Citation Nr: 1309863 Decision Date: 03/22/13 Archive Date: 04/01/13 DOCKET NO. 03-20 537 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in North Little Rock, Arkansas THE ISSUES 1. Entitlement to service connection for a back disability (low back disability), secondary to service-connected right foot disability. 2. Entitlement to service connection for a bilateral hip disability, secondary to service-connected right foot disability. 3. Entitlement to service connection for a right knee disability, to include as secondary to service-connected right foot disability. 4. Entitlement to service connection for a left knee disability, secondary to service-connected right foot disability. 5. Entitlement to service connection for a right leg disability, secondary to service-connected right foot disability. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL The Veteran and his spouse ATTORNEY FOR THE BOARD Andrew Mack, Counsel INTRODUCTION The Veteran had active service from May 1967 to April 1969. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a January 2002 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in North Little Rock, Arkansas. In April 2005, the Veteran was afforded a videoconference hearing before John J. Crowley, who is the Veterans Law Judge (VLJ) rendering the determinations on these claims and was designated by the Chairman of the Board to conduct that hearing, pursuant to 38 U.S.C.A. § 7102(b) (West 2002). In June 2005 and May 2007, the Board remanded the claims for additional development. In a May 2008 decision, the Board denied the Veteran's appeal as to the issues listed on the title page. The Veteran appealed to the U.S. Court of Appeals for Veterans Claims (Court). In February 2010, the Court granted a joint motion of the Veteran and the Secretary of Veterans' Affairs (the Parties), vacated the May 2008 decision, and remanded the matters to the Board for compliance with the instructions in the joint motion. In February 2011, the Board again remanded these matters a third time to the RO via the Appeals Management Center (AMC) in Washington, D.C. to afford the Veteran another VA examination. The action specified in the February 2011 Remand was completed, and the matter was properly returned to the Board for appellate consideration. See Stegall v. West, 11 Vet. App. 268 (1998). In August 2012, the Board again remanded the matters, a fourth time, and they have been returned for further appellate consideration. The Board has not only reviewed the Veteran's physical claims file but also the Veteran's file on the "Virtual VA" system to ensure a total review of the evidence. FINDINGS OF FACT 1. The Veteran does not have a back disability, a hip disability, a knee disability, or a right leg disability that was caused or has been aggravated by his service-connected right foot disability. 2. Clear and unmistakable evidence demonstrates that a previous right knee injury existed before acceptance and enrollment into service and was not aggravated by such service, and no right knee disability is otherwise related to the Veteran's service. CONCLUSIONS OF LAW 1. The criteria for service connection for a back disability, secondary to service-connected right foot disability, have not been met. 38 U.S.C.A. §§ 1110, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.310 (2012). 2. The criteria for service connection for bilateral hip disability, secondary to service-connected right foot disability, have not been met. 38 U.S.C.A. §§ 1110, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.310 (2012). 3. The criteria for service connection for a right knee disability, to include as secondary to service-connected right foot disability, have not been met. 38 U.S.C.A. §§ 1110, 1111, 1132, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.310 (2012). 4. The criteria for service connection for a left knee disability, secondary to service-connected right foot disability, have not been met. 38 U.S.C.A. §§ 1110, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.310 (2012). 5. The criteria for service connection for a left leg disability, secondary to service-connected right foot disability, have not been met. 38 U.S.C.A. §§ 1110, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.310 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran asserts that service connection is warranted for a low back disability, a hip disability, a knee disability, and a right leg disability, with all disabilities claimed as caused or aggravated by his service-connected right foot disability. Also, the record reflects that the Veteran may have had a right knee disability that existed prior to his period of service, may have been aggravated by such service, and might, therefore, be directly related to such service. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). Service connection requires competent evidence showing: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see also Caluza v. Brown, 7 Vet. App. 498 (1995). For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity and sufficient observation to establish chronicity at the time. Service connection may also be granted for any disease diagnosed after discharge when all of the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). In addition, for certain chronic diseases, such as arthritis, a presumption of service connection arises if the disease is manifested to a degree of 10 percent within a prescribed period following discharge from service; the presumptive period for arthritis is one year. 38 C.F.R. §§ 3.307, 3.309(a). When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support a claim for such diseases. 38 C.F.R. §§ 3.303(b); see Walker v. Shinseki, ___ F.3d ___, No. 2011-7184, 2013 WL 628429 (Fed. Cir. Feb. 21, 2013). A veteran who served after December 31, 1946, is presumed to be in sound condition when he or she entered into military service, except for conditions noted on the entrance examination, or where clear and unmistakable evidence demonstrates that the injury or disease existed before acceptance and enrollment and was not aggravated by such service. 38 U.S.C.A. §§ 1111, 1132. Service connection may also be established on a secondary basis for a disability that is shown to be proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) caused by or (b) aggravated by a service-connected disability. Id.; Allen v. Brown, 7 Vet. App. 439 (1995) (en banc) (additional disability resulting from aggravation of a nonservice-connected disorder by a service-connected disorder is also compensable under 38 C.F.R. § 3.310). With disability compensation claims, VA adjudicators are directed to assess both medical and lay evidence. As a general matter, a layperson is not capable of opining on matters requiring medical knowledge. See 38 C.F.R. § 3.159(a)(2); see also Routen v. Brown, 10 Vet. App. 183, 186 (1997). In certain circumstances, however, lay evidence may be sufficient to establish a medical diagnosis or nexus. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). In addressing lay evidence and determining its probative value, if any, attention is directed to both 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"). See Layno v. Brown, 6 Vet. App. 465, 469 (1994). In terms of competency, lay evidence has been found to be competent with regard to a disease with "unique and readily identifiable features" that is "capable of lay observation." See Barr v. Nicholson, 21 Vet. App. 303, 308-09 (2007) (concerning varicose veins); see also Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007) (a dislocated shoulder); Charles v. Principi, 16 Vet. App. 370, 374 (2002) (tinnitus); Falzone v. Brown, 8 Vet. App. 398, 405 (1995) (flatfoot). That notwithstanding, a Veteran is not competent to provide evidence as to more complex medical questions and, specifically, is not competent to provide an opinion as to etiology in such cases. See Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (concerning rheumatic fever); see also Routen, 10 Vet. App. 183. In weighing credibility, VA may consider interest, bias, inconsistent statements, bad character, internal inconsistency, facial plausibility, self-interest, consistency with other evidence of record, malingering, desire for monetary gain, and demeanor of the witness. See generally Caluza v. Brown, 7 Vet. App. 498 (1995). The Board may weigh the absence of contemporaneous medical evidence against the lay evidence in determining credibility, but the Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence. See Buchanan v. Nicholson, 451 F.3d 1331, 1335 (Fed. Cir. 2006); but see Maxson v. Gober, 230 F.3d 1330 (Fed. Cir. 2000) (evidence of a prolonged period without medical complaint after service can be considered along with other factors in the analysis of a service connection claim). In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C.A. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination, the benefit of the doubt is afforded the claimant. Secondary Service Connection Service connection is currently in effect for bony exostosis, right foot, with arthrodesis, first tarsal-metatarsal joint with traumatic arthritis and tenderness, rated 20 percent disabling. The pertinent post-service medical evidence consists of VA and non-VA reports, dated between 1982 and 2012. This evidence shows that the Veteran has been treated for a number of joint pains and right leg pain. A VA X-ray report, dated in 1986, shows that the Veteran was noted to have had degenerative joint disease of the lumbar spine. Subsequently dated VA and private reports indicate that the Veteran has had intraarticular changes in the hips. A November 1987 report from a private physician, R.J., M.D., indicates that the Veteran had arthritis in his right leg. Reports from another private physician, R.L.W., M.D., dated between 1982 and 1998, contain notations of mild arthritis of the left hip, and "complaints of back and leg pain from arthritis." Private X-rays and of the spine beginning in September 1993 revealed degenerative disc changes at L2-3 and L5-S1, and private X-rays and treatment notes beginning in March 1996 indicate severe degenerative joint disease of the L5-S1 area of the spine. VA X-ray reports for the knees, dated in October 2006, indicate a normal left knee and an osteochondroma on the postero-lateral side of the right tibia. A July 2007 VA X-ray report for the knees reflects an impression of "negative knees bilaterally." VA X-ray reports for the hips, also dated in July 2007, reflect degenerative arthritis with joint space narrowing and osteophytic change of the right hip, and left hip within normal limits. The claims file includes a decision of the Social Security Administration (SSA), dated in June 1994, which shows that the SSA determined that the Veteran was disabled as of November 1992. The report notes that the Veteran testified that he had the previous work experience of a farm laborer, which he described as "unskilled manual labor that required him to perform routine heavy lifting and repetitive bending, stooping, pushing, and pulling." He complained of "arthritic pain" in his back, neck, shoulders, hips, and legs, and stated that he was no longer able to lift anything and that it was painful for him to bend. His primary diagnosis was noted to be chronic obstructive pulmonary disease, and there were notations of a secondary diagnosis of "arthritis" (not otherwise specified). In a VA examination report, dated in December 1996, the examiner stated, "I do not believe that the involvement of the right foot, in any way, accounts for this patient's degenerative changes, along the axial skeleton, or the major joints (shoulders - leg - spine)." The examiner stated that the Veteran's claims file had been reviewed, providing evidence against the claims. A VA spine examination report, dated in January 2002, indicates that the examiner stated that he had previously examined the Veteran in September 2001 (actually, September 2000) (only the right foot was examined at that time), and that, "This patient continues to experience the effects of a generalized osteoarthritic process. In my opinion based on these two examinations, there is no etiological relationship specifically between the generalized osteoarthritic process and the condition of the right foot." The examiner stated that the Veteran's claims file had been reviewed, providing more evidence against his claims. A VA joints examination report, dated in October 2006 (completed by examiner J.S.K.), notes DJD (degenerative joint disease) of the bilateral knees and hips, and that the Veteran had been able to farm until his retirement. The examiner stated that it "is less likely than not (less than 50/50 probability)" that the Veteran's right foot disability was the cause of his DJD, providing yet more evidence against these claims. The examiner noted that the Veteran had been able to farm for many years. The examiner also stated that the Veteran's claims file had been reviewed. A VA spine examination report, dated in October 2006, also completed by J.S.K., shows that on examination, there was no muscle spasm, localized tenderness, or guarding severe enough to be responsible for an abnormal gait or abnormal spinal contour. The report indicates that scoliosis was present. The examiner stated, "I think it is as least as not, not likely" that his DJD was able to spread all over his body, and that the Veteran's DJD was due to the aging process, providing yet more evidence against this claim. He noted that the Veteran's right foot disorder symptoms permitted him to farm until his retirement. In an addendum, dated in July 2007, J.S.K. stated that the Veteran's DJD was not caused by or a result of his right foot injury. He noted that the Veteran had been able to farm until about 1990, and that his DJD and myalgias were most likely due to age, weight, and genetics, providing more a rational to an opinion that providers more negative evidence against the Veteran's central claims. In another addendum, dated in December 2007, J.S.K. stated that the Veteran's "minor right foot injury" had not caused a severe low back, right leg, bilateral knee, or hip condition. He noted that the Veteran was 66 years old, and that he had minimal arthritis in his lumbar spine, hips and knees. He further concluded that the Veteran's arthritis in these joints had not been aggravated by his right foot condition, and that the amount of arthritis found was consistent with his age. The examiner stated that the Veteran's VA reports from October 2006 and July 2007 had been reviewed. The report of a March 2011 VA examination by another VA examiner, N.S., reflects that September and October 2010 hip X-rays revealed that the left hip joint compartment was within normal limits and articular surfaces were normal, but that on the right side the joint space was absent, and there was some bone on bone contact, and that multiple degenerated lumbar discs were seen. The impressions were increased arthritis in the right hip more than left, and degenerated right hip joint. On examination of the spine, the Veteran had right leg dysthesia in the L4-S1 and L4-5 distributions. October 2010 X-rays were noted to have revealed rightward convex lumbar scoliosis with extensive degenerative spondylosis and degenerative discs seen with degenerative changes slightly worse than four years prior. The examiner diagnosed lumbar degenerative disc disease with sciatica and greater trochanter bursitis of the right hip. The examiner noted review of the claims file, that the Veteran had had corrective surgery on the right foot in service for a childhood injury, and that he had corrective shoes with inserts that made his foot discomfort better. The examiner further opined that the Veteran's current low back, hips, knees and right leg conditions were less likely than not caused by or a result of, or permanently aggravated by, his service connected-right foot condition, providing more evidence against this claim. The examiner explained that the Veteran had age-related DJD and DDD (degenerative disc disease) of the lumbar spine, hip, and knee, and that he had worked in heavy labor work for most of his life after service and retired as a farmer. This explanation gives the medical opinion more probative weight as it not only indicates that the disabilities at issue are not related to service, but actually provides the cause of the problem (age). The report of a May 2012 VA examination by J.S.K. reflects the opinion that the Veteran's "claimed condition" was at least as likely as not caused by the claimed in-service injury, and explained that the Veteran had an altered gait and traumatic degenerative joint disease, right greater than left, in the hips and knees. It also reflects that the Veteran reported injuring his right knee at age eight while riding a bike, and that he had had progressive bilateral knee pain. It was noted that the Veteran had a 5-centimeter scar on the right knee and a right lateral knee mass of 2 centimeters, and that a right tibial mass was palpated. In a June 2012 addendum opinion, J.S.K. stated that after reviewing the Veteran's claims file it was found that the Veteran had a right knee injury at age eight while riding his bike, and that he did have an altered gait. The examiner stated that at age 71 the Veteran had had evidence of pretibial soft tissue swelling consistent with residuals of previous trauma, with no significant arthritic changes noted. The Veteran's hip X-rays revealed mild hip arthritis on the left and severe hip arthritis on the right. The examiner stated that, with history of previous knee injury prior to service, the examiner did not believe that the Veteran's current hip and knee complaints were due to his service-connected foot condition. He did not believe that the right knee or hip had been aggravated by service due to the right foot disability, and stated that he believed it had been aggravated by its normal progression, age, and the Veteran's current weight, providing more evidence against this claim. The report of a September 2012 examination, again by J.S.K., reflects that the Veteran's claims file was reviewed. It was noted that the Veteran incurred a right knee injury at age eight while riding a bike, and had had progressive bilateral knee pain. After examining the Veteran, as above, the examiner opined that the Veteran's claimed conditions were less likely than not incurred in service or caused by any claimed in-service injury, event or illness. The examiner explained that the Veteran had age-related DJD and DDD of the lumbar spine, hip and knee, and had performed heavy labor work for most of his life after service and retired as a farmer. The examiner further explained that there was no sign of injuries to the right knee in service. Together, these VA etiological opinions weigh very heavily against the Veteran's claims for secondary service connection. These opinions were based on a review of the Veteran's claims file and, collectively, discuss the Veteran's relevant history and current relevant findings, attribute the Veteran's arthritis to factors other than his service-connected right foot disability, and rule out the possibility of aggravation. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000) (factors for assessing the probative value of a medical opinion include the thoroughness and detail of the opinion). Specifically, these opinions relate the Veteran's back disability, bilateral hip disability, bilateral knee disability, and right leg disability to such factors as age, genetics, weight, natural progression of the diseases, and the fact that the Veteran had performed heavy labor work for most of his life after service and retired as a farmer. This rationale is consistent with the record and, specifically, is supported by the June 1994 SSA report, which reflects that the Veteran testified that he had the previous work experience of a farm laborer, which he described as "unskilled manual labor that required him to perform routine heavy lifting and repetitive bending, stooping, pushing, and pulling." This adds probative weight to the VA medical opinions. Moreover, as reflected in the March 2011 opinion by N.S. and the June 2012 addendum opinion by J.S.K., such opinions have taken into consideration the following: the Veteran's progressively worsening disabilities, including rightward convex lumbar scoliosis with extensive degenerative spondylosis and degenerative discs seen with degenerative changes slightly worse than four years prior, revealed in October 2010 X-rays; the Veteran's right foot disability and resulting functional impairment, including the fact that the Veteran had corrective surgery on the right foot in service for a childhood injury, and that he had corrective shoes with inserts that made his foot discomfort better; the Veteran's altered gait; and the fact that the Veteran has had more severe arthritis in the right hip than in the left. However, for the reasons described above, these examiners nonetheless concluded that it was unlikely that the Veteran's service-connected right foot disability caused or aggravated any back, hip, knee, or right leg disability. This also adds probative weight to these opinions. The Board notes that in the May 2012 VA examination report, J.S.K. stated that the Veteran's "claimed condition" was at least as likely as not caused by the claimed in-service injury, as the Veteran had an altered gait and traumatic degenerative joint disease right greater than left in the hips and knees. However, in an addendum to that examination given just one month later, J.S.K., while acknowledging that the Veteran did have an altered gait, and that hip X-rays revealed mild hip arthritis on the left and severe hip arthritis on the right, nonetheless opined that the Veteran's current hip and knee problems were not due to or had been aggravated by his service-connected foot condition, but rather had been aggravated by their normal progression, and the Veteran's age and weight. Moreover, the other October 2006, June 2007, and December 2007 reports by J.S.K. also reflect the opinions that the Veteran's claimed disabilities were not caused or aggravated by his service-connected right foot disability. This appears to have been a typographical error. In any event, the correct opinion clearly provides yet more evidence against these claims. Also, in reaching these decisions, the Board has considered three statements from R.L.W., M.D. In a notation scrawled on a page of an old statement of the case, dated in March 1997, (which was, in turn, attached to a VA Form 9 [substantive appeal]), he stated that the Veteran's "lumbar spine and right leg arthritis may be related to an abnormal gait caused by his right foot injury." In a letter dated in July 2003, he stated, "He has suffered a right foot injury, which causes an abnormal gait and may be the cause of his hip and back problems." In a letter, dated in February 2006, Dr. R.L.W. stated that he has been treating the Veteran since 1989, that he had reviewed "his record from his military service and the VA," and that the Veteran's right foot injury had caused an abnormal gait, "and it is likely that this is the cause of his hip and back problems." The Board finds that these opinions of Dr. R.L.W. are insufficient to warrant a grant of any of the claims, are of limited probative value, and are overwhelmed by the extensive highly probative evidence against these claims. Initially, these statements do not specifically address the claims for knee disabilities. In addition, VA has not adopted a "treating physician rule," which would give preference to this type of evidence. See White v. Principi, 243 F.3d 1378 (Fed. Cir. 2001). Furthermore, although these statements indicate a review of relevant records, they do not discuss why such factors as age, weight, genetics, and the effect of the Veteran's prior work history had been ruled out. See Elkins v. Brown, 5 Vet. App. 474, 478 (1993) (medical opinions as to a nexus may decline in probative value where the physician fails to discuss relevant medical history). This is particularly relevant, given the June 1994 SSA report reflecting the Veteran's testimony that his previous work experience was as a farm laborer with routine heavy lifting and repetitive bending, stooping, pushing, and pulling, and given that Dr. R.L.W. specifically opined that the Veteran's right foot disability caused (as opposed to merely aggravated) his claimed disabilities. Thus, these opinions lack sufficient probative value to warrant a grant of any of the claims and are outweighed by the medical evidence cited above that provides more probative evidence against these claims. Evidence in support of the Veteran's claims also includes a March 2000 private treatment note reflecting that, during a nurse practitioner visit, the Veteran reported a history of arthritis pain which bothered him, and that his right foot pain altered his gait so that he now had pain in the knees, hips, and back. The assessment was DJD of multiple joints, exacerbated by antalgic gait from old right foot injury. However, the assessment of the nurse practitioner appears to have been primarily based on the Veteran's own subjective remarks, rather than on objective findings. See LeShore v. Brown, 8 Vet. App. 406, 409 (1995) (a bare transcription of a lay history is not transformed into "competent medical evidence" merely because the transcriber happens to be a medical professional). Furthermore, the assessment does not provide a rationale or explanation, and does not discuss any other factors such as age, weight, genetics, or the Veteran's work history. Thus, the Board finds the assessment to be of diminished probative value in this case, outweighed by the extensive evidence cited above against these claims. Also, the Board notes that a VA examination report dated in September 2000 reflects the opinion of the examiner that the Veteran's right foot pain accounted for pain during weight bearing, arrestive phase, and rollover phase of the gait. The examiner stated that these findings would account for inability to participate in rapid walking or activates requiring impact such as running or jumping, and that he had a functional loss and limitation due to pain in the right foot. This note reflects that the Veteran's service-connected foot disability has caused functional impairment related to waking, standing, and other uses of the feet; in this regard, the Board again notes that the Veteran's service-connected right foot disability is currently rated 20 percent disabling. However, the note does not suggest that any back, bilateral hip, bilateral knee, or right leg disability is caused or aggravated by such functional impairment caused by the Veteran's right foot disability. In light of the above, the Board finds that, in combination, the VA opinions weighing against the Veteran's claims, including those of J.S.K. and N.S., are more probative than those weighing in favor of them. Simply stated, the Board finds that the post-service record, as a whole, provides probative evidence against the Veteran's claims that outweighs all evidence that supports them, including the Veteran's own statements to the VA. Regarding the Veteran's own contentions, including his April 2005 hearing testimony that his joint pain was the result of the way that he walked due to his service-connected right foot disability, lay testimony is competent to establish the presence of observable symptomatology and "may provide sufficient support for a claim of service connection." Layno, 6 Vet. App. at 469. Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau, 492 F.3d 1372. However, while the Veteran might believe that a low back disability, a hip disability, a knee disability, and a right leg disability, are medically related to a service-connected right foot condition, the question of causation in this case extends beyond a cause-and-effect relationship immediately observable to a layperson, and is one that requires medical expertise to answer. As such, the Veteran is not competent to address etiology in the present case. His opinion regarding these types of issues is of limited probative value. In light of the above, the Board finds that the evidence of record, as a whole, weighs very heavily against the Veteran's claims of service connection on a secondary basis for a low back disability, bilateral hip disability, bilateral knee disability, and right leg disability. Direct Service Connection for a Right Knee Disability Service treatment records reflect that on the Veteran's January 1967 examination of entry into service, no right knee problems or previous right knee injuries were noted, and the Veteran reported no right knee problems or prior medical history related to the knee. In March 1968, when receiving treatment for his right foot, a past medical history of a laceration of the right knee, which had been sutured, in 1959, was noted. Service treatment records contain no further findings or reports related to any right knee problems. At the time of his March 1969 examination for separation from service, the Veteran was noted to have had two and three-inch right knee scars, well-healed, but no other right knee problems were noted; the Veteran reported no current or past knee problems at that time. The earliest indication of any possible right knee problems after service is an August 1985 treatment record reflecting that the Veteran complained of pain in the right leg, but had no known injury. In November 1987, the Veteran's private physician stated in a letter that the Veteran had "arthritis in his right foot and leg." In March 2000, the Veteran reported having bilateral knee pain. The report of a May 2012 VA examination by J.S.K. reflects that the Veteran had degenerative joint disease in the right knee. It also reflects that the Veteran reported injuring his right knee at age eight while riding a bike, and that he had had progressive bilateral knee pain. It was noted that the Veteran had a 5-centimeter scar on the right knee and a right lateral knee mass of 2 centimeters, and that a right tibial mass was palpated. In a June 2012 addendum opinion, J.S.K. stated that after reviewing the Veteran's claims file it was found that the Veteran had a right knee injury at age eight while riding his bike, and that he did have an altered gait. The examiner stated that at age 71 the Veteran had had evidence of pretibial soft tissue swelling consistent with residuals of previous trauma, with no significant arthritic changes noted. The report of a September 2012 examination, again by J.S.K., reflects the opinion that the Veteran's claims file was reviewed. It was noted that the Veteran incurred a right knee injury at age eight while riding a bike, and had had progressive bilateral knee pain. After examining the Veteran, the examiner opined that the Veteran's claimed conditions were less likely than not incurred in or caused by any claimed in-service injury, event or illness, and that his right knee condition clearly and unmistakably existed prior to service and clearly and unmistakably was not aggravated beyond its natural progression by in-service injury, event or illness. The examiner explained that the Veteran had age-related DJD in the knee, and had performed heavy labor work for most of his life after service and retired as a farmer. The examiner further explained that there was no sign of injuries to the right knee in service. Considering the pertinent evidence in light of the governing legal authority, service connection for a right knee disability must be denied on direct basis. No right knee disability was noted on the Veteran's entrance examination in January 1967, and the Veteran is therefore presumed to have been in sound condition when he entered into military service. However, while two right knee scars were noted at the time of his separation examination, and a current right knee disability has been documented, the Board finds that clear and unmistakable evidence demonstrates that a previous right knee injury existed before acceptance and enrollment and was not aggravated by such service, and that no right knee disability is otherwise related to the Veteran's service. First, the Veteran's right knee injury, noted in service, clearly and unmistakably preexisted service. While right knee scars were noted on March 1969 separation examination, no contemporaneous knee laceration, injury or problem was reported in service. While undocumented injuries may sometimes occur during service, service treatment records reflect that in March 1968, when receiving treatment for his right foot, a past medical history of a laceration of the right knee in 1959, which had been sutured, was noted. Furthermore, in May 2012, the Veteran reported injuring his right knee at age eight while riding a bike. Thus, the Board finds that clear and unmistakable evidence demonstrates that a previous right knee injury existed before acceptance and enrollment into service, based on two highly credible forms of evidence. Second, the Veteran's preexisting right knee injury clearly and unmistakably was not aggravated during service. Again, other than the history reported in March 1968, service treatment records reflect no findings or reports related to any right knee injury or problems, despite extensive orthopedic treatment records, primarily related to the right foot. Such a fact only provider evidence against this claim. The earliest indication of any possible right knee problems after service is the August 1985 treatment record reflecting right leg pain, but no known injury. Furthermore, the only medical opinion of record on the issue is the that of the September 2012 VA examiner that the Veteran's right knee condition clearly and unmistakably existed prior to service and clearly and unmistakably was not aggravated beyond its natural progression by in-service injury, event or illness, as there was no sign of injuries to the right knee in service. The examiner's opinion was based on a review of the record and examination of the Veteran, and the basis of the opinion is persuasive and consistent with the evidence of record. Moreover, significantly, the Veteran has never asserted or contended that a right knee disability was aggravated during his period of service or is otherwise directly related to his period of service. Thus, the Board finds that there is clear and unmistakable evidence that a previous right knee injury existed before service and was not aggravated by such service, and that there is no other basis for the award of service connection on a direct basis for a right knee disability, and the Veteran has not contended otherwise. Accordingly, service connection for a right knee disability on a direct basis must be denied. Thus, the Board finds that the preponderance of the evidence is against each of the Veteran's claims for secondary service connection, and against any claim for service connection for a right knee disability on a direct basis. Accordingly, the Board finds that the claim for service connection for a low back disability, bilateral hip disability, bilateral knee disability, and right leg disability must be denied. In reaching these conclusions, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against each claim, that doctrine is not applicable. See 38 U.S.C.A. § 5107(b); Gilbert, 1 Vet. App. at 53-56. Duties to Notify and Assist Under applicable criteria, VA has certain notice and assistance obligations to claimants. See 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). Notice must be provided to a claimant before the initial unfavorable agency of original jurisdiction (AOJ) decision on a claim for VA benefits and 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 the claimant is expected to provide. Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004) (Pelegrini II). With respect to service connection claims, a section 5103(a) notice should also advise a claimant of the criteria for establishing a disability rating and effective date of award. Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 486 (2006). In the present case, required notice was provided by letter dated in June 2007, which informed the Veteran of all the elements required by Pelegrini II and Dingess/Hartman. While the June 2007 notice letter was provided subsequent to the initial RO determination in January 2002, after issuance of the letter and opportunity for the Veteran to respond, a January 2013 supplemental statement of the case (SSOC) reflects the most recent readjudication of the claims. Hence, the Veteran is not shown to be prejudiced by the timing of this notice. See Mayfield v. Nicholson, 20 Vet. App. 537, 543 (2006); see also Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006) (the issuance of a fully compliant VCAA notification followed by readjudication of the claim, such as in an SSOC, is sufficient to cure a timing defect). As to VA's duty to assist, the Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). The Veteran's service treatment records, VA medical treatment records, SSA records, and identified private treatment records have been obtained. Also, the Veteran was provided VA examinations and/or opinions in December 1996, January 2002, October 2006, July 2007, December 2007, May 2011, May 2012, June 2012, and September 2012. The medical opinions in this case, collectively, notwithstanding any evidence in support of these claims, provider particularly highly probative negative evidence against all claims, to the point that any perceived or argued weakness in any one examination does not limit the overall highly probative value of these medical opinions as a whole. As noted by the JMR itself, the VA must make "reasonable" efforts to assist claimant's. In this case, over the last 10 years, it is difficult to argue that the "reasonableness" standard has not been met, and surpassed, in this case. These examinations and opinions were adequate because, along with the other evidence of record, they provided sufficient information to decide the appeal and a sound basis for a decision on the Veteran's claims. The examination reports were based on examination of the Veteran by examiners with appropriate expertise, and the opinions were based on review of the claims file. 38 C.F.R. § 3.159(c)(4) (2012); Barr v Nicholson, 21 Vet. App. 303 (2007). The Board finds no cogent reason to obtain what would appear to be a tenth medical report/examination in this case. Moreover, the RO has substantially complied with the Board's remand instructions. The Veteran was provided a VA examination in September 2012 that contained an opinion as to whether there was clear and unmistakable evidence that the Veteran had a right knee disability that preexisted service and, if so, whether there was clear and unmistakable evidence that this preexisting disability was not permanently aggravated by service. As noted by the Veteran's representative in a February 2013 Appellant's Brief, the September 2012 VA examiner did not provide an opinion as to whether the Veteran's service-connected right foot condition had caused or permanently worsened any of the identified disorders of his low back, hips, knees, and/or right leg. However, as discussed above, the record already contained several VA examinations and opinions addressing these matters, including several previously provided by the September 2012 examiner, J.S.K., and therefore the absence of such an opinion in the September 2012 examination report is not prejudicial to the Veteran. Again, the Board finds no cogent basis to obtain a tenth medical report in what would be a fifth remand of a case that has been ongoing for years. Under these circumstances, the Board finds that there has been substantial compliance with its remand instructions, and an additional remand to comply with the Board's directives is not required. See D'Aries v. Peake, 22 Vet. App. 97, 104-106 (2008); Stegall v. West, 11 Vet. App. 268 (1998). Also, in compliance with the joint motion of the Parties, granted by the Court in February 2010, the Veteran has been provided several examinations to determine what current disabilities were present and whether any such disabilities had been caused or aggravated by the Veteran's service-connected right foot disability, and no opinion contained in any such report is based on the Veteran's arthritis being symmetrical; rather, such reports acknowledged that his arthritis was not symmetrical. Therefore, VA has satisfied its duties to notify and assist, and additional development efforts would serve no useful purpose. See Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991); Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). Because VA's duties to notify and assist have been met, there is no prejudice to the Veteran in adjudicating this appeal. ORDER Service connection for a low back disability, secondary to service-connected right foot disability, is denied. Service connection for a bilateral hip disability, secondary to service-connected right foot disability, is denied. Service connection for a right knee disability, to include as secondary to service-connected right foot disability, is denied. Service connection for a left knee disability, secondary to service-connected right foot disability, is denied. Service connection for a right leg disability, secondary to service-connected right foot disability, is denied. ____________________________________________ JOHN J. CROWLEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs