Citation Nr: 1311801 Decision Date: 04/09/13 Archive Date: 04/19/13 DOCKET NO. 06-03 571A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Cleveland, Ohio THE ISSUES 1. Entitlement to service connection for a low back disorder (claimed as a tailbone disorder). 2. Entitlement to service connection for a right knee disorder. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD G. Jivens-McRae, Counsel INTRODUCTION The Veteran served on active duty from March 1978 to May 1983. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an April 2005 rating decision of the Cleveland, Ohio, Department of Veterans Affairs (VA) Regional Office (RO), which determined that the evidence of record was not new and material to reopen the claims. The Board remanded the claims in December 2009 for further development. In April 2011, the Board reopened the claims for service connection for a low back disorder and right knee disorder, and then remanded the claims for further development. The Board remanded the claims again in September 2012. FINDINGS OF FACT 1. The competent and credible evidence fails to establish that the Veteran's low back disorder (tailbone disorder), to include degenerative changes, had its onset in service, within one year of service discharge, or is otherwise related to his active service. 2. The competent and credible evidence fails to establish that the Veteran's right knee disorder had its onset in service or is otherwise related to his active service. CONCLUSIONS OF LAW 1. A low back disorder (tailbone disorder) was not incurred in or aggravated by active service, nor may degenerative changes (arthritis) be presumed to have been so incurred. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131, 5103, 5103A, 5107(b) (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309 (2012). 2. A right knee disorder was not incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107(b) (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duty to Assist and Notify Before addressing the merits of the claim, the Board notes that VA has a duty to notify and a duty to assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5103 , 5103A (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 3.326(a) (2012). The notice requirements of the VCAA apply to all five elements of a service-connection claim, including: (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. See Dingess/Hartman v. Nicholson, 19 Vet.App. 473 (2006). Further, this notice must include information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Id. at 486. Neither the Veteran nor his representative has alleged prejudice with respect to notice, as is required. See Shinseki v. Sanders, 129 S. Ct. 1696 (2009); Goodwin v. Peake, 22 Vet.App. 128 (2008); Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet.App. 112 (2007). None is found by the Board. Indeed, the VCAA duty to notify was satisfied by way of letters sent in February 2005, April 2010, and June 2010. The letters fully addressed all notice elements. They informed him of what evidence was required to substantiate the claims and of his and VA's respective duties for obtaining evidence. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). With those letters, the RO effectively satisfied the notice requirements with respect to the issues of new and material evidence, and later after the reopening of the claims, service connection, on appeal. Under these circumstances, the Board finds that adequate notice was provided to the Veteran prior to the transfer and certification of his case to the Board. See Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); 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 an statement of the case or supplemental statement of the case, is sufficient to cure a timing defect). VA also has a duty to assist a veteran in the development of the claims. This duty includes assisting him or her in the procurement of service treatment records, private treatment records, and other pertinent VA treatment records, and providing an examination when necessary. 38 U.S.C.A. § 5103A (West 2002); 38 C.F.R. § 3.159 (2010). The RO associated the Veteran's service treatment records, private treatment record, and VA treatment records with the claims file. No outstanding evidence has been identified. The Veteran was also afforded VA examinations in connection with the claims. The Board finds the April 2011 VA examination and addendum to the April 2011 VA examination dated in December 2012 related to his low back and right knee claims were obtained and associated with the claims. The VA examination reports were thorough and adequate upon which to base a decision. The VA examiners personally interviewed and examined the Veteran, including eliciting a history from the Veteran, and provided the information necessary to decide the claims. Discussion of the Veteran's August 2005 RO hearing is necessary as well. The individual presiding over a hearing must comply with the duties set forth in 38 C.F.R. § 3.103(c)(2). Bryant v. Shinseki, 23 Vet. App. 488 (2010). These duties consist of (1) fully explaining the issues and (2) suggesting the submission of evidence that may have been overlooked. They were met here. The Veteran was questioned with regard to the onset of his low back and right knee disorders and how they related to his active service. The Board concludes that all the available records and medical evidence have been obtained in order to make an adequate determination as to these claims. Hence, no further notice or assistance is required to fulfill VA's duty to assist in the development of the claims. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd, 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet.App. 183 (2002). Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1110; 38 C.F.R. § 3.303. Service connection may be established for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes the disease was incurred in service. 38 C.F.R. § 3.303(d). Generally, the evidence must show: (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, 1166-67 (Fed. Cir. 2004) (citing Hansen v. Principi, 16 Vet.App. 110, 111 (2002); Caluza v. Brown, 7 Vet.App. 498, 505 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996) (table)). Service connection may be established under the provisions of 38 C.F.R. § 3.303(b) when the evidence, regardless of its date, shows that a veteran had a chronic condition in service or during the applicable presumptive period. In addition, certain chronic diseases, including degenerative changes, such as arthritis, may be presumed to have been incurred or aggravated during service if they become disabling to a compensable degree within one year of separation from active duty. 38 U.S.C.A. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309. In this case, the low back disorder at issue is a "chronic disease" listed under 38 C.F.R. § 3.309(a); therefore, 38 C.F.R. § 3.303(b) applies. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Where the evidence shows a "chronic disease" in service or "continuity of symptoms" after service, the disease shall be presumed to have been incurred in service. 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. With chronic disease as such in service, subsequent manifestations of the same chronic disease at any later date, however remote, are service-connected, unless clearly attributable to intercurrent causes. If a condition noted during service is not shown to be chronic, then generally, a showing of "continuity of symptoms" after service is required for service connection. 38 C.F.R. § 3.303(b). However, the right knee disorder, diagnosed as a right knee strain is not a chronic disease " listed under 38 C.F.R. § 3.309(a); therefore, 38 C.F.R. § 3.303(b) does not apply in this regard. Additionally, where a veteran served ninety days or more of active service, and certain chronic diseases, such as degenerative arthritis, become manifest to a degree of 10 percent or more within one year after the date of separation from such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309(a). While the disease need not be diagnosed within the presumption period, it must be shown, by acceptable lay or medical evidence, that there were characteristic manifestations of the disease to the required degree during that time. Id. In each case where a veteran is seeking service connection for any disability, due consideration shall be given to the places, types, and circumstances of such veteran's service as shown by such veteran's service record, the official history of each organization in which such veteran served, such veteran's treatment records, and all pertinent medical and lay evidence. 38 U.S.C.A. § 1154(a). The United States Court of Appeals for the Federal Circuit (Federal Circuit) has rejected the view that competent medical evidence is required when the determinative issue in a claim for benefits involves either medical etiology or a medical diagnosis. Under 38 U.S.C.A. § 1154(a), 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. Davidson v. Shinseki, 581 F.3d. 1313 (Fed. Cir. 2009); see also Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331, 1335 (Fed. Cir. 2006). The ultimate credibility or weight to be accorded evidence must be determined as a question of fact. The Board determines whether (1) the weight of the evidence supports the claim, or (2) the weight of the "positive" evidence in favor of the claim is in relative balance with the weight of the "negative" evidence against the claim: the appellant prevails in either event. When, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding service origin, the degree of disability, or any other point, such doubt will be resolved in favor of the claimant. By reasonable doubt is meant one which exists because of an approximate balance of positive and negative evidence which does not satisfactorily prove or disprove the claim. 38 C.F.R. § 3.102. The Veteran asserts that service connection is warranted for a low back disorder and a right knee disorder based on service incurrence. He maintains that he fell backward onto a desk and hurt his tailbone/lumbar spine in service. He complains of pain in that area to this date. He stated that he had right knee pan in service and since that time. Service treatment records show that the Veteran complained of low back pain due to an injury in November 1978. He was sent for lumbar spine series. The x-ray was negative. He was referred to physical therapy. One day later, it was noted that he had increased pain in the right knee. The assessment was that it had not improved and he needed knee strengthening. It was noted that he would begin functional knee rehabilitation. In October 1982, the Veteran underwent an examination for extension of his duty. Clinical evaluation of his lower extremities and his musculoskeletal spine proved normal. He was found qualified for retention. After service, the Veteran underwent a VA examination in August 1993. He gave a history of a chair rolling back and landing on his rear end while in service. X-rays taken at that time showed no fractures were detected. Three weeks prior to the VA examination, he sustained a work-related injury of the lumbar area. He was seen in the emergency room and treated with Motrin and muscle relaxants. Subjective complaints in the tailbone region showed sitting and walking aggravated the pain in the region of the tailbone. He was able to squat fully. Objective complaints showed on examination of the lumbosacral spine, there was tenderness elicited at the tip of the coccygeal area and tenderness was elicited in the region of the sacrum. Range of movements were essentially normal. There was paravertebral spasm of the upper lumbar area. The diagnoses were residual, injury of the tailbone and lumbosacral strain (work related injury). In May 1995, a letter was received by VA from A.C.A., MD. Dr. A.C.A. indicated that while working for Spiral Bonding Company of Ohio, the Veteran was involved in a work related injury in August 1993. He state while disputing with another employee, he was pulled by the shirt. As he tried to release himself, he backed into some pallets, injuring his middle back. In April 1998, an Occupational Injury Report was made on the Veteran's behalf. It was noted that the Veteran was lifting 100 pound bags of sugar with another employee, and he started feeling pain in his back and neck when attempting to put the sugar over on a pallet. VA outpatient treatment records from August 1995 through March 2005 were associated with the claims folder. These records show that he was seen periodically for low back pain and physical therapy. In February 2005, it was noted he had patellofemoral syndrome which started 10 years prior to that date when he fell backwards on a table and then fell forward to the floor. He received physical therapy for his low back and his right knee. The Veteran testified at a DRO hearing in August 2005. He stated that he was taking 800 mg Motrin for pain in his back and his right knee. He stated that he first sought treatment for these conditions after service in 1995. In April 2011, the Veteran underwent a VA examination. He complained of right knee strain which he twisted in service in the 1970's. He was treated with physical therapy. Over the years, he continued to have knee pain. He had x-rays performed which proved normal, and did not show any arthritis. He complained that he still had medial compartment tenderness and soreness in that knee, but no swelling or giving way. No surgery had been performed and he used no assistive devices. He could do his normal job, his normal daily activity, and there was only slight pain on extremes of motion. The final diagnosis s was right knee strain. According to the examiner, having reviewed the record and examination, due to the length of time and lack of nexus, any relationship of current symptoms to service would have to be considered speculative. The Veteran was also seen for back pain. He stated that he had a fall in service, in the 1970's, hitting his back on something. Over the years, he has had back pain. He now had some arthritis documented in his cervical, dorsal, and lumbar spine, a natural age progression. He complained of soreness, ache, and tenderness across the lumbar spine. He was noted to use no assistive device and he was able to do a normal job. The final diagnosis was lumbar disc disease. According to the examiner, having reviewed the examination, based on the fact that he had arthritic conditions over his spine already, this was not likely related to one incident in service but rather to natural age progression. Pursuant to the Board's September 2012 remand, an addendum to the April 2011 VA examination was provided in December 2012. The examiner stated that it was less likely that the Veteran's right knee complaints were related to complaints in service as his right knee x-rays were still normal and were more likely due to natural age progression. As for the low back complaints, the examiner stated that the claims file review showed other injuries after service to his back with arthritis, and it was less likely that his back condition was related to the complaints in service and were too, due to the natural age progression. As to the Veteran's low back disorder claim, there were complaints of low back pain in service, but x-ray findings connected with those complaints were negative. Less than 6 months prior to service discharge, the Veteran underwent an examination for retention in service, and his musculoskeletal spine was clinically normal at the time. There was no evidence of back complaints within one year of service discharge. These findings indicate that any low back complaints made in service in 1978 were acute and transitory and resolved without residual disability. Not until 1993, 10 years after service discharge, is there evidence of further low back complaints. Although the Veteran raised the issue of injury in service in 1978, there was a 1993 work-related injury and other intervening low back injuries in 1995 and 1998. Even with these intervening injuries sustained in the workplace and many years after service, the December 2012 VA addendum stated in addition to the injuries after service, it still was less likely that his back disorder was related to the complaints in service but to natural age progression. There is, however, evidence of present DJD of the lumbar spine, and therefore, the first element of Shedden has been established. The Board has also considered the Veteran's statements concerning the onset of his low back disorder. Specifically, he testified that he was taking 800 Motrin for his back and his aunt submitted an August 2005 statement on behalf of his claim that indicated, in pertinent part, that the Veteran came to see her in June 1983 to July 1983. At that time, he was taking Motrin for back and knee complaints that he told her he injured in the service. Accordingly, Shedden element (2) is satisfied. A finding of a nexus between the Veteran's current low back disorder (DJD of the lumbar spine) and service is still needed to satisfy Shedden element (3). In this case, there is no indication that his low back pain in service resulted in any DJD of the lumbar spine or any other lumbar spine disability. The Veteran's service treatment records do not indicate any abnormalities with respect to the Veteran's lumbar spine six months prior to separation on his retention examination. The record is devoid of any competent medical evidence which even hints of a low back disorder in service. Moreover, there is medical evidence of at least two intervening work-related injuries after service. The lack of disability or injury in service does not in itself preclude a grant of service connection. Indeed, 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. See 38 C.F.R. § 3.303(d). Nevertheless, a review of the post-service evidence does not support the conclusion that any current low back disorder is causally related to active service sufficient to establish service connection. The post-service evidence does not reflect complaints or treatment for the Veteran's low back prior to the 1990's,when the Veteran gave medical history of low back pain in connection with a work-related injury. This was at a minimum 10 or more years following the Veteran's separation from active duty service. Indeed, the objective evidence does not reflect continuity of symptomatology. In addition to the absence of documented post-service symptomatology related to his low back disorder for at least a decade, the evidence includes the Veteran's statements asserting continuity of symptoms with respect to his low back disorder since active duty service. The Board acknowledges that lay evidence concerning continuity of symptoms after service, if credible, is ultimately competent, regardless of the lack of contemporaneous medical evidence. Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). The Board must analyze the credibility and probative value of the evidence, account for the evidence that it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. See Caluza v. Brown, 7 Vet.App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir.1996) (table); Gabrielson v. Brown, 7 Vet.App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency of evidence differs from weight and credibility. The former is a legal concept determining whether testimony may be heard and considered by the trier of fact, while the latter is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet.App. 67, 74 (1997); Layno v. Brown, 6 Vet.App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet.App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). There is no dispute that the Veteran is competent to report symptoms of low back pain/disorder because this requires only personal knowledge as it comes to him through his senses. Layno v. Brown, 6 Vet.App. 465, 470 (1994). When a condition may be diagnosed by its unique and readily identifiable features, the presence of the disorder is not a determination "medical in nature" and is capable of lay observation. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 at n.4 (Fed. Cir. 2007) ("Sometimes the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer."). In such cases, the Board is within its province to weigh that testimony and to make a credibility determination. Here, the Board finds that the Veteran's reported history of continued low back disorder since active service, while competent, is nonetheless not credible. First, as noted, the Veteran denied spine complaints within six months of service discharge. Thereafter, he indicated in 1993 that he had an intervening work-related injury to his back and he again injured his back in 1998 at work. He then testified that he had low back complaints since service, but he did not report them or seek treatment until 1995 which was 12 years after service discharge. These statements weigh against the Veteran's credibility as it would have been in his best interest to report problems with a low back disorder since service, if such had been the case. Curry v. Brown, 7 Vet. App. 59, 68 (1994) (contemporaneous evidence has greater probative value than history as reported by the claimant); Rucker v. Brown, 10 Vet. App. 67, 73 (1997) (statements made to physicians for purposes of diagnosis and treatment are exceptionally trustworthy because the declarant has a strong motive to tell the truth in order to receive proper care). His assertions of service onset were not made until after his claim was initially denied. Caluza v. Brown, 7 Vet. App. 498, 511 (1995) (noting that the credibility of a witness may be impeached by a showing of interest, bias, inconsistent statements, consistency with other evidence), aff'd, 78 F.3d 604 (Fed. Cir. 1996). Finally, and while not outcome determinative, emphasis is placed on the multi-year gap between discharge from active duty service (1983) and initial reported symptoms and diagnosis as early as 1993, over 10 years after service separation. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) (lengthy period of absence of medical complaints for condition can be considered as a factor in resolving claim). Accordingly, the Board finds the Veteran's statements asserting in-service incurrence or continuity of symptomatology since service lack credibility and are without probative value. See, e.g. Madden v. Gober, 125 F.3d 1477, 1481 (1997) (the Board is entitled to discount the credibility of evidence in light of its own inherent characteristics and its relationship to other items of evidence). Next, service connection may be granted when the evidence establishes a causal relationship between active duty service and current complaints. The weight of the competent evidence does not attribute the Veteran's low back disorder to active service. To that end, the Board places significant probative value on the December 2012 addendum to the April 2011 VA examination, undertaken to specifically address the Veteran's low back disorder claim. The December 2012 VA examiner opined that the Veteran's low back disorder was less likely as not caused by or a result of his active service. The VA examiner's negative opinion was based on the intervening work-related injuries and that his lumbar spine complaints appeared to be the result of natural age progression. The Board finds that the December 2012 VA examination addendum to the April 2011 VA examination and opinion are adequate for evaluation purposes. Specifically, the examiner reviewed the claims file. Moreover, the April 2011 VA examiner interviewed the Veteran, and conducted a physical examination. The Board finds this opinion to be of great probative value. The Board has also considered the Veteran's statements asserting a nexus between his currently diagnosed low back disorder (DJD low back) and his active duty service. The Federal Circuit held in Colantonio v. Shinseki, 606 F.3d 1378 (Fed. Cir. 2010) and in Waters v. Shinseki, 601 F.3d 1274, 1278 (2010) that the Board errs when it suggests that lay evidence can never be sufficient to satisfy the requirement of 38 U.S.C.A. § 5103A(d)(2)(B) that there be a nexus between military service and a claimed condition. Although the Veteran is competent to report that he had low back complaints or soreness of the low back, he is not competent to render a medical opinion as to the etiology of this claimed disorder. Such requires a level of medical expertise that the Veteran does not possess. Indeed, as highlighted by the December 2012 VA addendum, this low back disorder is of a natural age progression. The Board does not find the Veteran's statements concerning the etiology of his claimed low back disorder to be credible, as they are inconsistent with probative and objective medical evidence of record which concluded that his claimed low back disorder was not a result of events in service. Moreover, he claims that he has had low back disorder since service, but he gave history of intervening work-related injuries during which time he first acknowledged his low back disorder since service. As such, the preponderance of the evidence weighs against a finding that the Veteran's low back disorder developed in service or is due to any event or injury in service. The Board has considered whether presumptive service connection for a chronic disease is warranted. Service connection may be established under the provisions of 38 C.F.R. § 3.303(b)when the evidence, regardless of its date, shows that a veteran had a chronic condition in service or during the applicable presumptive period. Certain chronic diseases, including degenerative joint disease/arthritis, may be presumed to have been incurred or aggravated during service if they become disabling to a compensable degree within one year of separation from active duty. 38 U.S.C.A. §§ 1101 , 1112; 38 C.F.R. §§ 3.307, 3.309 (2012). As the evidence of record fails to establish any clinical manifestations of degenerative joint disease of the lumbar spine within the applicable time period, the criteria for presumptive service connection on the basis of a chronic disease have also not been satisfied. For the foregoing reasons, Shedden element 3 is not met as to a sufficient causal relationship between a low back disorder and service and therefore, the claim for service connection for low back disorder must be denied on a direct or presumptive basis. In arriving at the decision to deny the claim, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, that doctrine is not applicable. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102 ; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). As such, the appeal is denied. As for the Veteran's claim for a right knee disorder related to service, again, there is no evidence of right knee complaints in service after that one knee complaint in November 1978. Strengthening exercises were recommended and these complaints were acute and transitory and resolved without residual disability. The retention examination less than 6 months prior to service discharge showed the lower extremities to be clinically normal. The first evidence of right knee complaints after service were in 2005. Physical therapy was provided but at his March 2005physical therapy treatment he denied knee pain. During the April 2011 VA examination, his right knee was stable, and x-ray findings were normal. The December 2012 VA addendum related that it was less likely that his right knee complaints were related to complaints in service, and more likely related to age progression. Such was the basis for the negative conclusions related to both his low back and right knee disorders. As stated in the other claim, Sheeden element 1 and 2 have been established as the Veteran has been diagnosed with right knee strain (element 1) and he did have right knee complaints on at least one occasion in service requiring strengthening exercises (element 2). However, the totality of the evidence of records is lacking for a causal relationship between the present disability and the disease or injury incurred or aggravated during service , necessary to establish element 3. Again, the December 2012 VA addendum indicates that after a thorough review of the claims file and the examiner's examination of the Veteran, it is less likely as not that the Veteran's knee complaints are related to his complaint in service as his present x-rays of the right knee are still normal and his complaints are more likely related to age progression. The Veteran and his aunt's statements have been considered. Although competent to report that he had right knee complaints in service, both the Veteran and his aunt lack the credibility to render a medical opinion as to the etiology of this claimed disorder. This requires medical expertise which neither the Veteran or his aunt claim to possess. The VA examiner's December 2012 addendum, based on a review of the record, examination of the Veteran, and his medical expertise, is of significant probative value. As such, the preponderance of the evidence weighs against a finding that the Veteran's present right knee disorder developed in service or is due to any event or injury in service. As such the appeal for service connection for a right knee disorder is also denied. ORDER Service connection for a low back disorder (tailbone disorder) is denied. Service connection for a right knee disorder is denied. ____________________________________________ F. JUDGE FLOWERS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs