Citation Nr: 1304491 Decision Date: 02/07/13 Archive Date: 02/19/13 DOCKET NO. 07-25 026 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Muskogee, Oklahoma THE ISSUES 1. Entitlement to service connection for a left knee lateral ligament strain (hereinafter left knee disability). 2. Entitlement to service connection for a cervical spine injury, to include as secondary to a service-connected lumbar spine disability. 3. Entitlement to service connection for headaches, to include as secondary to a cervical spine disability or a service-connected lumbar spine disability. 4. Entitlement to an initial rating higher than 10 percent for degenerative arthritis of the right knee. REPRESENTATION Veteran represented by: Disabled American Veterans WITNESS AT HEARINGS ON APPEAL Veteran ATTORNEY FOR THE BOARD A. D. Jackson, Counsel INTRODUCTION The Veteran served on active duty (AD) from March 1987 to September 1996 and May to July 1999 with time in the Air Force Reserves as well, presumably this included active duty for training (ACDUTRA) and inactive duty for training (INACDUTRA) service. This case comes before the Board of Veterans' Appeals (Board) on appeal from an October 2005 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Muskogee, Oklahoma. The Veteran testified at a RO hearing in June 2009 and again at a Board hearing at the RO in March 2011. These transcripts have been associated with the file. The issues of entitlement to service connection for a left knee disability, cervical spine disability, and headaches were remanded in June 2011 and have been returned for appellate review. As explained below, the issue regarding entitlement to an initial rating higher than 10 percent for degenerative arthritis of the right knee is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. VA will notify the Veteran if further action is required. FINDINGS OF FACT 1. The Veteran's service entrance examination report reflects a normal spine, with no noted cervical spine disability. 2. Any current cervical spine disability is not related to a disease or injury in service. 3. The Veteran entered service with a preexisting left knee disability, which was noted on enlistment examination. 4. The Veteran's service-connected right knee disability aggravated a left knee disability. 5. The Veteran's headache disability was not initially manifested during his military service, or for many years after service, and it has not otherwise been attributed to his military service, including to his already service-connected lumbar spine and bilateral shoulder disabilities. CONCLUSIONS OF LAW 1. The cervical spine disability was not incurred in or aggravated by service and is not proximately due to, the result of, or aggravated by a service-connected disability-namely, by his lumbar spine and bilateral shoulder disabilities. 38 U.S.C.A. §§ 1110, 1111, 1112, 1113, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.304, 3.310 (2012). 2. Resolving all reasonable doubt in his favor, osteoarthritis of his left knee was aggravated by his service-connected right knee disability. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.304, 3.3.06, 3.310 (2012). 3. The Veteran's headache disability was not incurred in or aggravated by his military service, and is not proximately due to, the result of, aggravated by a service-connected disability, namely, his lumbar spine disability. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.310 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Board has thoroughly reviewed all the evidence in the Veteran's claims file. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, each piece of evidence submitted by the Veteran or on his behalf. 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, as regards the claim on appeal. The Veteran must not assume that the Board has overlooked any 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 Board must assess the credibility and weight of all evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the Veteran. Caluza v. Brown, 7 Vet. App. 498, 506 (1995). Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 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 a claim, in which case, the claim is denied. Id. I. The Veterans Claims Assistance Act (VCAA) The Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (2000) (codified as amended at 38 U.S.C. §§ 5100, 5102, 5103, 5103A, 5107, sets forth VA's duty to notify and assist claimants in substantiating a claim for VA benefits. See 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). The Veteran was provided notice of the VCAA in May 2005. The VCAA letter indicated the types of information and evidence necessary to substantiate the claims, and the division of responsibility between the Veteran and VA for obtaining that evidence, including the information needed to obtain lay evidence and both private and VA medical treatment records. Note also that the more recent August 2011 letter discussed the downstream disability rating and effective date elements of the claims. And of equal or even greater significance, after providing that additional notice, the AMC went back and readjudicated the Veteran's claims in the May 2012 supplemental statement of the case (SSOC), including considering the additional evidence received in response to that additional notice. So the timing defect in the provision of this additional notice, since it did not precede the initial adjudication of the claims, has been rectified ("cured") since the claims have been reconsidered since providing all necessary VCAA notice. Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 484 (2006); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004) (Pelegrini II). All relevant evidence necessary for an equitable resolution of the issue on appeal has been identified and obtained, to the extent possible. The evidence of record includes service treatment records (STRs), private medical records, VA outpatient treatment reports, adequate VA examination and opinion as well as statements from the Veteran and his representative. This case was previously remanded by the Board in June 2011 to provide the Veteran with adequate VA opinions for his claimed disabilities. The Board notes that the October 2011 VA examination report and opinions reflect that the examiner reviewed the Veteran's past medical history, documented his current medical condition, and rendered an appropriate diagnoses and opinions consistent with the remainder of the evidence of record, and with supporting rationale. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Consequently, the Board concludes that the medical examination and opinion are adequate for adjudication purposes. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (holding that when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate). As the October 2011 VA examiner complied with the Board's remand instructions and provided an appropriate rationale for her opinion, the Board is satisfied that the development requested by its June 2011 remand has now been satisfactorily completed and substantially complied with respect to his claimed disabilities. See Stegall v. West, 11 Vet. App. 268 (1998) (where there was substantial compliance with the Board's remand instructions). The Veteran has not indicated that he has any further evidence to submit to VA, or which VA needs to obtain. There is no indication that there exists any additional evidence that has a bearing on this case that has not been obtained. The Veteran and his representative have been accorded ample opportunity to present evidence and argument in support of his appeal. All pertinent due process requirements have been met. See 38 C.F.R. § 3.103. II. General Statutes, Regulations and Precedent Cases Governing Claims for Service Connection Service connection is granted for disability resulting from a disease or an injury incurred in or aggravated by active military service in the line of duty. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Stated somewhat differently, to establish entitlement to direct service connection for the claimed disability, there must be: (1) competent and credible evidence confirming the Veteran has the claimed disability - or, at the very least, showing he has at some point since the filing of his claim; (2) competent and credible evidence of in-service incurrence or aggravation of a relevant disease or injury; and (3) competent and credible evidence of a nexus or link between the claimed in-service disease or injury and the current disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004), citing Hansen v. Principi, 16 Vet. App. 110, 111 (2002). Active military service includes disability resulting from injury or disease incurred in or aggravated during AD and ACDUTRA and disability resulting from injury (but not disease) incurred in or aggravated during inactive duty training (INACDUTRA). 38 U.S.C.A. §§ 101(21)-(24), 106; 38 C.F.R. § 3.6(a), (d). Reserve and National Guard service generally means ACDUTRA and INACDUTRA. ACDUTRA is full time duty for training purposes performed by Reservists and National Guardsmen pursuant to 32 U.S.C.A. §§ 316, 502, 503, 504, or 505. 38 U.S.C.A. § 101(22); 38 C.F.R. § 3.6(c). Basically, this refers to the two weeks of annual training, sometimes referred to as "summer camp," which each Reservist or National Guardsman must perform each year. It can also refer to the Reservist's or Guardsman's initial period of training. INACDUTRA includes duty, other than full-time duty, performed for training purposes by Reservists and National Guardsmen pursuant to 32 U.S.C.A. §§ 316, 502, 503, 504, or 505. 38 U.S.C.A. § 101(23); 38 C.F.R. § 3.6(d). Basically, this refers to the twelve four-hour weekend drills that each Reservist or National Guardsman must perform each year. These drills are deemed to be part-time training. So to the extent the Appellant is alleging that his disabilities are a result of injury or disease incurred or aggravated during his time in the Reserve, it must be remembered that only "Veterans" are entitled to VA compensation under 38 U.S.C.A. §§ 1110, 1131 and 38 C.F.R. § 3.303(a). Thus, to establish status as a "Veteran" based upon a period of ACDUTRA, a claimant must establish that he was disabled from disease or injury incurred or aggravated in the line of duty during that period of ACDUTRA. 38 C.F.R. § 3.1(a), (d); Harris v. West, 13 Vet. App. 509, 511 (2000); Paulson v. Brown, 7 Vet. App. 466, 470 (1995). The fact that a claimant has established status as a "Veteran" for purposes of other periods of service (e.g., his periods of active duty) does not obviate the need to establish that he is also a "Veteran" for purposes of the period of ACDUTRA if the claim for benefits is premised on that period of ACDUTRA. Mercado-Martinez v. West, 11 Vet. App. 415, 419 (1998). Similarly, in order for the Appellant to achieve "Veteran" status and be eligible for service connection for disability claimed during his inactive service, the record must establish that he was disabled from an injury (but not disease) incurred or aggravated during his INACDUTRA. See Mercado- Martinez v. West, 11 Vet. App. 415, 419 (1998); Paulson v. Brown, 7 Vet. App. 466, 470 (1995); Biggins v. Derwinski, 1 Vet. App. 474, 478 (1991). Certain chronic diseases, such as arthritis, will be presumed to have been incurred in service if manifested to a compensable degree of at least 10-percent disabling within one year after service. This presumption, however, is rebuttable by affirmative evidence to the contrary. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309(a). This presumption also does not apply to ACDUTRA and INACDUTRA service, only AD. The same is true of the presumptions of soundness and aggravation. See Smith v. Shinseki, 24 Vet. App. 40 (2010); Biggins v. Derwinski, 1 Vet. App. 474, 478 (1991). Furthermore, every veteran shall be taken to have been in sound condition when examined, accepted, and enrolled for service, except as to defects, infirmities, or disorders noted at the time of examination, acceptance, and enrollment. 38 C.F.R. § 3.304(b). A veteran is presumed to be in sound condition when he entered into military service except as to conditions noted on an entrance medical examination. 38 U.S.C.A. § 1111. When determining whether a defect, infirmity, or disorder is "noted" at entrance into service, supporting medical evidence is needed, and mere transcription of medical history does not transform information into competent medical evidence. Crowe v. Brown, 7 Vet. App. 238 (1994); LeShore v. Brown, 8 Vet. App. 406 (1995). The law provides that the burden to rebut the presumption of both soundness and aggravation of a pre-existing disability during service is an onerous one that lies with the government. See, e.g., Cotant v. Principi, 17 Vet. App. 117, 131 (2003); Kinnaman v. Principi, 4 Vet. App. 20, 27 (1993). Importantly, VA Office of the General Counsel determined that VA must show by clear and unmistakable evidence that there is a pre-existing disease or disability and that it was not aggravated during service. See VAOPGCPREC 3-03 (July 16, 2003). The veteran is not required to show that the disease or injury increased in severity during service before VA's duty under the second prong of this rebuttal standard attaches. Id. The Board must follow the precedent opinions of the General Counsel. 38 U.S.C.A. § 7104(c). As noted in a decision of the U.S. Court of Appeals for the Federal Circuit (Federal Circuit), when no preexisting condition is noted upon entry into service, the veteran is presumed to have been sound upon entry. Wagner v. Principi, 370 F. 3d 1089 (Fed. Cir. 2004). The burden then falls on the government to rebut the presumption of soundness by clear and unmistakable evidence that the veteran's disability was both preexisting and not aggravated by service. Id. The government may show a lack of aggravation by establishing that there was no increase in disability during service or that any "increase in disability [was] due to the natural progress of the" preexisting condition. 38 U.S.C. § 1153. Id. If this burden is met, then the veteran is not entitled to service-connected benefits. Aggravation may not be conceded where the disability underwent no increase in severity during service on the basis of all the evidence of record pertaining to the manifestations of the disability prior to, during, and subsequent to service. 38 C.F.R. § 3.306(b). See also Davis v. Principi, 276 F.3d 1341, 1345 (Fed. Cir. 2002) (holding that evidence of a temporary flare-up, without more, does not satisfy the level of proof required of a non-combat veteran to establish an increase in disability). However, if the government fails to rebut the presumption of soundness under § 1111, the veteran's claim is one for service connection. This means that no deduction for the degree of disability existing at the time of entrance will be made if a rating is awarded. See 38 C.F.R. § 3.322. Id. III. Service Connection for Cervical Spine Disability The Veteran originally alleged that his cervical spine disorder, although pre-existing his military service, nonetheless was aggravated by his service. He now claims in the alternative that his cervical spine disorder is secondary to his service-connected lumbar spine disability. When determining whether service connection is warranted, all potential or alleged theories of entitlement - direct, presumptive, and secondary, must be considered. See Szemraj v. Principi, 357 F.3d 1370, 1371 (Fed. Cir. 2004). The record on appeal contains a September 1986 statement from a private chiropractor which shows that prior to entrance into service, the Veteran was involved in an automobile accident. The chiropractor stated that he sustained an acute moderately severe cervical-thoracic strain/sprain, which resulted in an acute moderately severe cervical-thoracic myofascitis. This also resulted in acute moderate lumbosacral sprain/strain resulting in acute moderate lumbosacral myofascitis. He underwent physical therapy between October 1985 and February 1986 to reduce physical manifestations including muscle spasm. In the opinion of the chiropractor, the Veteran responded well to conservative chiropractic care. He also stated the Veteran was released from care in February 1986. He had reached maximal medical improvement. On a September 1986 medical pre-screening form, the Veteran reported a history of back trouble, which he states was caused by a 1985 whiplash injury. This history was noted on the October 1986 enlistment examination report. The examiner wrote "1985 minor whiplash-chiro Rx-fine now." In the Report of Medical History the Veteran answered yes to the question of whether "he ever had or have now" recurrent back pain. After an objective examination, however, the Veteran's head, face, and neck, and spine were noted to be normal. The STRs for the Veteran's period of active service between March 1987 and September 1996 show treatment for various conditions not at issue. The Veteran claims that he complained of shoulder and neck pain during service. Beginning in March 1990, he was treated for left shoulder impingement syndrome. He also received treatment for bilateral rotator cuff tendonitis beginning in December 1993. While the clinical records clearly refer to shoulder dysfunction, there is no record of complaints, findings or diagnoses referable to the neck during that period of service. There is no report of an examination that was conducted prior to separation from his first period of service in September 1996. However, on an August 1996 Dental Patient Medical history, he denied that he had any diseases or conditions. In fact, the record contains several of these dental questionnaires and Annual Medical certificates that date between 1992 and 2001. He never referred to neck problems. Prior to his second period of service, a February 1999 Air Force Reserves Annual Medical Certificate shows that the Veteran reported that he was involved in automobile accidents in September 1998 and in February 1999, in which he sprained his back on each occasion. A private diagnostic radiographic study was conducted in February 2002 in conjunction with back complaints. This report indicated that the cervical spine was normal. In March 2002, he received private treatment for complaints of neck and shoulder pain. He reported that he was involved in another motor vehicular accident 5 days previously. The diagnostic assessment was post MVA muscle strain. Records from the remainder of his Air Force Reserve service, which ended in January 2003, show that for the most part, he was evaluated for his now service connected lumbar spine disability. According to a November 2002 memorandum, he was found unfit for duty, due to his lumbar spine disability. Pursuant to Board remand, VA examinations were conducted in October 2011 to provide medical nexus opinions regarding his claimed disabilities. After reviewing the Veteran's history and examining the Veteran, a nurse practitioner diagnosed cervical strain. She further concluded that he had pre-existing cervical-thoracic myofascitis prior to entrance into service. She indicated that there was no evidence that he injured the cervical spine during service or that the cervical-thoracic myofascitis was aggravated during service. Furthermore, the first evidence of a cervical spine disability was not until January 2008. Therefore, she concluded that it was unlikely that his cervical spine disability was linked to military service. The preponderance of the evidence, as will be discussed below, shows that the Veteran's cervical spine disability was not incurred in or aggravated by service. In this case, a report of the Veteran's October 1986 enlistment examination shows that the Veteran's neck and spine was normal upon entrance into service. As such, the presumption of soundness attaches. Although it is acknowledged that the Veteran was involved in a car accident prior to service, in September 1985, there is no evidence that such was productive of a chronic cervical spine disability. In this regard, a letter from a private chiropractor dated prior to service entry, in March 1987, noted that following the car accident the only diagnoses the Veteran had were muscle spasm. He found that the Veteran had reached the maximum benefit from physical therapy. Indeed, the Veteran underwent an evaluation on service entrance in October 1986, and there were no additional defects as far as the neck was concerned and he was deemed fit for service. A neck disability was not indicated. The October 2011 VA examiner's report is acknowledged. This report reflects that the Veteran had neck problems prior to service, but does not indicate that the Veteran entered service with a preexisting chronic neck disability. An examination report from a private physician noted neck and back complaints in March 2002 (more than 6 years after his first period of service and two and a half years after his second period of service) in which he sustained from an automobile accident. As the Board has found that the presumption of soundness has attached in this case, it must now determine whether there is clear and unmistakable evidence that the Veteran entered service with a preexisting disability . To that end, the Board finds that the presumption that the Veteran's neck was sound upon entry to service has not been rebutted by clear and unmistakable evidence. Despite the opinion from the October 2011 examiner, which reflects that the Veteran had a residual neck disability when he entered service, three different examinations (October 1986, April 1992, and November 1997), failed to yield a diagnosis of a neck disability but instead showed that the Veteran's neck was within normal limits. In reviewing the evidence of record, it is not undebatable or clear and unmistakable that the Veteran entered service with a preexisting neck disability. See Vanerson v. West, 12 Vet. App. 254, 258 (1999); accord Cotant, 17 Vet. App. at 131 (noting that "[t]he clear-and-unmistakable-evidence standard is an 'onerous' one"). Given this determination, the Board need not address the second prong of the rebuttal standard (which requires that there be clear and unmistakable evidence that the preexisting disability was not aggravated in service). The Board finds that the presumption of soundness is not rebutted, and an analysis of in-service aggravation is not relevant to a determination in this case. Nevertheless, even assuming that the Board had found to the contrary that the Veteran did enter service with a preexisting neck disability, the evidence on file is insufficient to warrant service connection on the basis of aggravation. Rather, the October 2011 VA examiner specifically indicated that the Veteran's neck condition was not aggravated during active duty. As the presumption of soundness has not been rebutted, the Board finds that the Veteran entered service with a normal neck. Furthermore, as a discussion of aggravation is unnecessary, the Board now proceeds to an analysis of service connection for a cervical spine disability on the basis of in-service incurrence. As noted there are no complaints, findings, or diagnoses regarding the neck during service. Although the Veteran clearly complained of shoulder problems, just as clearly, there are no references to his neck. Except the one time when he was treated for body aches when diagnosed with viral syndrome. Indeed, the medical evidence, including post-service private and VA medical reports, shows that the Veteran had no complaints of neck problems until a motor vehicle accident in 2002, again 6 years after his first period of service and over 2 and a half years after his second period of active service. The passage of many years between discharge from active service and the medical documentation of a claimed disability weighs against a claim for service connection. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000); Shaw v. Principi, 3 Vet. App. 365 (1992). In October 2011, after an extensive review of the claims folder including the Veteran's service treatment records and numerous private medical reports, the VA examiner indicated that there was no evidence that he injured the cervical spine during service or that the cervical-thoracic myofascitis was aggravated during service. Furthermore, the first confirmed evidence of a cervical spine disability was not until January 2008. So this examiner disassociated any current disability from the Veteran's service, including in the way of aggravation (meaning chronic worsening) of any pre-existing disability. See Watson v. Brown, 4 Vet. App. 309, 314 (1993). As lay persons, the Veteran, his family and acquaintances are not qualified through education, training, and expertise to offer a diagnosis or an opinion on causation concerning complex medical matters of whether his pre-existing cervical spine disorder was aggravated during or by his service beyond the condition's natural progression. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). The VA examiner in 2011 acknowledged the medical history as reported by the Veteran, as well as the objective evidence of records, and, yet, determined the cervical spine disability was not incurred or worsened by the Veteran's military service. The Veteran also has claimed alternatively that his cervical spine disorder is a byproduct of his already service-connected lumbar spine and bilateral shoulder disabilities. Service connection also may be established on a secondary basis for disability that is proximately due to or the result of a service-connected condition. See 38 C.F.R. § 3.310(a). Secondary entitlement is also available when a service-connected condition has permanently aggravated the disability in question, but compensation is limited to the degree of disability (and only that degree) over and above the degree of disability existing prior to the aggravation. See 38 C.F.R. § 3.310(b); Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). The provisions of 38 C.F.R. § 3.310 were amended, effective from October 10, 2006; during the pendency of the appeal. The new provisions require that service connection not be awarded on an aggravation basis without establishing a pre-aggravation baseline level of disability and comparing it to current level of disability. 71 Fed. Reg. 52744 -47 (Sept. 7, 2006). Although the stated intent of the change was merely to implement the requirements of Allen, the new provisions amount to substantive changes to the manner in which 38 C.F.R. § 3.310 has been applied by VA in Allen-type cases since 1995. Consequently, the Board will apply the older version of 38 C.F.R. § 3.310, which is more favorable to the claimant because it does not require the establishment of a baseline before an award of service connection may be made. Generally speaking, supporting medical evidence is needed to associate a claimed condition with a service-connected disability to establish this cause and effect. See Wallin v. West, 11 Vet. App. 509, 512 (1998); Velez v. West, 11 Vet. App. 148, 158 (1998); and McQueen v. West, 13 Vet. App. 237 (1999). The Veteran's conclusory lay statements (and that of his family and friends) certainly do not reach the status of competent and credible evidence to establish this required correlation. In this regard the VA examiner, in considering this disability on a secondary basis, noted that degenerative arthritis is not a systemic disease and would not spread from his service connected lumbar disability. Furthermore, anatomically, the lumbar spine would not aggravate the cervical spine. Still further, the bilateral shoulder disability would not be related to or cause a cervical spine disability. She concluded that there was no evidence of record clinical or otherwise linking the service connected lumbar spine and bilateral shoulder disabilities to his chronic strain of the cervical spine. Again, there is no competent medical and or otherwise credible evidence suggesting entitlement to service connection for the cervical spine disorder, including under the theory of aggravation. As noted in the prior remand, in January 2008, the Veteran reported that he injured his back (and presumably his neck) when he fell on an AWAC aircraft. He submitted email correspondence (that is dated in 2001) between him and a fellow serviceman. This serviceman indicated that he remembered that the Veteran hit his leg when he stepped into a forward lobe hatch that had been left opened. However, there are no STRs showing that the Veteran sustained any injury or received treatment to his back, let alone his neck during this time period. His buddy statement does not actually confirm that he injured his neck at this time, in fact. Furthermore, the STRs show while undergoing his Physical Examination Board considerations in 2002 and 2003, he never reported such an incident. The Board finds the STRs more credible than statements made years after the fact and in conjunction with a claim for benefits. See Kowalski v. Nicholson, 19 Vet. App. 171 (2005) and Coburn v. Nicholson, 19 Vet. App. 427 (2006) (indicating reliance on a Veteran's statements and history of a claimed disorder only may be rejected if the Board rejects the Veteran's statements as lacking credibility). See also Washington v. Nicholson, 19 Vet. App. 363 (2005) (A Veteran is competent to report what occurred in service [so also, logically, what has occurred since service] because testimony regarding first-hand knowledge of a factual matter is competent). In fact there is no evidence of neck complaints until March 2002 when he was involved in a motor vehicle accident. At that time his neck complaints and problems were considered post motor vehicle accident strain. The Veteran has not indicated that this injury occurred while he was on duty in the Air Force Reserves. In summary, the evidence falls short in several areas and does not support a grant of service connection for cervical spine strain. The Board finds that the evidence of record to include the Veteran's statements is insufficient substantiation to link the Veteran's current cervical spine strain to he military service. Therefore, the Board concludes that the preponderance of the evidence is against the claim for service connection for cervical spine strain. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). IV. Service connection for a Left Knee Disability, to Include as Secondary to Service-Connected Right Knee Disability As with his cervical spine disability, the Veteran alleges that his pre-existing left knee disorder was aggravated during or by his military service. He also claims in the alternative that his left knee disability is secondary to his already service-connected right knee disability. But unlike the claim concerning his cervical spine disability, there is at least sufficient evidence for and against this claim on this posited alternative theory of secondary service connection to warrant resultantly resolving this reasonable doubt in his favor and granting this claim for his left knee disability. 38 C.F.R. § 3.102. In reviewing the Veteran's medical history prior to entrance into service, a May 1983 private orthopedic record shows that he underwent surgery for a compound fracture of the left femur. The service treatment records (STRs) show that on a September 1986 service medical pre-screening form, the Veteran reported that he was hospitalized in 1983 for broken bones due to a motorcycle accident. On the October 1986 enlistment examination, the lower extremity was deemed abnormal. It was noted that with respect to the left femur, he had extensive scar tissue which was normal following surgical fixation. It was also noted he had left knee valgus and varus stress both medially and laterally. It was suggested that he undergo an orthopedic consultation of the knees and X-rays. A consultation report dated in October 1986 shows that a further evaluation of the left knee was conducted. Following an examination, the impression was slight ligament laxity. Given the finding of abnormality of the lower extremities on enlistment examination and subsequent finding (a few days later) of ligament laxity of the left knee , the Board finds that the Veteran entered service with a preexisting left knee disability. The STRs for the Veteran's period of active service between March 1987 and September 1996 show treatment for various conditions including the right knee. However, there are no complaints, findings, or diagnoses regarding the left knee. In January 1988, the Veteran sustained a right knee strain while riding a horse. At that time, while examining the right knee the examiner also commented on the left knee. The left knee was considered normal. The examiner specifically noted that the left knee ligaments were stable. There was no effusion, atrophy, or tenderness. He had full range of motion. In April 1992 and November 1997, the Veteran underwent periodic examinations. On the April 1992 examination, it was noted that his lower extremities were normal; however, scarring was noted from the previous left femur fracture surgical fixation. On the November 1997 examination, the lower extremities were deemed normal and it was specified that the Veteran had tenderness to palpation of the right hamstring. There was full painless range of motion, negative Drawer sign, and no collateral ligament laxity. Left knee problems were not indicated in either examination. On the associated history form, dated in November 1997, the Veteran reported that he was good except for ". . .left knee..." He stated that he initially injured the left knee while playing football at the age of 16. A March 2000 medical record from Bernhardt Medical Clinic shows that the Veteran was required to undergo a physical examination for foster parenting purposes. At this examination, a diagnostic assessment included osteoarthritis of the knees. As stated above, records for the remainder of his Air Force Reserves service which ended in January 2003 show that he underwent Medical and Physical Board evaluations involving his lumbar spine disability. An August 2008 VA outpatient record shows that the Veteran complained of bilateral knee pain. Eventually, bilateral knee early osteoarthritis was diagnosed in October 2008. This was confirmed by VA X-rays in March 2009. As noted above a VA examination was conducted in October 2011. Regarding the left knee, the nurse practitioner concluded that it was less likely than not that the Veteran's left knee was caused or aggravated by military service. She also concluded that his left knee disability was not aggravated by the service connected right knee disability. In providing her rationale, she noted there was no evidence in the record to show that his left knee was aggravated during military service. The only reference to the left knee is the Veteran's 1997 report of knee problems. The medical records are silent in regard to the left knee between 1996 and 2000. While the March 2000 medical report notes a diagnosis of ostearthritis of the knees, it is not confirmed by X-ray until 2008, 11 years after service discharge. In this case, a report of the Veteran's October 1986 enlistment examination shows that there was abnormality of the lower extremities. It was suggested that he undergo an orthopedic consultation. Following examination, it was noted he had slight ligament laxity. As such, the presumption of soundness does not attach. He entered service with a preexisting condition. The Board concludes that there was no aggravation in service. In this regard, there is no evidence of complaints, treatment or diagnoses pertaining to the left knee from 1987 to 1996. Although he complained of a history of left knee issues in November 1997, a left knee disability was not noted. Indeed, the Veteran underwent a subsequent evaluation in January 1988 in conjunction with a right knee injury. At that time, he had full range of motion and the ligaments were considered normal bilaterally. No left knee disability was indicated. The Board acknowledges the October 2011 VA examiner's report, reflecting that the Veteran's left knee problems were not aggravated in service. The Veteran, while competent to report having left knee issues (e.g., pain), he is not competent to link such problems to service through incurrence or aggravation. A probative opinion establishing linkage (via aggravation) requires medical expertise. The weight of the medical evidence establishes that the Veteran's current left knee disability was not aggravated by service. In fact, there is no evidence, other than the Veteran's own contentions, that his current disability of the left knee is related to service. As noted, the Veteran and his family and friends, as lay persons, have not been shown to be capable of making medical conclusions, and thus his statements regarding causation are not competent. Consequently, as there is no competent medical evidence suggesting in-service aggravation of the currently-diagnosed left knee disability, and as the Veteran's current left knee arthritis was not manifested within the applicable one year presumptive period following discharge from either the first or second period of active service, the Board concludes that service connection for left knee disability is not warranted on the basis of in-service incurrence. See Shedden, supra. The Veteran also has posited the alternative possibility, however, that his left disability is secondary to his service-connected right knee disability-meaning, as mentioned, proximately due to, the result of, or aggravated by it. A private physician in January 2011 reviewed the Veteran's medical history and conducted an examination. This physician concluded that as a result of the cumulative trauma of his long standing problems with his right knee, this, led to his left knee arthritis and synovitis. He stated that this was due to him compensating for his right knee disability. Furthermore, his leg discrepancy which was noted in military records has led to pain in his knees. The physician determined that his right and left knee disabilities were a result of his military service. As noted above a VA examination was conducted in October 2011. Regarding the left knee, the nurse practitioner concluded that it was less likely than not that the Veteran's left knee was caused or aggravated by military service. She also concluded that his left knee disability was not aggravated by the service connected right knee disability. In providing her rationale, she noted that there is no documentation of an abnormal gait (which would be indicative of abnormal weight bearing) that would place undue stress on the opposite extremity until December 2008, when the Veteran was noted to have a broad based gait with knee pain. She stated that one would expect to see documentation of additional complaints of knee pain and an abnormal gait, if the Veteran was placing additional weight on the left knee. As such, she concluded that there is no evidence found in the record that would link the left knee disability to an aggravation by the right knee disability. In this case, there are two opposing opinions of record. In such instances, the Board must weigh the credibility of these medical opinions to determine their ultimate probative value and, in so doing, the Board may favor one medical opinion over another provided there is sufficient explanation of the underlying reasons and bases. See Evans v. West, 12 Vet. App. 22, 30 (1998). The Board must account for the evidence it finds persuasive or unpersuasive and provide reasons for rejecting material evidence favorable to the claim. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994). The medical opinions of record are considered competent as they were provided by those possessing the necessary medical competence, education, training, qualifications or experience to, according to 38 C.F.R. § 3.159(a)(1), offer medical diagnoses, statements or opinions. See Cox v. Nicholson, 20 Vet. App. 563 (2007). See also Rizzo v. Shinseki, 580 F.3d 1288 (Fed. Cir. 2009) (indicating that, where this is not called into question, VA need not affirmatively establish an examiner's competency). They both provide reasoning that can be debated but neither opinion can be dismissed based on their assumptions or reasoning. In light of the medical evidence establishing the required relationship or correlation between the Veteran's left knee disability and his service-connected disability, the Board finds that 38 C.F.R. § 3.102 warrants application. According to 38 C.F.R. § 3.102, when reasonable doubt arises regarding service origin, the degree of disability, or any other point, this doubt will be resolved in the Appellant's favor. A reasonable doubt is one that exists because of an approximate balance of positive and negative evidence that does not satisfactorily prove or disprove the claim. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). This is particularly significant in this case, as the VA examiner despite not having concluded in favor of the Veteran's position, did acknowledge, in essence, that an abnormal gait is indicative of aggravation, which began in 2008. This would imply that the right knee aggravates the left knee, albeit not until 2008. The evidence supporting the claim certainly is at least on balance with and as probative as any evidence against the claim concerning whether the Veteran's right knee disability aggravates the left knee disability. Therefore, especially when resolving all reasonable doubt in his favor, it is at least as likely as not that his right knee disability caused his left knee disability. 38 C.F.R. § 3.102. His claim therefore must be granted. See Alemany v. Brown, 9 Vet. App. 518, 519 (1996) (indicating that an "absolutely accurate" determination of etiology is not a condition precedent to granting service connection, nor is "definite" or "obvious" etiology). V. Service connection for a Headache Disability, to Include as Secondary to Service-Connected Lumbar Spine Disability In the notice of disagreement (NOD) received in August 2006, the Veteran claimed that he has headaches that resulted from his problems with his neck, shoulders, and back. He states that the pain in his cervical spine, lumbar spine, and shoulders cause his muscles to knot up which leads to migraine headaches. He also states that his pain medication that is prescribed for his service connected disabilities causes his headaches. In considering whether service connection is warranted on a direct basis. The VA examiner in 2011 diagnosed tension headaches. So he has this claimed condition. See Shedden, supra. Significantly, however, the Veteran's STRs do not show any complaints, findings, or diagnoses regarding a headache disorder. In October 1989, he complained of body aches to include neck pain, headaches, and general malaise. However, the diagnosis was viral syndrome. For the remainder of AD service as well as his Reserves service there are no references to headaches; migraine, tension, or otherwise. This is probative evidence against this claim. See Struck, supra. There also is no indication of a headache disorder for an extended period of time after his discharge from military service. The earliest evidence of a headache disorder is in 2005 when the Veteran applied for benefits. That was many years after his discharge from the military. This is a substantial lapse of time between the conclusion of his military service and the initial manifestation of this condition after service, which, as previously explained, is a factor for consideration in deciding this claim. See Maxon. More importantly, the record also does not contain any competent and credible evidence suggesting the headache disorder dates back to his military service or is related to his service. Consequently service connection is not warranted on a direct basis. The Veteran's claim, however, as mentioned, is more so predicated on the notion that his tension headaches are somehow secondary to his cervical spine as well as his already service-connected lumbar spine and bilateral shoulder disabilities. As mentioned to warrant granting service connection on this alleged secondary basis, there must be medical nexus evidence indicating his tension headaches are proximately due to, the result of, or chronically aggravated by his service-connected disabilities. See 38 C.F.R. § 3.310(a) and (b); Allen v. Brown, 7 Vet. App. 439, 448 (1995). But the Board emphasizes again that supporting medical evidence, not just lay evidence, is generally required to establish this cause-and-effect correlation between these conditions. See Wallin, Velez McQueen, supra. Concerning his headaches, the VA examiner in October 2011 found that it was unlikely that his headaches are related to military service or his service connected disabilities. She noted that there is no clinical indication that a lumbar spine disability would cause or aggravate tension headaches. She noted that the Veteran also reports that his pain medication is worsening his headaches and cervical spine disability. She pointed out that he reports that he has had cervical spine pain and headaches for many years. However, he has been only taking the pain medications Tramadol, Lisinopril, and Indomethacin for the last few years. There is no indication that these drugs cause cervical spine pain. She noted that the medications Tramadol and Indomethacin do contain warnings that they may cause headaches as a side effect, so they do have the potential of causing headaches. However, she stated that they would not chronically aggravate pre-existing headaches. Further, there is no evidence in the clinical records that the Veteran ever discussed this subject with his primary physician or that attempts have been made to change his medications. Moreover, there was no evidence in the review of medical literature that Tramadol and Indomethacin aggravate tension headaches. The Board has considered all lay and medical evidence as it pertains to this claim to include from the Veteran, his family and his acquaintances. However, ultimately, the medical opinion is more competent and credible on the determinative issues of causation and aggravation, especially since tension headaches is not the type of condition that is readily amenable to probative lay comment regarding its etiology. 38 C.F.R. § 3.159(a)(1) versus (a)(2). See, too, Buchanan, 451 F.3d 1331, 1335 (Fed. Cir. 2006) and Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (reiterating this axiom in a claim for rheumatic heart disease). And there simply is no competent and credible evidence in the file specific to this claim supporting this assertion that the tension headaches were either caused or aggravated by the service-connected disabilities. So there is no basis for granting this claim. And since the preponderance of the evidence is against this claim, there also is no reasonable doubt to resolve in the Veteran's favor. 38 C.F.R. §3.102. ORDER Service connection for a cervical spine disability is denied. Service connection for a left knee disability is granted. Service connection for tension headaches is denied. REMAND In a September 2011 rating decision, the RO granted service connection for degenerative arthritis of the right knee and assigned a 10 percent rating effective in April 2005. In response, he filed a timely NOD in November 2011 to the 10 percent rating that was assigned. While a May 2012 letter shows that the AMC notified the RO of his disagreement, he has not been provided a statement of the case (SOC) concerning this other claim or given an opportunity to perfect an appeal to the Board regarding this claim. 38 C.F.R. § 20.200. So the Board is remanding this other claim to the RO, rather than merely referring it there. See Manlincon v. West, 12 Vet. App. 238, 240-41 (1999). Accordingly, the case is REMANDED for the following action: Send the Veteran an SOC concerning his additional claim of entitlement to a higher initial rating for degenerative arthritis of the right knee. Advise him that he still needs to file a timely substantive appeal (VA Form 9 or equivalent statement) in response to the SOC to perfect the appeal to the Board concerning this additional claim. 38 C.F.R. §§ 20.200, 20.302(b). If, and only if, he perfects a timely appeal of this claim should it be returned to the Board for further appellate consideration. The Veteran 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). ______________________________________________ K. Parakkal Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs