Citation Nr: 1306999 Decision Date: 02/28/13 Archive Date: 03/01/13 DOCKET NO. 05-09 659 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Baltimore, Maryland THE ISSUES 1. Entitlement to service connection for a low back disability. 2. Entitlement to service connection for a bilateral knee disability. WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD J. L. Prichard, Counsel INTRODUCTION The Veteran had active service from November 1998 to November 2002. This matter comes before the Board of Veterans' Appeals (Board) on appeal of a July 2004 rating decision of the Baltimore, Maryland, regional office (RO) of the Department of Veterans Affairs (VA). The Veteran testified in support of these claims during a hearing held before a Decision Review Officer at the RO in July 2005. A transcript of the hearing is in the record. In April 2008, January 2011, and August 2012 the Board remanded these claims to the RO via the Appeals Management Center (AMC) in Washington, D.C. The issues of entitlement to service connection for migraines and entitlement to service connection for left ear hearing loss were also on appeal and remanded by the Board. However, in May 2012 the AMC granted service connection for migraines. The Board denied service connection for left ear hearing loss in August 2012. Therefore, these issues are no longer before the Board. The Board has reviewed the Veteran's electronic record (Virtual VA) prior to rendering a decision in this case. It does not contain any evidence not already in the claims folder or considered by the RO. FINDINGS OF FACT 1. The Veteran has current low back disability, diagnosed as lumbar strain with minimal degenerative joint disease; that is related to an in-service injury. 2. The Veteran's current bilateral knee strains are not related to a disease or injury in active service. CONCLUSIONS OF LAW 1. Lumbar strain was incurred due to active service. 38 U.S.C.A. §§ 1110, 5107(b) (West 2002); 38 C.F.R. § 3.303 (2012). 2. Bilateral knee disabilities were not incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 5107(b) (West 2002); 38 C.F.R. §§ 3.303, 3.304(b) (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VCAA The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations imposes obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2009); 38 C.F.R §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). Proper VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 U.S.C.A. § 5103(a) (West 2002); C.F.R. § 3.159(b)(1) (2012). Pelegrini v. Principi, 18 Vet. App. 112 (2004). In Pelegrini, the United States Court of Appeals for Veterans Claims (Court) held that VCAA notice, as required by 38 U.S.C.A. § 5103(a), must be provided to a claimant before the initial unfavorable adjudication by the RO. The Court has also held that the VCAA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those five elements include: 1) veteran status; 2) existence of a disability; 3) a connection between the veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). The Court held that upon receipt of an application for a service-connection claim, 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) require VA to review the information and the evidence presented with the claim and to provide the claimant with notice of what information and evidence not previously provided, if any, will assist in substantiating or is necessary to substantiate the elements of the claim as reasonably contemplated by the application. Additionally, this notice must inform a claimant that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Id. In a pre-adjudication letter dated in March 2004, the RO notified the Veteran of the evidence needed to substantiate his claim for service connection. This letter also satisfied the second and third elements of the duty to notify by delineating the evidence VA would assist him in obtaining and the evidence it was expected that he would provide. Quartuccio v. Principi, 16 Vet. App. 183, 186-87 (2002); Charles v. Principi, 16 Vet. App. 370 (2002). The Veteran has substantiated his status as a Veteran. He was also notified of all other elements of the Dingess notice, including the disability-rating and effective-date elements of his claim, in March 2006 and October 2008 letters. The Board recognizes that these notices were provided after the initial decision. However, the deficiency in the timing of these notices was remedied by readjudication of the issue on appeal in subsequent supplemental statements of the case. See Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). The Board concludes that the duty to notify has been met. The VCAA also requires VA to make reasonable efforts to help a claimant obtain evidence necessary to substantiate his claim. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c), (d). This "duty to assist" contemplates that VA will help a claimant obtain records relevant to his claim, whether or not the records are in Federal custody, and that VA will provide a medical examination or obtain an opinion when necessary to make a decision on the claim. 38 C.F.R. § 3.159(c)(4). The Veteran's service treatment records were reportedly lost during his participation in Operation Enduring Freedom in Afghanistan. The National Personnel Records Center (NPRC) was able to procure records from the Defense Personnel Records Image Retrieval System (DPRIRS), but they do not contain any findings referable to the claimed disabilities and contain essentially no medical records for the period after the Veteran's examination for entrance into service. Destruction of service treatment records does not create a heightened benefit of the doubt, but only a heightened duty on the part of VA to consider the applicability of the benefit of the doubt, to assist the claimant in developing the claim, and to explain its decision. Cromer v. Nicholson, 19 Vet App 215 (2005); Russo v. Brown, 9 Vet. App. 46, 51 (1996). Where service treatment records are missing, VA also has a duty to search alternate sources of service records. Washington v. Nicholson, 19 Vet. App. 362 (2005). Thus, in the April 2008 remand, the RO was directed to contact Camp Pendleton Naval Hospital, Camp Forester Naval Center in Okinawa, Japan, 22 Area Branch Medical Station, and 29 Palms California Base and request all available records of the Veteran's treatment. The record shows that the RO contacted these facilities and they all responded that they did not have any records for the Veteran. In an October 2010 Memorandum, the RO made a Formal Finding of Unavailability of these records and outlined its attempts to obtain these records. Thus, any further attempt to obtain these records would be futile. VA is obligated to continue requests for records in federal custody until the records are obtained, or it is reasonably certain that they do not exist or further requests would be futile. The Federal entities reported that they did not have any records; hence it is reasonably certain that further requests from those locations would be futile. No additional sources of the records have been suggested. As for other evidence, all post service VA treatment records identified by the Veteran have been obtained. The Veteran indentified two private treatment sources on a single VA Form 21-4142 Authorization and Consent to Release Information to the Department of Veterans Affairs (VA) in June 2012. He was requested to complete separate forms for each treatment source and provided with these forms in a VA letter dated August 2012. This letter also notified the Veteran that it was ultimately his responsibility to obtain all private records. The Veteran did not respond with either the VA Form 21-4142s or with the records, and the Board concludes that no further action is necessary. VA is only obligated to seek records for which necessary authorization is provided. 38 C.F.R. § 3.159(c)(1)(ii). The Veteran was provided with VA examinations, and opinions have been obtained regarding the etiology of his claimed disabilities. The Veteran had offered testimony at a hearing before a Decision Review Officer at the RO. There is no indication that there is any relevant evidence outstanding in these claims, the duty to assist has been completed, and the Board will proceed with consideration of the Veteran's appeal. In addition to efforts to obtain treatment records, the 2008 remand sought to afford the Veteran an adequate examination. The January 2011 examination was for efforts to obtain a post deployment assessment, and remedy deficiencies found in the examination reports. The records were obtained and the Veteran was afforded a new examination. The examination provided an opinion with rationales that took into account an accurate history, including the Veteran's reports. The August 2012, remand was for efforts to obtain treatment records from Drs. Avery and Middlebrooks; and VA treatment records. The Appeals Management Center (AMC) obtained available VA treatment records, and was informed that there were no additional records available from one of the identified facilities. The AMC asked the Veteran to complete an authorization to obtain records treatment from Dr. Avery and Middlebrooks or submit the evidence himself, but he did not respond. These actions substantially complied with the remand instructions. Cf. Steal v. West, 11 Vet App 268 (1998). Service Connection The Veteran contends that he developed chronic low back and bilateral knee disabilities as a result of injuries in active service. He states that low back pain began after doing pull-ups, and that his symptoms have continued on and off since that time. The Veteran also notes that he was a radioman in service and required to carry a 70 pound radio on his back. As for the knees, the Veteran notes that he was treated for bilateral shin splints in service, and that he developed bilateral knee pain as a result of the shin splints while he was still in service. He believes that his current symptoms are a continuation of the same condition for which he was treated in service. Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active military service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). Establishing service connection generally requires evidence of (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed.Cir.1996) (table); Hickson v. West, 12 Vet. App. 247, 253 (1999); 38 C.F.R. § 3.303. If a chronic disease, such as arthritis (or degenerative joint disease), becomes manifest to a degree of 10 percent within one year of separation from active service, then it is presumed to have been incurred during active service, even though there is no evidence of arthritis during service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C.A. §§ 1101, 1112, 1113 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.307, 3.309 (2012). If a chronic disease is identified in service or at any time thereafter, no matter how remote; service connection will be conceded. 38 C.F.R. § 3.303(b). Under 38 C.F.R. § 3.303(b), an alternative method of establishing the second and third Shedden/Caluza element with regard to a claim based on a chronic disease; is through a demonstration of continuity of symptomatology. Continuity of symptomatology may be established if a claimant can demonstrate (1) that a condition was "noted" during service; (2) evidence of post-service continuity of the same symptomatology; and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology. 38 C.F.R. § 3.303(b). With regard to the medical evidence, a diagnosis or opinion by a health care professional is not conclusive, and is not entitled to absolute deference. Indeed, the Court has provided guidance for weighing medical evidence. The Court has held, for example, that in meeting our responsibility to weigh the credibility and probative value of the evidence, we may accept one medical opinion and reject others. Schoolman v. West, 12 Vet. App. 307, 310-11 (1999); Evans v. West, 12 Vet. App. 22, 30 (1998), citing Owens v. Brown, 7 Vet. App. 429, 433 (1995). But, the Board is mindful that it cannot make its own independent medical determinations, and that it must have plausible reasons, based upon medical evidence in the record, for favoring one medical opinion over another. Evans v. West, supra; see also Rucker v. Brown, 10 Vet. App. 67, 74 (1997), citing Colvin v. Derwinski, 1 Vet. App. 171 (1991). Thus, the weight to be accorded the various items of evidence in this case must be determined by the quality of the evidence, and not necessarily by its quantity or source. In assessing medical opinions, the failure of the physician to provide a basis for the opinion goes to the weight or credibility of the evidence in the adjudication of the merits. See Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998). Other factors for assessing the probative value of a medical opinion are the physician's access to the claims file and the thoroughness and detail of the opinion. See Prejean v. West, 13 Vet. App. 444, 448-49 (2000). The probative value of a physician's statement is dependent, in part, upon the extent to which it reflects "clinical data or other rationale to support his opinion." Bloom v. West, 12 Vet. App. 185, 187 (1999), and a medical opinion is inadequate when it is unsupported by clinical evidence. Black v. Brown, 5 Vet. App. 177, 180 (1995). A lay witness is competent to testify as to the occurrence of an in-service injury or incident where such issue is factual in nature. Grottveit v. Brown, 5 Vet. App. 91, 93 (1993). In some cases, lay evidence will also be competent and credible on the issues of diagnosis and etiology. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). Specifically, lay evidence may be competent and sufficient to establish a diagnosis where (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d at 1377; see also Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009. A layperson is competent to identify a medical condition where the condition may be diagnosed by its unique and readily identifiable features. Barr v. Nicholson, 21 Vet. App. 303, 307 (2007). Additionally, where symptoms are capable of lay observation, a lay witness is competent to testify to a lack of symptoms prior to service, continuity of symptoms after in-service injury or disease, and receipt of medical treatment for such symptoms. Layno v. Brown, 6 Vet. App. 465, 469-71 (1994); Charles v. Principi, 16 Vet. App 370, 374 (2002). Once evidence is determined to be competent, the Board must determine whether such evidence is also credible. See Layno, supra (distinguishing between competency ("a legal concept determining whether testimony may be heard and considered") and credibility ("a factual determination going to the probative value of the evidence to be made after the evidence has been admitted"). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. Presumptive periods are not intended to limit service connection to diseases so diagnosed when the evidence warrants direct service connection. The presumptive provisions of the statute and VA regulations implementing them are intended as liberalizations applicable when the evidence would not warrant service connection without their aid. 38 C.F.R. § 3.303(d). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the VA shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107(b). Low Back As noted, many of the Veteran's service treatment records are missing. His spine was found to be normal on the February 1998 enlistment examination. Physical therapy records from November 2000 show that the Veteran had experienced low back pain for 18 months that was aggravated primarily with running and field work. A physical examination was grossly normal. The Veteran was seen at the chiropractic clinic in January 2001 with an 18 month history of low back pain that was not improving. A motor vehicle accident two weeks earlier had lead to a worsening of the symptoms. On examination, the objectives did not equal the subjectives. There was a full range of motion with no muscle hypertonicity or nerve root irritation. The assessment was cervical/thoracic/lumbar strain/sprain. An X-ray study was normal. Service treatment records dated in May 2001 report that the Veteran had a year and a half history of low back pain, with initial occurrence while doing pull-ups. He denied any significant history. The Veteran had been through chiropractic treatment, physical therapy, light duty and anti-inflammatory medications without significant improvement. A January 2001 motor vehicle accident had temporarily increased his back symptoms but they subsequently resolved to baseline. The Veteran currently noted localized low back pain which was constant and throbbing, without radiation into the lower extremities. On examination, the Veteran had full range of motion of the lumbar spine, and straight leg raising was 80 degrees bilaterally with low back pain only. A June 2001 record shows the Veteran continued to report localized back pain. The impression was lumbar pain syndrome. The Veteran completed a post deployment health assessment in May 2002. He reported that his health was good. The Veteran denied that any physical problems had developed during his deployment. He did not report any health concerns, and there were no referrals indicated, including no orthopedic referral. Post service medical records show that the Veteran was seen at a VA facility in April 2005. He gave a history of being a radio operator in service which required him to wear a 70 pound pack. He reported subsequent back pain. At the July 2005 hearing, the Veteran testified that he had been diagnosed as having mechanical low back pain during service. He said that he continued to receive treatment for back pain throughout service, but he was told that the pain would eventually resolve after service. However, his back pain continued to persist after discharge, and when it finally became clear that it would not resolve he decided to submit his claim for service connection. The Veteran testified that he had continued to experience low back pain ever since his discharge from service. A VA treatment record dated in November 2005 shows that the Veteran reported chronic pain. He again reported chronic low back pain and the use of pain medication as needed in February 2006. A January 2010 X-ray study showed mild degenerative changes in the bilateral L5-S1 facet joints. The alignment, disc spaces and vertebral body heights were maintained. The impression was bilateral facet disease at L5 to S1. The Veteran was provided a VA examination of his low back in August 2010. He reported a history of developing back pain while doing pull-ups in service. The Veteran believed his pain continued to be a chronic issue with flare-ups precipitated by moderate levels of physical activity. He was also involved in a motor vehicle accident in March 2010 and sustained further injury to his back. The Veteran said that he experienced flare-ups every two to three weeks. These were precipitated by prolonged exertion and would last for hours. At the conclusion, the examiner stated that the physical examination was limited because of the recent motor vehicle accident in which his back was reinjured. The current limitations to his range of motion and the pain he exhibited with range of motion were due to the accident. The Veteran underwent a VA examination of his low back in March 2011. The examiner reviewed the Veteran's medical records. The Veteran again recalled initially developing back pain doing pull-ups, and said he had continued to experience pain since that then. He reported sleeping on the floor during service to decrease his pain. The Veteran used various pain medications as needed. Currently the pain came and went but would flare up with increased physical activity. He had been involved in a car accident in 2010 which caused his pain to flare significantly. He received spinal injections and the pain had now returned to baseline. The flare-ups occurred about twice a week and lasted for a few hours. After a complete physical examination the diagnosis was lumbar strain and mild L5 to S1 degenerative joint disease. The examiner summarized that there were service treatment records that documented that the Veteran's back pain began shortly after doing pull-ups in service, but X-rays done shortly after this time were negative. The pain was stabilized but re-aggravated by a 2001 motor vehicle accident. His symptoms again restablized until after the automobile accident in 2010 after which the Veteran was disabled for six months. The examiner concluded that "Although he did have lumbar strain in the service it seems that its persistence is secondary to post-service injuries." The examiner added that the Veteran did not note any complaints on his May 2002 discharge examination. Analysis The March 2011 VA examiner diagnosed the Veteran as having lumbar strain and noted X-ray evidence of mild degenerative changes. This satisfies the requirement for evidence of a current disability. The available service treatment records confirm the Veteran's reports that he developed back pain after doing pull-ups early in service and that this pain persisted for at least a year and a half. This fulfills the requirement for evidence of an inservice injury or illness. The final requirement for service connection is evidence of a relationship between the Veteran's current disability and the injury for which he was treated in service. While the May 2002 post deployment health assessment did not include any back complaints, the Board notes that this was not an examination but a questionnaire completed by the Veteran. It did not specifically ask the Veteran whether or not he had back complaints. The Veteran testified that he continued to experience back pain on and off throughout service and after discharge from service. He is competent to report his back pain and the Board also finds his testimony and statements to be credible. Post service VA treatment records show that the Veteran continued to report ongoing back pain in 2005 and 2006. A January 2010 X-ray study revealed mild degenerative changes. The Board notes that these records are all dated prior to the March 2010 motor vehicle accident that subsequent VA examiners have said is the reason for the Veteran's current disability. The August 2010 examiner opined that the Veteran's current complaints were due to the March 2010 accident, but acknowledged that the current examination was limited due to the proximity of that accident. The March 2011 VA examiner found that the Veteran had by then returned to the baseline symptoms of before the accident, and said of the Veteran that "Although he did have lumbar strain in the service it seems that it's persistence is secondary to post-service injuries." The use of the word "persistence" seems to acknowledge the Veteran's lumbar strain began during service and had persisted since; albeit aggravated by post-service injuries. As the evidence suggests that the Veteran has had consistent low back symptomatology from his initial injury in 1999 to the present, service connection for lumbar strain is warranted. Bilateral Knees The Veteran's February 1998 entrance examination found that his lower extremities were normal. He answered "no" to a history of having a trick or locked knee on the Report of Medical History that was obtained at that time, and also answered "no" to all other questions that could relate to the knees. The Veteran completed a post deployment health assessment in May 2002. He reported that his health was good. The Veteran denied that any physical problems had developed during his deployment. He did not report any health concerns, and there were no referrals indicated, including no orthopedic referral. Post service medical records show that the Veteran was seen at a VA facility in April 2005. He gave a history of being a radio operator in service which required him to wear a 70 pound pack. He reported subsequent knee pain. May 2005 VA treatment records state that the Veteran was seen in order to establish primary care. He had a past medical history of bilateral knee pain. The Veteran testified in July 2005 that he was told in the service that he had shin splints, and that it was the pain from the shin splints that was making his knees hurt. He did not initially seek treatment for his knees after discharge because he was told they would eventually get better. After his symptoms remained the same for a year and a half after discharge he decided to file his claim. See Transcript. VA treatment records from October 2005 state that the Veteran had been in a dance class when he tried to execute a turn but his left knee did not turn with him. He was unable to bear weight and had immediate pain and swelling. The assessment was a likely severe strain but tear of the ligaments was possible. November 2005 VA treatment records show that the Veteran reported chronic knee pain and occasional swelling after activity. VA treatment records include the report of a November 2005 magnetic resonance imaging (MRI) study of the left knee. The findings were consistent with transient patella dislocation with an associated medial retinacula sprain. There was also fluid collection that could indicate a partial muscle tear and joint effusion. Other November 2005 VA treatment records make reference to a right knee injury and state that he was now able to walk without crutches. A February 2006 follow up examination notes the Veteran's injury in a dance class. The assessment was a left knee strain that resolved with time. There was full strength and range of motion without any residual deficits. A January 2010 X-ray study of the left knee noted a linear density in the medial aspect of the lateral compartment of the femorotibial joint, which could be a residual of a prior trauma such as a lateral meniscus calcification. A January 2010 X-ray study of the right leg was unremarkable. At the VA orthopedic examination in August 2010, the Veteran reported having developed shin splints during physical training in service, which continued to get worse. He then developed pain in his left knee within six months to a year and was told that this was due to the shin splints. The Veteran reported knee pain since that time, and the October 2005 injury was noted. He was also reported to have been in a March 2010 motor vehicle accident. At the conclusion of the examination, the diagnoses were status post left knee sprain with transcient patella dislocation in October 2005, and status post left knee strain due to motor vehicle accident in March 2010. The examiner added that the Veteran's present knee symptoms were due to the March 2010 accident. The Veteran was afforded another VA examination in March 2011. The claims folder was reviewed by the examiner. The Veteran reported that he experienced shin splints during service, which was followed by left knee pain. He was treated with pain medication that resulted in improvement, but eventually the right knee began to hurt as well. Overall his pain was reduced but he continued to have symptoms when running and his symptoms persisted until he left service in 2002. Post service, the Veteran would feel knee pain with working out and increased use. He had experienced post service accidents to his left knee in the dance class in October 2005 and a car accident the previous year that had re-aggravated bilateral knee pain. The Veteran said his current pain was "not too bad," but he had not run since the most recent accident. After a physical examination of both knees, the diagnosis was bilateral knee strain with mild right patellar subluxation and moderate left patellar subluxation. The March 2011 examiner opined that in terms of the Veteran's bilateral leg disability, which was actually his bilateral periodic knee pain, it was unlikely to be service related. The Veteran had a good response to anti-inflammatory medications while in service for his shin splints and knee strain. Shin splints were not known to cause knee pain although both injuries could be secondary to overuse. By the Veteran's own account he was able to resume his normal activities after service and even take a dance class, and it was not until performing a maneuver in that class that he experienced a left patellar dislocation which caused six months of increased left knee pain. Afterwards the Veteran was able to return to the gym and his pain resolved until a 2010 motor vehicle accident. The Veteran did seem to have bilateral patellar laxity, left greater than right, which could predispose him to chronic knee strain. This condition was typically found in teenagers and young adults. The examiner suspected that it existed prior to service but there was no documentation to support this. Analysis The March 2011 examiner suggested that the Veteran's bilateral patellar laxity existed prior to service. By statute and regulation, the Veteran is considered to have been in sound condition when examined, accepted and enrolled for service, except as to defects, infirmities, or disorders noted at entrance into service, or where clear and unmistakable evidence demonstrates that an injury or disease existed prior thereto. Only such conditions as are recorded in examination reports are to be considered as noted. 38 U.S.C.A. § 1111; 38 C.F.R. § 3.304(b). In this case, the Veteran's entrance examination showed that his lower extremities were normal. The March 2011 examiner admitted that there was no documentation to support his suspicion. Therefore, there is no clear and unmistakable evidence that a bilateral knee condition existed prior to service, and the Veteran is entitled to the presumption of soundness. The March 2011 examiner diagnosed bilateral knee strain. This meets the evidentiary requirement of a current disability. However, the evidence does not demonstrate that the Veteran had a knee disability during service, or that there is a relationship between his current disability and the complaints he reported in service. The Veteran testified that he was told he had shin splints in service, and that the pain from his shin splints radiated into his knees. The Veteran is competent to describe his symptoms and report what he was told, and his testimony is credible. However, the Board notes that he has not reported having a knee disability in service but only pain due to shin splints. There is no post service evidence of shin splints of either leg. The March 2011 examiner provided the opinion based on medical knowledge that shin splints did not lead to knee disabilities. The initial post service medical records dated April and May 2005 note knee pain by history only. As noted by the March 2011 examiner, the Veteran apparently felt that his knees were well enough to take a dance class in the fall of 2005. He also returned to the gym after his October 2005 injury resolved. While the Board notes the Veteran's testimony regarding knee pain since service, his credibility in this regard is impeached by his actions. This evidence weighs against a finding of continuity of symptomatology between the pain the Veteran reportedly experienced in service and his current symptoms. It is not until the Veteran sustained a dance injury in October 2005 that a post service left knee strain was noted. Furthermore, the Veteran's medical professional stated that this injury was completely resolved in February 2006. He sustained a second injury in March 2010, which resulted in bilateral knee strain. The examiner opined that the current bilateral knee strain was unlikely to be related to service. There is no other competent medical opinion that contradicts this examiner. The Veteran is not competent to say that shin splints would lead to the development of knee strain. See Jandreau, Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). In the absence of evidence of a chronic disease, continuity of symptomatology of a bilateral knee disability since discharge from service, or competent evidence that relates the current knee disabilities to active service, the preponderance of the evidence is against the Veteran's claim for service connection for a bilateral knee disability. ORDER Entitlement to service connection for a low back disability is granted. Entitlement to service connection for a bilateral knee disability is denied. ____________________________________________ Mark D. Hindin Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs