Citation Nr: 1310034 Decision Date: 03/25/13 Archive Date: 04/02/13 DOCKET NO. 06-32 840 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Oakland, California THE ISSUE Entitlement to service connection for a right knee disorder. REPRESENTATION Appellant represented by: California Department of Veterans Affairs WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD J. H. Nilon, Counsel INTRODUCTION The Veteran served on active duty from March 1972 to August 1974. He subsequently served in the Reserve Component until retirement in January 1997. This matter comes before the Board of Veterans' Appeals (Board) on appeal of a January 2005 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Oakland, California that in relevant part denied service connection for a right knee disorder. In July 2009 the Veteran testified before a Veterans Law Judge in a hearing at the RO ("Travel Board" hearing); a transcript of his testimony is of record. Prior to final adjudication of the appeal the Veterans Law Judge who presided at that hearing left the Board. The Veteran was notified of his entitlement to a new hearing, and the subsequently testified before a different Veterans Law Judge in a Travel Board hearing in November 2011. A transcript of that hearing is also of record. Unfortunately, the Veterans Law Judge who presided at the November 2011 Travel Board hearing has also left the Board. The Veteran was notified in February 2013 that he is entitled to yet another hearing before a current Member of the Board, but he responded in writing that he does not wish to appear at another hearing and wants the Board to consider the appeal based on the evidence of record. In March 2012 the Board remanded the case to the Originating Agency for further development, which has been accomplished. Stegall v. West, 11 Vet. App. 268 (1998). The file has now been returned to the Board for further appellate review. FINDINGS OF FACT 1. The Veteran's right knee disorder, diagnosed as degenerative arthritis, was not incurred during active service and was not manifested to a compensable degree within the first year after discharge from active service. 2. The Veteran had an injury to the right knee during Inactive Duty for Training in November 1993; his already-existing right knee disorder was not caused by or worsened beyond the normal progression of the disability by such injury. CONCLUSION OF LAW A right knee disorder was not incurred in or aggravated by service, and incurrence in service of arthritis of the right knee may not be presumed. 38 U.S.C.A. §§ 1110, 1154(a), 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307. 3.309 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION Duties to Notify and Assist Before addressing the merits of the Veteran's claim on appeal, the Board is required to ensure that the VA's "duty to notify" and "duty to assist" obligations have been satisfied. See 38 U.S.C.A. §§ 5103, 5103A (West 2002); 38 C.F.R. § 3.159 (2012). The VA is required to assist a claimant in obtaining evidence necessary to substantiate a claim but is not required to provide assistance to a claimant if there is no reasonable possibility that such assistance would aid in substantiating the claim. The VA is required to notify a claimant and the claimant's representative, if any, of any information, and any medical or lay evidence, not previously provided to the Secretary that is necessary to substantiate the claim. As part of the notice, the VA is to specifically inform the claimant and the claimant's representative, if any, of which portion, if any, of the evidence is to be provided by the claimant and which part, if any, the VA will attempt to obtain on behalf of the claimant. In addition, the United States Court of Appeals for Veterans Claims (Court) has held that the plain language of 38 U.S.C.A. § 5103(a) requires that notice to a claimant be provided "at the time" of, or "immediately after," the VA's receipt of a complete or substantially complete application for VA-administered benefits. Pelegrini v. Principi, 18 Vet. App. 112, 119 (2004). VA must also notify the claimant that, should service connection be awarded, a disability rating and an effective date for the award of benefits will be assigned. Dingess v. Nicholson, 19 Vet. App. 473 (2006). In this case, notice fully compliant with the law, including the disability-rating and effective-date elements, was not provided to the Veteran prior to the January 2005 rating decision on appeal. However, he was subsequently sent fully compliant notice by a letter in May 2006, after which the Originating Agency readjudicated the claim in September 2006. See Mayfield v. Nicholson, 444 F.3d 1328, 1333-34 (Fed. Cir. 2006) (holding that VA may cure a timing defect through compliance via proper remedial measures, such as the issuance of compliant VCAA notice followed by readjudication of the claim). In any event, the Veteran has neither alleged nor demonstrated any prejudice with regard to the content or timing of the notice. See Shinseki v. Sanders, 129 S.Ct. 1696 (2009 (reversing prior cases law imposing a presumption of prejudice on any notice deficiency and clarifying that the burden of showing harmful or prejudicial error normally falls on the party attacking the agency's determination). See also Mayfield, 444 F.3d at 1333-34. The record also reflects that service treatment records (STRs), service personnel records and all available post-service medical evidence identified by the Veteran have been obtained. The Veteran has been afforded appropriate medical examinations in regard to the claims on appeal; as noted in the Introduction he testified before members of the Board who have retired and he does not wish another hearing. The Veteran has not made the RO or the Board aware of any additional evidence that needs to be obtained in order to fairly decide this appeal, and has not argued that any error or deficiency in the accomplishment of the duty to notify and duty to assist has prejudiced him in the adjudication of this appeal. See Shinseki v. Sanders, 129 S.Ct.1696 (2009) (reversing prior case law imposing a presumption of prejudice on any notice deficiency, and clarifying that the burden of showing that an error is harmful, or prejudicial, normally falls upon the party attacking the agency's determination). The record also reflects that service treatment records (STRs), service personnel records and all available post-service medical evidence identified by the Veteran have been obtained. As noted in the Introduction the Veteran has been afforded two hearing before the Board and has waived an additional hearing. The Board previously remanded the case in November 2009 for medical examination, which was performed in June 2010; the Board has carefully reviewed the examination report and finds the Originating Agency substantially complied with the Board's remand instructions. See D'Aries v. Peake, 22 Vet. App. 97 (2008); see also Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (holding that in the context of medical examinations/opinions only substantial compliance, not strict compliance, with the terms of the Board's opinion request is necessary). The Board remanded the case again in March 2012 for further development (specifically, to pursue any additional Reserve Component records not associated with the file), which has been accomplished as documented in a request by the Originating Agency through the Personnel Information Exchange System (PIES) in March 2012, with negative response received the same month. Stegall, 11 Vet. App. 268 Based on a review of the claims file, the Board finds that there is no indication in the record that any additional evidence relevant to the issue to be decided herein is available and not part of the claims file. See Mayfield, 499 F.3d 1317. Therefore, the Board finds that duties to notify and assist have been satisfied and will proceed to the merits of the issue on appeal Applicable Legal Principles Service connection criteria Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active duty. 38 U.S.C.A. § 1110 (West 2002); 38 C.F.R. § 3.303 (2012). Service connection may be granted for any disease initially diagnosed after service when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an 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. See Davidson v. Shinseki, 581 F.3d 1313 (Fed.Cir.2009); Hickson v. West, 12 Vet. App. 247, 253 (1999); Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F. 3d 604 (Fed. Cir. 1996) (table). Service connection may be presumptively granted for arthritis that becomes manifest within one year of discharge from service, even if not shown during service. 38 C.F.R. §§ 3.307, 3.309(a). Active Duty for Training is defined as full-time duty in the Armed Forces performed by Reserves for training purposes; see 38 U.S.C.A. § 101(22). Inactive Duty for Training is defined as other than full-time training performed by Reserves; see 38 U.S.C.A. § 101(23). Service connection may be granted for injury or disease incurred while on Active Duty for Training; service connection may be granted for injuries incurred during Inactive Duty for Training but not for disease; see 38 U.S.C.A. § 101(24). In the service connection context, the presumption of soundness upon entry into service and the presumptive service connection provisions of 38 C.F.R. § 3.307, applicable to active duty, do not apply to periods of Active Duty for Training or Inactive Duty for Training. See 38 U.S.C.A. §§ 1111, 1112, 1137; 38 C.F.R. § 3.307. Thus, service connection on a presumptive basis is not available where the service performed is Active Duty for Training or Inactive Duty for Training. See Biggins v. Derwinski, 1 Vet. App. 474, 476-78 (1991). Evidentiary criteria In making all determinations, the Board must fully consider the lay assertions of record. A layperson is competent to report on the onset and continuity of his current symptomatology. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a Veteran is competent to report on that of which he or she has personal knowledge). Lay evidence can also be competent and sufficient evidence of a diagnosis or to establish etiology if (1) the 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. Davidson, 581 F.3d 1313, 1316; Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). When considering whether lay evidence is competent the Board must determine, on a case-by-case basis, whether the Veteran's particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau, id. The Board is charged with the duty to assess the credibility and weight given to evidence. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997), cert. denied, 523 U.S. 1046 (1998); Wensch v. Principi, 15 Vet. App. 362, 367 (2001). Indeed, in Jefferson v. Principi, 271 F.3d 1072 (Fed. Cir. 2001), the United States Court of Appeals for the Federal Circuit (Federal Circuit), citing its decision in Madden, recognized that that Board had inherent fact-finding ability. Id. at 1076; see also 38 U.S.C.A. § 7104(a) (West 2002). Moreover, the United States Court of Appeals for Veterans Claims (Court) has declared that in adjudicating a claim, the Board has the responsibility to weigh and assess the evidence. Bryan v. West, 13 Vet. App. 482, 488-89 (2000); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992). As a finder of fact, when considering whether lay evidence is satisfactory, the Board may also properly consider internal inconsistency of the statements, facial plausibility, and consistency with other evidence submitted on behalf of the Veteran, and the Veteran's demeanor when testifying at a hearing. See Dalton v. Nicholson, 21 Vet. App. 23, 38 (2007); Caluza, 7 Vet. App. 498, 511. Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits under the laws administered by VA. VA shall consider all information and medical and lay evidence of record. Where there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Where, as here, service treatment records are not available, case law does not establish a higher benefit-of-the-doubt standard, but rather heightens the duty of the Board to consider the benefit-of-the-doubt rule, to assist the claimant in developing his claim, and to explain its decision. Ussery v. Brown, 8 Vet. App. 64 (1995). Evidence and Analysis The Veteran served on active duty from March 1972 to August 1974. Service treatment records (STRs) from that period show no indication of any complaints of knee pain or injury. A separation examination in August 1974 noted clinical impression of the lower extremities as "normal." STRs associated with the Veteran's Reserve Component service include a treatment note dated in November 1993 in which the Veteran complained of right knee pain. The Veteran reported having had a right knee injury 17 years before (i.e., in approximately 1976); his knee had been sore for the past several days but worse since a physical readiness test (PRT) run that day. Clinical examination showed a right varus deformity with swelling and good lateral stability. The clinical impression was right knee arthritis versus internal derangement. Reserve Component STRs show the Veteran was identified in October 1995 with a venous disorder of the right leg, for which he was placed on light duty restriction for thrombophlebitis. He was returned to full duty in February 1996. The profile and the treatment record are silent in regard to complaints regarding the knee. The Veteran had a private X-ray of the right knee in October 1995. The interpreter's impression was no evidence of abnormality of the tibia or fibula and probable multiple interarticular and Baker's cyst loose calcified bodies. Treatment records from Dr. Cecil Bullard show the Veteran was injured in a motor vehicle accident (MVA) in November 1999; the nature of his injuries was not specified. Treatment records from Dr. S.S. Shantharam dated in May 2004 show the Veteran reported having injured his knee while running approximately 25 years earlier (i.e., approximately 1979), with increasing pain since then. Recent X-rays were reviewed that showed severe degenerative arthritis. Dr. Shantharam's diagnostic impression was degenerative joint disease (DJD) of the right knee. In his claim for service connection, filed in May 2004, the Veteran stated his right knee problems dated from 1985. In a contemporaneous Statement in Support of Claim, the Veteran asserted he had injured his right knee while performing physical fitness training at the Naval Reserve Center. The Veteran had a VA-contracted compensation and pension (C&P) examination in June 2006 in which he reported onset of symptoms in November 1993 with the PRT cited above. The examiner noted the Veteran's subjective symptoms in detail; the examiner also performed a clinical examination and recorded a diagnosis of right knee DJD with varus. The examiner stated an observation that the Veteran had sustained an injury while on active duty [sic] with the Reserve Component and that it is at least as likely as not that the Veteran's current right knee disorder was caused by or the result of the right knee injury in November 1993. The Veteran's service representative submitted a Memorandum in September 2006 stating the Veteran had been queried about his drill status in November 1993, and had responded that he was on Active Duty for Training at the time of his cited knee injury. (In that regard, the file contains a document titled Annual Retirement Point Record and issued by the Naval Reserve Personnel Center; the document shows the Veteran performed no active duty or Active Duty for Training during the period between February 1993 and February 1994. However, the Veteran did accrue seven inactive drill points during that period so he demonstrably did perform some Inactive Duty for Training. Although a considerable amount of effort has been expended during the course of the appeal in clarifying the Veteran's drill status in November 1993, the Board essentially found in November 2009 that the Veteran was injured during Inactive Duty for Training, and since service connection may be granted for injuries incurred during Inactive Duty for Training any further discussion of the question of his drill status is rendered moot.) In his substantive appeal, dated in October 2006, the Veteran stated he had a right knee injury prior to entering the Reserve Component, but the pain of that injury was bearable until he re-injured the knee in November 1993. Private X-rays of the bilateral knees in March 2009 showed an impression of bilateral osteoarthritis, severe on the right and moderate on the left. Thereafter, the Veteran had private magnetic resonance imaging (MRI) of the right knee in April 2009 that confirmed severe osteoarthritis and also showed multiple loose bodies and an underlying chronic meniscal tear. Treatment records from Dr. Peter Simonian, an orthopedic surgeon, show the Veteran presented for evaluation in June 2009. The Veteran reported having injured his right knee in the late 1970s while running. The Veteran reported the pain had progressively worsened; notably, the Veteran did not cite the November 1993 incident on which he bases his current claim for service connection. Dr. Simonian's clinical assessment was severe knee arthritis with varus deformity. Also in June 2009 the Veteran was examined by Dr. Deniz Baysal, another orthopedic surgeon. The Veteran stated during interview that he was consulting Dr. Baysal in regard to a right knee condition that first began over 30 years previously (i.e., since 1979 or before) that began as a running-related injury. Once again the Veteran did not mention any re-injury in the Reserve Component. A history and physical (H&P) examination by Dr. Baysal states the Veteran reported knee pain "for many years" and that he had hurt his knee in the 1970s when he was running. Dr. Baysal recommended the Veteran undergo total knee replacement. The Veteran testified before the Board in July 2009 that he had a running-related injury in the late 1970s, with residual knee pain but no other problems. He treated the knee pain with ice and aspirin. Subsequently he re-injured the knee in November 1993 while taking a PRT; he reported the injury at the time. The re-injury caused increased knee pain, but until approximately 2004 the Veteran continued to manage the knee pain with ice and aspirin. In approximately 2004 the Veteran consulted an orthopedic surgeon, who recommended knee replacement surgery. The file contains operative report and post-operative treatment reports documenting a right total knee replacement (arthroplasty) performed by Dr. Baysal in July 2009. Admitting and discharge diagnosis was right knee DJD. The file contains a note by Dr. Bullard, dated in August 2009 and written on a prescription slip. The note states that the Veteran has osteoarthritis of the right knee that was aggravated due to running during physical training in November 1993. The file contains a letter dated in September 2009 from Dr. Baysal asserting that he had performed a right total knee replacement on the Veteran in July 2009. Dr. Baysal stated that according to the Veteran's H&P examination, the Veteran injured his knee while in the military; based on clinical findings this injury more than likely caused deterioration to the point where the Veteran developed severe arthritis and deformity of the right knee. The Veteran had a VA examination in June 2010, performed by a physician who reviewed the claims file; in that regard the examiner stated he had examined the Veteran's STRs as well as private medical records from various physicians. The Veteran reported to the examiner that his symptoms began in 1976 or 1977 while running for pleasure; the Veteran stated he consulted an orthopedic specialist at the time but could not remember the name of that specialist. The specialist told the Veteran at the time that his knee was normal, but the Veteran believed some residual problem persisted. In November 1992 [sic] the Veteran had an injury during a training run with the Reserve Component, but the injury did not cause a catastrophic knee collapse or cause the knee to give way. The VA examiner performed a clinical examination and noted observations in detail. The examiner diagnosed current status post total right knee arthroplasty, performed in July 2009 as secondary to advanced and severe degenerative arthritis. In regard to the etiology of the Veteran's right knee disorder, the examiner stated the record did not show that the Veteran's need for right knee surgery was caused by running or by events cited in the 1970s or mid-1990s. The Veteran had only begun to discuss his chronic knee problem with Dr. Bullard in 2009; while it was certainly possible that degenerative arthritis began during military service this could not be demonstrated due to the absence of X-rays or detailed examinations. Moreover, the Veteran's right knee condition may have been affected by events that occurred outside military service such as the MVA in October 1999; for these reasons the exact cause of the arthritis in the right knee was not known. The Veteran also had degenerative arthritis of the left knee, which suggested the Veteran has a degenerative disease related to age and other factors. Therefore, it appears the Veteran's arthritis is related to a natural progression, but it could not be stated with any certainty that it is related to active or Reserve Component service. The examiner stated it is important to understand there are no records showing chronicity of a right knee disorder during active service. Degenerative arthritis is a fairly common occurrence and worsened by obesity; the Veteran is overweight. The Veteran did not have a job with occupational conditions that alone would have been a likely explanation for development of arthritis. The examiner stated in summary, "It is least likely that the Veteran's chronic degenerative disease was caused by or worsened beyond the normal progression of the disease by reserve military service. I also suspect that the Veteran's right knee condition is similar although more severe than the left knee condition although this particular knee was not injured in the military service. This further underscores the possibility of underlying degenerative disease as influenced by age and activity apart from injury as common force to both knees." The examiner also noted that the Veteran had reported to his primary care physicians that he had onset of symptoms in the 1970s or 1990s that may or may not have occurred during active or inactive service, but neither of these events is supported by adequate records or radiographs. The file contains a treatment note by Dr. Bullard dated in November 2011 stating the Veteran had recently undergone a left knee replacement. Dr. Bullard stated the Veteran had a right knee injury in the military many years ago, and as a result of this right knee injury may have exacerbated the left knee to require a left total knee replacement earlier than anticipated. The Veteran might also require eventual right knee surgery in the future secondary to "the extensive damage that occurred in the military." The Veteran testified before the Board in November 2011 that his original right knee injury occurred in 1991during Reserve Component PFT. He reported the injury and was told not to perform physical training for six months. Thereafter he had pain that increased progressively, and he eventually had both knees replaced. Review of the file shows the Veteran has had a diagnosed right knee disorder during the course of the appeal, characterized as DJD prior to his knee replacement surgery in July 2009 and characterized thereafter as status post total right knee arthroplasty, secondary to advanced and severe degenerative arthritis. Accordingly, the first element of service connection - medical evidence of a claimed disability - is met. However, a veteran seeking disability benefits must establish not only the existence of a disability, but also an etiological connection between his military service and the disability. Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000); D'Amico v. West, 209 F.3d 1322, 1326 (Fed. Cir. 2000); Hibbard v. West, 13 Vet. App. 546, 548 (2000); Collaro v. West, 136 F.3d 1304, 1308 (Fed. Cir. 1998). The Board finds at the outset that the Veteran's STRs do not document a right knee disorder during active service (March 1972 to August 1974). The Veteran had a normal evaluation of the lower extremities at the time of his discharge in August 1974, and he has not asserted that his current knee disorder is related to injury prior to August 1974. As there is no indication that arthritis was manifested to any degree during the first year after active service (i.e., during the period August 1974 to August 1975), the Board finds that presumptive service connection under the provisions of 38 C.F.R. § 3.309(a) is not for consideration. Because the Veteran does not assert, and the evidence of record does not show, that the claimed right knee disorder was incurred in active service, resolution of the claim turns on whether his claimed disorder is due to an injury incurred during Inactive Duty for Training in November 1993. As noted above, presumptions of soundness and aggravation are not applicable in this situation. The Veteran testified before the Board in November 2011 that his original right knee injury occurred in 1991 [sic] during Reserve Component PFT, but this is flatly contradicted by the contemporaneous November 1993 treatment record, which shows he had knee problems prior to that injury, and is also inconsistent with his previous testimony before the Board in July 2009 and his statements to numerous medical examiners and providers. The Veteran's testimony in November 2011 that he had been placed on limited-duty profile due to his knee injury is contradicted by the service record, which shows he was actually placed on profile for thrombophlebitis. The record shows the Veteran had a right knee injury in the 1970s, after discharge from active service and before the re-injury in November 1993. The question accordingly is whether the Veteran's injury in November 1993 caused an increase, permanent in nature, of the existing right knee disorder. This is a medical question that cannot be answered by the Board based on its own unsubstantiated medical opinion, but rather on the basis of independent medical evidence or adequate quotation from recognized medical treatises. Colvin v. Derwinski, 1 Vet. App. 171 (1991). Where an opinion is used to link the current disability to a cause during service, a competent opinion of a medical professional is required. Caluza, 7 Vet. App. 498. The medical opinions in this case are conflicting. The VA examiner in June 2006 provided an opinion essentially supporting a relationship between the Veteran's Reserve Component service and his claimed right knee disorder, as did Dr. Bullard (statement in August 2009 and letter in November 2011) and Dr. Baysal (letter in September 2009). However, the VA examiner in June 2010 stated that the Veteran's claimed right knee disorder was not caused, or worsened beyond the normal progression of the disease, by his Reserve Component service. It is the Board's duty to assess the credibility and probative value of evidence, and, provided that it offers an adequate statement of reasons or bases, the Board may favor one medical opinion over another. Owens v. Brown, 7 Vet. App. 429, 433 (1995). As true with any piece of evidence, the credibility and weight to be assigned to these opinions are within the province of the Board as adjudicators. Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993). For the reasons cited below, the Board finds the opinion of the VA examiner in June 2010 to be the most probative opinion of record. In determining the probative value to be assigned to a medical opinion, the Board must consider three factors. The first inquiry is to assess whether a medical expert was fully informed of the pertinent factual premises (i.e., medical history) of the case. The second inquiry involves consideration of whether the medical expert provided a fully-articulated opinion. The third and final factor in determining the probative value of an opinion involves consideration of whether the opinion is supported by a reasoned analysis. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 303-304 (2008). The opinion of the VA examiner in June 2010 fully complies with the criteria articulated in Nieves-Rodriguez; the other opinions do not. The VA examiner in June 2010 reviewed all available medical evidence, including STRs (which documented the November 1993 incident as it happened), private treatment records and examination reports by private and VA examiners, and cited to those documents extensively; thus, the first element in Nieves-Rodriguez is satisfied. The VA examiner in June 2010 also provided a fully-articulated opinion which was supported by a reasoned analysis of several pages, which satisfies the second and third elements cited by Nieves-Rodriguez. Thus, the opinion meets all three criteria for probative value cited by Nieves-Rodriguez. The opinion by the VA examiner in June 2006 does not meet all the standards of Nieves-Rodriguez. The VA examiner in June 2006 reviewed the claims file and thus had access to all relevant medical evidence, which satisfies the first element of Nieves-Rodriguez, although unlike the examiner in June 2010 he did not cite any of those treatment records in his discussion; this is significant because he cited "an injury while on active duty in the United States Naval Reserve" but did not mention the previous injuries that were clearly of record in the claims file. The VA examiner in June 2006 provided a fully-articulated opinion that "it is at least as likely as not caused by or a result of his right knee injury that he sustained while in the United States Naval Reserves when he was performing the physical readiness test, in November 1993," which satisfies the second element of Nieves-Rodriguez. However, he did not provide a reasoned analysis, so the third element of Nieves-Rodriguez is not met. In that regard, in assessing evidence such as medical opinions, the failure of the physician to provide a basis for his opinion goes to the weight or credibility of the evidence in the adjudication of the merits. Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998). Turning to the statements by Dr. Bullard in August 2009 and November 2011, both statements are bare conclusions that provide no indication of an underlying clinical rationale or the evidence that was considered. Thus, while Dr. Bullard provided a fully-articulated opinion, neither the first element of probative value (fully informed of the pertinent factual premises) nor the third element of probative value (reasoned analysis) cited in Nieves-Rodriguez is met. Further, a bare conclusion, even one reached by a health care professional, is not probative without a factual predicate in the record. Miller v. West, 11 Vet. App. 345, 348 (1998). Finally, the September 2009 letter from Dr. Baysal expressed a fully-articulated opinion with underlying rationale ("According to his history and physical examination, he injured his knee while in the military. This injury based on the clinical findings more likely than not caused deterioration of his knee to the point where he developed severe arthritis and deformity in that right knee"). However, in the June 2009 H&P cited by Dr. Baysal, the Veteran reported he had injured his right knee over 30 years previously, without mentioning the November 1993 injury in the Reserve Component; Dr. Baysal evidently believed erroneously that the Veteran had been on active service at the time of the original injury in the 1970s. Thus, the opinion is based on an inaccurate factual premise and is not probative per the first element of Nieves-Rodriguez (whether the medical expert was fully informed of the pertinent factual premises). In sum, the Board has found the most probative medical opinion of record is that of the VA examiner in June 2010; this opinion states a reasoned conclusion that the Veteran's chronic degenerative disease was not likely caused by or worsened beyond the normal progression of the disease by reserve military service. VA must consider all favorable lay evidence of record. 38 USCA § 5107(b); Caluza v. Brown, 7 Vet. App. 498 (1995). Accordingly, in addition to the medical evidence cited above the Board has carefully considered the lay evidence offered by the Veteran in the form of his testimony before the Board on two occasions, his correspondence to VA and his statements to various medical providers and examiners. The Board must consider the purpose for which lay evidence is offered. Washington v. Nicholson, 19 Vet. App. 362 (2005). In this case, neither the diagnosis nor the etiology of the Veteran's current disorder is in dispute. The Veteran's lay evidence is offered for the purpose of showing that his right knee disorder, which existed prior to November 1993, was aggravated beyond the normal progress of the disorder by the later injury. A layperson is competent to testify in regard to the onset and continuity of symptomatology. Layno, 6 Vet. App. 465, 470. However, the question of whether an existing disorder was aggravated beyond its normal progress by a subsequent injury is a medical question, and this Veteran is not shown to have the competence to make such a determination. Kahana, 24 Vet. App. 428; Jandreau, 492 F.3d 1372. As the most probative medical opinion of record states the Veteran's claimed right knee disorder did not increase in severity as a result of injury during his Reserve Component service, the Board finds the criteria for service connection are not met and the claims must be denied. Because the preponderance of the evidence is against the claim the benefit-of-the-doubt rule does not apply. Gilbert, 1 Vet. App. 49, 54. ORDER Service connection for a right knee disorder is denied. ____________________________________________ MICHAEL E. KILCOYNE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs