Citation Nr: 1306080 Decision Date: 02/21/13 Archive Date: 02/27/13 DOCKET NO. 06-23 659 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUES 1. Entitlement to service connection for a bilateral knee disability. 2. Entitlement to service connection for a neck disability. REPRESENTATION Veteran represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD Saira Spicknall, Counsel INTRODUCTION The Veteran served on active duty from April 1968 to August 1992 with service in the Republic of Vietnam. His awards and decorations include the Army Commendation Medal with "V" Device. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a May 2005 rating decision of the Huntington, West Virginia, Department of Veterans Affairs (VA) Regional Office (RO). Jurisdiction remains with the Montgomery, Alabama RO. During the pendency of this appeal, by a June 2010 rating decision, the RO granted the Veteran's claim for service connection for an anxiety disorder with depression thereby constituting a full grant of the benefits sought on appeal for the claim for service connection for depression. Thus, as this issue was granted in full it is not in appellate status before the Board and need not be addressed further. The Veteran testified at a hearing at the RO before a Decision Review Officer (DRO) of the RO (DRO hearing) in June 2009. A transcript of that hearing has been associated with the claims file. A review of the Virtual VA paperless claims processing system reflects that additional records have been added to the present appeal. These records include VA medical records. A supplemental statement of the case (SSOC) was issued in December 2012, which addressed this additional evidence. This case was previously remanded by the Board in May 2012 for additional development. FINDINGS OF FACT 1. Affording the Veteran the benefit of the doubt, the probative evidence of record demonstrates that a bilateral knee disability was incurred during active service. 2. The probative evidence of record demonstrates that a current neck disability did not originate during the Veteran's active service or for many years thereafter and is not related to his active service. CONCLUSIONS OF LAW 1. The criteria for the establishment of service connection for a bilateral knee disability have been met. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002); 38 C.F.R. § 3.303 (2012). 2. The criteria for the establishment of service connection for a neck disability have not been met. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002); 38 C.F.R. § 3.303 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veterans Claims Assistance Act (VCAA) The VCAA, codified, in part, at 38 U.S.C.A. § 5103, was signed into law on November 9, 2000. Implementing regulations were created, codified at 38 C.F.R. § 3.159 (2012). VCAA notice consistent with 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) must: (1) inform the claimant about the information and evidence not of record that is necessary to substantiate the claim; (2) inform the claimant about the information and evidence that VA will seek to provide; and (3) inform the claimant about the information and evidence that the claimant is expected to provide. 38 C.F.R. § 3.159(b)(1) (2012). The United States Court of Appeals for Veterans Claims (Court) held in Pelegrini v. Principi, 18 Vet. App. 112 (2004) that to the extent possible the VCAA notice, as required by 38 U.S.C.A. § 5103(a) (West 2002), must be provided to a claimant before an initial unfavorable decision on a claim for VA benefits. Pelegrini, 18 Vet. App. at 119-20; see also Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). Prior to the initial adjudication of the Veteran's claims for service connection, he was provided notice of the VCAA in December 2004. An additional VCAA letter was sent in June 2012. The VCAA letters indicated the types of information and evidence necessary to substantiate the claim, 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. The Veteran also received notice in June 2012 and December 2012, pertaining to the downstream disability rating and effective date elements of his claims with subsequent readjudication in a December 2012 SSOC. Dingess v. Nicholson, 19 Vet. App. 473 (2006); see also Mayfield and Pelegrini, both supra. All relevant evidence necessary for an equitable resolution of the issues on appeal has been identified and obtained, to the extent possible. The evidence of record includes service treatment records, private medical records, VA outpatient treatment reports, an adequate VA examination and statements and testimony from the Veteran and his representative. This case was previously remanded by the Board in May 2012 to provide the Veteran with an adequate VCAA letter, including the requirements under Dingess, 19 Vet. App. 473, obtain the Veteran's ongoing VA treatment records since June 2011, attempt to obtain private treatment records from all identified medical providers, and provide an adequate VA examination for the bilateral knees and neck. The Veteran was provided adequate VCAA notice in compliance with Dingess in June 2012. The RO requested and received private treatment records from the 4nd Medical Group at Maxwell Air Force Base and obtained and associated VA medical records from June 2011 to June 2012 with the record. A VA examiner performed all the tests necessary to evaluate the Veteran's current bilateral knees and neck I July 2012 and complied with the Board's remand instructions. The Veteran was also provided notice in the June 2012 VCAA letter pertaining to any outstanding private medical records from the Southern Pain Control Center and was asked to provide any records he may have related to the neck or bilateral knees or to complete the VA Form 21-4142 Authorization and Consent to Release Information for the Southern Pain Control Center or any other private physician. No response was received. Therefore, the Board is satisfied that the development requested by its May 2012 remand has now been satisfactorily completed and substantially complied with regarding the Veteran's claims for service connection for a bilateral knee disability and a neck disability. See Stegall, 11 Vet. App. 268 (remand not required under Stegall v. West, 11 Vet. App. 268 (1998) where Board's remand instructions were substantially complied with). The Board notes that the June 2012 VA examination reports reflect that the examiner reviewed the Veteran's past medical history, documented his current medical condition, and rendered 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). In addition a supplemental independent opinion in December 2012 pertaining to the Veteran's neck was also obtained which included an appropriate opinion consistent with the remainder of the evidence in the claims file. Accordingly, the Board concludes that the medical examinations and independent medical 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). 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 (2012). Pertinent Laws and Regulations Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. § 3.303(a) (2012). In addition, service connection may be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). In order to establish service connection for a claimed disorder on a direct basis, there must be: (1) medical evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of the 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). Service connection will also be presumed for certain chronic diseases, including arthritis, if manifested to a compensable degree within one year after discharge from service. 38 U.S.C.A. § 1112; 38 C.F.R §§ 3.307, 3.309. This presumption, however, is rebuttable by probative evidence to the contrary. 38 U.S.C.A. § 1113. The determination as to whether the requirements for service connection are met is based on an analysis of all of the evidence of record and the evaluation of its credibility and probative value. 38 U.S.C.A. § 7104(a) (West 2002); 38 C.F.R. § 3.303(a) (2012). See Baldwin v. West, 13 Vet. App. 1 (1999). When there is an approximate balance of positive and negative evidence regarding a material issue, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. § 3.102 (2012). See Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001). If the Board determines that the preponderance of the evidence is against the claim, then it has necessarily found that the evidence is not in approximate balance, and the benefit of the doubt rule will not be applicable. Ortiz, 274 F.3d at 1365. With regard to VA examinations, the Board notes that the most recent examination is not necessarily and always controlling; rather, consideration is given not only to the evidence as a whole but to both the recency and adequacy of examinations. See Powell v, West, 13 Vet. App. 31, 35 (1999). Factual Background In statements and testimony presented throughout the duration of the appeal, the Veteran has maintained that his current bilateral knee disability and current neck disability are related to his active service. Specifically, in a January 2005 statement, the Veteran reported had right knee problems since 1975, for which he was seen by a physician in Germany. He also stated that his left knee was treated while in Fort Campbell, Kentucky and was provided x-rays, an arthrogram and magnetic resonance imaging (MRI). Finally, he contended that his cervical spine problems started while he was in Fort Campbell, Kentucky after going through Air Assault School in 1981. The Veteran stated that he was still taking Motrin as needed for joint and back aches. Service treatment records (STRs) reflect that, in a March 1968 pre-induction examination, no abnormalities of the spine, neck or lower extremities were noted upon clinical evaluation. A March 1968 pre-induction Report of Medical History reflects that the Veteran reported no history of neck or knee problems. In an August 1972 Report of Medical History, the Veteran reported having a history of cramps in the legs, however, he denied any history of swollen or painful joints, arthritis, bone, joint or other deformity, and "trick" or locked knee. A June 1974 annual examination reflects no abnormalities of the spine, neck or lower extremities were noted upon clinical evaluation and the Veteran provided a signed statement indicating that he was in good health with no significant interval history. In December 1975, he sought treatment for discomfort in the posterior portion of his right leg and knee, for which he reported an injury to the right knee or leg approximately a month earlier. He was referred to the orthopedic clinic at that time. A December 1975 radiographic report revealed that the Veteran reported that he had injured his right knee approximately a month earlier and thought he had a muscle or ligament strain. Examination of his right knee revealed no effusion, a full range of motion, no crepitus, no deep pain on palpation, no locking, no giving way and a negative McMurray's test. The radiologist was asked to read the x-ray an evaluate an area of increased opacity in the distal femur proximal to the right medial femoral condyle. The impression was that there was no acute disease and the reviewing radiologist commented that multiple views of the right knee showed no evidence for disease. He also noted that there was a linear island of dense bone within the medulla of the metaphysis of the distal right femur, which was an entirely benign process and a probably represented some localized derangement of bone metabolism during the Veteran's growth period. While a more generalized form of this derangement was noted as being called osteopathia striata, the reviewing radiologist found that there was no pathological significance to that finding. In June 1976, the Veteran sought treatment for an injury in his left knee and upper leg incurred while playing softball. He complained of swelling in the knee, muscle tightness and pain in the upper leg and a decreased range of motion. Swelling with fluid in the joint space was noted on examination. The muscle mass over the knee was swollen and very tender and good ligament stability was found. The Veteran was assessed with a probable muscle tear or severe strain with prescribed bed rest and heat for treatment. In January 1977, the Veteran's was treated for complaints of left knee pain and swelling with no known injuries. Torn cartilage in his knee was noted, although no radiographic reports were provided at this time to confirm this report. In February 1977, the Veteran alleged having pain in the left knee radiating from the hip with symptoms of popping and giving way. He was provided an ACE bandage. At that time, a physical examination revealed no effusion in the left suprapatella pouch, no instability, no crepitus, negative McMurray's and no Baker's cyst. An arthrogram was scheduled. The Veteran underwent a left knee arthrogram in February 1977. Examination revealed a normal appearance of the lateral and medial menisci, of the medial and lateral collateral ligaments, and of the cruciate ligaments. A small bursa was seen on the flexion lateral view of the knee. No other significant findings were made. The conclusion was that the Veteran had a small Baker's cyst without other findings. In an August 1977 annual examination, no abnormalities of the neck or lower extremities were noted upon clinical evaluation. Although low back pain at L5-6 and disc damage was noted at that time with respect to abnormalities of the spine. In an August 1977 Report of Medical History, the Veteran denied any history of swollen or painful joints, arthritis, bone, joint or other deformity, and "trick" or locked knee. At that time, he specified problems with the lower back and left ankle only. An August 1977 hospital report from Fitzsimons Army Medical Center revealed that the Veteran suffered an evulsion fracture of his left distal tibia in April 1976 and that he was placed in a cast, after which he began experiencing hip and knee pain. An arthrogram of the left knee was noted to have been taken in the fall of 1976, which was normal. The Veteran again sought treatment for persistent left knee pain in July 1983, after being struck in the knee with a softball four days previous. He was noted to have a full range of motion, and no significant edema. He was treated with Indocin and placed on a temporary physical profile. The diagnosis at that time was a contused left knee. In a November 1984 service treatment report, the Veteran was treated for complaints of chest pain while watching a ball game on television. He referred to the pain as first evident in his jaws and neck and then moving down into the chest. He also reported first experiencing neck pain two weeks earlier when he was awakened by a similar pain. An examination of the head, ears, nose, throat and neck were within normal limits and the Veteran was diagnosed with musculoskeletal pain. In February 1986 airborne examination, no abnormalities of the neck, spine or lower extremities were found upon clinical evaluation and the service medical officer noted the Veteran's history of lumbar disc disease in 1977 with no sequelae. In a February 1986 Report of Medical History, the Veteran reported he was in good health and was on no medications and denied any history of swollen or painful joints, arthritis, bone, joint or other deformity, and "trick" or locked knee. In a July 1988 "Over 40" examination, no abnormalities of the neck, spine or lower extremities were found upon clinical evaluation. In a July 1988 Report of Medical History the Veteran reported he was in good health and on no medications and denied any history of arthritis, bone, joint or other deformity, and "trick" or locked knee. While he noted a history of swollen or painful joints, such was specified as a fractured right elbow in 1983 with pain for the last four months and a fractured right wrist in 1983. In June 1989, the Veteran once again sought treatment for persistent left knee pain for the past six to eight weeks. He was initially diagnosed with a questionable meniscal tear and referred for an orthopedic consultation. X rays were also ordered. A June 1989 consultation report reflects the Veteran was assessed with left knee pain, rule out meniscus tear posteriorly. A June 1989 x-ray report revealed no significant abnormalities. In a later June 1989 consultation report, the Veteran was assessed with rule out degenerative meniscus tear versus tendonitis. The Veteran was again seen for knee pain in July 1989. A July 1989 left knee arthrogram revealed that the anterior most portion of the medial meniscus appeared to be small but was not blunted. Findings were noted to possibly be related to degenerative change. The final impression was a small Baker's cyst, with no evidence of a meniscal tear. Subsequently in July 1989, the Veteran was followed up for left knee pain, at which time it was noted that an arthrogram showed a small Baker's cyst and no meniscal tear. In August 1989, the Veteran was referred to the orthopedic clinic where he was noted to have complaints of left popliteal fossa pain following a back procedure. The probable pathology was noted to be a small Baker's cyst. An August 1989 electromyography (EMG) report revealed normal EMG and nerve conduction study (NCS) of the left lower extremity and there was no electrodiagnostic evidence of significant root, plexus or peripheral (peroneal) nerve pathology at that time. The Veteran returned to the orthopedic clinic for a follow-up consultation regarding his left leg and knee pain in September 1989, at which time a Baker's cyst by arthrogram was noted and the Veteran had no locking, swelling, or trauma noted. An EMG report was found to be negative and an MRI was planned. A September 1989 MRI revealed an amorphous area of increased signal intensity near the gastrocnemius muscle which was consistent with a ruptured Baker's cyst given a previously documented Baker's cyst on arthrogram. In October 1989,the Veteran was evaluated for his knee pain and the MRI was noted to demonstrate a positive Baker's cyst. The Veteran was also noted to have tenderness along the sciatic nerve. The service medical officer questioned a recurrence of disc symptoms. A September 1991 retirement examination revealed no abnormalities of the neck, spine or lower extremities upon clinical evaluation and a May 1992 notation in the examination reflects that he was cleared for retirement. A May 1992 Report of Medical History reflects that the Veteran reported he was in good health and on Motrin 800 mg. He denied a history of swollen or painful joints, arthritis, bone or joint deformity and "trick" or locked knee. In addition, he only specified a history of previous fractures to the radial heads bilaterally, which healed, and having frequent elbow pain. He also noted a history of back pain with previous surgery. The post service medical evidence includes private medical records from March 2000 to May 2012 and VA outpatient treatment reports from February 2004 to June 2012. These records reflect that the Veteran was initially treated for complaints chronic neck pain for the past two months in October 2000, at which time he denied experiencing radiation of pain or weakness into the upper extremities or incurring head trauma. No obvious deformity was noted on examination. Paravertebral tenderness to palpation and spasms were noted. Additionally, he was found to have a limited range of motion secondary to his pain. He was diagnosed with neck pain and spasms, and rule out degenerative joint disease. The Veteran was not again treated for complaints related to the cervical spine or neck until July 2005, at which time he was diagnosed with cervicalgia. Subsequent private medical records reflect that the Veteran was treated for and diagnosed with neck pain, cervicalgia, cervical spondylosis, cervical intervertebral disc degeneration and cervical disc degeneration at C5-6. The post service medical evidence also reflect that the Veteran was initially treated for the bilateral knees in July 2005 by a private physician, wherein he was diagnosed with osteoarthrosis of the knee and radiology reports of the left and right knee revealed arthritis. Subsequent private treatment reports reflect that the Veteran was treated for and diagnosed with knee pain and osteoarthrosis of the knee. Private x-rays taken of the Veteran's cervical spine in April 2009 revealed mild changes of cervical spondylosis and a small left cited cervical rib. A June 2009 private MRI of the Veteran's neck revealed altered curvature of the cervical spine, possibly due to muscle spasm; degenerative disc disease (DDD) with minimal disc bulge and with associated minimal spondylosis, as noted; and mild to moderate bilateral foraminal stenosis at the C3-4, C4-5, and C5-6 levels. In a June 2009 private treatment report, the Veteran stated that he needed a medical statement letter for VA disability for the neck, depression and knees. He provided the private physician with a copy of his STRs and the Veteran reported a history of neck pain was noted initially in 1970 with recurrent pain after field training in 1988, for which he attended physical therapy with greatly improved symptoms. A history of knee pain was also noted with an initial evaluation in July 1975 for which the Veteran reported being sent to physical therapy for just the right knee. He also reported a history of left knee and arthrogram, which was performed in February 1977, at which time a small Baker's cyst was noted. A history of treatment in June 1989 for worsened pain and physical therapy was noted as well as a September 1989 MRI report which demonstrated a ruptured Baker's cyst to the left knee. The private physician concluded that the Veteran's neck pain symptomatology began while he was on active duty. The private physician also concluded that the knee, left greater than right, was well documented, especially with the left and radiographic study results were noted in the active duty medical record. The Veteran testified at his June 2009 DRO hearing that his first issue with the neck occurred during a field training exercise in 1988 for which he went to sick call and was prescribed medication. He stated that he did not return for treatment thereafter and was no provided a diagnosis but that "they just said it was probably a neck strain at that time." The Veteran testified that he sought medical attention for the neck after service within "two or so years" and he was still receiving medical attention for this disability. He also reported that his private physician said his neck was probably contributed to from the initial accident in 1988. The Veteran testified that he was initially treated in July 1975 for knee pain and was provided Motrin and referred for physical therapy. He reported visiting sick call for the left knee after treatment for the right and that it was noted in 1989 that he had a ruptured Baker's cyst in his left knee. He complained of normal knee pain after service and was initially treated within a "year or so" after service. The Veteran testified that he continued to receive treatment for the knees currently. He reported that a physician had said that with his physical therapy and running for 25 years, he had to expect a knee disability. A July 2009 private treatment report revealed that the Veteran complained of ongoing neck pain for eight months that more recently began radiating around to the side of his neck. He was diagnosed with chronic intractable pain in the neck and shoulder, cervical facet syndrome, cervical radiculitis with DDD, and muscle spasms. In December 2010 private MRI reports of the Veteran's knees revealed mild patellofemoral joint degenerative changes in the right knee and no evidence of internal derangement in the left knee. During a March 2010 VA examination of the joints, the Veteran was diagnosed with mild degenerative arthrosis s of both knees. X-rays taken at that time revealed bilateral minimal joint space narrowing of the knees, although the impression was no significant degenerative changes in the knees. No other abnormality of the bones, soft tissues, or joints of the knees was noted. Following examination of the Veteran's knees, the examiner provided the opinion that the Veteran's bilateral knee disorder was less likely as not caused by or a result of injury during his active service. He explained that no significant disorder of either of the Veteran's knees was found on evaluation during his service, including during rather extensive orthopedic specialist evaluations of the left knee. He further asserted that there was only one single right knee complaint. He then asserted that the mild form of degenerative arthrosis found in the Veteran's current x-rays was essentially symmetrical, indicating that it was most likely the result of usual wear and tear associated with aging. In the May 2012 remand, the Board found the March 2010 VA examiner's opinion had failed consider the July 1989 finding that the anterior most portion of the medial meniscus appeared to be small and that this finding was possibly related to degenerative change, nor did he appear to address the Veteran's contention that his knee disability was incurred over time as a result of running during his service, but rather asserted that his knee disability was not related to an in-service knee injury. Finally, the Board noted that the medical evidence received following the Veteran's VA examination contradicted the VA examiner's assessment that the Veteran had essentially symmetrical degenerative changes in his knees, finding that the December 2010 MRI reports indicated that the Veteran had a more severe abnormality in his right knee than in the left. Accordingly, the Board found this examination report to be inadequate and remanded the claim for a new VA examination and opinion. At a July 2012 VA examination of the cervical spine, the Veteran was diagnosed with degenerative disc disease of the cervical spine, which was noted to have been diagnosed in the 2000s. The Veteran reported that he had problems with his neck when he got out of service and stated that he had been seen a couple of times in service and was treated with Motrin for sprains in the neck in service. The Veteran was also provided a VA examination of the knees at this time, in which he was diagnosed with a resolved Baker's cyst of the left, diagnosed in the 1970s, and knee arthritis of both knees, diagnosed in the 2000s. He reported that, while in service, he had an extensive workup for the injury to the left knee and was thought to have a possible Baker's cyst in the 1970s. The Veteran reported that he was treated sporadically for the right knee and that since his service, his bilateral knee symptoms had progressed. The examiner noted that he has had MRIs in the 2000s which confirmed arthritis on the right but not on the left. The examiner provided an opinion addressing both the bilateral knee and cervical spine disabilities. He opined that it was less likely than not that the Veteran's claimed condition, including degenerative disc disease of the cervical spine, incurred in or wars caused by the claimed in-service injury, event or illness. The examiner noted that the STRs did not show any evidence of the current conditions in service, noting that the 1989 statement regarding the left knee was a concern for possible arthritis but was not confirmed by imaging. He also found that it was not until the 2000s that knee arthritis was confirmed on imaging, which was at least 10 years after the Veteran's service. The examiner pointed out that the arthritis at this point was mild and it had only very recently been that the left knee was shown to have any arthritis per imaging. He also concluded that the left Baker's cyst was found on arthrogram in service, however, this test did not have specificity and subsequent, more advance imaging, in particular an MRI, did not show any Baker's cyst or residuals from this at all. Therefore, he reasoned that either the arthrogram had a false positive or the Baker's cyst had completely resolved. The examiner also found that the Veteran's current bilateral knee condition was most likely due to aging and having a body mass index (BMI) of greater than 30 for the past several years. With respect to the Veteran's cervical spine, the examiner explained that there was no objective medical evidence for the current neck disc disease until the 2000s and all the STRs did not show any evidence of this condition. He also found that it was not until the past 10 years that the condition had been diagnosed and that the extent of this condition was most consistent with age. A December 2012 Independent Medical Opinion was sought to provide clarification to the July 2012 VA examiner's opinion regarding the cervical spine. The physician reviewed the Veteran's C-file, clinical files, medical records and CAPRI records for the opinion. A summary of the medical history also indicates that STRs were reviewed. The physician, Dr. L. T., opined that it was less likely than not that the cervical spine condition incurred in, was caused by or was aggravated by the Veteran's military service. She explained that there was no medical evidence, documentation for diagnosis, treatment or injury to the cervical region of the spine, however, there were copious medical notes pertaining to the lower back, knee, and right elbow conditions. Dr. L.T. also noted that there was no medical evidence or documentation for diagnosis, treatment or injury to the cervical region of the spine during the presumptive period following separation. She explained that the July 2012 VA examination indicated objective findings, to include a limited range of motion at the cervical level, however, there was no radiculopathy, neurovascular or significant radiologic (bony or disc space) changes to warrant a diagnosis other than cervical strain. She concluded that the lack of active duty and/or post service documentation deemed this claimed cervical spine condition less likely than not incurred in, caused by or aggravated by the Veteran's time in military service. Dr. L.T. found no evidence or insufficient evidence, that the current cervical spine condition may be related to any in-service event. Therefore, in her opinion, it was at least as likely as not that the etiology for this claimed cervical spine condition was consistent with the Veteran's normal and natural aging process. Analysis Bilateral Knee Disability After a careful review of the record and resolving all doubt in the Veteran's favor, the Board has determined, based upon the satisfactory and probative evidence set forth above, that service connection for a bilateral knee disability is warranted. The Board notes that Veteran has a current diagnosis of arthritis of the bilateral knees, per the private medical records and July 2012 VA examination. Service treatment reports reflect that the Veteran was treated in December 1975 for discomfort in the posterior portion of his right leg and knee, which reportedly lasted for the past month. He also was treated for the left knee in June 1976 with a diagnosis of probable muscle tear or severe strain and was subsequently treated or the left knee on service on several occasions, including in January 1977 and February 1977 for a Baker's cyst, August 1977, July 1982 for a contused left knee, and from June 1989 through October 1989 for a Baker's cyst, noted to have been ruptured by a September 1989 MRI report. The Board also finds that the Veteran's statements regarding a continuity of bilateral knee symptoms, namely pain, since his treatment for each knee in service are competent and credible evidence of a continuity of symptoms. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); see also Baldwin v. West, 13 Vet. App. 1 (1999) (the Board must analyze the credibility of the evidence). The Board finds his statements regarding his knees are internally consistent and consistent with the contemporaneous medical evidence of record. The post-service medical evidence demonstrates that the earliest documentation for the bilateral knees was in July 2005, at which time he was diagnosed by x-ray with arthritis for each, approximately 13 years since his discharge from active service. These records also demonstrate that he has been subsequently treated for and diagnosed with bilateral knee disabilities. The Board also finds that despite the July 2012 VA examiner's opinion, his conclusion failed to consider the Veteran's history of a continuity of symptoms in service and since that time as well as the September 1989 MRI report which indicated the presence of a ruptured Baker's cyst, consistent with the Veteran's treatment for the left knee throughout his active service. In addition, the Board has afforded significant probative value to the Veteran's statement of a continuity of symptoms since his treatment for each knee in service as these statements are supported by the evidence in the record. Therefore, the Board finds that the July 2012 VA medical opinion and the Veteran's statements, taken together, place the evidence in relative equipoise and the benefit of the doubt rule will therefore be applied to resolve doubt in favor of the Veteran. Accordingly, on balance, the evidence of record collectively shows that the Veteran's bilateral knee disability is directly related to his active service. Thus, as the evidence supports the Veteran's claim, service connection for a bilateral knee disability is warranted. 38 C.F.R. §§ 3.102, 3.303 (2012). See also 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). Neck Disability After a review of the record, the Board concludes that entitlement to service connection for a neck disability is not warranted. In this regard, the Board finds that, while the Veteran is currently diagnosed with degenerative disc disease of the cervical spine and cervical strain, the credible and probative lay and medical evidence of record does not demonstrate a nexus between the Veteran's currently diagnosed neck disability and his active service. The Board notes that the STRs are absent of any findings related to a cervical spine disability during active service. In this regard, the Board observes that, while the Veteran complained of neck pain on one occasion in a November 1984 service treatment report, this report was part of his main complaint for chest pain. He initially reported having chest pain which was described as pain being as evident first in his jaws and neck and then moving down into the chest. While the Veteran also reported first experiencing neck pain two weeks earlier when he was awakened by a similar pain at that time, an examination of the head, ears, nose, throat and neck were within normal limits and he was diagnosed with musculoskeletal pain with no specified documentation of a neck disability at that time. In addition, subsequent STRs are wholly absent of any complaints, treatment or findings related to the cervical spine. Successive periodic in-service examinations revealed no abnormalities of the neck or spine, other than the low back, upon clinical evaluation and the later Reports of Medical History reflect that the Veteran continued to deny a history of swollen or painful joints, arthritis and bone or joint deformity and did not specify any history of neck pain or a neck disability. The Board acknowledges the lay statements by the Veteran made throughout the record that the onset of neck disability was during his active service and he continued to have problems with his neck since that time. Although lay persons are competent to provide evidence regarding injury and symptomatology, they are not competent to provide evidence regarding diagnosis or etiology. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); see also Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. Sept. 14, 2009). The Board finds that the Veteran is competent to attest to the onset of his neck symptoms and the continuity of symptoms since his active service. The Board finds, however, that the statements regarding the onset of his neck disability in service and a continuity of neck symptoms since active service, while competent, are not credible evidence as they are internally inconsistent and are inconsistent with the contemporaneous medical evidence of record. In making a determination, the Board has an obligation to evaluate the credibility of evidence and to assign probative weight to competent evidence. See Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997) (recognizing the Board's "authority to discount the weight and probity of evidence in light of its own inherent characteristics and its relationship to other items of evidence"). As to some of the factors that go into making these determinations both the Veterans Court and the U.S. Court of Appeals for the Federal Circuit (Federal Circuit) have provided guidance. See Buchanan v. Nicholson, 451 F3.d 1331, 1336-37 (Fed. Cir. 2006) (stating that "the Board, as fact finder, is obligated to, and fully justified in, determining whether lay evidence is credible in and of itself, i.e., because of possible bias, conflicting statements, etc."); see also Caluza v. Brown, 7 Vet. App. 498, 511 (1995) (stating that "[t]he credibility of a witness can be impeached by a showing of interest, bias, inconsistent statements, or, to a certain extent, bad character."). In this regard, the Board points out that the Veteran indicated in a January 2005 statement that he first experienced cervical spine problems after Air Assault School in 1981. He later testified during his June 2009 hearing before a DRO that he experienced neck pain during a field training exercise in 1988, and that he reported to sick call. In addition, in a June 2009 private treatment report, the Veteran stated that he needed a medical statement letter for VA disability for the neck, depression and knees and reported a history of neck pain was noted initially in 1970 with recurrent pain after field training in 1988, for which he attended physical therapy with greatly improved symptoms. In addition, in the October 2000 private treatment report, the Veteran reported having chronic neck pain only for a few months at that time, which is the first instance of record of treatment for a neck problem. Accordingly, the Board finds the statements regarding the onset of his neck disability and continuity of his neck symptoms since active service are internally inconsistent with his other statements of record. In addition, the record reflects that the earliest indication of a neck disability in the record was not until October 2000, approximately 8 years following his discharge from active duty. In fact, the Veteran's STRs do not indicate any complaints or findings of a neck problem throughout his entire period of active service, except for one report of neck pain in conjunction with treatment sought for chest pain. However, the Veteran reported his chest pain initially began in the jaws and neck and no neck disability was noted or diagnosed. Moreover, with respect to the Veteran's report of the dates of onset of neck pain, including 1970, 1981 and 1988, the STRs are wholly absent of any complaints or findings related to the neck during any of these times. Finally, the Board observes that periodic in-service examinations revealed no abnormalities of the neck or spine, other than the low back, upon clinical evaluation. Therefore, the Board finds the statements regarding the onset of his neck disability and continuity of his neck symptoms since active service are inconsistent with the contemporaneous medical evidence of record. Accordingly, the internally inconsistent statements furnished by the Veteran and the lack of contemporaneous evidence in this instance diminishes the reliability of these statements of the onset of a neck disability and a continuity of neck symptoms since his active service, and they are afforded no probative value. The post-service medical evidence of record demonstrates that there is no evidence of treatment or complaints of the neck until October 2000, wherein the Veteran was diagnosed with a neck pain and spasm, approximately eight years after his separation from active service. In addition, the Board observes that the Veteran has been most recently diagnosed with degenerative disc disease of the cervical spine and cervical strain. The Board observes that the June 2009 private medical report indicates that a private physician reviewed the Veteran's service records and concluded that the Veteran's neck pain symptomatology began while he was on active duty, however, he provided no explanation for this conclusion and his opinion was based, in part, on the Veteran's reported history that neck pain was noted initially in 1970 with recurrent pain after field training in 1988 which the Board has found to be not credible evidence. Moreover, the June 2009 private physician's opinion is not supported by the STRs, as no neck disability was indicated during the Veteran's active service. Therefore, this opinion is afforded little probative value. Finally, there is no competent, credible and probative evidence of record indicating a nexus between the Veteran's currently diagnosed degenerative disc disease of the cervical spine and his active service. In this regard, the Board observes that the July 2012 VA examiner explained that there was no objective medical evidence for the current neck disc disease until the 2000s and all the STRs did not show any evidence of this condition. He also found that it was not until the past 10 years that the condition had been diagnosed and that the extent of this condition was most consistent with age. In addition, the December 2012 independent medical also supported the July 2012 VA examiner's opinion, finding it was less likely than not that the cervical spine condition incurred in, was caused by or was aggravated by the Veteran's military service. She explained that there was no medical evidence, documentation for diagnosis, treatment or injury to the cervical region of the spine, although there were copious medical notes pertaining to the lower back, knee, and right elbow conditions and noted that there was no medical evidence or documentation for diagnosis, treatment or injury to the cervical region of the spine during the presumptive period following separation. In addition, she found that it was at least as likely as not that the etiology for this claimed cervical spine condition was consistent with the Veteran's normal and natural aging process. As noted earlier in this decision, these opinions have been found to be adequate and are afforded significant probative weight. Accordingly, the evidence does not demonstrate any nexus between the Veteran's neck disability and his active service. Therefore, service connection for a neck disability is not warranted. In reaching the conclusion above the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claim for service connection for a neck disability, that doctrine is not applicable in the instant appeal. See 38 U.S.C.A. § 5107(b); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1990). ORDER Service connection for a bilateral knee disability is granted. Service connection for a neck disability is denied. ____________________________________________ P.M. DILORENZO Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs