this but never as severe as he was currently experiencing in the right knee. The pain in the right knee was currently constant and was interfering with his sleep. The diagnosis was right knee medial meniscus tear and surgery was being considered. The Veteran also received injections for the right knee pain. Also in February 2007, a left knee X-ray revealed mild tricompartmental osteoarthritis with patellar spurring. In March 2007, synvisc injections were recommended for the Veteran's right knee osteoarthritis. The Veteran subsequently received these injections in both knees. In a November 2007 statement, the Veteran reported that his arthritic condition started about August 1968 while he was stationed at Fort Lewis, Washington. He had more recently been treated with steroid shots and had also taken Ibuprofen until his stomach became sensitive to the latter medication. His arthritis pain had migrated to several parts of his body and he noted that the MRI had shown that his knees were in such bad condition that they would probably have to be replaced. He also noted that he had been receiving synvisc shots in the right knee since February 2007. During a September 2008 MAMC visit, the Veteran reported a two year history of bilateral knee pain without any trauma to either knee. He stated that the pain had been progressively worsening and was exacerbated by ambulation and ascending/descending stairs. The pain was greater in the right knee than in the left. He had had 3 series of synvisc injections in the right knee and 2 in his left knee. These provided some short term relief but he continued to have pain. He denied effusions and denied instability or mechanical locking/popping. He had tried an off-loader brace. An X-ray of the right knee showed mild medial compartmental osteoarthritis with a preserved joint space and an X-ray of the left knee showed mild lateral compartment osteoarthritis with a preserved lateral and medial joint space. The diagnostic assessment was bilateral early knee arthritis with pain and the plan was for continued steroid injections as needed. In a March 2009 Form 9, the Veteran's representative indicated that the Veteran had put in more than 20 years of military service, which included many years of marching. Also, his various jobs in the military required him to be on his feet for many hours, which would in itself cause wear and tear on his knees over a period of time. Additionally, the Veteran did his physical training in combat boots over hard surfaces like asphalt, which also could account for his knee pain. At a May 2009 QTC examination, the Veteran reported constant bilateral knee pain, along with symptoms of weakness, lack of endurance and fatigability. He indicated that his physical balance was almost gone and that it was painful to go from sitting to standing. It was painful to walk even a short distance. Range of motion of the right knee was 0 degrees extension to 120 degrees flexion bilaterally. X-rays showed tricompartmental arthritis in both knees with a moderate sized joint effusion on the right and a small joint effusion on the left. After review of the claims file, the examiner commented that the Veteran had a previous history of arthralgia to the knees due to an infection. There were no records in service to indicate any knee pathology that would have resulted in arthritis. The notes from February and March 2007 indicated that there was some injury to the meniscus that required surgery to the right knee although the Veteran was unable to remember any injury. The medical records indicated that the Veteran had a history of knee pain but none of the records indicated any pathology for the pain (especially the left knee). As there were no other records during service revealing a knee complaint and the records reviewed showed a 20 year span between exit from service and any knee pathology, it was less likely than not that the Veteran's current bilateral knee disability was related to his medical service. During a June 2009 MAMC evaluation, the Veteran was found to have extensive osteoarthritis of his knees, right greater than left. He had had physical therapy and joint injections and was currently having difficulty walking. Thus, he was sent for a joint replacement evaluation. On July 2009 VA examination, after completing a physical examination of the Veteran and reviewing the claims file, including the December 1973 VA examination, the examiner found it less likely than not that the current right and left knee disabilities were related to service. The examiner concluded that despite the complaints of knee pain in service, absent any further complaints, diagnosis, or treatment for a knee disability at that time or in December 1973, or for the interim twenty years, there was no continuity to relate the in-service complaints with the current knee disabilities. In an October 2010 letter, the Veteran's son indicated that he vividly recalled that the Veteran displayed problems with his right knee upon his return from his final tour of duty in Vietnam. The son recalled this because at the time, the Veteran was unable to play tag with him and his siblings in the backyard. After a short time of playing, the Veteran would have to stop due to his knee. Also, on long hikes with the son's Cub Scout den, the Veteran was not able to keep up due to right knee pain. The son indicated that the Veteran's problem with his knee had persisted ever since his return. During the October 2010 Board hearing, the Veteran's representative indicated that the Veteran did hurt his right knee in 1970 during service when he was exposed to small arms fire. Also in 1972, the Veteran's right knee was hit by a stake. The Veteran testified that after service he worked as an electrician. This did not involve a lot of walking but did involve a lot of standing and sitting in a van, monitoring. He indicated that he did not experience any falls or other knee injuries post-service. Also, the left knee started to bother him sometime after service. Because he was compensating for the pain in the right knee, this put stress on the left knee. The Veteran indicated that he received a lot of treatment at MAMC for the right knee after service. At first, the evaluating medical professionals had X-rays done and indicated that they could not see anything wrong. The Veteran was provided with a cane to use. In 1989, he also went to see a private doctor. Additionally, the Veteran reported that during the period after service, he traveled around quite a bit, to other countries such as Saudi Arabia and Thailand. When he would complain about the knee to medical personnel, they generally would simply give him Ibuprofen for pain. He did more recently receive the synvisc injections at MAMC to the point where the treating medical professionals indicated that it would be too dangerous to give him any more injections. At that point, they decided that he needed a right knee replacement, which he received in January 2010. The left knee was under observation for possible replacement in the future. The Veteran's wife testified that ever since she married him ten years prior, the Veteran had had problems with his knees. At a May 2011 VA examination, the examiner noted that he reviewed the claims file. The Veteran reported that he was initially in the infantry and that during the last 10 to 12 years in service he served as an electronics technician. He reported that he did a lot of marching with physical training during military service. He recalled a laceration of the right knee when he was driving a metal tent stake and a piece of metal broke off and came into the side of the right knee. He reported no history of any twisting injuries or falls. Post-service, the Veteran continued to work as an electronics technician and eventually retired from work in 2000. The examiner noted that the Veteran had contended both that his knee disability was related to marching and the general rigors of service and that his service-connected arthritis of the shoulders, hands and wrists had spread to his knees. The Veteran reported that predominantly, his pain in the right knee was much less than his pain in the left knee. The Veteran also reported poor coordination, stiffness of the joints and at times, swelling of the right knee. He noted numbness of the right anterior knee at the site of the total knee replacement surgical scar. He indicated that he stopped playing horseshoes in 1988 due to knee pain. Physical examination showed that the Veteran used a cane correctly in the left hand and that he experienced increased pain when turning around. Range of motion of the knees was approximately 5 degrees to 100 degrees on the right and 5 degrees to 120 degrees on the left. There was laxity of the cruciate of the right knee, which was expected after a total knee replacement. There were mild patellofemoral total knee symptoms in the right knee and mild tenderness along the edges of the patellofemoral joint of the right knee. The right knee appeared slightly swollen. The examiner diagnosed the Veteran with status postoperative right knee total knee replacement and degenerative joint disease of the left knee. The examiner commented that as an examining board certified orthopedic surgeon, it was less likely than not that the Veteran's current right and left knee disabilities were related to his military service. It was also his impression that the arthritis of the Veteran's other joints did not spread to his knee joints nor worsen his knee condition. In the August 2012 Veteran's Health Administration opinion, a VA Board Certified orthopedic surgeon noted that he had reviewed the Veteran's claims file and that his opinion was based on this review and more than 30 years of orthopedic practice. The orthopedic surgeon found that it was unlikely that any currently diagnosed knee disability was the result of the Veteran's military service. It was more likely that the bilateral knee osteoarthritis was the result of an inherited predisposition, aging and use over many years. It was also unlikely (less than 50 percent probability) that any diagnosed knee condition had any relation to the Veteran's service-connected degenerative joint disease of the shoulders, hands or wrists. Additionally, it was at least as likely as not that any diagnosed left knee disability was aggravated by the Veteran's right knee disability due to increased stresses placed across his less symptomatic but arthritic left knee. In an October 2012 addendum, the August 2012 VA orthopedic surgeon explained in more detail the rationale for his August 2012 opinions. He noted that osteoarthritis was a very common condition and that there was no record of the Veteran suffering any knee injury or overuse during service that could have resulted in this diagnosis. This was confirmed by the normal X-rays and knee examination at the time of the Veteran's separation from service. There was also no record of any upper extremity condition or injury that caused or aggravated the knee condition. With a normal knee examination and normal X-rays at the time of service separation, any condition or aggravation was further precluded. The orthopedic surgeon noted that there was simply no medical connection between the Veteran's knee disability and the degenerative joint disease of the shoulder, hands and wrists. The knee condition would be the same with or without the degenerative upper extremity conditions. Additionally, there was no evidence in the orthopedic literature that the use of ambulatory devices, which might be inhibited by the presence of upper extremity disease, would retard the progression of knee arthritis. The Veteran is shown to have had some right knee pathology during service, in the form of pain. On March 1973 separation examination, however, the lower extremities were found to be normal and on his March 1973 report of medical history at separation, the Veteran did not affirmatively report any knee problems. Similarly, the December 1973 VA knee examination, just nine months after service, revealed no loss of motion, disturbance of gait or traumatic or inflammatory process and X-rays showed no significant osseous or soft tissue abnormality of either knee. Thus, although the Veteran clearly experienced right knee pain, a chronic right knee disability is not shown during service and there is no evidence or allegation indicating that degenerative joint disease (i.e. arthritis) of either knee was shown in service or during the year after service so as to warrant entitlement to presumptive service connection. 38 C.F.R. § 3.307, 3.309. The medical evidence of record then does not show any indication of right knee pathology until after 2000. Such a prolonged period without medical complaint, along with other factors concerning a claimant's health and medical treatment during and after military service, may be considered as evidence of whether an injury or a disease was incurred in service, which resulted in a chronic or persistent disability. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). The evidence also weighs against a finding that the Veteran's current knee disability is otherwise related to service. Notably, the May 2009 QTC examiner, the July 2009 VA examining orthopedic surgeon and the 2012 VA orthopedic surgeon, after reviewing the claims file, specifically found that it was less likely than not that the Veteran's current right knee disability is related to service. The Board finds the 2012 orthopedic surgeon's opinion particularly persuasive as it was supported by a clear rationale; that it was more likely that the knee osteoarthritis was the result of an inherited predisposition, aging and use over many years. The orthopedic surgeon explained that osteoarthritis is a very common condition and that there was no record of the Veteran suffering any injury or overuse during service that could have resulted in this diagnosis, as confirmed by the normal X-rays and knee examination at the time of the Veteran's separation from service. (The Board is cognizant that the orthopedic surgeon referred to the normal knee X-rays and examination as occurring at separation, when in fact they occurred 9 months later during the December 1973 VA examination. This discrepancy does not significantly lessen the probative weight that may be afforded to the opinion, however, as normal X-ray findings accompanied by a normal physical examination nine months after service appears to provide equal support for a finding that the Veteran had not experienced an arthritis-causing right knee injury during service.). The Board notes that the August 2012 VA examiner's mentioning of "use over many years" as one of the causes of the Veteran's right knee disability, if considered in isolation, could lead to a conclusion that the examiner determined that the Veteran's military service (i.e. part of the Veteran's use of the knee over his lifetime) was a partial cause of the current right knee disability. Considering the opinion as a whole does not lead to this conclusion, however. Once again, after a full review of the record, the orthopedic surgeon specifically concluded that it was less likely than not that any current right knee disability resulted from service. He did not conclude that it was likely, or at least as likely as not, that the current right knee disability was partially the result of military service. In making his conclusion, the examiner specifically noted that arthritis is a very common condition (e.g. one that many people suffer from at some point in their lives whether or not they have been through military service). He also specifically noted the normal X-ray findings at the time of separation (i.e. in December 2012) and specifically indicated that there was no record of the Veteran suffering any injury or overuse during service that could have resulted in the current arthritis/degenerative disc disease. Thus, it is apparent that the examiner ultimately concluded that it was unlikely that the "use" of the knee by the Veteran in service resulted in the current arthritis/degenerative joint disease. In sum, the orthopedic surgeon's opinion concerning the potential direct relationship between service and current right knee disability is adequate as it sufficiently informed the Board of the medical expert's judgment on this question and the rationale for his opinion. Monzingo v. Shinseki, 26 Vet. App. 97 (2012). As this opinion is also supported by the earlier May 2009 QTC examiner's opinion and the July 2009 VA examiner's opinion, and as there is no medical evidence to the contrary (i.e. evidence tending to indicate that the Veteran's current right knee disability is related to service), the weight of the medical evidence is clearly against a finding that the Veteran's current right knee disability is directly related to service. The Veteran has also asserted that his service-connected arthritis of the shoulders, hands and wrists has essentially spread to his knees, thus forming a basis for awarding service connection for the knees on a secondary basis. The August 2012 VA orthopedic surgeon specifically found that it was unlikely that any diagnosed knee condition had any relation to the Veteran's service-connected degenerative joint disease of the shoulders, hands or wrists, however. He explained that there was no record of any upper extremity condition or injury causing or aggravating the knee condition; that there was simply no medical connection between the Veteran's degenerative joint disease of the knees and the degenerative joint disease of the shoulder, hands and wrists; that the Veteran's knee condition would be the same with or without the degenerative upper extremity conditions; and that there was no evidence in the orthopedic literature that the use of ambulatory devices (which might be inhibited by the presence of upper extremity disease) would slow the progression of knee arthritis. This opinion specifically weighs against a finding that the Veteran's bilateral knee disability was caused or aggravated by his service connected arthritis of the shoulders, hands or wrists and there is no medical opinion evidence to the contrary (i.e. an opinion tending to indicate that the bilateral knee disability was caused or aggravated by the arthritis of the shoulders, hands or wrists). The orthopedic surgeon's opinion concerning this potential secondary relationship between his already service-connected orthopedic disabilities and current bilateral knee disability is also adequate as it sufficiently informed the Board of the medical expert's judgment on this question and the rationale for his opinion. Monzingo, 26 Vet. App. 97 (2012). The Veteran and his son have alleged that the Veteran has had continuity of right knee symptomatology since service and they are competent to do so as this is a matter, which is capable of lay observation. To the extent that the Veteran and/or his son are alleging continuous right knee pain since service, the Board does not find this assertion credible as it conflicts with the specific report of the intermittent nature of the knee pain (prior to the onset of more severe pain around November 2006) made by the Veteran while receiving treatment in February 2007. The Board finds this report more believable as it was made specifically in the context of receiving treatment rather than in the context of the claim for benefits and the accompanying prospect for potential pecuniary gain. Additionally, the Board does not find a basis in the record for finding this latter report, made in February 2007, not credible. Given the specific opinion of the 2012 VA orthopedic surgeon, provided after a review of the claims file (which the Board presumes includes review of the Veteran's reported medical history), along with the supporting opinions of the 2009 VA and QTC examiners, however, the weight of the overall evidence is against a finding that there is any direct relationship between the Veteran's current right knee disability and his military service. In this regard, the ultimate question is not whether the Veteran has experienced intermittent knee symptoms since service but whether there is a relationship between the current right knee disability (i.e. degenerative joint disease) and service, a matter in which the Veteran's lay assertions are entitled to minimal probative value. See Bostain v. West, 11 Vet. App. 124, 127 (1998); Routen v. Brown, 10 Vet. App. 183, 186 (1997). Thus, there is no basis for awarding service connection for right knee disability as directly related to service. 38 C.F.R. § 3.303, Gilbert 1 Vet. App. 49, 55 (1990). Further, as noted above, the medical evidence, in the form of the 2012 VA orthopedic surgeon's uncontradicted opinion, clearly weighs against a finding that the Veteran's service-connected arthritis of the shoulders, hands and wrists has caused or aggravated the arthritis in either knee. Once again, the Veteran's lay assertion concerning the presence of such causation or aggravation is entitled to minimal probative value. Bostain, 11 Vet. App. 124, 127 (1998); Routen, 10 Vet. App. 183, 186 (1997). Thus, there is also no basis for awarding service connection for left or right knee disability on this secondary basis. As there is no basis for awarding service connection for right knee disability on either a direct or secondary basis, there is also no basis for awarding service connection for left knee disability based on this disability being caused or aggravated by the right knee. 38 C.F.R. § 3.310. Additionally, a direct relationship between the Veteran's service and his current left knee disability is neither shown nor alleged, with both the May 2009 QTC examiner and the July 2009 VA examiner specifically finding that it was less likely than not that the Veteran's left knee disability was related to service. In summary, given that arthritis of neither knee was shown in service or within the first post-service year and given that the evidence weighs against a finding that the Veteran's current bilateral knee disability is related to service, or that it was caused or aggravated by the service-connected degenerative joint disease of the shoulders, hands and wrists, the preponderance of the evidence is against the claims and they must be denied. Gilbert, 1 Vet. App. 49, 55 (1990). ORDER Service connection for a right knee disability, to include on a secondary basis, is denied. Service connection for a left knee disability, to include on a secondary basis, is denied. ____________________________________________ JOHN Z. JONES Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs